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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., (Copyright © 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Anorectal Malformation (ARM) and Hirschsprung's 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.

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.

Background: A cross-sectional study carried out at a teaching hospital in Kaduna, Nigeria, to investigate the extent and reasons for the delay between onset of symptoms and admission for treatment of symptomatic breast cancer., Methods: The patients had histologically proven breast cancer and had been admitted for treatment. Data were obtained from interviews and patients' clinical and referral records., Results: One hundred and eleven consecutive breast cancer patients were interviewed from July 2003 to June 2005. Only 12 (10.8%) could be admitted for treatment within a month of onset of symptoms. Delays were significantly associated with younger patients, elementary or no Western education, and domicile outside the Kaduna metropolitan area. Patients who were referred from, or received initial treatment at, peripheral hospitals had longer delays than those who came for first consultation at the teaching hospital. The proportion of early breast cancer cases (stages I and II) decreased from 45.9% at diagnosis to 25.2% at treatment, as concerns about mastectomy and hospital treatment led a significant number of the patients to temporarily abandon hospital treatment for alternatives, only to return with advanced cancers. The predominant reasons among the 99 patients who had delays of more than a month before admission were: ignorance of the seriousness of a painless breast lump (47.5%), non-acceptance of hospital treatment (46.5%), and preference for traditional treatment (38.4%). A significant number of patients referred from peripheral hospitals had inappropriate surgeries and biopsy management which contributed to the advanced stage on admission., Conclusion: This study shows that delayed treatment of symptomatic breast cancer at this centre in Nigeria is as much related to the quality of medical care as it is to local beliefs, ignorance of the disease, and lack of acceptance of orthodox treatment.

Background: Umbilical discharge is not an unusual presentation in infants and children. However, the evaluation and management are rarely discussed., Method: A retrospective review of 18 patients presenting with persistent umbilical discharge over a period of 22 years, excluding neonates with omphalitis., Results: The patients' ages ranged between 11 days and 9 years. Presentation was usually discharge of clear, serous or purulent fluid or faecal matter from the umbilicus, sometimes dating back to the neonatal period. Evaluation consisted of bacteriology, fistulogram (one patient) and histopathology. The cause of discharge was patent vitello-intestinal duct in 11 patients, umbilical granuloma in three, umbilical sinus in two and patent urachus and osteomyelitis of the ischium in one each. Definitive treatment was exploration and complete excision of the lesion and antibiotics. Two patients with patent vitello-intestinal duct died, one before surgery from hypokalaemia and sepsis, and the other from anaesthetic complications., Conclusion: There is a need for early referral and treatment in patients with persistent umbilical discharge. Conservative treatment is usually not successful as the common causes would normally require complete excision.

Background: Pediatric surgery is a well-established specialty in many developed countries, but little is known about the status of the specialty in most developing countries., Method: The status of pediatric surgery in Nigeria was reviewed., Result: Nigeria currently has an estimated population of 126 million people with a growth rate of 2.8%, one half of whom are children. Pediatric surgery is a well-recognized specialty in the country. At the moment, there are 35 trained pediatric surgeons but only 26 are fully functional (1 pediatric surgeon:2.2 million children). Most of the available pediatric surgeons are in tertiary hospitals in major cities and towns. There is a well-established formal training program and certification run by the West African College of Surgeons; it takes an average of 4.5 to 6 years to train in pediatric surgery, 2 years of which must be spent in general surgery. Only 1 to 2 trainees graduate every year, and there are less than 10 trainees in the 5 accredited training centers at the moment. Funding for training is poor, and pediatric surgical research receives little or no funding., Conclusion: There is a need for more pediatric surgeons in Nigeria. More trainees need to be mentored and encouraged to take up the specialty. Collaboration with centers in developed countries and other parts of Africa and improved funding are necessary to improve the profile of the specialty.

