Search

IntroductionAs childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).MethodsA multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A pResults1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.ConclusionMortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

Vulval/vaginal teratomas are rare occurrences in newborns. We report a case of a neonate that was born with a vulva teratoma, a rectovestibular anomaly, and a bifid T12 vertebra. To our knowledge, this combination is the first to be reported in the literature. The patient had a tumour excision in conjunction with a Primary Posterior Sagittal Anorectoplasty (PPSARP). She had post-operative complications of a wound breakdown that was managed conservatively. She is now being followed up on out-patient basis.

Introduction Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. Methods A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. Results Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. Conclusion Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital., Highlights • Non-trauma conditions constitute a third of surgical emergencies and a quarter of deaths in the emergency room. • Acute abdomen, urological conditions and malignancies are the leading causes of non-trauma emergencies. • Available facilities could provide care for only half of the non-trauma patients requiring emergency room admission.

Since the first pedestrian road fatality of 1896, pedestrians still remain vulnerable, with fatalities in Africa being 55% of global statistics. Many previous reports from Nigeria have emphasized passengers and drivers over pedestrians; this study was done in the most densely populated Nigerian city with no previous publication exclusively dedicated to pedestrians-the megacity has been projected by the World Bank to be the third largest in the world by 2015 (after Tokyo and Mumbai), so the study results would aid injury control and reduce morbidity and mortality.This is a one-year prospective study on pedestrians attending the surgical emergency room of the busiest referral hospital in Lagos, Nigeria, detailing age, sex, occupation, regions injured, injury mechanism, incident vehicles, highway collisions, and immediate outcomes.Some 702 pedestrians were seen, including 494 (70%) males with overall peak incidence in the third decade, but the peak incidence among females is lower and in the first decade. Common injuries sustained were to the head (40%), lower limbs (35%), upper limbs (9%), multiple regions (6%), pelvis (3%), and others (7%). Gender differences also were noted-the predominant injury location in males was the head, followed by lower limbs; the opposite was true for females, though both regional injuries were fewer in females than in males. Students were 20% of the entire pedestrians, with nearly half of them injured by a motorcycle. The mechanism of injury included crossing a highway (63%), walking along the pavement (17%), standing by a bus stop (12%), at a shop/house (5%), and others (3%). However, 76% injuries occurred on highways, 22% on inner city roads, and 2% elsewhere. Vehicles included motorcycles (33%), cars (27%), buses (22%), trucks (6%), tricycles (2.4%), and other (9%). Overall fatality was 10% and about half were due to being knocked down by buses and cars.This study suggests a high incidence and significant underreporting of pedestrian injuries. A reduction in morbidity and mortality is possible (from head and lower limb injuries) by traffic calming techniques in crossing the highway, especially injuries due to being struck by motorcycles, cars, and buses.

Introduction : Herniotomy is a common procedure performed by Paediatric Surgeons. However, opinions differ as to whether to open the inguinal canal when performing this procedure or not. Those who advocate performing herniotomy without opening the inguinal canal believe that in early childhood, the superficial inguinal ring is directly superimposed on the deep inguinal ring, there being no appreciable inguinal canal in this age group. Our study was planned to open the inguinal canal and simply measure the distance between the pubic tubercle medially and the inferior epigastric vessels laterally. Finding a measurable inguinal canal in all cases studies debunks the belief that the superficial inguinal ring frequently overlaps the deep inguinal ring. Materials and Methods : From October 2007 to September 2008 and from May 2012 to April 2013 the inguinal canals of 75 children from 1 day to 2 years old were measured during herniotomies and orchidopexies. Premature babies were excluded from this study. The inguinal canals were all opened. Using a simple sterilized metallic ruler, the distance between the ipsilateral inferior epigastric vessels and the ipsilateral pubic tubercle was measured. Results: The lengths of the inguinal canals ranged from 1cm to 4.5 cm (mean 2.88cm+/-.71cm SD). The shortest inguinal canal length was 1 cm while the longest inguinal canal was 4.5 cm. Conclusion : Children with inguinal hernia up to the age of 2 years have a measurable inguinal canal and we suggest the excision of the hearnial sac superficial to the external inguinal ring runs the risk of leaving substantial sac behind proximal to the transfixing suture, even when some traction is applied to the sac before applying the transfixing suture. DOI: http://dx.doi.org/10.3126/jnps.v33i3.8355 J. Nepal Paediatr. Soc. 2013;33(3):182-185

This study examined medical specialty selection by Nigerian resident doctors using a marketing research approach to determine the selection criteria and the role of perceptions, expected remuneration, and job placement prospects of various specialties in the selection process.Data were from the Community of residents from April 2014 to July 2014. The cohort included 200 residents, but only 171 had complete information. Data were obtained from a cross section of resident doctors in the Lagos State University Teaching Hospital and at the 2014 Ordinary General Meeting of the National Association of Resident Doctors(NARD) where representatives from over 50 Teaching hospitals in Nigeria attended. Using a client behaviour model as a framework, a tripartite questionnaire was designed and administered to residents to deduce information on their knowledge about and interests in various specialties, their opinions of sixteen specialties, and the criteria they used in specialty selection.A total of 171 (85.5%) questionnaires were returned. ln many instances, consistency between selection criteria and perceptions of a specialty were accompanied by interest in pursuing the specialty. Job security, job availability on completion of programme, duration of training and qualifying examinations were highly correlated with p value0.05. Results of the Principal Component Analysis show two components (with Eigen values greater than one) explaining 65.3% of the total variance. The first component had placement and training and practice related variables loaded on it while the second component was loaded with job security and financial remuneration related variables.Using marketing research concepts for medical specialty selection (Weissmanet al 2012) stipulates that choice of speciality is influenced by criteria and perception. This study shows that job security expected financial remuneration, and examination requirements for qualification are major determinants of the choice of speciality for residents.

