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Nigerian Journal of Surgery : Official Publication of the Nigerian Surgical Research Society logoLink to Nigerian Journal of Surgery : Official Publication of the Nigerian Surgical Research Society
. 2016 Jul-Dec;22(2):138–146.

NSRS/ASON Abstracts Nnewi 2016

PMCID: PMC5013743
Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Accuracy of Clinical and Ultrasound Examination of Palpable Breast Lesions in A Resource-poor Society

Ebubedike UR 1, Umeh EO 1, Anyanwu SNC 1

Background: Palpable breast masses are common presentations in resource-poor societies. Clinical and ultrasonographic breast examinations are commonly available means of evaluation.

Objective: To compare the accuracy of clinical breast examination and ultrasonography in the diagnosis of palpable breast masse.

Methodology: Consenting females presenting with palpable breast masses at the general surgical outpatient clinic were assessed clinically by the most senior surgeon, ultrasonographically by two radiologists and the diagnosis compared with histologic examination, all in Nnamdi Azikiwe University Teaching Hospital, Nnewi.

Results: One-hundred thirteen patients were recruited during the study period from January 2013 to April 2014. Of these, 53 patients (46.9%) had breast core biopsy while 60 (53.1%) had open surgical biopsy. Only 67 (59.3%) patients had their histological results available. The mean age was 41.58 years (range 16–78). Clinical breast examination achieved a sensitivity of 82.1%, specificity 67.9%, positive predictive value 78%, negative predictive value 73%, overall accuracy 76.1%, false positive rate 32.1%, and false negative rate 17.9%. Breast ultrasonography had a sensitivity of 86.8%, specificity 72.4%, positive predictive value 80.5%, negative predictive value 80.8%, overall accuracy 80.6%, false positive rate 27.6%, and false negative rate 13.2%.

Conclusion: This study revealed no statistically significant difference between the accuracy of clinical breast examination and breast ultrasonography. We recommended that both should be used in the evaluation of palpable breast masses.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Changing Pattern of Peptic Ulcer Diseases Perforation: Is Nonsteroidal Anti-inflammatory Drug to be Blamed?

Egwuonwu OA 1, Okoli CC 1, Chianakwana GU 1, Anyanwu SNC 1

Introduction: Perforated peptic ulcer disease (PUD) is a major cause of morbidity and mortality in surgical patients. Understanding the risk factors is important in improving the overall health of the community.

Aim: To determine the association between perforated peptic ulcer and use of nonsteroidal anti-inflammatory drugs in patients presenting to the general surgical unit of NAUTH, Nnewi.

Methods: A combined four-year retrospective review from May 2011 to April 2015 and 1-year prospective study from May 2015 to April 2016. All patients with intraoperative diagnosis of perforated PUD formed part of this study. Death was the primary outcome whereas the presence of other postoperative complications was the secondary outcome.

Results: During the period, forty patients had perforated PUD. More males were affected, with a male:female ratio of 4:1. More gastric perforations were recorded 34 (85%) versus 6 (15%). The age ranged from 21 to 80 years. Twenty-eight patients (70.0%) were on nonsteroidal anti-inflammatory drugs (NSAIDs) during the time of perforation while 40.0% and 17.5% of the cases had significant premorbid alcohol and smoking history. Eleven patients had combined risk of alcohol and NSAIDS use while six patients had combined risk of smoking and NSAIDS use. There was no significant association between NSAIDS use and gastric perforation (χ2= 0.092, P = 0.553) though 24 (70.59%) of patients with gastric perforations were on NSAIDS. Gastric perforations and NSAIDS use were significantly associated with mortality (χ2= 4.432, P = 0.041) and (χ2= 5.584, P = 0.019), respectively, while duodenal perforations, patients age, and gender were not significantly associated with mortality.

Conclusion: Gastric perforation and NSAIDS use were significantly associated with mortality.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Patient-reported Outcomes Following Laparoscopic Cholecystectomy for Symptomatic Cholelithiasis: Owerri Experience

Ekwunife CN 1, Enendu SE 1, Egwuonwu OA 1, Afudo KK 2, Anolue FC 2

Background: Evaluation of treatment outcomes from the patients’ perspective has become an important tool for monitoring and improving quality of care. Patients with symptomatic cholelithiasis expect improved quality of life after operation, but in a considerable number of patients, pain persists. It is pertinent to study patients’ experiences after laparoscopic cholecystectomy as this procedure becomes increasingly common place in our subregion.

Methods: An independent assessor conducted phone and clinic interviews on patients who had cholecystectomy at the Federal Medical Owerri and Carez Clinic Owerri, in the period between 2009 and 2015. The questionnaire enquired about the nature of abdominal pains before and after operation, level of satisfaction, and body image after the procedure.

Results: A total of 41 of 69 patients in the medical records were available for the assessment. Three patients have persistent mild upper abdominal pains after operation while 6 (14.5%) developed painful scars. All the patients were either very satisfied or satisfied with the procedure. A quarter of the patients have referred someone else for laparoscopic cholecystectomy.

Conclusion: Persistence of symptoms after laparoscopic cholecystectomy does not seem to be much of a problem in our practice, and patients’ satisfaction is very high.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Audit of Emergency Hernia Presentation at Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife, Nigeria

Etonyeaku AC 1, Wuraola FO 1, Akinkuolie AA 1, Olasehinde O 1, Mosanya A 1, Agbakwuru EA 1

Introduction: Emergency surgery for abdominal wall hernia is not uncommon and is associated with increased risk for morbidity and mortality.

Objective: To evaluate the clinical profiles of patients and pathological characteristics of the hernia repaired on an emergency basis.

