Female children with ambiguous genitalia in awareness- Poor Subregion

Congenital aberrations of female children’s external genitalia are common worldwide with varied mode of presentation especially in regions with poor awareness. This prospective experience between July2004 and June 2008 at two Nigerian healthcare facilities is on the mode of presentation and challenges of management of female children with ambiguous genitalia. Congenital adrenal hyperplasia (CAH) 19(47.5%), female pseudohermaphroditism 20 (50%) and vaginal atresia 1 (2.5%) manifested as aberrations of external genitalia of 40 female children who presented between the ages of 3 months and 16 years (average 9 years). Cultural influence, lack of awareness, inadequate examination of external genitalia at birth and lack of diagnostic facilities resulted in late presentation and diagnosis with all the cases of CAH and pseudohermaphroditism raised as males. Five cases who developed female secondary sexual characteristics at puberty attempted suicide before presentation. Gender reassignment and feminizing genitoplasty were major challenges, but outcomes were encouraging.(Afr J Reprod Health 2009; 13[4]:129-136

Pattern and Outcome of Pediatric Surgical Admissions to a Nigerian Tertiary Hospital

Background/Purpose: The patterns and the factors influencing outcome of paediatric surgical admissions may be crucial to policy formulation. This study reports the pattern and the outcome of paediatric surgical admissions in a developing country. Materials & Methods: The pattern and the outcome of paediatric surgical admissions at the University of Benin Teaching Hospital between January and December 2009 were audited in a retrospective study. Results: In total, 871 children aged between one day and 16 years who accounted for 43% of paediatric surgical workload were admitted, 322 (37%) on emergency basis. Of these, only 530 (60.8%) were admitted to a paediatric surgical ward while the rest were admitted in different wards, including nonsurgical wards, due to shortage of manpower and lack of paediatric surgical facilities. Three consultant paediatric surgeons and 17 nurses (only one paediatric nurse) managed an average of 46 new admissions per month with doctor to patient and nurse to patient ratio of 1: 15 and 1:33 respectively. Shortage of bed spaces also resulted in the admission of many clean surgical cases in the same ward with septic medical cases. This increased postoperative infective complications, duration of hospitalization and mortality rate especially among 106 neonates admitted to Special Care Baby Unit compared to those in paediatric surgical ward (P<0.0001). Conclusion: The need for the provision of more paediatric surgical facilities and training of more paediatric surgical personnel to match the high paediatric surgical workload is emphasized by this audit.Index Word: Pattern, Paediatric, Surgical, Admissions, Outcome

The Predictors, Prevalence and Outcome of Burst Abdomen in Emergency Paediatric Surgical Centre

Background: Combination of certain risk factors in children may predict burst abdomen, a preventable postoperative complication. We sought to determine the prevalence, outcome, and predictors of burst abdomen in emerging pediatric surgical centers.Methods: Cases of laparotomy on children at two referral pediatric surgical centers in Nigeria between January 2002 and June 2009 were analyzed in a retrospective study that determined the prevalence, outcome, and predictors of burst abdomen.Results: A prevalence rate of 31 (2.1%) was recorded among 1465 children who had open laparotomy. They were mainly neonates [19 (61.3%)] during index laparotomy with a mean age 14.8 ± 6.7 months (range 2 days to 12 years), and a male: female ratio 1.5: 1 (18 males/12 females). Burst abdomen occurred between 4-10days in 5 (3%) children after resection/anastomosis due to gangrenous/perforated bowels, 4 (5.5%) following colostomy creation, 3 (7.7%) after open reduction of intussusception, 2 (1.7%) of exploratory laparotomy, 3 (33.3%) after enterocutaneous fistula closure, 9 (39.1%) following primary closure of bowels perforation, 1 (20.0%) after drainage of intra-abdominal abscess, and 4 (1.9%) following resection of intra-abdominal malignant tumour. Only 54.8% children survived, 19.4% having incisional hernia and 12.9% ugly abdominal scars. Surgery on neonates, late referral, emergency laparotomy, infective indication, intraperitoneal soiling, inanition, and postoperative abdominal distension owing to protracted ileus that occurred in different combinations were predictive of burst abdomen in these cases.Conclusion: The prevalence of burst abdomen is high with attendant poor outcome, but identifying the predictors may influence early institution of preventive measures