Introduction : Intestinal atresia is one of the most common causes of neonatal intestinal obstruction worldwide. The pattern of presentation and management in our institution is reviewed. The objective of the study was to evaluate the pattern of intestinal atresias and stenoses in newborns who presented to our unit. Materials and Methods: A retrospective study of patients with intestinal atresias and stenoses who presented between September 2004 and November 2008. The clinical presentation, diagnoses, operative management, post operative care and outcome were obtained from the case notes. Results: Thirty cases were seen in that period, M:F; 1:1.5. Eleven (36.7%) were duodenal pathologies and 19 (63.3%) were jejunoileal. The main presenting symptom was bilious vomiting. Overall mortality is 40.9%. Prematurity and delayed presentations are the major contributing factors to mortality. Conclusion: Improvement of health care facilities as well as public health education to seek early intervention will improve outcome. Maternal awareness of this condition would lead to prompt seeking of treatment for paediatric patients. Key words: Intestinal atresia; congenital malformation; total parenteral nutrition DOI: http://dx.doi.org/10.3126/jnps.v32i1.5382 J. Nepal Paediatr. Soc. Vol.32(1) 2012 28-32

Child pedestrian injuries and fatalities in developing countries continue to increase. We examined child pedestrian injuries and fatalities in the most populated urban agglomeration in Africa in order to develop control measures.Two-year prospective study of injured child pedestrians (≤15 years) at the Surgical Emergency Room (SER) to determine demography, vehicles involved, road location, injury mechanism, pre-hospital transport, injury-arrival time, regions injured, injury severity and fatalities was done.Some 226 pedestrians (114 boys and 112 girls) comprising 42 children aged ≤4 years, 91 aged 5-9 years and 93 aged 10-15 years were seen with car collisions (83 pedestrians, 36.7%), motorcycles (76, 33.6%), buses (41, 18.1%), others (15, 6.6%) and 11 undetermined vehicles. Injuries on the highways were 147 (65%); inner-city roads 77 (34.1%) and two undetermined roads. Crossing the road was responsible for 168 (74.3%) pedestrian injuries; while three other mechanisms produced 58 (25.7%) patients. Regions injured were head (42.9%), lower limbs (35.4%) and others (21.7%). Relatives, bystanders and police/ambulance brought 186 (82.3%), 31 (13.7%) and eight (3.5%) children, respectively; and within 6 h (43.4, 11.5 and 2.2%) and after (38.9, 2.2 and 1.3%). Nineteen deaths (10 brought-in-dead, nine SER deaths) occurred; 15 of them girls, 15 had severe head injury, 15 were brought by relatives. However, fatality risks were truck collisions (OR 5.97), female child (OR 4.25), head injury (OR 4.18) and age ≤4 years (OR 3.7).The equal sex incidence, worse female fatality despite similar exposure and injury severity with male, deserve further research. Improved pre-hospital and SER care is needed.

We report a 4-month-old female infant who was apparently well before the onset of vomiting, abdominal distension, and the passage of red currant jelly stools. A clinical diagnosis of intussusception was made, and the infant was prepared for a laparotomy. Intraoperative findings were a gangrenous ileocolic intussusception with a proximal atretic ileal segment (similar to a type IIIa ileal atresia). An extended right hemicolectomy including the atretic ileal segment was done with an ileotransverse anastomosis to establish bowel continuity. The patient had a wound dehiscence on the fourth postoperative day that was repaired. She subsequently made satisfactory clinical recovery and was discharged on the 10th day.

Penetrating abdominal injury resulting from home accidents is rare. Only one such case was found in the English literature after online searching on PubMed. We report two cases of penetrating abdominal injury. The first was a 2-year-old girl who was brought into the emergency room (ER) with evisceration of most of the stomach through the left hypochondrium. She had fallen on a broken soft drink bottle; she was holding, after missing her steps. On examination, she had a penetrating injury in the left hypochondrium and a 1.5 cm perforation on the proximal aspect of the anterior wall of the stomach. She was explored within 3 h of presentation, during which the gastric perforation was closed eviscerated bowel returned into the peritoneum and primary wound closure achieved. The patient did well postoperatively. The second was a 9-month-old boy who was brought to the ER by parents on account of gut evisceration following injury from a soft drink bottle at home. He sustained injury from exploded soft drink bottle while crawling. Examination revealed a penetrating injury in the left upper quadrant with evisceration of small intestinal loops. He also had exploratory laparotomy within 4 h of presentation, during which intact abdominal viscera was found. Bowel loops were returned and primary abdominal closure done. Postoperatively, the patient did well. These cases are eye openers to an unusual form of domestic injury, exemplifying the potential hazards of soft drink bottles in the home. Awareness about this is pertinent.