Methods: It is a retrospective review of all patients who had emergency hernia repair at the Obafemi Awolowo University Teaching Hospital Complexes Ile-Ife between 2005 and 2015. Data were obtained from the theater register and clinical records of the patients and analyzed using SPSS (IBM, Chicago).

Results: The 65 patients who had emergency hernia surgery comprised 3.5% of all hernias repaired. The age range was 10–85 years (median age = 45 years). It was more frequent in those >60 years (26%). The male: female ratio was 5:1. A majority of the patients in this series were farmers (27.1%) and artisan (32.4%). Duration of groin swelling ranges from 2 months to 30 years but acute symptoms are within 2 h to 7 days. About 10.8% of patients presented in shock. Abdominal pain (80.4%) and groin swelling (73.8%) were common presenting complaints. Comorbidities: 5.3% had hypertensive heart disease, 1.5% had diabetes, and 3.1% had chrome obstructive pulmonary disease. The hernia was either obstructed (95.4%) or strangulated (4.6%) at presentation. Nylon darn (78.4%) was the most preferred method of repair. Surgical access was through incision in the groin (78.5%), abdominal midline (9.2%), or both (12.3%). The small bowel was the most common content of the sac and was adjudged to be viable in 66.2% of cases. Surgical site infection was the most common complication, and mortality rate was 4.3%.

Conclusion: Small bowel obstruction remains relatively common with groin hernia and older patients, in which mortality rate is still significant.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Laparoscopic Management of Nonpalpable Undescended Testes: Features and Outcomes

Ekwunife OH 1, Ugwu JO 1, Modekwe VI 1, Ugwunne C 1

Introduction: Nonpalpable undescended testes (NPTs) constitute 20–30% of undescended testes, and its management has been a challenge both in diagnosis and in treatment. Worldwide, laparoscopy is the current gold standard of management. In Nigeria, management of NPT has largely been by open surgery with consequent high morbidity.

Aim: To classify the laparoscopic features of NPT and determine the outcome of managed cases in our center.

Methodology: Prospective data were collected from consecutive patients who had laparoscopy for NPT at the Paediatric Surgical Unit of Nnamdi Azikiwe University Teaching Nnewi from June 20 14 to July 2016.

Results: A total of 15 patients with 23 testes were treated. There were eight patients with bilateral NPT, four had left NPT, and remaining three had right NPT. The age ranged from 14 months to 29 years with a median of 5 years. Eleven of the 22 internal inguinal rings were open. The position of the testes were canalicular (n = 2), peeping (n = 2), low abdominal (n = 6), high abdominal (n = 6), blind-ending vas (n = 1), and absence of vas and vessels (n = 5). No further intervention was needed for the six agenetic/atrophic testes. Standard open orchiopexy was carried out for the two canalicular testes. Eight testes were brought down by one-stage laparoscopic orchiopexy while four were brought down by staged laparoscopic Fowler–Stephens procedure. Laparoscopic orchiectomy was done in two patients (a grossly dysmorphic testis [nubbin] and a high abdominal testis in a 29-year-old). Orchiopexy was successful in 11 of 15 fixed testes. Of the unsuccessful ones, three testes were atrophic (volume less than what it was initially) while two were high scrotal (one testis had both complications). There was no conversion to open abdominal surgery. All patients were discharged within 24 h of surgery.

Conclusion: Laparoscopy provides for a better management of NPTs by combining diagnosis and intervention in the same sitting with a good success rate and minimal postoperative morbidity.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Laparoscopic-assisted Transanal Endorectal Pull-through for the Management of Hirschsprung's Disease: Report of Two Cases from Southwest Nigeria

Ademuyiwa AO 1, Elebute OA 1, Balogun OS 2, Idiodi-Thomas HO 1, Desalu I 3, Chirdan LB 4, Bode CO 1

Background: The management of Hirschsprung's disease has evolved over the years from staged procedures with colostomy to single-stage abdominal pull-through. More recently, the transanal single-stage pull-through without abdominal scar and laparoscopic-assisted procedure have gained popularity. This is the report of our first two cases of laparoscopic-assisted transanal endorectal pull-through (LATEP) from the Lagos University Teaching Hospital, Lagos.

Case Reports: Case 1: O.D, a 19-month-old boy, presented with a history of constipation since birth. The patient was noted to have passed meconium after 72 h of life. There was associated abdominal distension, no straining on defecation, and no fever. On examination, abdomen was distended, with hyperactive bowel sounds. A full thickness rectal biopsy done histologically confirmed Hirschsprung's disease. The patient was worked up for surgery and had LATEP and was discharged home 5 days postoperative with no untoward sequelae. Case 2: M.J. is a 3-year-old boy who presented with 28 months history of constipation. Constipation was noticed from 6 months of his life. Patient strains at defecation had associated significant abdominal distension with colic. There is also failure to thrive despite intact appetite. Examination showed that the abdomen was distended with normoactive bowel sounds. Full thickness rectal biopsy confirmed Hirschsprung's disease. The patient was optimized for surgery and had LATEP. He had uneventful postoperative period and he was discharged on postoperative day 5.

Conclusion: From our initial experience, collaboration among surgeons can enhance skill transfer and LATEP is a feasible therapeutic option for patients with Hirschsprung's disease in our center.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Congenital Anomalies: Prospective Study of Pattern and Associated Nongenetic Risk Factors in Infants Presenting to a Tertiary Hospital, Anambra State, Southeast Nigeria

Ekwunife OH 1, Okoli CC 1, Ekwesianya AC 1

Introduction: Developing nations have a higher burden of prevalence, morbidities, and mortalities from congenital anomalies. Understanding of the contemporary pattern is important both in the clinical management of the condition and in improving the overall community health.

Aim: To determine the pattern and possible risk factors associated with congenital anomalies in infants presenting to our institution.

