Annals of Pediatric Surgery, Vol 4, No 3,4, July& October, 2008 PP 110-123

PAPSA 2008 Abstracts

Papers presented at the 7th Biennial Meeting of Pan African Pediatric Surgical Association (PAPSA)

August 17-23 2008 Accra, Ghana

7th Biennial Meeting of Pan African Pediatric Surgical Association *(PAPSA) August 17-23 , 2008 Accra, Ghana

Surgical Presentations of HIV Positive Children Sarcoma of Kaposi witch involve intussusception, an other boy had psoas abscess. The third boy had urethral stenosis, and the Bankolé Sanni R., Nandiolo R., Vodi L., Yebouet Eric, Coulibaly last boy had anal . D., Kirioua B., Mobiot L.,

HIV treatment was not available in our country before 2003 for children, 10 of girls with acquired rectovaginal fistula died and the Introduction: Human immunodeficiency virus (HIV) disease is an others did not come for follow-up after . increasingly common infection in children in Sub Sahara Africa. Acquired recto vaginal fistula is the more frequent surgical The five boys have received anti retroviral therapy. The urethral condition, but other disease can reveal this infection in children. stenosis resolved with the HIV treatment. Methods: From January 1999 to December 2006, a retrospective Conclusion: Different presentations can reveal HIV disease in study found 37 children presenting with HIV relative disease. children. With the available of HIV treatment in our country, a They were 32 females’ patients and 5 males’ patients with age precocious diagnosis and treatment can save these children. ranging from 4 week to 15 years. Background/purpose: The aim of this study was to evaluate the functional outcome specifically continence after a one-stage Results: Among the female children, 30 had acquired recto transanal pull-through operation for Hirschsprung's disease in fistula, 2 had perianal and perineal condyloma. One of the children. five boys had a perianal condyloma, an other one had intestinal ------Abstracts Papers presented at the 7th Biennial Meeting of Pan African Pediatric Surgical Association *(PAPSA) August 17-23 , 2008 Accra, Ghana

Mortality audit in an urban paediatric surgery setting The Treatment Of neonates With Oesophageal Atresia in a developing country At The University Hospital Of Treichville (Abidjan). Hesse AAJ, Bankole Sanni R., Nandiolo R., Yebouet E. ; Bosson K., Coulibaly Paediatric Surgery Unit, Korle-Bu Teaching Hospital, Accra, D., Vodi L., Mobiot L. Ghana Treichville Medical University Center, Côte D'ivoire Aim: The World Health Organisation estimates that the risk of Purpose: The objective of this study is to analyse the result of the neonatal death is 6 times higher in developing countries than in treatment of neonates with oesophageal atresia in our country developed countries. This study aims to review the mortality rate Methods: It was a retrospective study of 20 cases of infant with at the Paediatric surgery Unit for causes of death especially those oesophageal atresia treated from January 1984 to December of neonatal patients to the unit. 2007. Method: The mortality data for 2 years, 2006 and 2007 were Results: They were 13 females and 7 males. The diagnosis was reviewed. Data was compiled for sex, age, cause of death, time made before 72 hours for 5 patients and between 3 days and 15 between presentation and death and postmortem findings when days for the other infants. Five of these infants had associated these were performed. malformations (ano-rectal malformation, , cardiac Results: 38 deaths were noted in 2006 out of 4172 patients seen malformation). Twelve of these infant had type III oesophageal during the year and 42 deaths out of 4684 in 2007. These atresia (distal tracheo-oesophageal fistula) . We performed end to constitute 0.91 % and 0.9 % of all cases seen in the Paediatric end oesophageal anastomosis by right thoracotomy in twelve surgery unit during those periods. cases and in five cases we performed gastrostomy. Three infants died before surgery. We observed one case of anastomotic leak 21 deaths occurred in neonates in 2006 and 22 deaths in 2007. which closed spontaneously. The mortality’s rate was 75%. Six These constituted 55.3% of deaths in 2006 and 52.4% in 2007. patients are alive. The number of deaths in neonates with oesophageal atresia, Tracheo-oesophageal fistula, , exomphalos major Conclusion: The frequency of this malformation is and Hirschsprung’s disease is detailed out. underestimated in our country. The mortality’s rate was high because of the absence of intensive care facilities. 10 deaths occurred in patients aged 1 month to 1 year and 10 deaths in patients over the age of 1 year in 2006 and 8 deaths and 7 deaths respectively in 2007. Small Intestinal Atresias: A Preliminary Report Of 22 Conclusion: Overall paediatric surgical mortality figures in this Cases setting is less than 1% annually on the average. The majority of *Mohammad AM, *Sani AA, Dr Musa I. deaths (>50 %) occur in neonates and much more needs to be *Department of Surgery Bayero University and Aminu Kano done to reverse this trend in our setting. Teaching Hospital and Murtala Mohammed Specialist Hospital, Kano Nigeria Introduction: In this study, the author reviews cases of small Surgical Site Infection In A Paediatric Surgical Unit intestinal atresias to evaluate their pattern of presentation, surgical treatment strategy and outcome of treatment. Dan Poenaru, Edita Stepita-Poenaru, Peter Nthumba BethanyKids at Kijabe Hospital, Kijabe, Kenya Methods: This is a prospective study of 22 consecutive cases. Data was taken on patients with intra-operative diagnoses of small intestinal atresia. Age at presentation, symptoms and signs, Introduction: Surgical site infection (SSI) is reported in 2-5% of preoperative preparation, intraoperative findings, type of atresia, patients in developed countries, and in 14-25% in African settings. postoperative complications and outcome of treatment. Patients These infections cause significant morbidity and are very costly, with small intestinal atresias, who underwent surgical repair, were especially in resource-poor countries. We investigate the extent, grouped into one of four groups, base on the type of lesion: Group nature and distribution of SSI in a paediatric surgical unit in I, membranous, Group II, interrupted, Group III, apple-peel and Kenya. Group IV, multiple. Group I patients were treated with an enterotomy, excision of the membrane and transverse closure, Methods: A prospective analysis of all consecutive clean and Group II with resection of the dilated bowel and one anastomosis, clean-contaminated surgeries performed at AIC Kijabe Hospital group III with minimal bowel resection and single anastomosis, between January and November 2007 was undertaken. Intra- Group IV with single (when atresias are close to each other) or operative data was collected, and clinical follow-up of all patients multiple anastomoses to preserve bowel length,. During surgery, attempted up to 30 days post-operatively. a uniform protocol was applied to minimize bowel resection and to perform an end-to-end anastomosis. Mortality, morbidity, and Results: Out of 3,330 patients qualified for the study, 1008 were duration of recovery were included in the review. children (less than 18 years). The overall SSI rate was 7.7%, 5.6% for clean cases and 11% for clean-contaminated. SSIs were Results: Group I, membranous (n = 6), Group II, interrupted (n = divided between superficial (69%%), deep (29%), and organ / 10) one of which is a case of , Group III, apple- space (2%). Median age at diagnosis of SSI was 16 days. Rates peel (n = 4) and Group IV, multiple (n = 2). Of the 22 patients, varied among specialties, with lower rates for orthopaedics and three patients had re-operation for leakage (n =2) and plastic surgery. SSI was significantly correlated to surgical anastomotic stenosis (n = 1). Oral feeding commenced on day 4 - contamination and the length of surgery, but not to age or 12 and full caloric intake via the enteric route on day 8 – 21 in specialty. most patients. Eight patients would have benefited from short or long-term intravenous nutrition if available. Mortality of 18.2% Conclusions: SSI is a significant cause of morbidity and cost. (n=4), two of which died of causes unrelated to operation (short Careful attention to its causative factors can reduce SSI bowel syndrome), while the other two died of severe sepsis significantly in developing world settings. flowing anastomotic dehiscence and re-operation.

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Conclusion: It was found out that the higher the type of atresia Findings: 86 patients were enrolled in the study. The duration of the more likely to be complicated. We also conclude that efforts symptoms was between 1 to 17 days. The length of hospital stay are made to preserve bowel length to avoid the short bowel varied depending on symptoms. Bowel resection rate was about syndrome that is difficult to treat in our environment without 30%, and overall mortality was less than 10 %. parenteral nutrition. Preservation of bowel length and single layer anastomosis contributes to early recovery of bowel function. Conclusions: The majority of patients seen in the Paediatric Surgery Unit of the KorleBu Teaching Hospital are managed by surgical reduction without resection and therefore laparotomy may not be required in most intussusceptions. Other non-operative Intestinal Atresia Treatment at The Teaching Hospital manoeuvre will thus need to be explored. Of Treichville (Abidjan-Cote D’ivoire) Jb Kirioua, Sr Bankole, Rk Nandiolo, E Yebouet, D Coulibaly, L Vodi, As Sika, L Mobiot