Neck masses in children: Etiopathology in a tertiary center

Background: Neck masses are common in children; they could present diagnostic challenges, and some may be malignant. This study determines the etiology, histopathology, and outcome of treatment in a Nigerian tertiary center.Materials and Methods: This is a three-year retrospective study of children managed with neck masses at the University of Benin Teaching Hospital between January 2007 and December 2009. The biodata, side distribution of the masses, clinical conditions of the children at presentation, methods of biopsy, histopathology results, definitive treatment options, follow-up, and outcome were analyzed.Results: A total of 35 children who were aged between one month and 16 years (mean, 8.1 ± 2.6 years) with a male : female ratio of 1.9 : 1 (23 males to 12 females) were managed with 26 (74.3%) acquired and nine (25.7%) congenital neck masses. The masses were located in the anterior triangle in 14 (40%) cases, right side of the neck in 12 (34.3%), and left side of the neck in seven (20%), with two (5.7%) bilateral/confluent. Twelve (34.3%) cases were enlarged lymph nodes; five (41.7%) of them due to malignant lesions. Except for the neck mass, 16 (45.7%) of the children enjoyed clinically stable health on presentation. Twenty (57.1%) acquired tumors were malignant compared with 15 (42.9%) mainly congenital tumors which were benign. Four malignant tumors (11.4%) were rare in anterior triangle. Hodgkin’s lymphoma, 9 (25.7%), and thyroglossal duct cyst, 5 (14.3%), were most common malignant and nonmalignant masses, respectively. Surgical excision was curative in 12 (34.3%) cases, but others required additional chemo and/or radiotherapy, with two (5.7%) mortality recorded due to late referral of children with Hodgkin’s lymphoma.Conclusions: Many neck masses in otherwise healthy children in our setting were malignant. We advocate early surgical consultation and thorough histopathologic analysis of neck masses in children in our subregion

Management challenges and outcome of congenital giant intra-lingual fibroma in a 2-year old boy.

Oral fibromas are often acquired painless benign slowly growing tumour usually seen on the buccal mucosa along the plane of occlusion of the maxillary and mandibular teeth. Congenital intra -lingual fibroma is rare and not much has been reported on it in literature. A giant intra-lingual fibroma which was present at birth that completely filled and protrudes out of the mouth thereby resulting in feeding difficulty was diagnosed in a two-yearold boy. The case is reported to draw attention to this rarely congenital tumour found in an unusual location and highlights the challenges of surgical management in a financially constrained African setting.Keywords: Intra-lingual, Fibroma, Management challenges, Outcome

Adult Patients Presenting with Undescended Testis in Awareness-Poor Region

Objectives: The majority of patients with undescended testis present during childhood with minimal complications owing to straightforward treatment with excellent postoperative outcome. This paper reports the mode of presentation, challenges and outcome of management of adult patients with undescended testis. Methods: This prospective study included consecutive cases of adult patients managed with undescended testis from January 2004 to December 2008 in Evbuomore, Nigeria. Results: Eighteen adults with a mean age of 38.3 years (range 19-61) were managed during the period. Ten (55.5%) had bilateral, 5 (27.8%) right and 3 (16.7%) left lesions. Awareness was poor as they presented due to infertility in 8 (44.4%), associated hernia 5 (27.8%), wife/self discovery 4 (22.2%) and accidental discovery by a health worker 1 (5.6%), with 9 men (50%) presenting between 30 and 40 years of age. On inguinal exploration, only 3 (10.7%) patients had viable but significantly reduced testicular volume, 17 (60.7%) were atrophic/fibrotic while in 8 (28.6%) the vas deferens ended blindly in the inguinal canal with no viable testicular tissue. Apart from three patients who had children before presentation, infertility persisted even after treatment despite adequate hormone profiles and satisfactory sexual performance. Counseling of spouses was a major challenge, with 8 couples adopting children and three marriages ending in separation. Conclusion: Management of adults with undescended testis was challenging due to irreversible complications, psychological effects and poor outcome of treatment which shows the importance of awareness programs that will result in childhood presentation.Key Words:   Undescended testis, cryptorchidism, infertility, adults, presentation, outcom

Outcome of primary posterior sagittal anorectoplasty of high anorectal malformation in well selected neonates

Background: Conventional posterior sagittal anorectoplasty (PSARP) for high anorectal malformation (ARM) involves initial colostomy creation with its attendant complications, but primary PSARP in neonates requires no initial colostomy.Objectives: To report on locally adapted inclusion criteria and outcomes of primary PSARP in neonates in Benin City.Materials and Methods: Babies who presented during the first week of life in clinically stable conditions, without cardiac anomaly, and had hemogram and blood chemistry within normal ranges, were included in this prospective study undertaken at the University of Benin Teaching Hospital in 2008‑2011.Results: Fifty children with ARM comprising 19 (38%) low/intermediate and 31 (62%) high anomalies were treated during the period. Five (10%) singletons delivered via spontaneous vaginal delivery at term. Aged at operation between two and seven (mean 4) days and comprised three males and two females (ratio 1.5:1), met the inclusion criteria for primary PSARP. The procedure was well tolerated by all the babies; oral intake was commenced on the second post‑operative day with nine days median hospitalization duration. No mortality was recorded on six months to four years follow‑up. Apart from minor superficial perianal surgical site infection in one baby which responded to antibiotics, no post‑operative sepsis or breakdown of repair was recorded. Continence and other anal functions were found excellent using the modified Wingspread scoring during follow‑up.Conclusion: These outcomes showed that with meticulous selection, primary PSARP in neonates was feasible and safe in a developing country. Multicenter studies and long‑term follow‑up are advocated World‑wide.Key words: Anorectoplasty, anorectal malformation, neonates, primary, posterior, sagitta