Methodology: This is a 1-year prospective study which involved clinical screening of all infants who presented for the treatment at our institution from January 1, 2012 to December 31, 2012. Positive cases with congenital anomalies were further studied by a trained investigator using a structured close-ended interviewer-administered questionnaire

Results: Of the total of 5010 infants screened, 108 have congenital anomalies giving a prevalence of 2.2%. There were 71 males and 34 females giving a ration of 2:1. Three (28%) neonates have disorders of sex differentiation. Major anomalies were noted in 101 (93.5%) infants while the rest, 7 (6.5%) were minor. Fourteen (13.0%) infants had multiple anomalies. Only 2 (1.9%) infants were preterm. Consanguineous relationship was observed in another 2 (1.9%). Prenatal ultrasound was done in 33 (30.8%), but in only 7 (6.5%) was any anomaly detected Risk of anomaly progressively rises to a peak of 48% in the maternal age group of 26–30 years and drops steadily after. Mean peak maternal age (standard deviation) is 28.5 (6.05), and gastrointestinal tract anomalies were most common (n = 28, 25.9%). Seven (6.5%) took herbal preparations in the first trimester. Parents of close to half (45.4%) of the anomalies reside in Onitsha, a densely populated and industrial zone. Residences close to dump sites, telecom masts/base stations, electricity cables, industries, and heavy motorized highways contributed to risk factors in 9–12% of the cases.

Conclusion: The prevalence of congenital anomalies in Anambra State is at par with other regional studies. Cases are concentrated in urban areas with high population densities. The preliminary contributory effects of residence close to dump sites, telecom masts/base stations, electricity cables, and heavy motorized highways needs to be further evaluated for specificity of effects.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Traumatic Bowel Evisceration in Children: Place of Laparotomy

Eighemhenrio Aiwanlehi 1, Esteem Tagar 1, Odefiagbon Ernest 1, Akerele Williams 1

Introduction: Bowel evisceration refers to the process whereby the intestine which usually resides in the abdomen becomes displaced outside the cavity through a disruption of the wall of the cavity. The most common cause of bowel evisceration is penetrating abdominal injury. Penetrating abdominal injury in children is low, and those resulting from domestic accidents are rare. In children, most traumas occur as domestic accidents which are unintentional injuries that happen in or around the home. Materials and

Methods: Pediatric patients with traumatic bowel evisceration presenting to Irrua Specialist Teaching Hospital, Irrua, were recruited for the study over a 1-year period.

Results: Six children were seen over the period. The male:female ratio was 2:1. The age range was from 3 weeks to 8 years. Five (83.3%) of the cases were from domestic accidents. Stab injuries and fall from heights accounted for 40% each of the accidents. The eviscerated bowel was the ileum in all the cases. Four (66.6%) had laparotomy, and no perforation was seen in any of the cases.

Conclusion: Domestic accidents account majorly for traumatic bowel evisceration in children. Stab injuries to the abdomen and fall from heights constituted the main causes. The ileum is the most commonly eviscerated. There was a 100% finding of negative laparotomy for the patients operated.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Management Outcomes of Patients with Intestinal Atresia in Resource-challenged Setting

Ademuviwa AQ 1, Alakaloko FM 1, Elebute OA 1, Seyi-Olajide J 1, Bode CO 1

Background: The management of intestinal atresia in resource-poor setting is froth with many challenges. This study aims to evaluate the clinical presentation, diagnosis, and management outcome in neonates with intestinal atresia.

Methods: Retrospective observational study from 2005 to 2015. Data including age, gender, clinical features, investigations, intraoperative level of obstruction, and outcome were collated and analyzed.

Results: There were 331 neonates; 64 (20.1%) had small intestinal atresia. There were 38 (59%) males and 26 (41%) females. The level of obstruction was at the duodenum in 18 (28%) of neonates and jejunal in 40 (63%), and ileal in 6 (9%) of neonates. Bilious vomiting was seen in 53 (83%) of the patients while abdominal distension was present in 32 (50%) of the patients. Eleven (18%) patients with duodenal obstruction were treated by duodenoduodenostomy while 7 (11%) patients had duodenotomy with web excision. The patients with jejunal obstruction had resection of atretic segment with end to back anastomosis or excision with end to side anastomosis or simple web excision. All the patients with ileal atresia had resection and end to back anastomosis. None of the patients were managed in a neonatal intensive care although 23 (39%) of the neonates had access to some form of parenteral nutrition. Operative mortality for neonates with duodenal atresia was 7 (3 8.8%) while 10 (25%) for jejunal atresia. The major cause of mortality was sepsis.

Conclusion: Mortality from atresia in our setting is high. Sepsis is the major cause of mortality in these patients. Availability of neonatal intensive care unit and use of total parenteral nutrition may improve outcome.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Clinicopathologic and Treatment Outcome of Childhood Rhabdomyosarcoma in Irrua, Nigeria

Eighemhenrio Aiwanlehi 1, Azeke Terence 1, Okonji Festus 1, Esteem Tagar 1, Odefiagbon Ernest 1, Akerele Williams 1

Introduction: Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma of childhood. They are aggressive, painless, vascular soft tissue tumors originating from skeletal muscles. They spread mainly through hematogenous route. Confirmatory diagnosis is made on histology after a biopsy is taken. A multimodal treatment regime is recommended. Clinical and histological factors determine the outcome, and currently, overall survival is about 90%. However, factors peculiar to our environment is noted to interfere with the outcome. Materials and

Methods: The study was a retrospective study of pediatric patients with RMS presenting to the Irrua Specialist Teaching Hospital Irrua, Edo State. Information was obtained from case notes and Pathology Department.