A wide variety of anomalies may occur as a result of the vitelline duct (VD) failing to obliterate completely. Most reports on symptomatic VD focus on Meckel's diverticulum, while other anomalies are given little attention. A retrospective review was conducted at our institution. According to the records 18 symptomatic children with VD anomalies were seen over 22 years, including 10 boys and 8 girls aged 11 days -14 years (median 7.5 months). Twelve patients aged below 10 years (median 28 days) had patent vitelline ducts (PVDs), 3 children aged 13 months, 13 years and 14 years respectively had Meckel's diverticulum (MD), presenting as inflammation, tapeworm incarceration and volvulus respectively. Two patients, both 8 years old, had umbilical sinus, and a 3-year-old had a vitelline cyst. Only 1 patient with PVD had an associated anomaly (intestinal malrotation). The diagnosis of PVD was obvious clinically, but in 1 patient the fistula was demonstrated by fistulogram. The diagnosis of MD was intraoperative in all 3 patients. Treatment was by various types of resection for PVD and MD and excision for umbilical sinuses and cysts. One patient with PVD developed postoperative intestinal obstruction from adhesions, requiring re-laparotomy and adhesiolysis. Two patients with PVD died from sepsis and anaesthetic-related complications, respectively. Although MD is the most commonly VD anomaly, PVD is the most common symptomatic presentation in our environment.

Background: Fournier's gangrene is uncommon in childhood and little is known about the disease in this age group., Method: A retrospective review was carried out of neonates and infants treated for Fournier's gangrene over a period of 16 years., Results: Twelve neonates and infants aged 5 days-3 months (median 3 weeks) were treated in our hospital. The precipitating cause was omphalitis in 7 babies, strangulated inguinal hernia in 2 and in 3 babies there was no identifiable cause. Gram-negative bacteria were cultured in 3 patients, but in most the culture was sterile. Treatment consisted of debridement of devitalised tissue and administration of broad-spectrum antibiotics. Primary closure was achieved in 1 baby and secondary closure in 2 others. In 7 babies the wound contracted rapidly and healed. There was no mortality., Conclusion: Fournier's gangrene in neonates and infants in our environment is largely preventable. Early debridement and appropriate antibiotics give good results.

In developing countries, reports on adhesion intestinal obstruction in children are scanty. We report 30 children managed for adhesion intestinal obstruction during a 16-year period. The age range was 10 weeks-14 years (median 9 years). There were 24 boys and 6 girls. Postoperative adhesion was the cause in 13 (43%) patients, inflammatory in 11 (37%), and in 5 (17%) no cause could be identified. In one patient, adhesion followed missed ileal perforation from blunt abdominal trauma. Duration of symptoms was 1-21 days (median 4 days). Only four of the 13 patients with postoperative adhesion obstruction were managed conservatively initially, but this failed in all; one was found to have an intestinal perforation at laparotomy. The remaining nine had immediate laparotomy owing to presence of features of strangulation at presentation; two required intestinal resection for gangrene. All other patients had laparotomy soon after resuscitation. The resection rate for gangrene was 13% and 3% required closure of perforations. Postoperatively six (20%) patients developed eight infective complications. There was recurrence in three of 27 (11%) surviving patients within 3 months. Mortality was three (10%). The presentation of adhesion intestinal obstruction in children in northern Nigeria is late and morbidity and mortality are high. Early presentation should improve the outcome.

Umbilical hernia is a common problem in children, particularly in Africans, but complications in these hernias are thought to be rare. In a retrospective study of 47 children presenting for umbilical hernia repair in 14 years, 30 had complications. The complications included acute incarceration 15, recurrent incarceration 10 and spontaneous evisceration 5. Of the 15 with acute incarceration, 2 required bowel resection for gangrene, and an abscess formed in the hernia sac in one. The age of patients with acute incarceration was 2 months-8 years (median 5 years). The 10 with recurrent incarceration were aged 1-3 years (median 3 years). Of the 5 with spontaneous evisceration, one had umbilical sepsis and another intestinal obstruction from intussusception. These patients were aged 3-12 weeks (median 7 weeks). All the complications occurred in hernias that were 1.5 cm or more in diameter. The hernias were repaired using standard methods. Postoperatively, 2 patients developed wound infection. There was no mortality. Though complications of umbilical hernias appear to be rare, there is a need for more active observation of these hernias to identify complications early and treat promptly to avoid morbidity.

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.