Treichville Medical University Center, Côte D'ivoire Management of Intussusception In Children – The Role Of Pneumatic Reduction Purpose: the objective of this study is to describe the F. A. Abantanga1,2, B. Nimako2, M. Amoah2, K. P. Yankey2 epidemiologic, clinic, paraclinic, therapeutic and evolutive aspects 1School of Medical Sciences, College of Health Sciences, Kwame of the intestinal atresia. Nkrumah University of Science and Technology, Kumasi, Ghana; 2 Patients and Methods: A retrospective study of medical files of Directorate of Surgery, Komfo Anokye Teaching Hospital, new-borns treated for intestinal Artesia was done in pediatric Kumasi, Ghana surgery unit of Treichville teaching hospital from January 2000 to AIM: To evaluate the outcome of children with intussusception December 2007. We included all new-born aged to the birth day treated in our institution using air enema reduction of the until 20 days. We analyzed, clinic, paraclinic, therapeutic and intussusception. evolutive aspects METHOD: An analysis of children presenting to our hospital from Results: Twenty nine new-borns with intestinal atresia were March 2004 to April 2008 with intussusception was done. From treated in our hospital. The mean age was 2, 44 days with this group the data of a subset of children treated with air enema extremes to 0 day to 15 days. The sex-ratio was 1, 23 in favour of reduction (AER) or pneumatic reduction (PR) were analysed. male. The mean weight of new-born was 2291, 42 grams. The functional sign most frequent was vomiting followed by absence RESULTS: During this period fifty-two (56) children were of meconium emission. Three patients had associated diagnosed with intussusception. Treatment for twenty-eight (28) malformations. Plain abdominal x-ray was done to all patients. It children was started with an AER after resuscitation but then showed a double bubble aspect in 07 patients (duodenal atresia) twelve (12) were converted to open laparotomy with manual .In other 22 cases plain film showed multiple air-fluid levels reduction of the intussusception. Sixteen (16) were successfully (jejunum, ileum and colonic atresia).All patients with duodenal reduced using this method. Out of the last group of patients, we atresia had duodeno-duodenostomy or duodeno-jejunostomy. did a laparotomy in three because of suspicion that the Patients with jejuno-ileal atresia have been treated by resection of intussusceptions were not reduced. But it turned out that they atretic zone with end-to-end anastomosis .Three children with were all reduced despite the non-escape of air via the nasogastric colonic atresia had a left iliac colostomy. Two patients had post- tube. We did not give any time limit for attempting air enema operative occlusion and four children had post-operative infection. reduction i.e. from the start of clinical symptoms to initiation of PR Twelve new-born died, giving a mortality of 41, 37%. of the intussusception. The earliest we received a child with intussusception was about 24 hours and the latest - about 6 days Conclusion: Intestinal atresia is rare and the diagnosis is simple. after the occurrence of symptoms. There was a perforation in one The mortality is still high in our country because of lack of of the children undergoing PR. All children undergoing PR/AER intensive care unit. survived. CONCLUSION: All children with intussusception should first have a pneumatic reduction of intussusception attempted and if A Review of Intussusception At The Korlebu Teaching that fails a laparotomy should be done. We suggest that this Hospital In Accra, Ghana procedure be done in theatre and by a paediatric surgical team, if there are no facilities for monitoring the progress of reduction in Hesse AAJ, Glover-Addy H, Appeadu-Mensah W, Etwire V the hospital. This method should not be used if there is air under Paediatric Surgery Unit, UGMS, Accra, Ghana the diaphragm or there is peritonitis. Aim: To perform a prospective clinical audit of intussusceptions seen in the Paediatric Surgery Unit of the Korle-Bu Teaching Hospital from August 2005 to March 2008. The study aimed at reviewing the intussusceptions seen with a view to improving on An audit of the use of small intestinal enterostomies in our management protocols. Ahmadu Bello University Teaching Hospital, Zaria Methods: The study was prospective. Each patient’s parent was Anumah MA, Ameh EA, Mshelbwala PM, Lukong CS, Jabo B. interviewed using a standard questionnaire; the findings were Division of Paediatric Surgery, Ahmadu Bello University Teaching crossed checked from clinical findings and hospital records. Hospital, Zaria, Nigeria The questionnaires were administered during the period of Introduction: Ileostomies are not frequently performed for admission and on discharge of the patient, the questionnaires gastrointestinal disorders as . They are however more were then analyzed. associated with post operative complications. Despite the The study included the duration of symptoms, length of hospital challenges of post operative management of ileostomies, it is an stay, types of intussusceptions, methods of management and the indispensable procedure in paediatric surgical practice. Few bowel resection rate. The overall mortality was also noted. studies have been reported in this part of the world.

١١٢ Annals of Pediatric Surgery

Aims and objective: To identify indications for ileostomies and the Changing Trends in Management of Anorectal post operative complications associated with these procedures. Malformation in Zaria Methodology: This is a 7 year retrospective study of paediatric CS Lukong, EA Ameh, PM Mshelbwala, MA Anumah, BA Jabo, A patients who had colostomy performed in Ahmadu Bello Gomna, University Teaching Hospital. The case folders and operation OT Akiniyi, PT Nmadu. notes were the source of the data analysed. Division of Paediatric Surgery, Department of Surgery, Ahmadu Results: There were 35 ileostomies performed, there were Bello University Teaching Hospital, Zaria. 21males and 14 females, ratio of 3:2. Age range was 3 days to 12 years and median of 18 days. Background: Anorectal malformation is a common Complications occurred in 23 (64%) of patients. The commonest treated by paediatric surgeons worldwide. Over the years, the indication was for anastomotic leak 12 (33.3%), intestinal management of this condition has evolved. This is a review of the perforation in 8(22.2%), intestinal atresia and stenosis in changing trends in the management of this condition in Zaria in 4(11.1%). Sepsis was the commonest complication accounting for the last 2 decades. 9 (40%) of complications. Mortality occurred in 50% 0f the patients. Most of the mortalities were due to complications of Patients and Methods: This is a retrospective analysis of with underlining disease which occurred in 12(67%) of the mortalities. anorectal malformation managed from January 1988 to December 2007. The patients were divided into; Group A (patients managed Conclusions: Ileostomy is associated with significant morbidity from January 1988 to December 1997), and Group B (patients and mortality. However, most of the mortalities are due to non managed from January 1998 to December 2007). Information ileostomy post operative complications. regarding type of anomaly, evaluation, management and outcome were obtained from patient case notes, operation registers and discharge summary sheets. Data was analysed using SPSS version 11.o. Interest of The Dorsal Shred In The Thick Umbilical Results: A total of 295 patients (188 boys and 107 girls), aged 1 Hernias Of Child day – 9 years (median 8 days) were managed during the period. Dieth .AG, Moh-ello N, Fiogbe M, Yao Kreh JB, Tembely S, There were 134 patients in Group A (79 boys and 55 girls) and Bandre. E, Muaffo-Tambo F, Dick.kR, Anoma-da-Silva S. 161 patients inGroup B(109 boys and 52 girls). There were 73 and 106 emergency operations in groups A and B respectively. **, Cote D’Ivoire There were 61 and 55 elective operations in groups A and B The umbilical hernias are frequent in Africa. They present more of respectively. In group A, the main investigations for evaluation an aesthetic problem because their major complication of were invertogram (in neonatal period) and sacral X-ray. In group strangulation is rare. Authors bring back the result of their surgical B, the main investigations for evaluation were cross-table lateral treatment by a plastic from of dorsal shred. X-ray, abdominal ultrasonography, sacral X-ray and distal colostogram later. There was a shift in diagnostic terminology Material and Methods: It is about a study mixed retrospective over the years, in line with changing international nomenclature. and prospective achieved in the paediatric surgery service of Regarding treatments, in group A, patients requiring colostomy teaching hospital of Yopougon on a period of 10 years. The had transverse colostomy while in group B sigmoid (usually patients have been recruited to this hospital and in the private divided) colostomy was preferred. In group A and earlier patients structures of Abidjan. Two surgical techniques have been used. It in group B with rectovestibular fistula routinely had an initial is about in the both of the confection of a rectangular shred either colostomy followed later by definitive surgery. However, later of total skin either after resection of the superficial dermis of a patients in group B with rectovestibular fistula now have a one- pedicular shred. stage definitive surgery. The definite surgery done during the 2 periods were; Group A: cutback anoplasty 29(47.5%), anal Results: Thirty four children, 23 boys and 11 girls presenting transplant 5(8.2%), sacro-abdominoperineal pullthrough thick umbilical hernias have been operated. Eight by the 1st (Steven’s) 6(9.8%); Group B: posterior sagittal anorectoplasty method and 26 by the second. It doesn't note any complication 41(74.5%), anal transplant 1(1.8%), others had some complex with method I that is simpler faster but with a less satisfactory procedures. In group A faecal incontinence was the main problem result. We noted 2 dry ischemia with the II method, that is more following sacroabdominoperineal pullthrough while in group B delicate in its realization, longer but with a superior aesthetic anal stenosis and anal mucosal prolapse were the main problems result. following posterior sagittal anorectoplasty. Conclusion: The aesthetic worry is a constant preoccupation for Conclusion: There have been significant changes in the the paediatrics surgeons. Several surgical procedures have been management of anorectal malformation in Zaria in the last 2 proposed in the thick umbilical hernia treatment. This unpublished decades, due largely to improved understanding of the pathology work to Abidjan offers an alternative in the treatment of these and refinements in surgical techniques worldwide. The result has hernias. been an improvement in the overall outcome for the affected children.