Results: Six patients with RMS were seen over the 2-year period of the study. The male:female ratio was 2:1. RMS of the extremities was the most common with 66.6% of patients. Embryonal variant was the most common histological type seen. The average timing of presentation from noticing the swelling was 4.5 months. Surgery was performed for 50% of the patients, and 50% did not complete their treatment.

Conclusion: Childhood RMS presents late in our experience. Consultation of traditional practitioner was quite noticeable. A large proportion of our patients defaulted to the treatment.

Recommendation: Surgery should be considered early in the management of childhood RMS in our environment.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Comparison of Transperineal Ultrasound-guided Pressure Augmented Saline Colostomy Distension Study and Conventional Contrast Radiographic Colostography in Anorectal Malformation

Ekwunife OH 1, Umeh EO 1, Ugwu JO 1, Ebubedike UR 1, Okoli CC 1, Modekwe VI 1, Elendu CK 1

Introduction: In children with high and intermediate anorectal malformation (ARM), distal colostography is an important investigation done to determine the relationship between the position of the rectal pouch and the probable site of the neo-anus as well as the presence or absence of a fistula. Conventionally, this is done using contrast with fluoroscopy or still X-rays imaging. This, however, has the challenges of irradiation, availability, and affordability, especially in developing countries.

Objectives: The accuracy of transperineal ultrasound-guided pressure augmented saline colostomy distension study (SCDS) compared with conventional contrast distal colostography (CCDC) in the determination of the precise location of the distal rectal pouch, and in detecting the presence and site of fistulous communication between the rectum and the urogenital tract, was studied.

Methodology: Transperineal ultrasound-guided pressure augmented SCDS, conventional contrast distal colostography, and intraoperative measurements were done sequentially for qualified infants with ARM and colostomy. Pouch skin distance and presence or absence of rectourinary or genital fistula was measured prospectively in each case. Associations between categorical variables were explored with the paired t-test while correlation between the reference test (surgical measurements) and radiological test was determined with Pearson correlation. Statistical significance was inferred at P < 0.01.

Results: There were thirteen infants: Nine males and four females. The age at onset of investigation ranged from 2 to 12 months with a median value of 9 months. Using paired t-test at a confidence interval of 95%, the P value when SCDS values are compared with CCDC is 0.19 and 0.06 when SCDS was compared with intraoperative measurements. Hence, there was no statistical difference as P > 0.01. On its ability to detect the presence or absence of a fistula, SCDS had a sensitivity of 50.0%, specificity of 100.0%, accuracy of 69.2%, negative predictive value of fistulas of 55.6%, and a positive predictive value of fistulas of 100.0%.

Conclusion: Ultrasound-guided pressure augmented SCDS can safely and reliably be used to assess the distal colonic anatomy and the presence of fistula in infants with ARM, who are on colostomy.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Chronic Low Back Pain with Thoracolumbar Cord Compression: Symptom Pattern and Magnetic Resonance Imaging Findings among Adults at a Neurosurgical Center in Southeast Nigeria

Umeh EQ 1, Ebubedike UR 1

Background: The prevalence of spinal cord compression, its symptom pattern, and associated vertebrospinal anomalies in adults with chronic low back pain (LBP) are relevant due to the varying disorders affecting the thoracolumbar spine in our community. These may result in progressive neurological symptoms in addition to chronic LBP.

Objectives: To determine the prevalence of thoracolumbar cord compression among adults with chronic LBP on magnetic resonance imaging (MRI) and to document the symptom pattern, and MRI findings in this group.

Methodology: Review of MRI images of the thoracolumbar spine for 300 adults of both sexes with chronic LBP at Memfys Hospital for Neurosurgery, Enugu, and January 1, 2013, to December 31, 2013.

Results: Of 300 cases of chronic LBP, 33 (11.0%) showed MRI features of spinal cord compression. Mean and median age and age range were 51.6 years, 50.0 years, and 14–90 years, respectively. There were 19 males and 14 females giving a proportion of 57.6% to 42.4%. The main symptoms were; motor deficits (54.6%), sensory deficits (24.2%), sphincter anomalies (24.2%), sciatica (27.3%), claudication (0%). Positive MRI findings include vertebral compression fracture (36.4%), vertebral mass lesion (27.3%), retrolisthesis (24.2%), lumbar disc herniation (66.7%), discitis (24.2%), paravertebral collection (24.2), foramina narrowing (84.9%), and anomalous cord signal intensity (60.6%).

Conclusion: Lumbar disc herniation is the most common contributor to cord compression in patients with chronic LBP. However, multiple positive MRI finding coexists in 90% of patients.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Computed Tomography Evaluation of Petrous Bone Fractures

Ebubedike UR 1, Umeh EO 1

Background: Petrous bone trauma is the sequelae of blunt head injury and can have life-threatening complications resulting in immediate mortality. Early detection and good knowledge of the computed tomography (CT) findings ensure prompt treatment of both fractures and complications.

Objective: To document the frequency and most prevalent petrous bone fracture, coexisting intracranial hemorrhage, and other skull fractures as well as establish association between them.

Methodology: Forty-six CT images of patients aged 1 year and above investigated for petrous fractures and complications at two South-Eastern Hospitals (NAUTH and Iyi-Enu Mission Hospital) were enrolled into the study. Statistical analysis of data was done using SPSS software version 17.0 for Windows SPSS (IBM, Chicago).

Results: The study population had a mean age of 30.4 years with an age range of 1.4–80 years. Cases aged 21–30 years were of the highest frequency. The most common petrous fracture is longitudinal 58.7% while the least was mixed petrous fracture 6.5%. Among other skull fractures, the most common was parietal fractures while the most common intracranial hemorrhage was intracerebral. An association was found only between the mixed type and intracerebral hemorrhage, P = 0.042. There was no association between petrous fractures and other skull fractures.

