Paul T. Nmadu

Emergency neonatal surgery in a developing country

Abstract With better understanding of neonatal physiology and improvements in diagnostic facilities and neonatal intensive care units (NICU), the outcome of neonatal surgery has improved in developed countries. In developing countries, however, neonatal surgery is problematic, particularly in the emergency setting, but there are few reports from these countries. A retrospective analysis of 154 neonates who had emergency surgery over a 10-year period at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, was undertaken. Emergency surgery represented 40% of surgical procedures in neonates in the hospital. The majority of the patients (94.8%) were delivered at home or in rural health centers. The median weight was 2.7 kg (range 2.0–3.7 kg). In 89 cases (58%) the indications for surgery were intestinal obstruction, anorectal malformations in 60(67%) and in 33(21%) complicated exomphalos or gastroschisis. Nine patients (6%) required surgery for ruptured neural-tube defects. A colostomy was the commonest procedure (51, 33%), 27(53%) of which were performed using a local anesthetic without adverse effects. Thirty-three abdominal-wall defects were closed by various methods (fascial closure 23, skin closure 6, improvised silo 4). Overall, 37 (24%) procedures were performed using local anesthesia. Fifty-nine patients (38%) developed postoperative complications (infections 33, respiratory insufficiency 16, colostomy complications 8, anastomotic leak 2). The mortality was 30.5%, 66% due to overwhelming infection, 28% to respiratory insufficiency, and 4.3% to multiple anomalies. Other factors considered to have contributed to morbidity and mortality were late referral and presentation and a lack of NICUs. Thus, emergency neonatal surgery is attended by high morbidity and mortality in our environment at the present time. Early referral and presentation and provision of NICUs should improve the outcome.

Surgical site infection in children: prospective analysis of the burden and risk factors in a sub-Saharan African setting.

BACKGROUND Surgical site infections (SSI) add substantially to the morbidity of surgical patients. Our hypothesis was that the SSI rate is high in our setting, but there were no data regarding the prevalence and risk factors. METHODS Three hundred twenty-two children who had surgery (elective 144, emergency 178) between January, 2001 and September, 2005 were studied prospectively. All patients with clean-contaminated, contaminated, and dirty incisions received prophylactic antibiotics. Data were collected using a tool that captured demographics, diagnosis, co-morbid conditions, type of surgical incision, nature of surgery, type of anesthesia, use of perioperative antibiotics, and duration of surgery. Information also was collected postoperatively on the development of SSI, type of infection, associated signs, the day the infection was identified, the findings in cultures of swabs from infected incisions, duration of hospital stay, and outcome. The chi-square test for categorical variables was used to test for significance of association. The p value for significance was set at 0.05. RESULTS Seventy-six patients (23.6%) consisting of 40 boys and 36 girls developed SSI. The median age was nine months (range, 2 days-12 years) for those who developed SSI and 15 months (range, 1 day-13 years) for those who did not. The SSI rate was 14.3% in clean incisions, 19.3% in clean-contaminated incisions, 27.3% in contaminated incisions, and 60% in dirty incisions (p < 0.05). The infection rate was 25.8% in emergency procedures and 20.8% in elective procedures (p > 0.05). The infection rate was 31% in operations lasting >or= 2 h and 17.3% in operations lasting < 2 h (p < 0.05). Infection was detected before the eighth postoperative day in 56 of the patients (74.6%) with SSI, and bacteria were cultured from the incision in 32 patients (42.7%). The average length of stay was 26.1 days (range, 8-127 days) in patients with SSI and 18.0 days (range, 1-99 days) in those without SSI (p < 0.05). The mortality rate of patients with SSI was 10.5%, with six of the eight deaths related directly to the SSI, compared with a mortality rate of 4.1% in patients without SSI (p < 0.05). CONCLUSION The burden of SSI in this setting is high. The degree of incisional contamination and a long duration of surgery (>or= 2 h) are important risk factors.

Major complications of omphalitis in neonates and infants

Abstract.Omphalitis is a common problem in developing countries, and a wide range of complications requiring surgery may occur. We conducted a retrospective review of 19 neonates and infants treated for major complications of omphalitis: 13 boys and 6 girls aged 5–75 days (median 33 days). Five (26%) patients presented with spontaneous evisceration of small bowel through the umbilical cicatrix, resulting in intestinal gangrene in 1. Necrotizing fasciitis (NF) occurred in 5 (26%) patients involving mainly the scrotum, and in 2 involving the penis as well. Three (16%) patients had peritonitis, resulting in intra-abdominal abscesses in 2. Three (16%) had superficial abscesses, 2 (11%) had hepatic abscesses resulting in extensive destruction of the left lobe in 1, and 1 (5%) developed an adhesive intestinal obstruction. Although Staphylococcus aureus was the most commonly cultured organism, many cultures were sterile due to the use of antibiotics before presentation. Treatments consisted of repair of the umbilical cicatrix for evisceration (and intestinal resection for gangrene), radical debridement for NF, drainage and lavage for peritonitis, drainage of superficial abscesses, and lysis of adhesions. Broad-spectrum antibiotics were also given. No patient developed tetanus. One patient died from peritonitis. There was no death from NF. As serious complications may result from omphalitis in neonates and infants, with high morbidity and possible mortality, early recognition and prompt treatment are necessary for a good outcome.

