Philip M Mshelbwala

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.

Congenital Vaginal Obstruction in Neonates and Infants: Recognition and Management

BACKGROUND Congenital vaginal obstruction commonly presents after puberty and presentation in infancy is uncommon. Due to lack of awareness, diagnosis may be missed in infants, sometimes with disastrous consequences. METHOD A retrospective review of 9 neonates and infants treated for congenital vaginal obstruction in 16 years. RESULTS The patients were aged 2 days to 4 months (median 28 days) at presentation. The main presenting feature was a lower abdominal mass, producing intestinal and urinary obstruction in 7 patients. In 2 patients, other conditions were suspected and diagnosis made only intraoperatively and in one patient, diagnosis was incidental during treatment for another condition. The cause of vaginal obstruction were low transverse vaginal septum 6, imperforate hymen 2, high transverse vaginal septum one. Associated anomalies were present in 5 patients (persistent cloaca 3, Hirschsprung disease 1, polydactyly 1). Low vaginal septum was treated by incision and drainage of hydrometrocolpos, imperforate hymen by hymenotomy and drainage of hydrometrocolpos and high vaginal septum by excision. There was recurrence of hydrometrocolpos in one patient who had low vaginal septum, requiring repeat surgery. One patient, in whom diagnosis was missed, died from overwhelming infection. Short term follow-up was good. CONCLUSION Congenital vaginal obstruction is an uncommon presentation in this setting. Missing the diagnosis can lead to disastrous consequences. A high index of suspicion is required for prompt recognition and treatment.

Management of biliary atresia in Nigeria: the ongoing challenge

Abstract Background: In developed countries, the outlook for patients with biliary atresia has improved remarkably owing to early referral, good diagnostic facilities and the availability of liver transplantation. In Nigeria and most of sub-Saharan Africa, there is little information on the current outlook for these children. Methods: A retrospective review of 14 patients with biliary atresia managed from 1991 to 2004 at Ahmadu Bello University Hospital, Zaria. Results: Six girls and eight boys presented at between 6 and 24 weeks of age (median 16). Seven presented to another hospital with persistent jaundice in the neonatal period. Eleven at presentation already had liver cirrhosis and deranged coagulation and could not have corrective surgery. Three patients aged 8, 10 and 16 weeks had Kasais porto-enterostomy. Facilities for diagnosis were limited. Ten patients were lost to follow-up and their outcome is unknown. Of the three patients who had porto-enterostomy, one died at 2 years from gastro-enteritis, one from cholangitis after 8 weeks, and one did not recover from anaesthesia. One patient who had a laparotomy and liver biopsy died from peritonitis. Conclusion: Owing to late presentation, delayed referral and difficulties in diagnosis, the outlook for infants with biliary atresia in this environment is poor. A concerted effort to encourage primary practitioners to detect and refer these infants at an earlier age is critical to outcome.

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.

Early oral feeding following intestinal anastomoses in children is safe

BACKGROUND Oral feeding following intestinal anastomoses is frequently delayed. In settings with limited utilisation of parenteral nutrition, this policy is problematic. This report evaluates the safety of early oral feeding following intestinal anastomoses in children. MATERIALS AND METHODS A prospective study including 64 children aged ≤ 12-year-old who had intestinal anastomoses for varying surgical indications over a 6-year period. Oral feeding was started within 72 hours following surgery, if there was no contraindication. RESULTS There were 41 (64.1%) boys and 23 (35.9%) girls aged 6 hours to 12 years (median, 6 years). The indication for surgery was perforated typhoid enteritis (33, 51.6%), intestinal atresia (8, 12.5%), colostomy closure for anorectal anomaly (8, 12.5%), intussusception (3, 4.7%) and ileostomy closure (3, 4.7%). Type anastomoses were 39 (60.9%) ileoileal, 4 (6.3%) colocolic, 8 (12.5%) jejunoileal and 4 (6.3%) ileocolic. Oral feeding was commenced in 17 (26.6%) of the patients within 48 hours, 36 (56.3%) by third day and 45 (70.3%) before fifth day post-operative. Feed-related complication occurred in 5 (7.8%) patients, 3 (8.3%) of which was in patients fed within 72 hours post-operative and 2 (7.1%) in those fed after 72 hours. Full oral feed was achieved by fifth and seventh day post-operative in 42 (65.6%) and 61(95.3%), respectively. Two (6.1%) patients had oral feeding stopped and recommenced at seventh day post-operative due to feed-related complications. CONCLUSION Early oral feeding following intestinal anastomoses in children is safe, particularly in the setting of limited availability of parenteral nutrition.

Echocardiographic findings in children with surgically correctable non-cardiac congenital anomalies

Abstract Background: Congenital cardiac anomalies may co-exist with non-cardiac congenital malformations and, for those requiring surgical correction, there can be an anaesthetic risk. Aim: To estimate the burden of congenital heart disease (CHD) in children with surgically correctable non-cardiac congenital malformations. Patients/Methods: Records of 120 children aged between 1 week and 11 years [mean (SD) 0.6 (1.5) years] undergoing corrective surgery for non-cardiac congenital malformations were examined. Results of clinical cardiac examination and surgical and echocardiographic findings were analysed. Results: Cleft lip or palate was the commonest surgical anomaly (46, 38.3%), followed by ano-rectal malformation (32, 26.7%). Forty-two children (35.0%) had an abnormal echocardiographic scan. A cardiac abnormality was detected clinically and confirmed by echocardiography in ten patients (8.3%), which represents 24% of all the cardiac abnormalities. The commonest cardiac anomalies were atrial septal defect (ASD) (30 children, 25%), followed by ventricular septal defect (VSD) (seven children, 5.8%). The frequency of ASD was highest in children with a cleft lip or palate (14/46, 30.4%). Conclusions: Over one-third of patients undergoing surgical correction of congenital malformations have co-existing CHD. Echocardiography is important for pre-surgical evaluation. No association between type of CHD and specific non-cardiac congenital malformations was found.