Conclusion: The most common petrous bone fracture was the longitudinal type with intracerebral hemorrhage and parietal bone fractures being the most prevalent complications. An association is established only between the mixed perous fracture and intracerebral hemorrhage.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Extremity Amputations in Children from Complications of Traditional Bone Setters Care: A Report of Six Cases

Diamond TE 1, Ibeanusi SEB 1, Echem RC 1, Aniebo CC 1, Iwunze CI 1

Background: A traditional bone setter (TBS) is a person recognized by the community where he lives as competent to set bones using traditional appliances. This is an ancient practice dating back many centuries. In the developing world, the TBS still receives high patronage despite the numerous limb and life-threatening complications resulting from his treatment of limb injuries. Limb amputation in children resulting from bonesetter's gangrene is a common and disturbing complication. Children's inability to contribute to their own healthcare when injured, their complete financial dependence of parents/guardians and the strong societal faith on TBS practice irrespective of educational and financial status, are key among other contributing factors.

Aim: We report six consecutive cases of extremity amputations in children resulting from bone setters’ gangrene.

Results: Six consecutive extremity amputations resulting from bone setters’ gangrene were done at the study site from April 2013 to March 2016, constituting 8% of all limb amputations and 73% of all extremity amputations done in children within the same period. Five of the patients were males while one was female. Ages ranged from 18 months to 17 years with a mean age of 10.2 ± 13.3 years. All amputations involved the upper limb, with a left:right ratio of 1:2. All patients visited the TBSs with 80% of patients “admitted” in the bonesetter's place for more than 2 weeks. The treatment method was similar in all patients. It involved an initial application of a tight splint localized to the fracture site for 48–72 h with subsequent intermittent release for massage using local ointment. All six patients had upper amputations (or refashioning of the amputated stump) <24 h into hospital presentation for wet gangrene of the involved limb (from the fracture site to the rest of the distal limb). 83.3% were transhumeral amputations while 16.7% (n = 1) was at level about 5 cm above the supracondylar region. The mean duration of delayed primary wound closure was 14.6 ± 2.4 days. All patients had satisfactory wound healing by the end 1st week after wound closure and were discharged home not later than the 8th day postsurgery.

Conclusion: Limb gangrene is the most regrettable complication following TBSs treatment of extremity injuries. With poor rehabilitative function of amputated limbs in our subregion, urgent steps are needed to prevent such complications in our subregion.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Limb Injuries from Militancy Activities in Port-Harcourt: A Case Series

Diamond TE 1, Echem RC 1, Iwunze CI 1, Aniebo CC 1

Background: Militancy activities refer to the active, combative, and violent behavior of a given sect in support of a particular cause usually involving armed combat and civil unrest. The oil-rich South-South Region of Nigeria has seen such activities for over a decade now. Injuries form such activities could result from armed combats, oil theft and illegal oil refining activities, violent street protests by armed militants as well as robbery activities. Limb injuries from such activities are presumably common, but the true incidence is unknown. The high energy pattern of these injuries and the occasional bizarre presentations create management challenges.

Aim: We present a series of five cases with limb injuries from activities related to militancy in Port-Harcourt.

Methods: A retrospective study of five patients with limb injuries for militancy and related activities. Data were obtained from patient's hospital folders and analyzed using descriptive statistical method. Where further clarifications were needed; contacts were made through mobile phones and during follow-up visits.

Results: A total of five cases were reviewed. All patients were males. Ages ranged from 18 to 44 years With a mean of 26.2 years (SD 8.3). The most common mechanism was gunshot injuries (100%, n = 5) followed by speed boat propeller injuries (40%, n = 2). There were fractures in 80% of injured patients with the tibio-fibula fractures accounting for 60% of fractures. All were open fractures from high energy impact. External fixators were the most common treatment modality for fracture fixation. Repeat debridements were required in 60% of the wounds, with 40% of them requiring subsequent graft or flap cover. All fractured limbs achieved union within 18 weeks. Wound healing was also satisfactory for all five cases. Residual complications include pin site infection (20%, n = 1), wrist drop (20%, n = 1), foot drop (20%, n = 1), and elbow stiffness (20%, n = 1).

Conclusion: Militancy activities generate high impact injuries to the limbs with varying presentation patterns. Early and adequate clinical evaluation, prompt intervention, and good patient monitoring could save limbs. These injuries are, however, preventable.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Complications of Prostate Biopsy in Nauth Nnewi: A Preliminary Report

Mbaeri TU 1, Orakwe JC 1, Oranusi CK 1, Nwofor AME 1, Obiesie E 1, Abiahu JA 1

Introduction: Prostate cancer is the most common solid cancer in men. The incidence appears to be rising and this has been attributed to the increased use of prostate-specific antigen (PSA) screening. Although prostate cancer causes an elevation in PSA, other prostate diseases such as benign prostate hyperplasia, acute and chronic prostatitis, and prostatic trauma also cause elevation of PSA to varying degree. Thus, there is a need for prostate biopsy for a histologic diagnosis of the true cause of the elevated PSA. Prostate biopsy, however, is not without complications and in some cases grave. These ranged from hematuria, hematochezia, hematospermia, UTI, septicemia, pain, hypovolemic shock to acute urinary retention (AUR), etc.,

Aims: The aim of this study is to assess the incidence of these complications among our prostate biopsy patients. Materials and

Methods: This is the preliminary report of an 18-month prospective study of the complications of prostate biopsy in our patients who met the inclusion criteria starting from October 1, 2015, in a Tertiary Hospital in Nigeria. Patients were questioned and assessed for the various possible complications on day 1, 3, and 7 postprostate biopsy.

Results: A total of 55 patients have so far been enrolled. The most common complication is rectal bleeding which happened in 37 (67.27%) but significantly as to require readmission in three patient 5.4%. Other recorded complications are hematuria, AUR, and caudal paresthesia.