Management of Anorectal Malformation At The Moi Teaching & Referral Hospital (MTRH) – Eldoret – Kenya, R. Tenge-Kuremu, MTRH, Eldoret – Kenya

Background: A dedicated paediatric surgical service has been in existence at the MTRH since July 2003. Since then, a wide range

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of anomalies have been managed. Ano-rectal malformation is Jean-Martin Laberge MD1 and Carlos Noriega Eng.2 one of the common anomalies managed by the service. An Division of Pediatric General Surgery1 and Department of evaluation of the management of this anomaly has been done Biomedical Engineering2, Montreal Children’s Hospital, Mcgill and is reported in this paper. University Health Center, Montreal, Qc, Canada Objective: To evaluate the outcome of management of ano- Introduction: Muscle/nerve stimulators are essential in the rectal malformation at MTRH. surgery for . Such stimulators are fragile, Design: Retrospective study covering the period July 2003 to expensive and difficult to find. Several years ago the one we were December 2007 both dates inclusive. using, which had cost over $40,000.00 U.S., broke and could not be repaired. We could not even find a replacement on the market Setting: MTRH. This is the Moi University School of Medicine at that time. Together with our hospital’s biomedical engineer, we Teaching Hospital. decided to make one as a temporary replacement. Subjects: Children treated in this hospital for ano-rectal Methods: We used a standard 9V battery-powered anesthesia malformation. peripheral nerve stimulator, which is readily available in every operating room (cost =$1,000.00 U.S., but many old models are Results: Ano-rectal malformation is the second commonest available to give away). The lead wires that normally connect from congenital anomaly after hernia managed by the paediatric the stimulator to the skin electrode surface were then modified. surgical service. Fifty files were available for analysis. Of the The end that would normally clip on the skin electrode was cut off; fifty, 23 (46%) were male and 27 (54%) female giving a ratio of 1 cm of lead wire was stripped from its plastic sheath and was male:female of 1:1.2. The age ranged from 1 day to 11 years soldered to a rigid metal pin 0.6 mm in diameter and 36 mm in with a mode of 2 days and median of 1 week. Most, 40(80%) length (standard embroidery needle size 8, made of nickel coated were noted at birth while delay in noticing the problem took as steel with a resistance of 0.3 ohms). The total length of the lead long as 3 months in female babies with vestibula and anteriorly wire, including the tip is 50 cm and its total resistance is 1 Ohm. placed anuses. Thirty five (70%) of the patients were delivered at The leads with their rigid end were then passed in a narrow home. cylinder (the “body” of a Bic pen) which was filled with clear Age at first surgical procedure ranged from 2 days to 6 years with sealant general purpose silicone, keeping the two denuded a mode of 3 days. Divided sigmoid colostomy was done in wires/pins apart, thus preventing a short-circuit. The rigid pins 27(54%) and anoplasty for low lesions in 15(30%). Eight (16%) were left to stick out from the “Bic” by 1-1.5 cm and were kept had their colostomies done elsewhere. These included loop about 4 mm apart. colostomies in 5(10%). The 11 year old had had a colostomy The “pencil” with its attached leads could then be sterilized by since the age of 3 days. autoclave. At the time of surgery, the sterile leads can be passed Age at subsequent procedures ranged from 3 months to 11 years. to the circulating nurse who connects them to the stimulator. These were revision of all loop colostomies to divided stomas, pull Instead of asking the circulating nurse to press on the button through in 2 patients with high rectal stenosis, Anterior Sagittal every time the stimulator is to be used, it is best to place the Anorectoplasty (ASARP) for females and Posterior Saggital apparatus in a sterile transparent bag. The whole stimulator-lead- Anorectoplasty (PSARP) for males. pencil assembly can now be kept on the sterile field and used by the surgeon at any time during the operation. Colostomy closure was done when neo-anus could admit hegar dilator size 12 and above. Redo-anoplasty was required in 2 Results: The instrument was found to be very effective in the patients. Complications included anal stenosis in 2(4%), operating room. After the initial prototype, which used a more colostomy stenosis in 3(6%), failed Pena procedure in 1(2%), fragile transparent plastic “pencil”, we made two more permanent perineal wound sepsis in 2(4%), in 5(10%) and “Bic-type”, and used longer leads to facilitate their use in the mortality of 7(14%). sterile environment. We have used them for more than 15 years, using different stimulators that were discarded by the Problems were encountered in referred patients stemming from anesthesiologists. The only downside compared to commercially poor application of neonatal transfer principles. Delays in available stimulators is that someone has to keep pressing the completing the procedure in time were occasioned by financial “tetanus” button while the surgeon applies the 2-prong probe to constraints, anal dilatation challenges particularly in bigger the area to be stimulated. The instrument is powerful enough to children, co-morbidities and delay in presentation. obtain a good contraction even when stimulating through intact skin, for example to identify the exact location of the external Other malformations included heart disease in 2(4%), renal sphincter before making the skin incision. malformation in 1(2%) and choanal atresia in 1(2%). Conclusion: This “home-made” muscle/nerve stimulator is Conclusion: Management of ano-rectal malformation has inexpensive, easy to make, safe to use, effective, reliable and achieved good results. There is however need to improve the easy to back-up. The cost of materials other than the peripheral health service accessibility particularly obstetric services to nerve stimulator is less than $10.00 U.S. enable more mothers deliver in hospitals, as this will reduce challenges associated with referrals and minimize the mortality.

Exposure of Pediatric Surgical Trainees in Nigeria to A “home-made” muscle/nerve stimulator for use Teaching, Research and Conferences during imperforate anus repair Ademuyiwa AO, Ameh EA, Bode CO, Adejuyigbe O. LUTH, Teaching Hospital Jos, Teaching Hospital, Ile-Ife; Nigeria

AIM OF STUDY: To determine the teaching methods used by Residents in Pediatric Surgery in Nigeria and their exposure to research and conferences.

١١٤ Annals of Pediatric Surgery

METHODS: A Structured Questionnaire was administered to expected proficiency levels in 6th year. Paediatric surgeons senior registrars in pediatric surgery in Nigeria seeking identified 30 items as essential (mean score=1.8) and 8 items as information regarding different teaching methods employed by the non-essential items (mean score=2.5); but general surgeons residents, frequency of employing those methods, involvement in identified 18 items as essential (mean score=1.3) and 11 items as medical research as well as attendance of conferences and level non-essential items (mean score=1.4). The 6th year and House of participation. officers showed variability in their perceived knowledge of 25 of these 30 objectives was adequate. Comparison of the data with RESULTS: There were 11 respondents out of 12 questionnaires previous objectives showed a similar trend. Data from deans’ that were distributed. All of them are training in accredited offices varied but showed limited exposure to paediatric surgery in teaching hospitals in Nigeria and one of them who trained abroad undergraduate curriculum in most instances. as a General Surgeon is undergoing pediatric surgery training in Nigeria. All of them have been involved in teaching of medical Conclusion: This study revealed a hidden need for students. Ten residents are involved in teaching in wards and at standardisation in undergraduate curricula in Nigerian universities the bedside twice or more in a week and all were involved in to ensure adequate exposure to paediatric surgery. teaching at the clinics with demonstration of clinical signs and symptoms. Only one resident uses audiovisual aid at least once a week to teach students while 6 of the residents used such aids CAPSNet: The Canadian Pediatric Surgical Network once in 2-3months. Eight trainees used tutorial or seminar group discussion as a teaching tool once in a week. Four trainees have Jean-Martin Laberge MD1, Erik Skarsgard MD2 and the Canadian not used written essay as a way of teaching students while 5 have Pediatric Surgery Network never given students lectures in a classroom before. All of them 1Division of Pediatric General Surgery, Montreal Children’s were confident that they could take up employment as university Hospital, Mcgill University Health Center, Montreal, Qc, Canada, Lecturers asserting that their experience is satisfactory. All the and 2Division of Pediatric General Surgery, British Columbia respondents have been involved in retrospective research while 9 Children’s Hospital, University of British Columbia, BC, Canada had been involved in prospective research at various degrees of involvement. Nine residents had attended conferences nationally while only 2 attended international conference during the training. Introduction: Single institution studies of outcome for birth Six presented a paper or more at national conferences while one defects like gastroschisis (GS) and congenital diaphragmatic resident presented at an international conference. Two trainees hernia (CDH) are constrained by small numbers, prolonged were sponsored, including one for an international conference. accrual and non-standardized data collection. Our purpose was to create a national pediatric surgical network and database for birth CONCLUSION: Trainees in pediatric surgery in Nigeria are defects that tracks cases of GS and CDH from diagnosis to significantly involved in the teaching of undergraduate medical postnatal hospital discharge. students. Their involvement in research is encouraging; however, they need to be encouraged to present research papers at Methods: The network consists of all 16 Canadian perinatal conferences. centres and serves a population of 32 million. It is based on the Canadian Neonatal Network (CNN), which was established in 1995. Gastroschisis and CDH cases are ascertained at prenatal Undergraduate Paediatric Surgery Curriculum: How diagnosis (if made), and all pregnancy outcomes are recorded. Can We Harmonize The Student Learning Experience? Prenatal data includes maternal risk and fetal ultrasound variables specific to each malformation, while postnatal fields include a *A.F. Uba, ‡JYChinda, +O. Abdur-Rahaman, *L.B. Chirdan, §A. validated neonatal illness severity score as part of the CNN data, Mohammed and data fields specific to gastroschisis (such as a bowel injury *Jos University Teaching Hospital, Jos. Nigeria; ‡University of score, intended and actual surgical treatment) and to CDH (pre- Maiduguri Teaching Hospital, Maiduguri. Nigeria; +University of operative ventilation strategy, blood gases, operative findings Ilorin Teaching Hospital, Ilorin. Nigeria; §Aminu Kano Teaching including need for a patch repair and use of a chest tube). Hospital, Kano, Nigeria. Federally funded until 2009, data collection at each centre is IRB- approved, conforms to regional privacy legislation and is

