Laparoscopic Appendectomy in a Developing African Country

Background: The wide spread introduction of laparoscopic surgery to  surgical practice in Nigeria is a relatively new development. The benefits of laparoscopic appendicectomy are controversial. Laparoscopic  appendicectomy (LA) has always generated controversy due to its cost and time consuming nature and the multiple trocar points required which  arguably approximates to the length of the incision in open  appendicectomy. The purpose of this study is to describe the unit experience in a developing country.Method: This is a retrospective study conducted by the laparoscopic  surgery unit of the department of surgery. The study includes all patients who consented to laparoscopic appendicectomy over a period of eighteen months.Results: Thirty patients out of a hundred consented to laparoscopic appendicectomy with a male female ratio of 1:1.5.The mean operating time was 62 minutes. The duration of postoperative admission ranged from 1 to 7 days with a mean of 2.2days.There was 1(3.3%) conversion and 1(3.3%) pelvic collection. There was no readmission over three  months of follow up.Conclusion: Laparoscopic appendicectomy is safe and allows early  discharge. The low incidence of cholecystectomy in Nigeria compared with the high incidence of appendicitis in Nigeria supports the adoption of  surgery for a different disease entity apart from cholecystectomy for  training (hand and eye coordination). The level of safety demonstrated in the initial cases of laparoscopic appendicectomy supports adopting LA as a procedure of choice in acquisition of basic laparoscopic surgery skills

Pattern of Patient Presentation to the General Surgery Unit of a Tertiary Health Care Centre in a Developing Country

Background: Not much has been published on the surgical burden in Africa. This study describes the pattern and distribution of surgical  conditions treated by the general surgery division in a Nigerian tertiary hospital.Method: This was a retrospective study over thirty months. All patients treated by the general surgery divisions of the hospital were included in this study.Results: A total of 5631 new patients were seen over the period. Male: Female sex ratio was 1: 1.35 with a mean age of 39.6 years. malignant conditions accounted for 22.7% while 74.6% were benign. Breast carcinoma was the commonest malignancy in females. The commonest malignancyin males was abdominal (gastrointestinal, hepatobiliary and  retroperitoneal).Conclusion: Patients are getting increasingly educated. Appropriate manpower training is required so that tertiary hospitals are not encumbered by mundane surgical conditions .Specialty clinics for hernias, breast, gastrointestinal malignancy and anorectal conditions should beconsidered.Key words: Breast, Colon, Epidemiolog

An Audit of Perforated Peptic Ulcer Disease in a Tropical Teaching Hospital

Background: Perforated peptic ulcer (PPU) is associated with high  morbidity and a mortality rate. Thus it requires urgent surgical  intervention. Recently a reduction in the rate of peptic ulcer perforation in young men with a relative increase in the elderly and in women has been documented. This study is an audit of perforated peptic ulcer surgical emergencies treated by the gastrointestinal surgery division of a teaching hospital in Nigeria. It also reviews the early complications and the average duration of admission of these set of patients.Method: This was a retrospective five-year audit of patients admitted by the gastrointestinal surgery division of a tertiary teaching hospital in Ibadan Nigeria. The data extracted from the patients’ records included the bio-demographical data, the duration of symptoms prior to admission, thepatients’ vital signs at presentation and the results of the haematological investigations. Other information includes the duration from admission to surgery, the intra-operative findings and the outcome of the treatment.Results: Forty patients consisting of thirty three male and seven female were treated. The ages ranged from 20 years to 70 years. The peak incidence was in the fifth decade. None of the patients was seen within 6 hours of the onset of symptoms however fifteen patients were seen within twenty four hours of the onset of symptoms. Twelve patients (30%) had history of significant ingestion of non-steroidal anti-inflammatory drugs, nine (22.5%) had a significant history of alcohol ingestion, while one (2.5%) had a recent history of fasting prior to the onset of symptoms. The distribution of the sites of perforation, revealed a pattern of 9(22.5%), 21(52.5%) and 10(25%) in the body of the stomach, pre-pyloric region and the first part of the duodenum respectively. There were six mortalities.Conclusion: The outcome is excellent when prompt and adequate resuscitation and surgical repair of perforation are done. Health education  may increase patient awareness which may translate to early presentation. Risk scores may be helpful in predicting the outcome but an experienced clinical opinion is still essentia