Conclusion: Prostate biopsy remains a vital and safe armamentarium for the urologist in well-prepared patients.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Fournier's Gangrene: Utilizing the Immense Regenerating Power of the Genital Skin in Postgangrene Wound Management

Ukpong AE 1, Akaiso OE 1, Udoh E 1, Eshiet I 1

Background: Fournier's gangrene is an acute rapidly progressive, and potentially fatal, infective necrotizing fasciitis affecting the external genitalia, perineal or perianal regions. Following initial management and surgical debridement, a denuded genitalia results and the challenge is to restore normal cosmetic appearance of the genitalia.

Objective: To study the clinical presentation, etiological factors, comorbid conditions, and outcome of conservative management of the postgangrene wound.

Patients and Methods: Thirty-four consecutive patients seen with Fournier's gangrene in the Urology Unit of the University of Uyo Teaching Hospital between January 2007 and December 2015 were entered into prepared protocols that detailed demographic characteristics, clinical presentation, etiology, comorbid conditions, part of genitalia involved, bacterial isolates, treatment, and outcome.

Results: All patients were adult males with a mean age of 51 years (range: 24–75 years). A majority of the patients were artisans and farmers. All presented with scrotal pain and swelling which progressed to ulceration and discharge of malodorous, offensive material. Duration of symptoms ranged from 2 to 14 days. Etiological factors include scrotal itching, boils and self-attempts at incision, and drainage of such boils in 8 patients (23.5%); urethral stricture and fistulation in 5 (14.7%); inguino-scrotal hernia and infected herniorrhaphy wounds in 4 (11.7%). Comorbid conditions include diabetes mellitus (20.5%) and HIV infection (14.7%). Scrotum only was involved in 24 patients (70.5%). The most common bacterial isolate was Klebsiella in 9 patients (26.5%). Treatment involved intravenous (IV) fluids, IV antibiotics, emergency radical debridement and subsequent daily or twice daily saline sitz baths and honey dressings. Two patients (5.8%) died of overwhelming sepsis in the emergency room. All the other 32 patients (94.1%) were discharged home to continue with daily saline sitz baths and 14 (41.2%) of them who reported back to the outpatient had healed completely with normal looking genitalia.

Conclusion: The genital skin has immense regenerating capacity and with conservative daily saline sitz baths and honey dressings of the postgangrene wound, an excellent cosmetic result that is usually difficult to distinguish from any original one is achieved.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Correlation between Intravesical Prostatic Protrusion and International Prostate Symptom Score in Men with Benign Prostatic Hyperplasia at Nnamdi Azikiwe University Teaching Hospital, Nnewi

Eze BU 1, Oranusi CK 1, Mbaeri TU 1, Mbonu OO 1, Orakwe JC 1, Nwofor AME 1

Background: Urinary protblems in elderly men are often caused by prostate disorders, of which benign prostatic hyperplasia (BPH) is the most common. BPH presents with bladder outlet obstruction (BOO); urodynamic study is the gold standard for diagnosis of BOO but is invasive. Intravesical prostatic protrusion (IPP) is a noninvasive test that can predict BOO. International Prostate Symptom Score (IPSS) is an objective assessment of BOO symptom severity.

Objective: The objective of the study is to study the correlation between IPP and IPSS.

Patients and Methods: A hospital-based cross-sectional prospective study of new symptomatic BPH patients who presented to the urology clinics of Nnamdi Azikiwe University Teaching Hospital, Nnewi. Ethical approval was obtained from the Ethical Committee of the Hospital and informed consent from patients. After evaluation (including IPSS, PSA, and prostate biopsy when PSA >4 ng/ml), participants had abdominal ultrasonography measurement of IPP from midline sagittal image of the prostate (at bladder volume ^lOOml) using Prosound SSD3500 (Aloka Co Ltd, Tokyo, Japan) with abdominal probe frequency of 3.5 MHz. IPP was divided into three grades (Grade I: 0–4.9 mm; Grade 11: 5.0–9.9 mm; and Grade HI: 10.0 mm and above). Data were analyzed using SPSS version 20 (IBM, SPSS, Chicago, IL, USA). Data were subjected to ANOVA (to compare mean parameters among different grades of IPP) and Pearson's correlation was used to assess correlation where necessary. P < 0.05 was considered statistically significant.

Results: 101 men with a mean age of 67.09 ± 10.93 years were included in the study. The mean body mass index was 25.80 ± 3.92 kg/m2. Most of the participants had highest educational level of primary education (50.5%) while 82.2% were married. The average IPSS, IPSS-s, IPSS-V, quality of life (QoL) index, total prostate volume (TPV), IPP, and PSA were 17.05 ± 7.62, 7.81 ± 5.17, 9.24 ± 3.16, 4.75 ± 1.59, 68.33 ± 46.53 ml, 13.50 ± 7.47 mm, and 7.35 ± 12.49 ng/ml, respectively. There were significant differences between the mean IPSS (P = 0.000), mean IPSS-s (P = 0.000), mean IPSS-V (P = 0.002), mean TPV (P = 0.000), and mean PSA (P = 0.015) among the three grades of IPP. There were significant positive correlations between IPP and IPSS (P = 0.000); IPSS-S (P = 0.000); IPSS-V (P = 0.000); IPSS QoL index (P = 0.000).

Conclusion: There were significant positive correlations between IPP and IPSS, IPSS-S, IPSS-v, and IPSS QoL index. There were also significantly higher IPSS, IPSS-S, IPSS-V, and IPSS QoL index in BPH patients with IPP of 10.0 mm or more.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Urologic Injuries Complicating Obstetric and Gynecological Surgeries in Uyo: A 10-year Experience

Ukpong AE 1, Akaiso OE 1, Eshiet I 1, Umoiyoho A 1

Background: Patients undergoing obstetric and gynecological surgeries do sustain iatrogenic urologic injuries of such magnitude that requires a second major operation. This causes morbidity and mortality in patients, and a sense of remorse in the surgeon.