Cervical cystic hygroma: pre-, intra-, and post-operative morbidity and mortality in Zaria, Nigeria

Abstract The management of extensive cystic hygromas in the cervical region (CCH) presents difficult challenges. A retrospective study of 41 children with CCH treated over 24 years in Nigeria was carried out; there were 28 boys and 13 girls with an age range of 3 days to 10 years (median 6.5 months). Thirty-three (80%) presented with 34 life-threatening complications including infection in 11 (27%), rapid increase in cyst size in 10 (24%), respiratory obstruction in 7 (17%), and intracystic hemorrhage in 6 (15%). Complete excision was possible in only 14 of 34 (41%) patients, and injuries to neighboring structures occurred in 6 (18%) (facial nerve 2, recurrent laryngeal nerve 1, internal jugular vein 1, parotid duct 1, pharynx 1). Postoperatively, 8 (24%) patients developed 9 complications. Wound infections occurred in 5 incompletely-excised cysts and 2 patients had respiratory obstruction. One patient with a wound infection developed edema of the tongue lasting several days and drainage was prolonged (>6 weeks) in 1. Five patients died, 3 from respiratory obstruction and 1 each from wound and chest infection. Four patients (12%) developed a recurrence within 5 years of surgery. The pre-, intra-, and post-operative morbidity were high in this series. Although complete excision is the ideal treatment for CCH, this need not be pursued if neighboring structures are liable to injury. When cysts are incompletely excised, antibiotic prophylaxis is necessary as the incidence of wound infection is high.

Blunt abdominal trauma in children: epidemiology, management, and management problems in a developing country

Abstract Trauma is the leading cause of death in children in developed countries. In tropical Africa, it is only beginning to assume importance as infections and malnutrition are controlled. In developed countries, the availability of advanced imaging modalities has now reduced the necessity for laparotomy to less than 10% following blunt abdominal trauma (BAT) in children. This report reviews the epidemiology, management, and unnecessary laparotomies for pediatric BAT in a developing country in a retrospective review of 57 children aged 15 years or less at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria over 12 years. The average age was 9 years and the male-female ratio 3.8:1. Seventy-four percent (74%) of abdominal injuries in children were due to blunt trauma. The commonest causes of injury were road traffic accidents (RTA) (57%), 88% in pedestrians and 59% in children aged 5–9 years. Falls were the cause of trauma in 36%, 60% of them aged 10–15 years. Other causes of injury were sports in 5% and animals in 2%. Diagnosis was clinical, supported by diagnostic peritoneal lavage or paracentesis. Two patients had ultrasonography, and none had computed tomography. Fifty-three patients had a laparotomy, 2 died before surgery, 1 was managed nonoperatively, and in 1 surgery was declined. There were 34 splenic injuries, 20 treated by splenic preservation, splenectomy in 13, and non-operative in 1. Fourteen gastrointestinal injuries were treated in 12 patients. Of 9 hepatic injuries, 4 were minor and were left untreated, 3 were repaired, 1 was packed to arrest hemorhage, and a lacerated accesory liver was excised. Four injuries to the urinary tract (bladder contusion 2, bladder rupture 1, ruptured hydronephrotic kidney 1) were treated accordingly. There were 4 retroperitoneal hematomas associated with other intra-abdominal injuries and 2 pancreatic contusions. One lacerated gallbladder was treated by cholecystectomy and a ruptured left hemidiaphragm was repaired transperitoneally. In retrospect, 27 (51%) patients could have been managed by observation (splenic injury 20, liver injury 5, bladder contusion 2) using advanced imaging modalities. One patient developed an intra-abdominal abscess following splenorrhaphy. The average hospital stay was 17 days. Mortality was 8 (14.5%) from gastric perforation (3), liver injury (2), splenic injury (1), and 2 patients died before surgery. BAT in this population results predominantly from RTA in pedestrians. Laparotomy may be avoided in 51% of cases if advanced imaging modalities are readily available.

Spontaneous rupture of infantile umbilical hernia : report of three cases

Three Nigerian infants with spontaneous rupture of an umbilical hernia are described. In two, hernias developed in the neonatal period following umbilical sepsis. Rupture occurred at the ages of 2 and 3 months, respectively, and was probably precipitated by raised intra-abdominal pressure resulting from excessive crying. The third child had a large, ulcerated umbilical hernia which ruptured at 10 months and was precipitated by damage to the overlying skin. The children were treated successfully.