A 6-year old girl presented with a painless, progressive abdominal mass for 4 weeks without alteration in bowel habits. Physical examination showed a non-tender, irregular and mobile abdominal mass. Abdominal ultrasonography was unable to define the exact origin of the mass. An ileal tumour was found at laparotomy necessitating resection and anastomosis. Histology confirmed an intestinal leiomyoma. The patient has remained well at 3.5 years of follow up. Leiomyomas of the small intestine are rare in childhood. This report discusses the presentation, diagnosis and management of this condition by briefly reviewing the literature.

In a 10-year retrospective review of 15 newborns aged < or = 42 days presenting with Hirschsprung's 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 Hirschsprung's 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 Hirschsprung's 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 Hirschsprung's 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.

This is a report of two children aged twenty seven months and six years respectively presenting with gastrointestinal obstruction from phytobezoar. In the 27-month old child, laparotomy and gastrotomy was performed to evacuate the bezoar. However, death occurred from hypokalaemia. The six-year old child had a sacro-abdomino-perineal pull through for anorectal malformation previously and the bezoar lodged just above the neoanus. Neoanal dilatation allowed removal of the bezoar and relief of the obstruction. There has been no recurrence. The literature on bezoar is briefly reviewed.

Objectives: To study the presentation, management and outcome of achalasia of the oesophagus in children., Design: A retrospective case study., Setting: Ahmadu Bello University Teaching Hospital, Zaria, Nigeria., Subjects: Seven children managed for achalasia of the oesophagus in a period of 19 years., Results: There were six boys and one girl. The median age at presentation was ten years (range three months to fifteen years). The median duration of symptoms before presentation was 20 months (range: 2-24 months). Three children were treated on several occasions for pneumonia before the diagnosis was made. Dysphagia, vomiting and regurgitation were the main presenting symptoms. Diagnosis was by barium oesophagogram. Six had modified Heller's myotomy via celiotomy and a Thal fundoplication in a three month old. Transthoracic Heller's myotomy was done in the seventh child. There was complete resolution of symptoms in six children. One patient had post-operative retrosternal pain, which was controlled by oral nifedipine., Conclusion: Achalasia of the oesophagus should be excluded in children with recurrent chest infection. Modified Heller's myotomy without antireflux procedure via the abdominal route is effective in relieving symptoms of achalasia in children.

From January 1988 to December 1999, 43 adults with pyomyositis were managed at Ahmadu Bello UniversityTeaching Hospital, Zaria, Nigeria. Staphylococcus aureuswas the most commonly cultured organism (92.5%). All the 41 patients responded well to incision and adequate drainage, antibiotics and partial thickness skin grafting in 10 patients (23.2%).Two patients (4.65%) died from septicaemia, while being resuscitated.

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.

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.

Colorectal adenocarcinoma is predominantly a disease of the old and less than 1% of patients are below 20 years in most reports. Though increasingly younger patients are seen in Africa, most reports indicate that the disease is extremely rare in children and adolescents. This is a report of 8 patients below 20 years managed for colorectal adenocarcinoma in a 10-year period in Zaria, Nigeria. They represented 16.3% of all cases of colorectal adenocarcinoma seen at the institution, an incidence higher than that in other parts of Africa and developed countries. All the tumours were in the rectosigmoid region and are accessible to digital rectal examination and proctosigmoidoscopy. The histology was mucinous adenocarcinomas in 6 patients, 5 of who had a Duke's stage C or D disease and well-differentiated in 2 (Duke's stage B and C respectively). Haemorrhoids was found in association in 2 patients and schistosoma mansoni in one and were responsible for delay in referral and diagnosis. Only palliative treatment could be offered in most patients due to advanced disease. Three patients died within 7 months and one after 2 years from their disease. One patient died from sepsis following surgery. The outcome in 3 patients could not be ascertained. It is emphasized that children and adolescents with rectal bleeding must have digital rectal examination and proctosigmoiscopy as this is the only hope of making an early diagnosis.

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 hemorrhage, and a lacerated accessory 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.