Neonates presenting with severe complications of frenotomy: a case series

<p>Abstract</p> <p>Introduction</p> <p>Tongue-tie or ankyloglossia is an anatomic variation in which the lingual frenulum is thick, short or tight. It may be asymptomatic, or present with complications like breast feeding difficulties or speech, dental and cosmetic problems. The treatment of this condition, where indicated, is frenotomy. This procedure usually has few or no complications. However, when it is done by untrained personnel, it may lead to life-threatening complications. This paper highlights complications that could arise from improper treatment of ankyloglossia.</p> <p>Case presentation</p> <p>Case 1 was a one-day-old male neonate, a Nigerian of Igbo ethnicity, who was admitted with bleeding from the mouth and passage of dark stools after clipping of the frenulum by a traditional birth attendant. He was severely pale and in hypovolemic shock, with a severed frenulum which was bleeding actively. His packed cell volume was 15%. He was resuscitated with intravenous fluids and a blood transfusion. The bleeding was controlled using an adrenaline pack. He also received antibiotics. He was discharged five days later.</p> <p>Case 2 was a three-day-old male neonate, a Nigerian of Ikwerre ethnicity, who was admitted with profuse bleeding from a soft tissue injury under the tongue, after clipping of the frenulum by a community health worker. He was severely pale and lethargic. He was resuscitated with intravenous fluids and a blood transfusion. The bleeding vessel was ligated with repair of the soft tissue. He also received antibiotics and was discharged home one week later.</p> <p>Conclusion</p> <p>Treatment of tongue-tie, a benign condition, when done by untrained personnel may result in life-threatening complications. Clinicians should pay more attention to parents' worries about this condition and give adequate counseling or refer them to trained personnel for surgical intervention where clinically indicated.</p

Surgical Management of Inguinal Hernias at Bugando Medical Centre in Northwestern Tanzania: Our Experiences in a Resource-Limited Setting.

Inguinal hernia repair remains the commonest operation performed by general surgeons all over the world. There is paucity of published data on surgical management of inguinal hernias in our environment. This study is intended to describe our own experiences in the surgical management of inguinal hernias and compare our results with that reported in literature. A descriptive prospective study was conducted at Bugando Medical Centre in northwestern Tanzania. Ethical approval to conduct the study was obtained from relevant authorities before the commencement of the study. Statistical data analysis was done using SPSS software version 17.0. A total of 452 patients with inguinal hernias were enrolled in the study. The median age of patients was 36 years (range 3 months to 78 years). Males outnumbered females by a ratio of 36.7:1. This gender deference was statistically significant (P=0.003). Most patients (44.7%) presented late (more than five years of onset of hernia). Inguinoscrotal hernia (66.8%) was the commonest presentation. At presentation, 208 (46.0%) patients had reducible hernia, 110 (24.3%) had irreducible hernia, 84 (18.6%) and 50(11.1%) patients had obstructed and strangulated hernias respectively. The majority of patients (53.1%) had right sided inguinal hernia with a right-to-left ratio of 2.1: 1. Ninety-two (20.4%) patients had bilateral inguinal hernias. 296 (65.5%) patients had indirect hernia, 102 (22.6%) had direct hernia and 54 (11.9%) had both indirect and direct types (pantaloon hernia). All patients in this study underwent open herniorrhaphy. The majority of patients (61.5%) underwent elective herniorrhaphy under spinal anaesthesia (69.2%). Local anaesthesia was used in only 1.1% of cases. Bowel resection was required in 15.9% of patients. Modified Bassini's repair (79.9%) was the most common technique of posterior wall repair of the inguinal canal. Lichtenstein mesh repair was used in only one (0.2%) patient. Complication rate was 12.4% and it was significantly higher in emergency herniorrhaphy than in elective herniorrhaphy (P=0.002). The median length of hospital stay was 8 days and it was significantly longer in patients with advanced age, delayed admission, concomitant medical illness, high ASA class, the need for bowel resection and in those with surgical repair performed under general anesthesia (P<0.001). Mortality rate was 9.7%. Longer duration of symptoms, late hospitalization, coexisting disease, high ASA class, delayed operation, the need for bowel resection and presence of complications were found to be predictors of mortality (P<0.001). Inguinal hernias continue to be a source of morbidity and mortality in our centre. Early presentation and elective repair of inguinal hernias is pivotal in order to eliminate the morbidity and mortality associated with this very common problem