Paediatric Surgery: A Comprehensive Text for

Editors: Emmanuel A. Ameh Stephen W. Bickler Kokila Lakhoo Benedict C. Nwomeh Dan Poenaru

www.global-help.org ii Paediatric Surgery: A Comprehensive Text for Africa Table of Contents

Contributing Authors ...... iv 28. Thoracic Trauma ...... 180 Foreword ...... iv 29. Abdominal Trauma ...... 184 Publisher’s note & Preface ...... xxi 30. Craniocerebral and Spinal Trauma ...... 190 Acronyms ...... xx 31. Urogenital and Perineal Trauma ...... 200 32. Musculoskeletal Trauma ...... 208 BASIC PRINCIPLES 33. Burns ...... 214 Paediatric Surgery Specialty and its 1. 34. Injuries from Child Abuse ...... 222 Relevance to Africa ...... 3 35. Birth Injuries ...... 228 2. Neonatal Physiology and Transport ...... 8 3. Respiratory Physiology and Support ...... 14 HEAD AND NECK 4. Cardiovascular Physiology and Support . . . . . 17 36. Neck: Cysts, Sinuses, and Fistulas ...... 234 5. Fluids and Electrolyte Therapy 37. Lymphadenopathy in African Children . . . . . 240 in the Paediatric Surgical Patient ...... 23 38. Sternomastoid Tumour of Infancy 6. Nutritional Support ...... 30 and Congenital Muscular Torticollis ...... 248 7. Haemoglobinopathies ...... 34 39. Salivary Gland Diseases in Children 8. Wound Healing ...... 40 and Adolescents ...... 254 9. Vascular Access in Children ...... 47 40. Thyroid and Parathyroid Glands ...... 262

10. Anaesthesia and Perioperative Care ...... 55 THORAX 11. Pain Management ...... 61 41. Laryngoscopy, Bronchoscopy, 12. Intensive Care ...... 67 and Oesophagoscopy ...... 272 13. Ethics of Paediatric Surgery in Africa ...... 76 42. Paediatric Upper Airway Obstruction ...... 277 14. Psychological Issues in 43. Tracheomalacia ...... 283 Paediatric Surgery ...... 82 44. Congenital Cystic Lung Lesions ...... 287 SURGICAL INFECTIONS AND INFESTATIONS 45. Congenital Diaphragmatic Hernia and Diapharagmatic Eventration ...... 291 15. Common Bacterial Infections in Children . . . . 92 46. Pleural Effusion and Empyema ...... 299 16. Surgical Site Infection ...... 98 47. Lung Abscess ...... 304 17. Surgical Complications of Typhoid Fever . . . . 103 48. Oesophageal Atresia ...... 306 18. Tuberculosis ...... 111 49. Gastro-oesophageal Reflux Disease ...... 310 19. Pyomyositis ...... 120 50. Achalasia ...... 319 20. Omphalitis ...... 124 51. Corrosive Ingestion and 21. Necrotising Fasciitis ...... 129 Oesophageal Replacement ...... 323 22. Haematogenous Osteomyelitis 52. Aerodigestive Foreign Bodies in Children . . . . 329 and Septic Arthritis ...... 135 53. Chest Wall Deformities ...... 332 23. Parasitic Infestations of Surgical Importance in Children ...... 141 54. Mediastinal Mass ...... 338 24. HIV/AIDS and the Paediatric Surgeon . . . . . 151 55. Chylothorax ...... 342

TRAUMA ABDOMINAL WALL

25. Paediatric Trauma: Epidemiology, 56. Congenital Anterior Abdominal Wall Prevention, and Control ...... 157 Defects: Exomphalos and Gastroschisis . . . . 348 26. Paediatric Injury Scoring and Trauma Registry . . 164 57. Disorders of the Umbilicus ...... 352 27. Initial Assessment and Resuscitation 58. Inguinal and Femoral Hernias and of the Trauma Patient ...... 172 Hydroceles ...... 358 Paediatric Surgery: A Comprehensive Text for Africa iii