conducted by trained abstractors. Collected data is de-identified, Background: Surveys of subspecialty objectives can clarify uploaded to a central repository and accessible through the educational priorities and identify areas of proficiency and network steering committee. deficiency. This study evaluated the status of paediatric surgical Results: From the onset of data collection in May 2005 until instructions and the level of knowledge of medical students in 2007, 184 cases of pre and/or postnatal gastroschisis have been some medical schools in Nigeria. uploaded. The survival was 96%, with a median length of stay Materials and Methods: The cognitive and perceived knowledge (LOS) 35 days. Presence of bowel necrosis and low birth weight level of common paediatric surgical conditions of a cross section were associated with increased mortality. Fetal bowel dilatation of 4th and 6th year medical students in 4 Nigeria medical schools did not predict outcome. More than 60% were delivered vaginally, was surveyed using educational objectives. The same objectives less than 10% by planned C-section, and the rest by emergency were used to survey 10 paediatric surgeons, 30 house officers C-section. In 60% the intended treatment was urgent closure (silo and 15 general surgeons. Physicians’ expected and students’ self required in less than 10%); in the remainder, a preformed silo was assessed proficiency was scored for each objective on a scale of used to facilitate “elective” closure. Infants treated with urgent 0 to 3 (unaware of condition/not required-confident with diagnosis closure appear to have a shorter LOS and fewer TPN days. In the and management of condition). Information regarding paediatric same time period, 124 cases of CDH have been entered. Survival surgery curriculum was obtained from the office of deans of to discharge was 80%. faculty of 3 Nigerian medical schools. Data were analysed using Conclusions: Population-based databases allow rapid case descriptive methods and one-way analysis of variance (ANOVA) accrual and enable epidemiologic studies of birth defect and were compared with existing objectives listings in paediatric incidence. The application of multiple logistic regression analyses surgery. and outcomes modeling to large, standardized datasets should Results: Overall, students’ familiarity scores increased contribute to identification of optimal perinatal treatment significantly from 4th-6th year (P<.05), and approximated the strategies. At the time of grant renewal, we hope to extend the

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CAPSNet data collection to other surgical malformations such as draw attention to the need of newborn care in developing esophageal and intestinal atresias, sacrocoggygeal teratomas countries. and others. This study compares the surgical neonatal admissions between two linked institutions in Africa and Europe. PERFORMANCE INDICATORS IN NEONATAL Method: In a three year period, there have been 528 neonatal SURGERY - A nationwide project in The Netherlands. surgical admissions to the Kilimanjaro Christian Medical Centre (KCMC), Tanzania. During the same period 707 surgical Hugo A Heij *), L.W. Ernst van Heurn, on behalf of the neonates were admitted to the John Radcliffe Hospital, UK (JRH). Netherlands Association of Paediatric Surgeons. Results: Conditions more commonly seen in the JRH include *) Paediatric Surgical Center of Amsterdam, Emma Children’s necrotising enterocolitis (NEC) (10.2% vs. 0%), gastrochisis Hospital AMC and VU University medical centre. P.O. Box 22660, (5.5% vs. 0.9%), congenital diaphragmatic hernia (2.4% vs. 1100 DD, Amsterdam, The Netherlands 0.4%), congenital lung cysts (1.6% vs. 0.4%), meconium ileus (2.4% vs. 0%), malrotation (2.7% vs. 0.6%) and abdominal/pelvic Introduction: The motto of Sir Denis Browne was that paediatric cysts (1.1% vs. 0%). surgery aims to set the standard and not to seek a monopoly. In Conditions more commonly seen in KCMC include anorectal order to demonstrate the standards of surgical care for children, malformation (9.5% vs. 4.7%), sacrococcygeal teratoma (2.3% vs. instruments for objective assessment are needed. In the first 0.3%), Hirschsprung’s disease (10.2% vs. 4.5%), branchial fistula place, such assessment will enable surgeons to compare the (0.9% vs. 0%), haemangioma (2.1% vs. 0%) and cystic hygroma quality of their efforts and stimulate them to improve where (2.1% vs. 1.0%). necessary. Further, measuring quality of care will guide parents and health care providers in the choice for quality care for the Conclusion: The spectrum of neonatal surgical admissions in chlidren. We report on a nationwide project of development of our two institutions varied. We believe this is attributable to performance indicators for six neonatal surgical diagnoses. availability of antenatal diagnosis, primary health care, transport facilities, genetics as well as survival of delayed presentation. Methods: Members of the Netherlands Association of Paediatric This study demonstrates the extent and spectrum of neonatal Surgeons composed consensus-based protocols for diagnosis surgical pathology in this part of Africa and highlights the need for and treatment of six congenital malformations: oesophageal newborn surgical care in developing countries. atresia (OA), anorectal malformations (ARM), Hirschsprung’s disease (HD), congenital diaphragmatic hernia (CDH), abdominal wall defects (AWD) and (BA). Based on these protocols, performance indicators were developed by Neonatal surgery in LUTH: Pattern of presentation and representatives of the six paediatric surgical centers in The outcome Netherlands. Ademuyiwa AO, Bode CO Ikhisemoje SO, Fabiyi E, Opoola O. Results: For each diagnosis, four indicators were decided upon, Lagos University Teaching Hospital, Nigeria either of the process or outcome type (table). Checklists were then made to enable web-based registration of the relevant data. AIM: To determine the pattern of presentation and outcome of Each centre is responsible for entering the data, which will be neonatal surgery in LUTH. aggregated into a nation-wide anonymous system, to secure the METHODS: Records of neonates presenting in the pediatric privacy. This allows each centre to compare its performance with Surgical Unit of the Lagos University Teaching Hospital between the national standard (benchmarking), without releasing January 2005 and December 2007 were reviewed. Data including confidential data to other centres. the Biodata, indication for surgery, surgical procedure performed Discussion: A pro-active attitude regarding quality assessment is and final outcome were collated and analyzed using the Statistical required of the health care professionals to stay in the lead and Package for Social Sciences Version 13.0. prevent that other stakeholders (health assurance companies, RESULTS: Eighty one neonates had surgery within the study government bodies or media) decide on the content of medical period but complete records could only be retrieved for 63 care. This process will stimulate quality of care and lead to further patients. There were 46 boys and 17girls with a M:F ratio of 2.7:1. concentration of paediatric surgical services in The Netherlands The commonest indications for surgery in LUTH in the neonatal by showing the volume-output relationship. This process will be of period are Hirschsprung’s disease accounting for 20.6%, followed benefit to other pediatric survival communities. by anorectal malformation (14.3%), intestinal atresias (14.3%) and oesophageal atresia with tracheoesophageal fistula (11.1%). There were 10 deaths during the period giving a mortality rate of A Comparison of Neonatal Surgical Admissions 16%. Causes of death included severe bronchopneumonia, between Two Linked Surgical Departments in Africa overwhelming sepsis, annihilation from late presentation and and Europe associated multiple congenital anomalies. *C Mungongo, B Nandi, K Lakhoo CONCLUSION: Neonatal bowel obstruction is the commonest indication for neonatal surgery in LUTH. The mortality rate is 16% *Kilimanjaro Christian Medical College and Tumaini University, and causes include sepsis, annihilation and multiple congenital Tanzania anomalies.