Hirschsprung's disease in the newborn : experience in Zaria, Nigeria

Summary In a 10-year retrospective review of 15 newborns aged ≤ 42 days presenting with Hirschsprungs disease, there were 12 boys and three girls aged 4–42 days (median 18 days). Twelve babies presented with complete intestinal obstruction. In 12 babies, there was a history of delayed passage of meconium (after 2–6 days). One baby each developed caecal and sigmoid perforation. Barium enemas in three babies without complete intestinal obstruction suggested Hirschsprungs disease in two. Following resuscitation, the two infants who had perforated had caecostomy and sigmoid repair with right transverse colostomy, respectively. One infant had ileostomy for total colonic aganglionosis associated with ileal atresia. All the others had initial diversion colostomy. Rectal biopsies confirmed Hirschsprungs disease in all the babies. The ileum was injured during colostomy in one case, requiring repair. Postoperative anastomotic leakage occurred in the infant with ileal injury and colostomy necrosis occurred in another infant. Five babies (33%) died, three from overwhelming infection (caecal perforation, sigmoid perforation, ileal injury), one from hypokalaemia (ileostomy) and one from an unidentified cause. Few cases of Hirschsprungs disease present in the newborn period in our environment and, when they do, they usually present with complete intestinal obstruction with high morbidity and mortality.

Role of vesicostomy in the management of posterior urethral valve in Sub-Saharan Africa

OBJECTIVE To review the role of vesicostomy in the management of posterior urethral valve (PUV), in neonates and infants, given the limitations for endoscopic treatment in this setting. METHODS A review of 35 patients who presented with posterior urethral valve over a 10-year period. Demographic and clinical information were prospectively recorded on a structured pro forma, and the data extracted analysed using SPSS 11.0. RESULTS The 35 boys were aged 3 days to 10 years (median 3 weeks). Twenty-three (65.7%) had a vesicostomy (age range 3 days-3 years, median 3 weeks). The mode of presentation was poor urinary stream 15 (65.2%), urinary retention 4 (17.4%), and renal failure 6 (26.1%). Main findings were palpable bladder 23 (100%), hydronephrosis 4 (17.4%). Abdominal ultrasound confirmed hydronephrosis and thickened bladder wall, and voiding/expressive cystourethrogram confirmed dilated posterior urethra and vesicoureteric reflux in all 23 patients. Complications following vesicostomy were stoma stenosis 1 (4.3%), bladder mucosal prolapse 1 (4.3%), perivesicostomy abscess 1 (4.3%); there was no mortality. Following vesicostomy, 10 (43.5%) patients had excision of the valves and vesicostomy closure at age 2-8 years (median 4 years). They are well, with normal renal ultrasonographic findings, bladder capacity range 115-280 ml, and normal urea, serum electrolytes, creatinine, at 3 years of follow up. Thirteen (56.5%) are still awaiting valvotomy but have remained well and with normal ultrasonographic renal findings. CONCLUSION Vesicostomy is a useful temporising mode of urinary diversion in neonates and infants with posterior urethral valve (in the absence of unobstructed upper tracts) when facilities for endoscopic valve ablation are not readily available.

Sacrococcygeal teratoma in Zaria, Nigeria: report of 47 cases

This is a retrospective review of 47 children, 38 girls and 9 boys, with sacrococcygeal teratoma, aged between 1 day and 5 years (mean 30 weeks), and seen in Zaria over 19 years. There were 40 type I, four type II, two type III and one type IV. Only nine children presented during the 1st week of life, ten at 4 weeks and 28 (60%) after the 3rd month of life. All were operated upon soon after admission to hospital. Four of the tumours in children over 1 year of age were malignant.

Paediatric external abdominal hernias in Zaria, Nigeria.

The author reports a 4-year experience of external abdominal hernias in children in the Paediatric Surgical Unit of the Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. A general surgeon with wide experience of paediatric surgery and his well tutored assistants performed operations on various abdominal hernias in 311 children aged from 2 weeks to 12 years (mean age: 3.2 years). Fourteen children had a strangulated inguinal hernia and seven others a strangulated umbilical hernia. Two bowel resections were performed on each type. The majority of patients were followed up for periods of from 3 months to 2 years. Eighty patients with uncomplicated inguinal hernia developed mild scrotal oedema. Infection was limited to the operation site in 15 patients, in addition to two scrotal wound infections in two of those who had bowel resection. There were two early recurrent groin hernias, and no deaths. There was no overt testicular ischaemia in patients with strangulated groin hernias. Our results were comparable with those from similar and specialist centres elsewhere.