STOMACH, DUODENUM, AND SMALL INTESTINE 96. Phimosis, Meatal Stenosis, and Paraphimosis . . 573 Urolithiasis ...... 578 59. Infantile Hypertrophic Pyloric Stenosis . . . . . 381 97. Undescended Testis ...... 582 60. Peptic Ulcer Disease ...... 385 98. Disorders of Sex Development ...... 585 61. Neonatal Intestinal Obstruction ...... 389 99. Bladder Outlet Obstruction ...... 594 62. Duodenal Atresia and Stenosis ...... 394 100. Acute Scrotum ...... 603 63. Intestinal Atresia and Stenosis ...... 398 101. 64. Vitelline Duct Anomalies ...... 402 TUMOURS 65. Intestinal Malrotation and Midgut Volvulus . . . 406 102. Kidney Tumours ...... 610 66. Gastrointestinal Duplications ...... 410 103. Teratomas ...... 614 67. Meconium Ileus ...... 414 104. Lymphomas and the Paediatric Surgeon . . . 618 68. Intussusception ...... 417 105. Neuroblastoma ...... 622 69. Miscellaneous Causes of 106. Malignant Soft Tissue Tumours ...... 626 Intestinal Obstruction ...... 425 107. Liver Tumours ...... 635 70. Necrotizing Enterocolitis ...... 429 108. Primary Bone Tumours ...... 646 71. Short Bowel Syndrome ...... 437 109. Brain and Spinal Cord Tumours ...... 652 72. Gastrointestinal Stomas ...... 442 VASCULAR SYSTEM COLON, RECTUM, AND ANUS 110. Lymphangioma ...... 661 73. Colonic Atresia ...... 450 111. Haemangioma ...... 670 74. Appendicitis ...... 453 112. Arteriovenous Malformations ...... 673 75. Inflammatory Bowel Disease ...... 456 113. Unilateral Limb Enlargement ...... 677 76. Hirschsprung’s Disease and Malformations ...... 461 PAEDIATRIC GYNAECOLOGY 77. Anorectal Malformations ...... 468 114. Hydrometrocolpos ...... 685 78. Polyps ...... 474 115. Vaginal and Uterine Duplications ...... 691 79. Other Anorectal Conditions ...... 478 116. Labial Adhesions and Agglutination ...... 695 117. Ovarian Lesions ...... 698 HEPATOBILIARY SYSTEM, PANCREAS, AND SPLEEN 80. Obstructive Jaundice ...... 485 SURGICAL REHABILITATION 81. Biliary Atresia ...... 489 118. General Disability: the Concept ...... 707 82. Choledochal Cyst ...... 496 119. Neurodisability ...... 712 83. Cholelithiasis (Gallstones) ...... 500 120. Orthopaedic Disability ...... 722 84. Annular Pancreas ...... 504 121. Plastic and Reconstructive Surgery . . . . . 737 85. Pancreatitis ...... 507 SPECIAL TOPICS 86. Spleen ...... 512 122. Minimally Invasive Surgery 87. Portal Hypertension ...... 516 in Paediatric Patients ...... 751 PAEDIATRIC UROLOGY 123. Prenatal Diagnosis and Fetal Therapy . . . . 759 88. Cystic Diseases of the Kidney ...... 523 124. Conjoined and Parasitic Twins ...... 763 89. Congenital Uerteropelvic Junction Stenosis . . . 526 125. Otorhinolaryngology ...... 769 90. Ureteric Duplications and Ureterocoeles . . . . 531 126. Paediatric Transplantation ...... 779 91. Vesicoureteric Reflux ...... 536 127. Telemedicine and e-Health ...... 790 92. Bladder Exstrophy and Epispadias ...... 541 128. Paediatric Surgical Education in Sub-Saharan Africa ...... 796 93. Urethral Valves ...... 551 94. Hypospadias ...... 554 95. Circumcision ...... 567 iv Paediatric Surgery: A Comprehensive Text for Africa Contributing Authors

Francis A. Abantanga, MD, Cert Paed Surg, PhD, FWACS, Cert Emmanuel A. Ameh, MBBS, FWACS, FACS Cardio Surg, FGCS Professor and Consultant Paediatric Surgeon Associate Professor, Head, Department/Directorate of Surgery Chief, Division of Paediatric Surgery, Department of Surgery School of Medical Sciences/Komfo Anokye Teaching Hospital Ahmadu Bello University and Ahmadu Bello University Teaching Hospital College of Health Sciences Zaria, Nigeria Kwame Nkrumah University of Science and Technology Kumasi, Ghana Nkeiruka Ameh, MBBS, FWACS Senior Lecturer and Consultant Obstetrician and Gynecologist Hesham M. Abdelkader, MD, MRCS, FEBPS Reproductive Endocrinology & Infertility Unit Lecturer of Pediatric Surgery Department of Obstetrics & Gynecology Division of Pediatric Surgery Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Ain Shams University Zaria, Nigeria Cairo, Egypt Manali S. Amin, MD, FACS Lukman O. Abdur-Rahman, MBBS, MPH, FWACS Instructor, Department of Otology and Laryngology Senior Lecturer and Consultant Paediatric Surgeon Harvard Medical School Paediatric Surgery Unit, Department of Surgery Associate in Otolaryngology, Department of Otolaryngology College of Health Sciences, University of Ilorin and University of Ilorin and Communication Disorders Teaching Hospital Children’s Hospital Boston Ilorin, Nigeria Boston, Massachusetts, U .S .