Children’s Hospital, Oxford, University of Oxford, England

Emergency Neonatal Surgery In Zaria Introduction: Resources for neonatal surgery vary hugely between the developed countries and Africa. Due to the burden of P.M. Mshelbwala, C. S. Lukong, B.A.Jabo, M.A.Anumah, other childhood diseases, neonatal surgery is low priority for A.Gomna, and E.A.Ameh health care budget holders in the developing countries. Division of Paediatric Surgery, Department of Surgery, Ahmadu Admissions in two neonatal surgical institutions are compared to Bello University Teaching Hospital, Zaria, Nigeria

١١٦ Annals of Pediatric Surgery

Background: Emergency surgery represents a large bulk of incidence of complications following inguinal herniotomy in the neonatal surgery in Nigeria. This has been attended by several neonatal period in our centres.. challenges over the years. This is a report of our recent experience. Materials and Methods: Between October, 2000 and December 2007, a total of 86 neonates aged 30 days or below had a total of Patients and Methods: A Prospective analysis of neonates 124 operations for inguinal hernia at the Jos University Teaching requiring emergency surgical operation over a six year period ( Hospital, Jos , Nigeria (n=57) and Plateau State Specialist Jan 2001 – Dec 2006 ). A predesigned proforma was completed Hospital, Jos, Nigeria(n= 29). Their clinical and operative notes for every patient and information extracted analysed using SPSS have been retrospectively reviewed. 11. Results: There were 82 boys and 4 girls. Their ages at Results: There were a total of 190 patients comprising of 123 ( presentation ranged from 1-30 days (median 21 days). Their 64.7% ) boys and 67 ( 35.3 % ) girls. Age range was 1 day – 28 weight at presentation ranged from 1.8kg -5 kg (median 2.8kg). days ( median 6 days ) while the weight at presentation ranged Thirty four () infants were born premature (birth weight > 2.5kg). from 1.4kg – 3.2kg ( median 2.7kg ). The distance travelled by The follow-up period ranged from 1wk – 36 months (median 24 each neonate to reach our hospital was 1 – 3000km ( median months). Twelve hernias were incarcerated at presentation, 8 120km ). were reduced before operation while 4 were reduced at operation, 3 were gangrenous while 1 had developed fecal fistula. A total of The commonest indication for neonatal surgical emergency in our 38 children had bilateral hernias; 32 were left sided and 16 were setting is anorectal malformation accounting for 88( 46.3% ) on the right side. Eight hernias had associated undescended patients, Anterior abdominal wall defects in 24( 12.6% ) patients, testes requiring orchiopexy. There were a total of 19 ruptured myelomeningocele 18( 9.5% ). Jejuno-ileal atresia in 14( complications; 8 (6.5%) were wound infections, 6 (4.8%) were 7.4% ) patients. Oesophageal atresia with tracheo-oesophageal significant scrotal haematoma, 2 (1.6%) had testicular atrophy fistula and malrotation of the midgut in 8( 4.2% ) and 7(3.7% ) (both patients had incarceration) ; 2 (1.6%) had recurrence while patients respectively. Ruptured sacrococcygeal teratoma and 1 child had high testis requiring orchiopexy. prolapsed patent vitelline duct in 5( 2.6% ) patients each while Hirschsprung’s disease and duodenal stenosis was seen in 3( Conclusion: Complications following inguinal herniotomy are rare 1.57% ) patients each. Duodenal atresia, hydrometrocolpos and in our practice; majority being wound infection. Testicular atrophy omphalitis with peritonitis occurred in 2( 1.1% ) patients each. may supervene in infants presenting with incarceration and Scalp necrotising fascitis and Fournier’s gangrene was seen in 2( probable gangrenous bowel.

1.1% ) patients each. Other indications accounted for 12( 6.3% ). The surgical procedures performed include divided sigmoid Gastroschisis: multi-centre comparison of colostomy 71( 85.5% ) in patients with anorectal malformation, management and outcome resection and primary anastomosis in 10( 71.4% ) with jejuno-ileal atresia, 15( 62.5% ) patients with anterior abdominal wall defect Manson J, Kanvasser N, Chen T, Hesse AAJ, Emil S, Ade-Ajayi had primary closure and 6( 21.0% ) had silo applied. Six ( 62.5% ) N. patients with oesophageal atresia with tracheo-oesophageal Introduction: Gastroschisis (GS) is a congenital full-thickness fistula had feeding gastrostomy, duodenoduodenostomy 4( 80% ), defect of the anterior abdominal wall. The incidence world wide is Ramstedt’s pyloromyotomy 4( 100% ), excision and repair of increasing and in some regions is as high as 1:2,500 live births. myelomeningocele 18( 100% ), Ladd’s procedure in 7(100% ), Improvements in management have resulted in a substantial fall complete excision of sacrococcygeal teratoma in 5( 100% ), in mortality in many regions. Related factors include better resection and closure of prolapsed vitelline duct anomaly in 5( neonatal intensive care strategies, availability of parenteral 100% ) patients. Drainage of hydrometrocolpos 2( 100% ) and nutrition (PN) and the use of silos constructed from prosthetic many other procedures. materials to reduce compartment syndrome. Anecdotally, fewer The postoperative complications occurred in 36(18.9% ) patients, infants present with GS in many African paediatric surgery wound infection 13(36.1% ), wound dehiscence 6( 16.7% ), while centres. This may be related to the smaller numbers of infants sepsis and aspiration with respiratory tract infection occurred in 5( diagnosed antenatally resulting in neonates with this major 13.9% ) each. Jaundice was seen in 3( 8.3% ) patients and other structural anomaly being born unexpected at home or in small complications 4( 11.2% ). peripheral units The overall mortality was 43( 22.6% ) patients, mainly due to Aims: Our aim was to formally assess the similarities and sepsis, associated anomalies and respiratory failure. differences in presentation, management and outcomes of babies born with gastroschisis in Western and African centres. Conclusion: Emergency surgery in the neonate remains a significant component of neonatal surgery in this setting. Morbidity Methods: Retrospective data collection from hospital records for and mortality is still unacceptably high, due largely to delayed infants born with Gastroschisis between 1st January 2004 and presentation and facility limitation. 31st December 2007 in 3 centres; Kings College Hospital, London. UK, Complications following primary inguinal herniotomy University of California , Irvine Medical Center, Orange, CA, USA, in neonates. Korle Bu Teaching Hospital, University of Ghana Lohfa B Chirdan, Aba F Uba, *Emmanuel O Ojo Medical School, Accra, Ghana Paediatric Surgery Unit, Department of Surgery, Jos University Teaching Hospital and *Department of Surgery, Plateau State The data included birth weight, gestational age, surgical Specialist Hospital, Jos, Nigeria. interventions, complications, time to full feeds and discharge. Data are presented as median with ranges. Background: Primary inguinal hernitomy in neonates is a technically demanding procedure and usually associated with increased risk of complications compared to the general Results: paediatric population. The aim of this study was to document the

117 Vol 4, No 3,4, July- October, 2008

KINGS Irvine Korle Bu Method: All antenatally diagnosed and postnatally confirmed exomphalos registered with our fetal medicine unit, during 2002- Number 56 57 2 2007, were reviewed. Both prenatal and postnatal outcomes were analysed. Females (%) 55 56 50 Results: Of 88 cases identified with exomphalos, 85 were Gestation 37 37 36 prenatally diagnosed. 55 of them died in utero (45 terminations, 5 (n/40) (29-39) (30 – 39) (32-40) spontaneous abortions and 5 still births). There were 33 live births Birth Weight 2542 2591 2350 (38%), 7 of which were premature (30-35/40 gestation). Five (grams) (1170 -3646) (1455 -3904) (2000–2700) babies died before coming to surgery (all with major exomphalos Age at 1 1 1 as well as abnormal karyotype) while 28 were operated upon. presentation Fourteen cases with minor exomphalos, eleven of which were (days) isolated, were primarily closed and all survived to discharge. Of Pre-formed 68 72 0 fourteen babies with major exomphalos, four were closed st silo (PFS) 1 primarily. Nine required silo formation and six successfully intervention underwent secondary closure (one of which had a prenatal (%) diagnosis of giant ruptured exomphalos). Surgical 21 28 100 Three died before closure, two from sepsis and multi-organ primary failure, and one from an undiagnosed tracheo-oesophalgeal cleft. closure 1st All three deaths had antenatally diagnosed giant ruptured intervention exomphalos and were less than 34/40 weeks gestation. (%) One baby was managed conservatively with antiseptic solution Age at 6 5 1 applied to the sac and left to heal by secondary intention. There surgical (1 – 11) (2 – 15) were 17 cases of isolated exomphalos (with no other structural abnormalities), all of which survived. closure PFS group (days) Conclusion: Antenatal diagnosis of exomphalos is 96% Mortality (%) 3.6 3.5 0 sensitive. Severe karyotypic and structural abnormalities were present in all intra-uterine and early postnatal deaths. Overall Major 7.1 5.3 0 survival to discharge was 28%. Both minor and isolated complications exomphalos carried a good prognosis. Isolated exomphalos was (%) a better prognostic factor than severity of the exomphalos itself. Ruptured exomphalos were associated with a poorer outcome Time to full 27 20 unknown especially in premature babies. feeds (days) (10-243) (6 – 67) Length of 30 43 28 stay (days) (15 – 256) (16 – 187) (21-34)

Syndromic Exomphalos In Ile – Ife, Nigeria: Conclusion: The hospital admission rate for gastroschisis in a busy African paediatric surgery unit is lower than that in 2 Management Challenges comparably busy Western units OA Sowande1, LIC Anyanwu1, AO Talabi1, AW Inyang1, O 1 Two third of infants in the two Western units have been managed Adejuyigbe . using a PFS during the study period 1Paediatric Surgery Unit, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile – Ife, Key outcome indices in this cohort of patients are comparable Nigeria. across centres