In developed countries, intestinal volvulus in children is most frequently due to malrotation. To review the experience in Nigeria, a retrospective analysis of 28 patients managed over 25 years at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, was undertaken. There were 22 boys and 6 girls with an age range of 4 days to 14 years (median 4 years). There were equal numbers over and less than 5 years of age. Vomiting (89%) and abdominal distension (79%) were the most prominent features. Thirteen children (46%) had fever, associated with bowel gangrene in 5, while 8 (29%) presented with severe dehydration and shock. A plain abdominal radiograph was the only investigation performed, but the features were not specific for volvulus. In 11 children (39%) the volvulus was idiopathic, in 9 (32%) due to adhesions or bands, in 5 (18%) to malrotation, and in 1 each a Meckel's diverticulum, internal herniation, and ventriculoperitoneal shunt. Twenty-three patients had a small-bowel, 4 sigmoid, and 1 caecal volvulus. The bowel resection rate for gangrene was 46% (small bowel 9, sigmoid 3, caecum 1). All patients with malrotation had Ladd's procedure performed. Wound infections occurred in 10 patients (36%), complete wound dehiscence in 1, and recurrence in 1 (idiopathic terminal ileal volvulus). The mortality was 21%, mostly from overwhelming infection (2 neonates, 11-year-old, 3 >/= 5 years). Intestinal volvulus in our environment differs in aetiology from other reports. The resection rates are similar, however. This condition carries high morbidity and mortality.

Over a period of 19 years 22 children with intestinal atresia and stenosis were managed at the Ahmadu Bello University Teaching Hospital Zaria. The condition ranks as the fourth most common cause of neonatal intestinal obstruction after anorectal malformation, Hirschsprung's disease and strangulated inguinal hernia at the hospital. Three patients had duodenal atresia, 18 had jejunoileal involvement (atresia 15, stenosis 3) and one colonic atresia. The median age at presentation to the surgeon was 6 days (range 1 day-2 years). The common features were bilious vomiting and abdominal distension, the latter being more common in patients with lower atresia. Non-passage of meconium in the first 24 hours of birth occurred in 11 patients; mostly in those with lower jejunal, ileal and colonic involvement. Eight patients had associated anomalies, 5 of them with ileal atresia or stenosis. Diagnostic investigation was mainly plain abdominal radiography showing double-bubble shadow in duodenal atresia and varying degrees of air-fluid levels in other atresias. Contrast studies were not employed for diagnosis in any patient. The patients with duodenal atresia and had duodenoduodenostomy and duodenojejunostomy respectively while the jejunoileal atresia and stenosis were treated by resection and anastomosis. One patient with ileal atresia associated with total colonic Hirschsprung's disease and extensive atresia from terminal ileum down to descending colon had ileostomy. Postoperatively, 7 patients had infections of varying degrees and 3 anastomotic dehiscence. Mortality was 9 (41%) due mostly to septic complications and prematurity. While the survival of children with intestinal atresia and stenosis has improved over the years in developed countries, ours is still low (59%) due to late presentation and lack of neonatal intensive care facilities.

This is a report of a retrospective study of 24 children managed for penetrating abdominal injury over 10 years, and it represents 34% of all abdominal injuries in children in that period. Falls onto sharp objects within and around the home were responsible for ten of the injuries, seven were injured by animal horns and four were sporting injuries. Violence and road traffic accidents were uncommon. Most patients (67%) had evisceration of omentum or intestine, and one of these was found at laparotomy to have a jejuno-jejunal intussusception. Seven children had injury to hollow viscera. There were three deaths, one each from overwhelming sepsis, tetanus and haemorrhage.

A 3-year old male presented with a 12-month history of painless scalp swellings associated with cough, fever and night sweats. Physical examination showed tender, fluctuant, pulsatile right frontotemporal and temporoparietal masses. Skull radiographs showed osteolytic skull lesions in the frontal and temporal bones. Microscopy of drained caseous material and histology of biopsies from the affected bone edges confirmed tuberculous osteitis. Though there was an initial response to antituberculous agents, the child died after 5 weeks from hepatic failure. Tuberculosis of the skull bones though rare, may become more common with the recent upsurge of tuberculosis worldwide. A high index of suspicion is necessary for early diagnosis and treatment.

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.