Auwal M. Abubakar, MBBS, FWACS, FICS Safwat S. Andrawes, MBChB, MMed Surgery, MSc Urology, Associate Professor and Consultant Paediatric Surgeon FICS, FCS (ESCA) Paediatric Surgery Unit, Department of Surgery Consultant Paediatric Surgeon and Paediatric Urologist College of Medical Sciences, University of Maiduguri and Gertrude’s Children Hospital University of Maiduguri Teaching Hospital Nairobi, Kenya Maiduguri, Borno State, Nigeria William Appeadu-Mensah, MB, CHB, FWACS, FGCS Adesoji O. Ademuyiwa, MBBS, FWACS, FMCS (Nig) Paediatric Surgery Unit, Department of Surgery Lecturer and Consultant Paediatric Surgeon University of Ghana Medical School Paediatric Surgery Unit, Department of Surgery Korle-Bu Teaching Hospital College of Medicine, University of Lagos Accra, Ghana Lagos, Nigeria Marion Arnold, MBChB , DCH (SA) James O. Adeniran, MBBS (Ib), FRCS (Glasg), FWACS, Division of Pediatric Surgery Dip Paed Surg (Lond) University of Stellenbosch Professor of Paediatric Surgery Tygerberg, South Africa Paediatric Surgical Unit University of Ilorin and University of Ilorin Teaching Hospital Johanna R. Askegard-Giesmann, MD Ilorin, Nigeria Clinical Research Fellow Department of Pediatric Surgery Frank Agada, FRCS Ed Nationwide Children’s Hospital Department of ENT, Head and Neck Surgery The Ohio State University York Hospital Columbus, Ohio, U .S . York, U .K . Jane P. Balint, MD Sunday Olusegun Ajike, BDS, FWACS, PGDPA Associate Professor of Clinical Pediatrics Associate Professor and Consultant Maxillofacial Surgeon The Ohio State University College of Medicine Department of Dental Surgery Director, Intestinal Support Service Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Division of Pediatric Gastroenterology, Hepatology, and Nutrition Zaria, Nigeria Nationwide Children’s Hospital Columbus, Ohio, U .S . Jennifer H. Aldrink, MD Assistant Professor of Clinical Surgery Behrouz Banieghbal, MB, BCh, BAO, FRCSI, FRC (SA) Paed Surg The Ohio State University College of Medicine Paediatric Surgeon and Senior Lecturer Division of Pediatric Surgery Division of Paediatric Surgery Nationwide Children’s Hospital Johannesburg General Hospital Columbus, Ohio, U .S . University of the Witwatersrand Johannesburg, South Africa Christopher C. Amah, MB ChB, FWACS Senior Lecturer & Consultant Pediatric Surgeon Nick Bauman, MD, FRCSC Department of Pediatric Surgery BethanyKids at Kijabe Hospital University of Nigeria and University of Nigeria Teaching Hospital Kijabe, Kenya Enugu, Nigeria Paediatric Surgery: A Comprehensive Text for Africa v

Peter Beale, FCS (SA); M Med Chir (Pret), FRCS (Edin) Andrew Coatesworth, FRCS (ORL-HNS) Head of Paediatric Surgery Division Department of ENT, Head & Neck Surgery University of the Witwatersrand York Hospital Johannesburg, South Africa York, U .K .