Objective: To study these injuries with a view to identifying the types, etiology, presentation, treatment and outcome in our center.

Patients and Methods: The study was prospective in design covering a period of 10 years (January 2006 to December 2015). Twenty-two consecutive patients seen by the Urology and Gynaecology Units of the University of Uyo Teaching Hospital were entered into protocols that described the patient's personal biodata, type of primary surgery and its indication, clinical presentation, experience of the surgeon, type of urological injury, time of recognition, treatment, and outcome.

Results: Average age of the patients was 35 years (range 23–60 years). Hysterectomy and Cesarean section were the primary surgeries in 12 (54.5%) and 10 (45.5%) patients, respectively. The urinary bladder was most frequently injured in 13 patients (59%), followed by the lower ureter in 10 cases (45%). The bladder injuries presented as vesico-vaginal fistula in 7 patients (31.8%). The general practitioners were responsible for 12 (54.5%) of these injuries. Eight patients (36.4%) with ureteric injuries had reimplantation by the Leadbetter-Politano technique. There was no mortality and all patients recovered without complications.

Conclusion: Urologic injuries in gynecologic surgeries though tragic, can be managed with excellent results, if recognized early and appropriate, timely intervention by an expert is carried out.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Histological Pattern of Bronchogenic Carcinoma in ABUTH Zaria and the Rarity of Small Cell Lung Cancer in Our Subregion

Edaigbini SA 1, Alioke I 1, Samaila MOA 1, Liman AA 1

Introduction: Lung cancer is said to be of low incidence in our environment. This has been attributed to low exposure to risk factors such as cigarette smoking when compared to the western world. The relatively low incidence may also be related to challenges with diagnoses, poor record keeping, and attrition from low incidence of postmortem diagnoses.

Aim: To present the pattern of lung cancer in our institution and to highlight the low incidence of small cell lung cancer. Materials and

Methods: The histology results of all lung cancer biopsies (Taken between 2008 and 2012) were culled from the patients’ hospital records and the information analyzed with SPSS version 20 (IBM SPSS Statistics version 20, 2011. Armonk, New York, USA: IBM corp.).

Results: A total of 38 patients were managed over the period. There were 21 males (55.3%) and 17 females (44.7%) giving a male:female ratio of 1.2:1. The age range was 30–99 with a mean of 56.4 years. The histological diagnoses included small cell lung cancer 1 (2.6%), large cell 1 (2.6%), squamous cell 6 (15.8%), and adenocarcinoma 30 (78.9%). The tissues are obtained by trucut (39.5%), open biopsy (28.9%), incisional (18.4%), thoracotorny (7.9%), and pleural biopsy (5.3%). There was a progressive increase in the rate of tissue acquisition with 2008 and 2009 having the least rate at 5.3% and the year 2015 having the highest rate at 31.6%.

Conclusions: Small cell lung cancer is uncommon in our subregion, but the factors allowing for this favorable are yet to be identified.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

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

Edaigbini SA 1, Aminu MB 1, Delia IZ 1, Anemenechi N 1, Alioke I 1, Samaila MOA 1

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 and bronchoscopy.

Aim: To report our experience with CT-guided transthoracic biopsy. Materials and

Methods: Patients with clinical and radiological evidence of intrathoracic mass are 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. Following visualization of the lesion, its position in terms of depth and distance from the midline is measured with the machine in centimeter to determine the point of insertion of the trucut needle (14–18 gauge). The presumed site of the lesion is 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 (3 mm slices) 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: A total of 26 patients underwent this procedure between 2011 and 2015. There were 15 males and 11 females (male:female = 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 a sensitivity of 92.3%. There were 3 mild complications giving a rate of 1.2%.

Conclusions: CT-guided biopsy is a reliable procedure for obtaining deep-seated intrathoracic biopsies with high sensitivity and minimal complication rate.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Changing Patterns in Tissue Acquisition for the Diagnosis of Lung Cancer in ABUTH Zaria, Nigeria

Edaigbini SA 1, Samaila MOA 1, Liman AA 1

Introduction: The ultimate diagnosis of lung cancer and indeed all cancers is based on histological diagnosis from tissues obtained through biopsies. This could be via endoscopy, core needle biopsies, open approach, and bronchoalveolar lavage in lung cancer.

Aim: To present the pattern of tissue acquisition and the changing trend in our institution. Materials and

Methods: All patients who presented with clinical and radiological evidence of lung cancer were counseled and consent obtained. Tissues were obtained either through open approach, during chest tube insertion for drainage of pleural effusion on the ward or by means of CT-guided trucut lung biopsy. Thoracotomy was done when these procedures fail or during attempt at lung resection. The information was obtained from patients’ hospital record and analyzed with SPSS version 20 (IBM SPSS Statistics version 20, 2011. Armonk, New York, USA - IBM corp.).

Results: A total of 38 patients were managed over an 8-year period from 2008 to 2015. There were 21 males (55.3%) and 17 females (44.7%) giving a male:female ratio of 1.2:1. The age range was 30–99 years with a mean of 56.4 years. The tissues were obtained by trucut (39.5%), open biopsy (28.9%), incisional (18.4%), thoracotomy (7.9%), and pleural biopsy (5.3%). There was a progressive increase in the rate of tissue acquisition with 2008 and 2009 having the least rate at 5.3% and the year 2015 having the highest rate at 31.6%.