Infective thyroiditis which was more common in the pre-antibiotic era is now rare in developed countries but continues to occur in less developed areas. Over a 10-year period in Zaria, Nigeria which is situated in an endemic goitre region, nine such patients were treated. All were females, 30-50 years of age and had pre-existing, long-standing multinodular goitres. During the period, 84 patients (including the nine patients) with endemic multinodular goitres were treated, giving an infective rate of 10.7% in these goitres. Treatment was by adequate incision and drainage in all patients with suppuration. Staphylococcus aureus was the commonest organism cultured and Streptococcus Pyogenes and Pseudomonas were the infective agents in a minority. Only one patient required thyroidectomy later, the goitre having disappeared in the other patients. One patient developed hypothyroidism requiring replacement therapy with thyroxine. Thyroid abscess remains an ever present risk in endemic multinodular goitres in our environment. Early presentation after onset of pain, prompt administration of appropriate antibiotics and thyroidectomy soon after is likely to reduce the risk of abscess formation in these goitres.

In a rural hospital in northern Nigeria, general surgeons performed 217 obstetric and gynaecologic operations over a five-year period. These operations were responsible for 23% of all operations at the hospital. Emergency operations were most frequent with caesarean section accounting for 90%. Eighty five per cent of the caesarean sections were performed for cephalopelvic dysproportion. The complications encountered were mostly septic complications, predominantly in patients who had caesarean section for obstructed labour. The overall mortality was 5.1% and neonatal mortality from caesarean section was 4.8%. It is concluded that in the abscence of an obstetrician and gynaecologist general surgery experience is required to manage obstetric and gynaecologic problems in rural areas. Such experience should be considered when recruiting doctors for rural hospitals in developing countries.

A thirty year old Nigerian female presented with a large and advanced anorectal malignant melanoma. She had been treated for over eighteen months at a rural hospital for a mistaken diagnosis of haemorrhoids. The patient died before any form of treatment could be carried out. The rarity of this disease in the black Africa is highlighted and the characteristics of the disease briefly reviewed. The importance of digital and protoscopic rectal examination in patients bleeding per rectum is emphasised.

Objective: To illustrate blunt traumatic injury of the gallbladder in childhood., Design: A case report., Setting: Hospital., Subject: An eight year old boy., Main Outcome Measure: Incidence, history, treatment., Result: The gallbladder was ruptured at the neck necessitating a cholecystectomy. The child has remained well at three months follow up., Conclusions: Blunt traumatic injury of the gallbladder, though rare, does occur usually as a consequence of direct abdominal injury especially in children during sporting activities and fights. Minor injuries can be repaired but cholecystectomy is necessary in more extensive injuries or injury to the cystic duct and neck. A comprehensive history taking including direct questioning regarding trauma and a high index of suspicion are important for early diagnosis and prompt treatment.

The total number of operations performed for thyroid diseases at the ABU Teaching Hospital, Zaria from January 1986 to December 1995 has reduced. Those performed for thyrotoxicosis have tripled (18.5% of all thyroid operations compared to 5.7% ten years ago). Younger patients (mean age 27.7 years, range 13-15 years) with thyrotoxicosis are being seen but the clinical features of the disease and its management at the centre have not changed. It is suggested that the apparent increase in incidence and earlier onset of thyrotoxicosis in this environment may be due to the increasing use of iodised salt to combat endemic goitre.

We report a case of gastric outlet obstruction simulating gastric antral neoplasm resulting from a perforated Meckel's diverticulum. Presentation of this nature has not been previously reported.

Background: Typhoid fever is a public health problem in the developing world and gut perforation remains the major complication with a high associated mortality rate. Even though most surgeons agree that elimination of peritoneal soilage and endotoxaemia by surgery offers the best hope of survival, the extent of surgery remains controversial. This prospective study compared the results of three operations for this condition., Methods: A total of 64 patients with clinical suspicion of typhoid perforation were treated by one of three operations (simple closure, wedge excision and anastomosis or segmental resection and anastomosis) at this hospital. The management protocol was the same for the three groups. The risk of reperforation, mortality rate and duration of hospital stay were compared., Results: The risk of reperforation and mortality rate were highest (two and 13 of 21 respectively) in patients who had wedge excision and lowest (zero and nine of 25 respectively) in those who had segmental resection. The risk of reperforation and mortality rate were zero and nine of 18 respectively in the simple closure group., Conclusion: Segmental resection seems to be the best treatment for typhoid perforation and is recommended for surgeons practising in a similar environment.