A Descriptive Study of Clefts of the Primary and Secondary Palate Seen in a Tertiary Institution in Nigeria

Background: Cleft lip and palate is the commonest congenital malformation of the head and neck region. This article discusses the experiences of the authors′ in the management of clefts of the primary and secondary palate in a tertiary institution in Nigeria. Patients and Methods: This is a retrospective review of the clinical database for all children with cleft lip and palate. Data were analyzed for age at presentation, sex distribution, surgical technique, associated congenital anomalies, and complications. The results obtained were converted to relative values in frequency tables for analysis. Results: The average age at presentation for all patients with cleft was 2.47 years. Males were slightly more affected than females among all clefts with a frequency of 40 (53%) and 35 (47%). The distribution of clefts by location showed a preponderance of the left side 33 (44%), followed by right side 18 (24%) and bilateral cases 11 (15%). Three patients (4%) had a relative with a cleft of the primary or secondary palate. At least one congenital malformation coexisted with a cleft of the primary or secondary palate in 13 (17%) of the 75 babies. The commonest post-operative complication of cleft of the primary palate was wound dehiscence 3 (4%). Conclusion: This study has shown that there was a wide range of age at presentation. It is characterized by delays in the repair of clefts of the primary and secondary palate. We strongly support early repair of clefts of the primary and secondary palate to facilitate normal feeding, better speech and ensure social acceptance.

Management of anorectal malformation: Changing trend over two decades in Zaria, Nigeria

BACKGROUND Anorectal malformation is a common congenital defect and its management has evolved over the years. This is a review of the trend in the management of this condition in a major paediatric surgical centre in Nigeria over two decades. MATERIALS AND METHODS A retrospective analysis of 295 patients with anorectal malformations managed from January 1988 to December 2007 was carried out. RESULTS There were 188 boys and 107 girls aged 1 day-9 years (median 8 years) at presentation. There were 73 (54.5%) and 106 (65.8%) emergency operations in groups A and B, respectively. There were 61 (45.5%) and 55 (34.2%) elective operations in groups A and B, respectively. Regarding treatment, in group A, patients requiring colostomy had transverse loop colostomy, while in group B, sigmoid (usually divided) colostomy was preferred. The definitive surgery done during the two periods were: group A: cutback anoplasty 29 (47.5%), anal transplant 5 (8.2%), sacroabdominoperineal pull through (Stephens operation) 6 (9.5%) and others 21 (34.4%). In group B, posterior sagittal anorectoplasty (PSARP) 46 (83.7%), anal transplant 1 (1.8%), posterior sagittal anorectovaginourethroplasty (PSARVUP) 2 (3.6%) and anal dilatation 6 (10.9%) were done. Early colostomy-related complication rates were similar in the two groups (P > 0.05). The overall late complication rate was 65.5% in group A and 16.4% in group B (P < 0.05). The mortality was 25 (18.6%) in group A compared to 17 (10.6%) in group B (P < 0.05). CONCLUSION There have been significant changes in the management of anorectal malformations in this centre in the last two decades, resulting in improved outcomes.

Anorectal malformation coexisting with Hirschsprung's disease: a report of two patients.

Anorectal Malformation (ARM) and Hirschsprungs Disease (HD) are common causes of congenital intestinal obstruction in children. Simultaneous occurrence of both conditions is rare. Few have been reported in Europe and Asia, but we have no knowledge so far of such report from Nigeria. We present two patients managed in our centre to highlight the challenges of management of this uncommon coexistence. The first patient was a 5-year-old girl who was referred to us with intestinal obstructive symptoms despite an apparently adequate sized ectopic anus. She had colostomy and rectal biopsy, which confirmed HD. She had corrective surgery performed through a posterior sagittal approach. She did well post operatively. The second patient was a 3-year-old girl who presented with features of intestinal obstruction, had laparatomy and was also referred to us. It was observed in the referral hospital during laparatomy, to have features of HD and rectal atresia intraoperatively. She had colostomy done and rectal biopsy performed at the same time, which confirmed the diagnosis of HD. She had simultaneous correction of both conditions through a posterior sagittal approach. She was in good condition at follow up. It was therefore recommended that a high index of suspicion of HD, should be entertained while managing patients with anorectal malformation.

One-day bowel preparation in children with colostomy using normal saline.

BACKGROUND Colonic and colorectal surgery frequently requires bowel preparation. This is an evaluation of the use of normal saline for one-day bowel preparation in children with colostomy. PATIENTS AND METHODS A prospective study of 55 children with colostomy who had one-day bowel preparation for colonic and colorectal surgical procedures in a 3-year period. The information, along with clinical data was recorded on a structured proforma. Data were analysed using SPSS version 11.0. RESULTS There were 33 boys and 22 girls. The median age was 4 years (range, one month - 13 years). The primary diagnosis were as follows: Anorectal malformation, 24 (44%); Hirschsprung`s disease, 24 (44%); Faecal incontinence- post-abdominoperineal pull-through, 2 (4%); Penetrating rectal injury, 1 (2%); others, 4(8%). Intraoperative bowel luminal fluid cleanliness was assessed as clear in 36 (62%) and contaminated in 21 (38%). Overall, postoperatively, superficial surgical site infection occurred in 6 (10.9%) patients (2 had clean intraoperative colonic fluid, 5.9%. CONCLUSION One-day bowel preparation using normal saline is effective and safe in children with colostomy.