INTRODUCTION: Exomphalos is a centrally located congenital Neonatal survival of prenatally diagnosed Exomphalos abdominal wall defect covered by a membrane. It is commonly associated with other anomalies in 50 – 60% of cases, which Patel G,Sadiq J,Shenker N,Lakhoo K contribute to morbidity and mortality in the patients. The purpose of this study is to review the management of syndromic Department of Paediatric Surgery, Level 2 Children’s Hospital exomphalos in our centre, and to highlight the challenges faced in Oxford, Fetal Medicine Unit Women’s Centre, Oxford ,John our practice. Radcliffe Hospital and University of Oxford . METHODS: We reviewed the records of patients with Syndromic exomphalos who presented to our center between 1997 and Introduction: Exomphalos is characteristically a midline defect, 2007. usually near the insertion point of the umbilical cord, with a viable sac composed of amnion and peritoneum containing herniated RESULTS: There was a total of 10patients, distributed thus– abdominal contents. Incidence is known to be 1 in 4000 live Pentalogy of Cantrell (3), cloacal exstrophy (4), Beckwith– births. Associated major abnormalities which include trisomy 13, Wiedemann Syndrome (3). The ages at presentation of the 18 and 21, Beckwith Wiedemann syndrome (, patients ranged between 2hours and 6weeks with a median of gigantism, exomphalos), Pentology of Cantrell (sternal, 27hours. Their birth weights ranged between 1.6kg and 4.95kg pericardial, cardiac, abdominal wall and diaphragmatic defect), (median 2.45kg). Two of the patients with Pentalogy of Cantrell cardiac, gastrointestinal and renal abnormalities are noted in 60- were discharged against medical advise while the third was lost to 70% of cases. The aim of this study is to determine the factors follow up. Three of the patients managed for cloacal exstrophy that influence survival of antenatally diagnosed exomphalos. died in the immediate post operative period following first stage reconstructive surgery. All were of low birth weight (birth weight <2.5kg), while the fourth was discharged against medical advise.

١١٨ Annals of Pediatric Surgery

Of the patients managed for Beckwith – Wiedemann Syndrome, cervical teratomas allows for planned intervention by experienced two died in the neonatal period of sepsis and neonatal jaundice personnel. the third who had a traumatic vaginal delivery (birth weight 4.95kg) with rupture of her omphalocoele and a right humeral fracture, had surgery and was lost to follow up at age 6months. Of Management of Conjoint Twins in a Developing the 10 patients 4(40%) were discharged against medical advise (1 Country: Our Experience with Four Cases readmitted), 2(20%) were lost to follow up. 5(50%) of the patients had a low birth weight (birth weight <2.5kg). Mohammad AM, Sabiu L, Sani AA, Alhassan SU and Edino ST DISCUSSION: Congenital ventral body wall defects are an Department of Surgery, Bayero University Kano and Aminu Kano important cause of morbidity and mortality in sub-saharan Africa. Teaching Hospital, Kano, Nigeria Corrective surgery for these anomalies in the region is however Background: Conjoint twinning is an interesting anomaly unique froth with many challenges given the poor socio-economic status to multiple pregnancies. This is a rare disorder affecting 1:200 of majority of the populace and the paucity of trained personnel monozygotic twin pregnancies, 1:900 of all twin pregnancies and and facilities. 1:25,000 to 100,000 live births. Their management is extremely complex and experience with large numbers is restricted to few centers worldwide. Head and Neck Teratomas in Newborn: Presentation, Management and Postoperative Variability Methods: Four set of conjoint twins (two symmetrical and two asymmetrical) all delivered at home and diagnosed after delivery, Uba AF, Chirdan LB, Mohammed A, Ituen A, Soo , Osagie B managed in our Paediatric surgery unit are reported and the Paediatric Surgery Unit, Jos University Teaching Hospital, Jos, challenges faced during their treatment are highlighted. Nigeria Results: The management of conjoint twins can be divided in to BACKGROUND: Congenital teratomas of the head and neck are three groups. extremely rare, with high perinatal mortality and morbidity rates. Group 1, non-operative treatment, owing to cardiac fusion or This report is a review of the diagnosis, management and gross anatomical union, one set of our patient fell into this outcomes of head and neck teratomas in neonates presenting to category (Thoraco-omphalophagus) this set died within 24 hours a tertiary referral centre in Nigeria. of presentation. PATIENTS AND METHODS: A retrospective chart review of all Group 2, Those requiring emergency separation when one of the cases of congenital head and neck teratomas in newborn twins died or is threatening the survival of the other sibling or presenting within a 7-year period (2001-2007) was performed at there was a correctable life threatening associated anomalies two the Jos University Teaching Hospital, Jos. Nigeria. sets belongs to this category a set (heterophagus) did not make it RESULTS: There were six patients, 4 girls and 2 boys. Ages at to surgery while the other set (ischiophagus) died 4 days after presentation ranged between 0 and 4 days. Gestational age surgery. ranged between 36 and 42 weeks; the birth weight ranged Group 3, Are those that are stable and can be planned for elective between 2kg and 2.35kg. Maternal age ranged between 18 and separation, allowing time for detailed preoperative investigation 38 years. and planning. One set of our patient (Pygophagus) belong to this Sites were nose (1), cheek (2), inter-epicanthi (2), floor of the category. The separation was uneventful, the second twin died 11 mouth and neck [cervicofacial] (1). Presentation included severe hours after separation, the fist twin is now one year, she had her respiratory distress that necessitated urgent intervention in three colostomy closed at 10 month and she remain healthy afterward. patients. There was maternal polyhyrdamnios in these three Conclusion: Antenatal care and prenatal ultrasound scanning cases. All presented with masses involving the neck and/or face should be done in all suspected twin pregnancies. Accurate for a varying degree. preoperative investigations, multi-disciplinary approach, Four mothers had antenatal care, but only 2 had antenatal meticulous operative and postoperative management is a ultrasonography at 4 and 7 months, respectively. Four mothers prerequisite for successful outcome. had antenatal care in a teaching hospital. None was suspected or diagnosed prenatally. Pediatric Cancer Rates in Kenya All patients had surgical excision under a general anaesthesia. Histology confirmed that all teratomas were benign except one, Franklin C. Margaron, Heuric Rakotomalala, Dan Poenaru which exhibited malignant features. Three neonates died soon BethanyKids at Kijabe Hospital, Kijabe, Kenya after surgery with a mortality rate of 50%. No recurrence has been reported among the survivors. Introduction: The most commonly reported pediatric cancers are leukemias, lymphomas, CNS cancers, neuroblastoma, Wilms’ Although larger tumors caused polyhydramnios more frequently tumor, rhabdomyosarcoma, and osteosarcoma. However, this than smaller tumors, and were associated with more severe information in children is based on data published in developed respiratory distress, the relationship between tumor volume at countries. Epidemiologic cancer data for children in Africa is birth and final outcome could not be established. This makes limited. difficult the identification of fetuses with a disastrous prognosis. Methods: The AIC Kijabe Hospital Pathology database is a CONCLUSION: Although mostly benign, cervical teratomas are collection of all anatomo-pathologic specimens submitted from 45 still associated with high mortality rates. Timely antenatal mission hospitals in Kenya and the region between 1996 and diagnosis may help in reducing morbidity and mortality caused by 2006. A retrospective analysis of these electronic records was upper airway obstruction. All patients that undergo surgical undertaken, focusing on the paediatric age group (0 – 18 years). excision of these tumours must be closely observed for post- operative respiratory distress, even in the absence of pre- Results: The database contained a total of 65,536 specimens. Of operative symptoms. The antenatal diagnosis of large congenital this number, approximately 7,100 were from children under the age of eighteen. Review of this data was performed, identifying

119 Vol 4, No 3,4, July- October, 2008 percentages of both benign and malignant tumours as well as lympocytic interstitial pneumonitis. CD4 counts (n=7) ranged from their average age of presentation. Detailed data will be presented 22 to 631. with regards to cancer type, location, and age. Radiological assessment of retroperitoneal lymph nodes by Conclusions: An electronic pathologic database is very useful in ultrasound or CT scanning was unhelpful. CT scan failed to epidemiologic analysis of surgical pathologies. Generating local differentiate renal lymphoma from neuroblastoma. PET scanning and national data for Kenya is essential to contextualizing the was unable to differentiate metastatic tumour from HIV associated surgical practice in the country. lymphadenitis. One apparent lung metastases was a parenchymal lymph node at biopsy and one pulmonary schistosomiasis. Sacro-Coccygeal Teratomas: Our Experience In 27 Overall only 8 children remain alive. Two children developed IRIS Cases following the introduction of HART. One child suffered numerous infective complications including ethmoid sinusitis and brain Bankole Sanni R., Nandiolo Anelone R., Yebouet Eric., Coulibaly abscess before oncology treatment was abandoned at 1 year. D., Vodi L., Mobiot M.L., Bosson Kiroua She remains alive at 7 years on HART. Two children remain on Treichville Medical University Center, Côte D'ivoire treatment for Wilms’ tumour, tuberculosis and on HART along with nutritional support. Two patients refused treatment and one Introduction: Sacro-coccygeal teratomas (SCT) are defined as was terminal on admission. Ultimately 8 patients were started on vestigial tumoral malformations localized in sacro-coccygeal HART. region originated of multiple tissues from totipotential embryonic cells. In children with HIV/AIDS no imaging modality can reliably differentiate tumour from inflammatory conditions such as TB. Objective: the aim of the work is to give account in the Biopsy of the primary tumour and presumed metastases should management of these children in our context. be performed whenever practicable. False positive nodal disease Material and methods: Our study is retrospective based on 27 makes PET scanning an inappropriate follow-up tool. HIV +ve cases of children carried of SCT and treated in department of children can tolerate standard solid tumour protocols but pediatric-surgery of Treichville university teaching hospital of infectious complications are frequent. Abidjan from January 1983 to march 2005.

