Sunday Edaigbini

Arrow Injury to the Heart

Arrow injury to the heart is a common cause of penetrating trauma in rural areas of underdeveloped nations. We report such a patient who survived 3 days after such an injury and traveled 1000 km with a pulsating arrow in the chest for treatment. The literature on such injuries is reviewed.

The fate of end-stage renal disease patients after arteriovenous fistula creation in a northern Nigerian teaching hospital

With few end-stage renal disease patients having access to dialysis, we sought to determine the average duration of survival of these patients, after creation of an arteriovenous fistula. Out of 36 patients, 26 had died a little over 6 months later.

Vascular surgeries in West Africa: Challenges and prospects

Background The field of vascular surgery is evolving in sub-Saharan Africa but the practice is bedeviled by lack of expertise and infrastructure challenges. The consequences are a low volume of operations and a dearth of data. Available data are not representative of the wider picture, therefore, this study was undertaken to evaluate the practice of vascular surgery in a tertiary institution, in the light of the prevailing challenges. Methods Data from all patients with vascular-related pathologies managed in our surgical outpatient clinic and accident and emergency wards were obtained from the clinic and in-patient records from January 2008 to December 2012. Age, sex, diagnosis, treatment, and complications were noted. There were 73 patients comprising 45 (61.6%) males and 28 (38.4%) females. The age range was 1–90 years (mean 43.5 years). Results The pathologies managed included end-stage renal disease (n = 36, 49.3%), nontraumatic and posttraumatic aneurysms (n = 13, 17.8%), vascular trauma (n = 12, 16.4%), peripheral vascular disease (n = 5, 6.9%), congenital vascular malformations (n = 4, 5.5%), and thrombotic diseases (n = 3, 4.1%). Fifty-four (74.0%) surgeries were performed, with a complication rate of 5.5% and 2.7% mortality. Conclusions The practice of vascular surgery in Zaria, Nigeria, is fraught with challenges. The gap created by the dearth of skilled vascular surgeons is filled by competent cardiothoracic surgeons. Infrastructure decay and lack of prostheses limit the number and variety of operable cases. These challenges result in preventable morbidity and mortality.

Esophageal carcinoma presenting with cutaneous nodules

Esophageal cancer accounts for 7% of all gastrointestinal cancers but presentation with metastases in the form of cutaneous nodules is a rare occurrence. Majority of esophageal cancers are mainly those of squamous cell type and so are the reported cases of cutaneous metastasis as our own case. Here we report a 55-year old man with cutaneous metastasis from esophageal squamous cell carcinoma presenting as nodules on the face back and digital pulp with associated skeletal metastasis and pathological fractures. Our case represents the third in the reported series of digital pulp metastasis from esophageal squamous cell carcinoma. The nodule may appear before or after the onset of esophageal symptoms such as dysphagia and weight loss, and is a pointer of tumor aggressiveness.

Open drainage for chronic empyema thoracis; clarifying misconceptions by report of two cases and review of literature

Empyema thoracis is quite appreciated as a purulent pleural effusion. The basis for open drainage as an option for the treatment of chronic empyema thoracis is that the lung is trapped beneath a thickened and fibrosed visceral peel, which stabilizes and shields the trapped lung from the possible effect of pneumothorax when such a lung is exposed to the atmosphere either deliberately or accidentally. This is often unappreciated by many clinicians especially those with limited experience. From first principles, pus anywhere requires drainage and this applies equally to pleural space pus. Since these patients are often unfit for stressful procedures like decortication or the underlying lung is often unhealthy and will fail to expand or would be seriously violated in an attempt to free it, open drainage provides a safe and suitable option for the treatment of this pathology. We present the successful management of two patients by this approach as well as the review of literature in this respect.

Sensitivity of Computed Tomography‑guided Transthoracic Biopsies in a Nigerian Tertiary Institution

Introduction: The indications for open biopsies for intrathoracic lesions have become almost negligible. This development was made possible by less invasive maneuvers such as computed tomography-guided (CT-guided) biopsy, thoracoscopy or video-assisted thoracoscopy, and bronchoscopy. CT-guided percutaneous lung biopsy was first reported in 1976. Aim of Study: The aim of the study is to report our experience with CT-guided transthoracic biopsy. Materials and Methods: Patients with clinical and radiological evidence of intrathoracic mass were counseled and consent obtained for the procedure. They were positioned in the gantry, either supine or prone. A scout scan of the entire chest was taken at 5 mm intervals. The procedure was carried out by the consultants and senior registrar. Following visualization of the lesion, its position in terms of depth and distance from the midline was measured with the machine in centimeter to determine the point of insertion of the trucut needle (14–18-G). The presumed site of the lesion was indicated with a metallic object held in place with two to three strips of plasters after cleaning the site with Povidone-iodine. After insertion, repeat scans were performed to confirm that the needle was within the mass. A minimum of 3 core cuts was taken to be certain that the samples were representative. The results were analyzed by the determination of means and percentages. Results: Twenty-six patients underwent this procedure between 2011 and 2015. There were 15 males and 11 females (M:F = 1.4:1). The age range was between 30 and 99 years with a mean of 55 years. Histological diagnosis was obtained in 24 of the patients giving sensitivity of 92.3%. There were 3 mild complications giving a rate of 11.5%. The complications included a case of mild hemoptysis and two patients who had mild pneumothoraces which did not require tube thoracostomy. Conclusion: CT-guided biopsy is a reliable procedure for obtaining deep-seated intrathoracic biopsies with high sensitivity and minimal complication rate.