Objectives: To compare and contrast the symptomatology and the anatomical type of the intussusception in children and adults in Zaria., Design: Retrospective study., Setting: Hospital., Subjects: 93 patients with intussusception., Main Outcome Measures: Frequency of intussusception., Results: Colicky abdominal pain featured often enough in both groups with most symptoms and signs decreasing in frequency from infancy to adulthood. The ratio of small bowel to large bowel disease in infants, older children and adults was 1;8:1, 0;6:1 and 1:1 respectively. Infantile intussusception involving the small bowel was more common, and in older children large bowel involvement was commoner, while 50pc of adult intussusceptions were paradoxically small bowel. Overall, small bowel intussusception was most common with the ileocolic variety predominating., Conclusions: The most common type of intussusception in our environment is the ileocolic variety.

Objective: To evaluate the effect of staff mobility on student teaching, the training of young surgeons, and the volume of research in an academic department of surgery of a tropical teaching hospital., Design: Retrospective study of academic staffing in the department of surgery of the Ahmadu Bello University Teaching Hospital between 1975 and 1993., Setting: Zaria, Nigeria., Subjects: 42 academic staff, 1190 medical students, and 110 registrars (trainee surgeons)., Main Outcome Measures: Number of academic staff in post, medical students, and registrars; number of research papers in latter years of the study., Results: In 19 years, 42 academic staff worked for varying periods (1-15 years) in the university department of surgery in Zaria. These included six professors, 12 senior lecturers, and 24 lecturers. Although staff numbers diminished, numbers of students and registrars increased year by year. Average number of publications dropped from a peak of 14.4 to 7.4 a year., Conclusion: Staffing of the department has fallen steadily over the years and has adversely affected the department's primary responsibility of teaching students and training young surgeons.

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.

Eighty-eight teratomas of diverse sites were seen and managed in our institution between January 1972 and December 1991, in children between the ages of one day and 10 years. Forty seven (53%) tumours were in the sacroccoccygeal region, 17 (19.3%) were of gonadal origin (16 ovarian and one testicular), 13 (15%) were cervical, 4 retroperitoneal. The rest were teratomas of rarer sites. The female/male ratio for various sites were:-sacroccoccygeal teratoma (SCT) 4:1, gonadal 16:1, cervical 1:3, retroperitoneal was seen in 4 patients, all females and for rarer sites 1:1. Overall ratio was 3:1. There were 61 infants and 27 older children. Four SCTs, three of ovarian origin, one cervical and the testicular teratoma were malignant giving an overall malignancy rate of 9%. Serum alpha-foeto protein was not consistently estimated, but was elevated in those patients with malignant teratomas in whom it was sought.

This is a report of a rare benign neoplasm of the sweat gland in a 23 year old African male. Clinically, the growth had the appearance of an ulcerated malignant cutaneous neoplasm. It was completely and easily excised at surgery and the patient has remained well without recurrence five years after complete excision.

Appendicitis in the aged patient is uncommon even in developed countries although it is now more frequently seen and treated. A review of 84 patients aged between 40 and 80 years and who had appendicectomy for appendicitis in a sub-Saharan hospital is presented. The study covered the 10 years January 1982 to December 1991. This number constituted 8.1 pc of the total appendicectomies for appendicitis. There were 59 males and 25 females with a cluster of appendicitis between the ages of 40 and 50 years forming 85.7 pc. The mean age was 52.2 pc years and the females tended to be younger. Only five patients constituting of 0.5 pc of total appendicectomies performed in the study period were aged 60 years and above. The presentation was only classical the nearer the ages of the patients were to 40 years. The only reliable clinical parameter was an area of maximal tenderness in the right iliac fossa at McBurney's point which was present in 70 patients (83.3 pc). The diagnostic accuracy rate as confirmed by histological reports was only 60.7 pc as opposed to clinical and peri-operative diagnoses of 70 (83.3 pc) and 90 pc respectively. Five of the inflamed appendices were suppurative, four perforated and one gangerous, thus only about 12 pc of the appendices were potentially catastrophic. There was no death.

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.