Stage-specific five-year survival outcomes in women treated for early stage breast cancer in Ibadan, Nigeria

Background: The disparity between the overall survival of breast cancer between high-income countries (HICs) and low- and middle-income countries (LMICs) has been majorly attributed to the high rate of diagnosis of Early Stage Breast Cancer (ESBC) in HICs, with about three-quarters and one-fifth of the total breast cancer patients diagnosed with ESBC in HICs and LMICs respectively. The median 5-year survival rate of ESBC in HICs is 86% while it is about 72% in Sub-Saharan Africa.Objectives: To determine stage-specific five-year survival outcomes in women treated for ESBC.Methods: We conducted a longitudinal, cohort study to assess the treatment and outcome of ESBC in a Nigerian tertiary hospital. Patients diagnosed and treated for ESBC over 5 years were recruited and followed up for a minimum of 5 years after treatment. Clinicopathologic parameters, disease progression and known vital status, were retrieved. A 5% level of significance was used.Results: 67(9.6%)patients of 694 new cases of breast cancer seen over the study duration was treated for ESBC, of whichsixty- three (63) were followed up over the specified follow-up period. The mean age was 43(10) years. Based on the American Joint Committee on Cancer staging, 9 patients were stage IA, 16 stage IB, 16 stage IIA and 26 stage IIB respectively. The overall 5-year survival was 77.8%.Conclusion: The survival pattern of our cohort fairly compares with reports in HICs, despite the challenges faced in the multimodal treatment protocol received by our patients. Keywords: early breast cancer,survival, survival analysis, stage-specifi

A 12-month prospective study of intra-abdominal hypertension and abdominal compartment syndrome incidence and outcomes at a tertiary hospital in Nigeria

Background: Peritoneal sepsis is a life-threatening emergency, more so in the low- and middle-income countries (LMICs) where immediate hospital presentation for much needed urgent surgical care is the exception rather than the norm. Continued research into the multifactorial aetiopathogenesis responsible for the high level of morbidity and mortality is necessary. We aimed to determine the incidence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in patients presenting with generalized peritonitis in a tertiary hospital in Nigeria. Methods: We conducted a prospective study involving recruitment of consenting patients managed for generalized peritonitis over 12 months. Results: Fifty-seven consenting and appropriate patients were recruited over the course of the study and managed as per study protocol. The duration of symptoms ranged between 11 hours and 7 days. All patients had varying degrees of IAH and ACS at presentation with generalized peritonitis. A laparotomy with definitive surgery was done in 51 patients (89%), with 6 patients (11%) having only a bedside peritoneal drain inserted for decompression. Significant improvement of the respiratory rate (P < 0.001), oxygen saturation (P = 0.041), and urinary output (P = 0.021) only occurred after decompression by laparotomy or tube drainage. The consecutive mean ± standard deviation (SD) intra-abdominal pressures measured, respectively, at presentation, immediately postsurgery, then postoperatively at 6 h, 24 h, and 72 h reflected significant improvement at each point (respectively in cmH2O: 11.4 ± 6.03, 6.58 ± 5.58, 5.78 ± 3.29, 4.73 ± 2.86, 6.72 ± 5.18; P < 0.001). Conclusions: IAH and ACS are not uncommon in our setting, and ACS at presentation is a significant predictor of mortality in patients with peritoneal sepsis. Surgical decompression invariably leads to an improvement in all clinical variables investigated. Keywords: intra-abdominal hypertension; abdominal compartment syndrome; peritonitis; laparotomy; percutaneous catheter decompression; Nigeria

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Association of Body Composition with Odds of Breast Cancer by Molecular Subtype: Analysis of the Mechanisms for Established and Novel Risk Factors for Breast Cancer in Nigerian Women (MEND) Study