Conclusions: Acquiring tissues for the diagnosis of lung cancer has become more frequent and more convenient with the advent of CT-guided trucut biopsies.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Incidental Appendicitis after Esophageal Bypass for Treatment of Dysphagia

Edaigbini SA 1, Alioke I 1, Samaila MOA 1, Liman AA 1

Introduction: The lifetime risk of acute appendicitis is 6–7%. Incidental appendectomy is defined as the removal of a clinically normal appendix during nonappendiceal surgery. Guidelines have tried to determine candidates for incidental appendectomy, but the practice continues to attract controversies.

Aim: This study presents our observation after appendectomy performed during esophageal bypass/replacement procedures for treatment of dysphagia. Materials and

Methods: The histology results of all who underwent esophageal 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 esophageal bypass/replacement procedure between 2008 and 2015, during which 25 had incidental appendicectomy. We were able to retrieve the histology of only seven patients (three males and four females). Of these, one male had a normal appendix another had lymphoid hyperplasia. Four patients had acute recurrent appendicitis (three 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 appendicectomy as prophylaxis against future exploration which may put the conduit in harms.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Unsuspecting Skin Metastasis of Adenocarcinoma of the Prostate

Mbaeri TU 1, Orakwe JC 1, Ezejiofor OI 1

Prostate cancer remains the most common noncutaneous cancer in men, especially in this era of prostate-specific antigen assay. Prostate cancer metastases have been known to commonly affect the lymphatics, bones, and lungs. Prostate cancer metastasis to skin is very rare (<1%) and often signifies a terminal disease. We report a 74-year-old male who presented with skin metastasis at the sites of previous zoladex injection. The skin involvement in our patient is, however, so site-specific to the regions of zoladex injection that we imagined if there is a link between the two. We reviewed literature and found no connection. Is it a mere coincidence?

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

A Case of Retroperitoneal Malignant Triton Tumor in a Nigerian Boy

Ugwu JO 1, Onwukamuche M 1, Ekwunife OH 1, Emejulu JKC 2, Modekwe VI 1, Osuigwe AN 1

Introduction: Malignant peripheral nerve sheath tumor is a rare tumor occurring in 5–10% of all malignant soft tissues sarcomas and Triton tumor arising from type 1 neurofibromatosis (NF-1) is even rarer with associated high rate of mortality. No case of Triton tumor has been reported in Nigeria. We seek to report a case of lately detected retroperitoneal triton tumor presenting in a 12-year-old Nigerian child who was brought with bilateral lower limb weaknesses, weight loss, and a right lumbar mass. There were multiple cafe au lait spots but no nodules. Abdominal computerized tomographic scan revealed a huge inoperable right retroperitoneal mass, and core needle biopsy done gave the histological diagnosis of a malignant triton tumor; however, patient demised before the histology was out. The aim is to heighten suspicion of this very rare malignant tumor in children with NF-1 and to review literature.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Massive Hemorrhage from Mesenchymal Tumors of the Stomach: A Case Series

Ekwunife CN 1, Enendu SE 1, Ukah CO 1, Nweke IC 1, Mbah T 1

Background: Mesenchymal tumors of the stomach are rare, and about 80% are gastrointestinal stromal tumors. Majority are largely asymptomatic. Massive hemorrhage is quite uncommon in symptomatic cases. In patients with massive non-variceal upper gastrointestinal hemorrhage, there may be a tendency to assume that it is due to peptic ulcer bleeding where endoscopy facilities are not readily available. This report highlights our limited experience in the management of mesenchymal tumors under emergent conditions.

Case Presentation: We present four cases (three males and one female) of massive upper gastrointestinal hemorrhage seen over a 2 years period which were due to mesenchymal tumors. The age range of patients was 46–65 years. Three of the patients presented in shock. Upper gastrointestinal endoscopy was done within 48 h of presentation. The tumors were located at the fundus and the subcardial part of the stomach. Wedge resection of the stomach was done in two patients whereas sleeve gastrectomy was done in the other two. On immunohistochemistry, two of the cases were positive for c-kit. These patients were placed on imatinib mesylate. At 1 year of follow-up, there has been no evident recurrence.

Conclusion: Patients with bleeding mesenchymal gastric tumors have good prognosis, especially when early diagnosis is made.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

A Report of Synchronous Dedifferentiated Liposarcoma of the Lower Limb in a Nigerian Adolescent Girl

Ugwu JO 1, Ofiaeli RO 1, Osuigwe AN 1, Okechukwu J 1

Liposarcoma is a malignancy of fat cells. It is a very rare tumor and less than 150 cases have been reported in literature worldwide and across all age groups, far less is reported in children. It is one of the least frequent nonrahabdomyosarcomas, soft tissue sarcoma, occurring in childhood and dedifferentiated liposarcomas occur predominantly in the retroperitoneum. Moreover, we are not aware of any report of limb liposarcoma in a Nigerian child or a synchronous limb liposarcoma in a child. We seek to report a case of a 12-year-old Nigerian girl who presented with a slow-growing right thigh mass of 7 years duration and a right calf of 3 months duration. Histological diagnosis following an incisional biopsy was a dedifferentiated liposarcoma. She subsequently had a successful complete excision of both masses.

Niger J Surg. 2016 Jul-Dec;22(2):138–146.

Closed Suprapubic Cystostomy in a Resource-poor Setting

Oranusi CK 1

Suprapubic urinary diversion is a common procedure performed by urologist in the setting of an impassable obstruction in the urethra. It can be done either by the open or closed technique. In developing countries like Nigeria, the procedure is commonly done by the open method because of paucity of facilities for the closed method. Herein, we describe a closed method of suprapubic urine diversion using routine surgical instruments.

Articles from Nigerian Journal of Surgery : Official Publication of the Nigerian Surgical Research Society are provided here courtesy of Wolters Kluwer -- Medknow Publications

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