Results: The frequency of this condition was of 1, 2 cases per year in our series and the female predomination was noted with a A Prospective Study of Burns Injury in Children in sexual ratio of 0, 17. The tumour had an endopelvis development Imo, South Eastern Nigeria in 2 cases and an exopelvis development in 25 cases, thus 92, Okoro P.E. MBBS Nig, FWACS 1, Opara K.O. MBBS, FWACS 2, 5%. The treatment consist of resection of the tumour in 27 Ezeji G.C. MB,BCH 1Igwe P.O. MBBS 1, Ukachukwu A.K. MBBS children ; un children was discharged against medical advice; the Ib 1 chemotherapy with protocol C.A.V (Cyclophosphamide, Adriamycin, Vincristine) was added to surgery in 1 case due to Paediatric Surgery Unit, Department of Surgery, Federal Medical pulmonary metastasis. These children were followed with an Centre, Owerri, Imo State; average of ten and a half years. The post operative outcome was Paediatric Surgery Unit , Department of Surgery, Imo State uneventful in 60% of our patients. The parietal suppuration with University Teaching Hospital, Orlu, Imo State. disruption of sutures predominated in 30% of cases of complications. One case with anal stenosis was noted post operatively and needed anal dilatation. One case of urinary Introduction: Burns injury are recognized as a major health incontinence was also noted and one child died post operatively problem worldwide. In children, and particularly, in our of cachexia with pulmonary metastasis. The healing rate was of environment where poverty, ignorance and disease are still high, 96, 2% against 3, 8% cases of death. they constitute significant morbidity and mortality. Previous studies on this topic in parts of Nigeria either lumped adults and Conclusion: the management of these children is satisfactory in children together or were retrospective. We, therefore, conceived a developing country like ours. a prospective study of the current trends in burns in children in our region of Nigeria.

Radiological Pitfalls and Outcome in Children with Patients & Methods: Study was designed as a prospective one, Solid Tumours and HIV/Aids spanning over a period of 18 months (June 2006 & Dec 2007). The location of study was the Paediatric Surgery Units of the Imo Hadley GP, Naude F State University Teaching Hospital Orlu and the Federal Medical Departments of Paediatric Surgery and Nuclear Medicine, Centre Owerri, Imo State. Data were collected as the patients University of KwaZulu-Natal and Inkosi Albert Luthuli Hospital, came. Parameters recorded were- age, sex, cause/ type of burn, Durban, South Africa place of burn, presence or absence of adult/s, initial prehospital intervention, interval between injury and presentation, surface In KwaZulu-Natal the prevalence of HIV infection amongst women area and depth of burn, treatment and outcome. Data were then attending antenatal clinics is 39.1% and in 2002 there were compiled and subjected to simple statistical analysis. 70,000 children in the province living with HIV/AIDS. Results: 53 patients were encountered in the course of this Dual pathology makes diagnosis difficult. Children with HIV/AIDS study. 31(58.4%) were male and 22(41.6%) were female giving a who have a non-AIDS defining solid tumour are at risk of a wide M:F ratio of 1.4:1. Patients who were 2 years and below were range of co-morbidity. We have managed 16 children with solid worst affected. 31(58.5%) had burns due to hot water and this tumours (Wilms’ tumour 8, sarcoma 2, ovarian germ cell tumour being the commonest cause of burns injury in our series. The vast 2, hepatoblastoma 1, neuroblastoma 1, lymphoma 2), who were majority of these injuries happened in a domestic environment confirmed to have co-incidental HIV infection. Ten of the children (92.5%) and in the presence of competent adult/s(88.7%). had TB; in the lung in 8 and in the abdomen in 2. Four children Outcome of treatment was good with 2(3.8%) deaths and had either oral or oesophageal candidiasis. One child had 46(86%) complete recovery.

١٢٠ Annals of Pediatric Surgery

Discussion/ Conclusion: Burns is still a major health problem were retrospectively analyzed. Epidemiological data, clinical among children in South Eastern Nigeria. Fortunately, outcome of investigations, surgical details, complications and long-term appropriate treatment is good. However, we think that poor safety outcome data were collected. consciousness among parents is a major predisposing factor. Public enlightenment should emphasize that hot water should Results: There were 593 VPS procedures during the period. The only be boiled to be used immediately. Parents must avoid commonest etiologies were spina bifida (SB) (43.4%) and post- keeping or even storage of hot water for any reason. infectious hydrocephalus (27.7%). The overall mortality was 6% and the complication rate 20%, with 9.1% infectious complications. SB and gender were significantly correlated to complications. (p = 0.03 and p = 0.01 respectively). Mortality was higher among infants (p = 0.001) and those with SB (p = 0.015). Results of Secondary Alveolar Bone Grafting In Younger patients who survived had an overall good outcome (p = Children with Previous Primary Palate Closure 0.0001). Only 10% of patients with a head circumference > 60 cm had a good outcome. C. Medawar, P. Bortoluzzi, H. ElKhatib, L. Caouette Laberge Conclusions: In spite of many challenges, VPS procedures can Hopital Ste-Justine, Montreal, Canada be carried out in Sub-Saharan Africa with acceptable complication

rates and fair outcomes. Attention to morbidity factors can lead to Purpose: To evaluate the results of secondary alveolar bone improved outcomes and better care of these children. grafting in children with primary palate closure at the time of cleft lip repair. Hypospadias Repair In A Resource-Poor Region: Methods: The charts of children with cleft lip and palate who had Coping With The Challenges In 5 Years a primary palate closure at the time of cleft lip repair and secondary alveolar bone graft between 1990-2005 were Osifo O.David, Evbuomwan Iyekoretin, Mene O. Andrew reviewed, to document the type of cleft, age at surgery, presence AFFILIATION: Paediatric Surgery Unit, Department of Surgery, of a fistula and the need for a second alveolar bone graft. University of Benin Teaching Hospital, Benin City, Nigeria Occlusal radiographs obtained after the initial bone graft were reviewed and classified according to the Bergland scale. Objective: Hypospadias repair is challenging particularly in developing countries. The objective of this study is to report the Results: 315 children with unilateral (UCLP:177) or bilateral challenges and outcome of hypospadias repair in a developing (BCLP:83) cleft lip and palate, and cleft lip and primary palate country such as Nigeria. CLPP(55) presented 390 grafted clefts. A small fistula at the junction of primary and secondary palate was noted in 41.2% of Patients and methods: A prospective study on children that children and was closed during bone grafting. Occlusal presented and had hypospadias repair at the University of Benin radiographs were assessed an average of 3.6 years (0.5-10.8y) Teaching Hospital Benin City, between January 2003, and after the initial bone graft. A second bone graft was done in 27 December, 2007. The challenges and outcome of repair were clefts (6.9%). BCLP with unilateral alveolar defects were classified documented on structured pro forma with visual and serial with the UCLP for graft height assessment. photographs used to assess cosmetic outcome. Bergland I and II were present in 90.1% UCLP, 86.8% of BCLP Result: A total of 149 surgeries were done on 127 children with and 96.8% of CLPP. Clefts limited to the primary palate had hypospadias, aged 9 days and 12 years (mean 2.3 years ± 2.1) better overall results. Unilateral CLP results were slightly better with 33 (26.0%) presenting after circumcision; 118 (92.9%) had than the BCLP. The absence of a fistula prior to bone grafting single and 9 (7.1%) multistage, while 13 had closure of post favourably influenced the results (Bergland I and II 95.9 vs. hypospadias repair fistulae and redo surgery. Non availability of 82.2%, p=0.001) adequate paediatric urethral catheters, special dressing materials, microsurgical instruments/sutures, presentation after circumcision Conclusion: The overall success rate (Bergland I and II: 90.3%) and lack of parents/caregivers’ motivation were major challenges. compares favourably with previously published reports. Closure of Transurethral urinary diversion with size 6 FG feeding tube, the primary palate at the time of lip repair reduces the incidence dressing with petroleum jelly impregnated with of oro-nasal fistula prior to bone grafting and has a positive impact antibiotic/chloramphenicol eye ointment, use of mosquito forceps, on bone graft results. scrotal skin flaps, size 6/0 polyglactin sutures and organized counselling/home visits were employed. Overall, successful repair was achieved in all the children; excellent cosmetic result in 121 Complications and Outcome of Ventriculoperitoneal (95.3%), fair in 5 (3.9%) and poor in 1 (0.9%). Urethrocutaneous Shunting In Sub-Saharan Africa fistula was the main complication with no mortality recorded. Esther Gathura, Dan Poenaru, Richard Bransford, Leland Albright Conclusion: Despite the challenges, improvising with available materials, parents/caregivers counselling, adequate patient BethanyKids at Kijabe Hospital, Kijabe, Kenya recruitment and rightly timed repair gave encouraging results.