BACKGROUND: The association between obesity and breast cancer (BC) has been extensively studied among US, European and Asian study populations, with often conflicting evidence. However, despite the increasing prevalence of obesity and associated conditions in Africa, the continent with the highest age-standardized BC mortality rate globally, few studies have evaluated this association, and none has examined in relation to molecular subtypes among African women. The current analysis examines the association between body composition, defined by body mass index (BMI), height, and weight, and BC by molecular subtype among African women. METHODS: We estimated odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between measures of body composition and BC and molecular subtypes among 419 histologically confirmed cases of BC and 286 healthy controls from the Mechanisms for Established and Novel Risk Factors for Breast Cancer in Women of Nigerian Descent (MEND) case-control study. RESULTS: Higher BMI (aOR: 0.79; 95% CI: 0.67, 0.95) and weight (aOR: 0.83; 95% CI: 0.69, 0.98) were associated with reduced odds of BC in adjusted models, while height was associated with non-statistically significant increased odds of BC (aOR: 1.07, 95% CI: 0.90, 1.28). In pre/peri-menopausal, but not post-menopausal women, both higher BMI and weight were significantly associated with reduced odds of BC. Further, higher BMI was associated with reduced odds of Luminal A, Luminal B, and HER2-enriched BC among pre/peri-menopausal women, and reduced odds of triple-negative BC among post-menopausal women. CONCLUSIONS: Higher BMI and weight were associated with reduced odds of BC overall and by molecular subtype among West African women. Larger studies of women of African descent are needed to definitively characterize these associations and inform cancer prevention strategies

Association of body composition with odds of breast cancer by molecular subtype: analysis of the Mechanisms for Established and Novel Risk Factors for Breast Cancer in Nigerian Women (MEND) study

Background: The association between obesity and breast cancer (BC) has been extensively studied among US, European and Asian study populations, with often conflicting evidence. However, despite the increasing prevalence of obesity and associated conditions in Africa, the continent with the highest age-standardized BC mortality rate globally, few studies have evaluated this association, and none has examined in relation to molecular subtypes among African women. The current analysis examines the association between body composition, defined by body mass index (BMI), height, and weight, and BC by molecular subtype among African women. Methods: We estimated odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between measures of body composition and BC and molecular subtypes among 419 histologically confirmed cases of BC and 286 healthy controls from the Mechanisms for Established and Novel Risk Factors for Breast Cancer in Women of Nigerian Descent (MEND) case-control study. Results: Higher BMI (aOR: 0.79; 95% CI: 0.67, 0.95) and weight (aOR: 0.83; 95% CI: 0.69, 0.98) were associated with reduced odds of BC in adjusted models, while height was associated with non-statistically significant increased odds of BC (aOR: 1.07, 95% CI: 0.90, 1.28). In pre/peri-menopausal, but not post-menopausal women, both higher BMI and weight were significantly associated with reduced odds of BC. Further, higher BMI was associated with reduced odds of Luminal A, Luminal B, and HER2-enriched BC among pre/peri-menopausal women, and reduced odds of triple-negative BC among post-menopausal women. Conclusions: Higher BMI and weight were associated with reduced odds of BC overall and by molecular subtype among West African women. Larger studies of women of African descent are needed to definitively characterize these associations and inform cancer prevention strategies

Association of lipid profile biomarkers with breast cancer by molecular subtype: analysis of the MEND study

There is conflicting evidence on the role of lipid biomarkers in breast cancer (BC), and no study to our knowledge has examined this association among African women. We estimated odds ratios (ORs) and 95% confidence intervals (95% CI) for the association of lipid biomarkers—total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides—with odds of BC overall and by subtype (Luminal A, Luminal B, HER2-enriched and triple-negative or TNBC) for 296 newly diagnosed BC cases and 116 healthy controls in Nigeria. Each unit standard deviation (SD) increase in triglycerides was associated with 39% increased odds of BC in fully adjusted models (aOR: 1.39; 95% CI: 1.03, 1.86). Among post-menopausal women, higher total cholesterol (aOR: 1.65; 95% CI: 1.06, 2.57), LDL cholesterol (aOR: 1.59; 95% CI: 1.04, 2.41), and triglycerides (aOR: 1.91; 95% CI: 1.21, 3.01) were associated with increased odds of BC. Additionally, each unit SD increase in LDL was associated with 64% increased odds of Luminal B BC (aOR 1.64; 95% CI: 1.06, 2.55). Clinically low HDL was associated with 2.7 times increased odds of TNBC (aOR 2.67; 95% CI: 1.10, 6.49). Among post-menopausal women, higher LDL cholesterol and triglycerides were significantly associated with increased odds of Luminal B BC and HER2 BC, respectively. In conclusion, low HDL and high LDL are associated with increased odds of TN and Luminal B BC, respectively, among African women. Future prospective studies can definitively characterize this association and inform clinical approaches targeting HDL as a BC prevention strategy