Incidental appendectomy after esophageal bypass for treatment of dysphagia

Background: The lifetime risk of acute appendicitis is 7-14%. Incidental appendectomy is defined as the removal of a clinically normal appendix during non-appendiceal surgery. Guidelines have tried to determine candidates for incidental appendectomy, but the practice continues to attract controversies. This paper presents our observation after appendectomy performed during oesophageal bypass/replacement procedures for treatment of dysphagia. Patients and Method: The histology results of all who underwent oesophageal bypass/replacement patients for the treatment of dysphagia was trace from the patients hospital records and histopathology register. Results: A total of 28 patients underwent oesophageal bypass /replacement procedure between 2008 – 2015, during which 25 had incidental appendectomy. We were able to retrieve the histology of only 7 patients (3 males and 4 females). Of these, one male had a normal appendix another had lymphoid hyperplasia. Four patients had acute recurrent appendicitis (3 females with corrosive stricture and one male with HIV associated inflammatory stricture). Conclusions: There is a high incidence of incidental appendicitis in patients with dysphagia justifying the need for incidental appendectomy as prophylaxis against future exploration which may put the conduit in harms way.

Primary oral soft tissue angiosarcoma of the cheek: a case report and literature review.

Angiosarcoma is a rare and aggressive malignant tumor that has a poor prognosis. It represents less than 1% of all malignancies occurring in the oral cavity and salivary glands. We present a 35-year-old male with angiosarcoma of the cheek following traumatic injury and a review of the current literature.

Zaria Universal Oxygenator Holder Phase I

Introduction: The conduct of cardiopulmonary bypass surgery requires the use of equipment and devices like the oxygenator. The oxygenator comes in different makes and each manufacturer customizes the carrier or ′holder′ of this device specific to their design. Aim: This paper presents an innovation designed to overcome the need to purchase a different holder for every oxygenator thereby cutting the cost. Materials and Methods: A sheet of iron measuring 1.9 cm (width) × 0.1 cm (thickness) was used to design the holder circular main frame. Another sheet measuring 2 cm (width) × 0.6 cm (thickness) × 24 cm (length) was used to construct a V-shaped handle with the arms of the V attached to the main frame 7 cm apart. At the narrow base of the handle is a latch requiring two 13-gauge screws to attach the holder to the heart-lung machine. Within the circumference of the main frame are four T-shaped side arms which grip the oxygenator; located at 2, 5, 7 and 11 O′clock positions. The stem of the T consist of a 0.6 cm (thickness) × 13 cm (length) rod drilled through the main frame. The cross of the T consists of variable lengths of the same sheet as the mainframe attached to the stem by a screw mechanism. At the base of the T, is attached a circular handle (4 cm in diameter) made of 0.4 cm iron rod. Result: An oxygenator holder which weighs 1.75 kg with a total length of 54 cm (the diameter of the mainframe is 30 cm). Its advantages include (i) affordability, (ii) materials are locally accessible, (iii) versatility (iv) reproducibility. The disadvantages include, (i) it requires some time to fit, (ii) caution is required in fitting the oxygenator to avoid breakage, (iii) a spanner is required to lock the latch. Conclusion: The concept of a universal holder is pertinent, especially in resource poor environments to avoid purchasing a new holder whenever the usual oxygenator common to the centre is unavailable. This device is amenable to further modifications to meet the unforeseen challenges.

Indications and Complications of Tube Thoracostomy with Improvised Underwater Seal Bottles

Background: Tube thoracostomy is a lifesaving and frequently performed procedure in hospitals where the expertise and necessary tools are available. Where the ideal drainage receptacle is unavailable, the underwater seal device can be improvised with bottled water plastic can especially in emergency situations. Aims and Objectives: To determine the frequencies of the various indications and complications of tube thoracostomy with improvised underwater seal. Materials and Methods: A cross-sectional study with a structured proforma was used for assessment over a 3-year period (May 2010-April 2013). The proforma was filled at the time of the procedure by the performing surgeon and patients were followed up with serial chest X-rays until certified cured. A 1.5 L bottled water container was used as the underwater seal receptacle. The data was analysed with SPSS 15 software program. Results: A total of 167 patients were managed. There were 106 (63.5%) males and 61 (36.5%) females. The mean age was 34.85 ± 16.72 with a range of 1-80 years. The most frequent indication was for malignant/paramalignant effusion, 46 (27.5%). Others were trauma, 44 (26.3%), Parapneumonic effusion, 20 (12%), postthoracotomy 14 (8.4%), empyema thoracis 12 (7.2%), heart disease and tuberculous effusion 11 (6.6%) each, pneumothorax 8 (4.8%) and misdiagnosis 1 (0.6%). A hundred and one (60.5%) of the procedures were performed by registrars, 41 (24.6%) by consultants, house officers 15 (9%) and senior registrars 10 (6%). The overall complication rate was 16.8% with the more frequent complications been empyema (5.6%) and pneumothorax (3.6%). The average duration of tube placement was 13.02 ± 12.362 days and range of 1-110 days. Conclusion : Tube thoracostomy can be a relatively safe procedure with acceptable complication rates even with improvised underwater seal drainage bottles.