Introduction: Ventriculoperitoneal shunting (VPS) has been historically associated with high complication rates and poor The Ectopia Vesica Spectrum: 16 Consecutive Cases outcome in Sub-Saharan Africa. Factors include late presentation, in LUTH limited availability of shunts, technical limitations, and limited follow-up. Such poor outcomes have led to frequent questioning *BODE CO, **GIWA SO, *Pediatric Surgery Unit of the utility of treatment of children with advanced **Orthopaedic Unit hydrocephalus. This study reviews the experience of a single high-volume institution with this procedure and offers a more Department of Surgery, Lagos University Teaching Hospital, optimistic view, as well as suggestions for improving outcomes. Lagos Materials and methods: Records of all patients treated with VPS We present the surgical management of 16 cases of ectopia at one institution between January 2004 and December 2006 vesica seen at the Lagos University Teaching Hospital over a 5-

121 Vol 4, No 3,4, July- October, 2008 year period, highlighting the variation in severity of this anomaly form the prepuce while smegmoma was a result of incomplete from simple ones requiring little correction to complex cases removal of all smegma. Most of these complications were needing major surgery. The management challenges are managed with minor procedures but the urethrocutaneous fistulae highlighted in a how-I-do-it fashion. necessitated major surgery for correction. Conclusion: Circumcision is a common procedure done by a wide range of workers mostly for cultural and religious in our Complications of Circumcisions in the Korle-bu environment but has definite medical benefits. Considering the Teaching Hospital variety of practitioners the complication rate is relatively low in our environment. For this procedure to be truly beneficial however Appeadu-Mensah W, Hesse AAJ, Glover Addy H, Etwire V attempts should be made to avoid all preventable complications. Paediatric Surgery Unit, Department of Surgery Korle-bu. Proper training with a good referral system could help minimise

these complications. Introduction: Circumcision remains one of the commonest operations done in our country Ghana. Those who practise circumcision include locally trained ‘wanzams’, orderlies, nurses, Laparoscopic assisted ano-rectal pullthrough medical officers, and surgeons. The majority of complications (LAARP): lessons learnt from the first 10 cases at associated with circumcisions are seen and managed by the Tygerberg Children’s Hospital Paediatric Surgery unit of the Korle-bu Teaching hospital. In this paper we review the complications of circumcision seen in this D. Sidler unit over a 2 year period. Tygerberg Children’s Hospital, Stellenbosch University, Cape Method: This is a retrospective study of patients presenting with Town, South Africa complications of circumcision over a 2 year period between January 2006 and December 2007. The introduction of LAARP, has since its first description in 2000 Results: 79 complications of circumcision were seen over the brought new surgical options in the management of high ano- period. These included Urethrocutaneous fistulae (26), Bleeding rectal malformations (ARM). circumcisions(12), Smegmomas(2), Buried Penis(5), Meatal We present the first 10 cases of LAARP treated at the Tygerberg stenosis (2),Coronal Adhesions (8) and Incomplete excision of Children’s Hospital and reflect on the lessons learned. The male foreskin (24). There was no recorded case of infection, to female ratio was 9:1 and 8 males had a high ARM with a recto- amputation of the glans or excision of excess foreskin during this bulbar urethral fistula and one a recto-prostatic fistula. The female period. These complications were seen in patients referred to our patient had a high blind ending without a fistula. Six of the unit from other health or informal facilities. 10 patients had associated abnormalities. One patient presented 11 patients had repair of their urethrocutaneous fistulae, the with symptomatic midgut malrotation and required a Ladd’s bleeding circumcisions were controlled, and smegmomas procedure, performed laparoscopically at the same time. excised. The buried penises were exposed and the remnant inner Setting up the procedure was time consuming, but the average prepuce which was present in most of them excised. Those with surgical duration was shorter than a PSARP, on a mean less than meatal stenosis had meatoplasty done, coronal adhesions were two hours. lysed, and the remnant foreskins excised in those with incomplete circumcisions. Six early complications occurred in 4 patients. These included ongoing oozing of blood from releasing adhesions, an ischaemic During this period 140 circumcisions were done in our unit. One sigmoid colon (requiring a redo laparascopic pull-through), one patient bled on her way home and returned to the ward where early adhesive bowel obstruction requiring laparatomy and haemostasis was secured. This was the only complication noted inadvertant intra-operative injury of the vas deferens. The cause over the period. of the necrotic sigmoid was attributed to a division of the vascular Discussion: Circumcision remains a common surgical procedure arcade at the time of colostomy. performed by a variety of workers in our country, ranging from Other lesser problems included a small residual uretheric locally trained ‘wanzams’, to orderlies, nurses, medical officers diverticulum (that hasn’t caused any problems), a mild mucosal and surgeons. Indications in our environment are cultural and prolapse and an early tension-retraction requiring redo ano-plasty. religious for the majority of patients. Medical indications ranging from prevention of UTI in infancy to phimosis, paraphimosis, All patients recovered quickly, feed early and required very little balanitis xerotica obliterans, prevention of carcinoma of the penis pain management. Most suffer from constipation and some and prevention of sexually transmitted diseases including HIV are leakage, but toilet training has not yet been completed in the increasingly being recognised. Complications of the procedure majority. have been sited as reasons for avoiding this procedure1. There is however increasing evidence that the benefits far outweigh the LAARP is a feasible procedure in an African setting. It is of risks. For it to be truly beneficial however complications need to paramount importance that the original sigmoid colostomy is sited be minimised. In this paper 79 complications were noted over a at the right level without compromising length and vascularity. 2 year period in our centre which serves as a referral hospital for Improvement of long-term follow up is essential in order to patients in the southern half of the country .The country has a improve functional outcome. population of about 20 million people with 41% under 14 , male to female ratio of 1.03 to 1, and a birth rate of 24 per 1000 population. 24 of these patients presented for excision of remnant A Case against Neonatal Circumcision as a foreskin essentially for cosmetic reasons since they were not Preventative measure to reduce HIV Infection Rates satisfied with the initial procedure done. This necessitated another surgical procedure for the child. 26 presented with D. Sidler urethrocutaneous fistulae which usually occurs as a result of attempts to secure haemostasis. Patients who presented with Tygerberg Children’s Hospital, Stellenbosch University, Cape buried penis had a remnant inner preputial layer. Coronal Town, South Africa adhesions were associated with improper separation of the glans

١٢٢ Annals of Pediatric Surgery

Non-therapeutic circumcision is the most commonly published recently circumcised HIV-positive men have an 58% increased surgical procedure, still lacking a unambiguous and clear incidence of HIV acquisition. To roll-out a new program based on indication. Since its advent in the US during the Victorian period, scant evidence, suggesting to the African public that circumcision as a potential prophylaxis for masturbation, it progressed to could reduce a male’s chances of contracting HIV by 50–60% is prevention of different infective conditions (STDs, penile and not only inconclusive, but misleading. Coercing adults and forcing cervical cancer) and has been advocated as control of the sexual infants to be circumcised is unethical. drive. It has recently been advocated as intervention for the prevention of HIV/AIDS by the UNAIDS/WHO The use of adult male circumcision (MC) to curb HIV in Africa is, therefore, controversial, and has the potential to worsen the crisis Although it is agreed that the HIV/AIDS crisis demands while expending scarce resources that could be applied better for extraordinary intervention, it is nevertheless questionable if more effective preventive measures. The use of neonatal non- circumcision and particularly neonatal circumcision, could achieve therapeutic circumcision to combat the HIV crisis in Africa is such goal. A rational and critical analysis of the available scientific neither medically nor did ethically justifiable base on current evidence ought to lead to the conclusion that non-therapeutic medical evidence or universally recognized ethical and human infant circumcision could be nothing more than the medicalization rights principles. There are more effective prevention tools costing of an old ritual and that it should not be advocated as an considerably less and offering better HIV reduction outcomes than adequate prevention strategy of HIV/AIDS in the 21st century. circumcision. Before the three controversial RCTs were published, a Cochrane In conclusion the foreskin has evolved over millions of years and Systematic Review concluded that there was not enough is an integral part of the phallus with important function. To cut an evidence to suggest mass roll-out of circumcision to prevent infant’s genital unless medically indicated, is controversial. HIV/AIDS. Irrespective of this review, advocates of mass roll-out Medical indications for circumcision which has short- and long- of prophylactic circumcision continued publishing the multiple term benefits for the child, are rare. It is absolutely imperative that benefits of infant non-therapeutic circumcision either without any surgical procedure in children is done under anaesthetic and mention of the Cochrane Systematic Review or per occasion that post-operative analgesia is provided. Within the science and misrepresenting it. In South Africa infant non-therapeutic art of surgery, one recognises therapeutic and prophylactic or circumcision is becoming illegal, making the discussion of infant preventive procedures. Preventive or prophylactic surgery is only circumcision moot. undertaken if the condition to prevent is common, serious and if there are no other options to prevent it. These criteria are not met The three RCTs done in Africa, showing a reduction in female-to- in the suggested indications for preventive infant circumcision. male transmission of HIV after prophylactic circumcision, lack Therefore, circumcision as a tool of heightened hygiene and evidence of being applicable and repeatable in real-world prevention of infections can be seen as a medicalization of a situations. No field test has been performed to test the theory and religious ritual and a social infective meme that is used powerfully to analyze its effectiveness, cost, and complications. On the to subordinate the vulnerable. contrary, there is worrying data showing that female partners of

123 Vol 4, No 3,4, July- October, 2008