Stephen W. Bickler, MD, DTM&H, FACS, FAAP Oriana D. Cohen, BA Professor of Surgery & Pediatrics Department of Surgery, Division of Pediatric Surgery University of California, San Diego New York University Langone Medical Center Attending Pediatric Surgeon New York, New York, U .S . Children’s Hospital of San Diego San Diego, California, U .S . Sharon Cox, MBChB, FCS (SA), Cert Paed Surg (SA) Senior Consultant in Paediatric Surgery Christopher Bode, MBCHB, FWACS, FMCS (Nig) Department of Pediatric Surgery Associate Professor and Consultant Paediatric Surgeon School of Child and Adolescent Health and Red Cross War Memorial Paediatric Surgery Unit, Department of Surgery Children’s Hospital Lagos University and Lagos University Teaching Hospital University of Cape Town, Rondebosch Lagos, Nigeria Cape Town, South Africa

Laura Boomer, MD Olamide O. Dairo, MD Resident in General Surgery Assistant Professor of Anesthesiology University of Nevada School of Medicine The Ohio State University Las Vegas, Nevada, U .S . Attending Anesthesiologist Nationwide Children’s Hospital Eric Borgstein, MD, FRCS (Edin), FCS (ECSA) Columbus, Ohio, U .S . Professor of Surgery Consultant Paediatric Surgeon Osarumwense David Osifo, MBBS, FWACS, FICS College of Medicine, University of Malawi Lecturer/Consultant Paediatric Surgeon Queen Elizabeth Central Hospital University of Benin Teaching Hospital Blantyre, Malawi Benin City, Nigeria

Richard Bransford, MD, FACS Miliard Debrew, MD, FRCS (Eng), FCS (ECSA) Program Director Assistant Professor of Paediatric Surgery BethanyKids at Kijabe Hospital Black Lion Hospital, Addis Ababa University Kijabe, Kenya Addis Ababa, Ethiopia

Mairo Adamu Bugaje, MBBS (ABU), FWAC-Paed Ashish Desai, FRCS, FEBPS, MCh Paed, DNB Paed Surg Senior Lecturer and Consultant Paediatrician Consultant Paediatric Surgeon Head, Department of Paediatrics King’s College Hospital Ahmadu Bello University and Ahmadu Bello University London, U .K . Teaching Hospital Zaria, Nigeria David P. Drake, MA, MB, BChir, FRCS, DCH Consultant Paediatric Surgeon Brian H. Cameron, MD, FRCSC, FACS Department of Paediatric Surgery Associate Professor of Pediatric Surgery Great Ormond Street Hospital for Children McMaster Children’s Hospital London, U .K . Hamilton, Ontario, Canada Felicitas Eckoldt-Wolke, Professor of Pediatric Surgery Louise Caouette-Laberge, Paediatric Plastic Surgeon Chair and Chief of Clinic of Paediatric Surgery and Professor of Surgery Jena University Hospital Hospital Sainte-Justine Friedrich Schiller University of Jena Université de Montréal Jena, Germany Montréal, Qubec, Canada Stella A. Eguma, MBBS, DA, FWACS Richard F. Carter, MD Professor of Anaesthesia Senior Resident, General Surgery Ahmadu Bello University Department of Surgery Consultant Anaesthetist Virginia Commonwealth University School of Medicine Ahmadu Bello University Teaching Hospital Richmond, Virginia, U .S . Zaria, Nigeria Consultant Anaesthetist John Chinda, MBBS, FWACS John F Kennedy Memorial Hospital Lecturer and Consultant Paediatric Surgeon Monrovia, Liberia Paediatric Surgery Unit, Department of Surgery University of Maiduguri and University of Maiduguri Teaching Hospital Sebastian O. Ekenze, MBBS, FWACS Maiduguri, Nigeria Senior Lecturer & Consultant Pediatric Surgeon Department of Pediatric Surgery Lohfa B. Chirdan, MBBS, Dip Paed Surg (Lond), FWACS University of Nigeria and University of Nigeria Teaching Hospital Associate Professor and Consultant Paediatric Surgeon Enugu, Nigeria Paediatric Surgery Unit, Department of Surgery University of Jos and Jos University Teaching Hospital Khalid A. ElAsmar, MBBCH, MS, MRCS Jos, Nigeria Division of Pediatric Surgery Ain Shams University Cairo, Egypt vi Paediatric Surgery: A Comprehensive Text for Africa

Hesham Soliman El Safoury, MD Larry Hadley, MB .CHB .,FRCS (Edin),FCS (SA) Professor of Pediatric Surgery Professor and Head of Department of Paediatric Surgery Ain-Shams University Nelson Mandela School of Medicine Cairo, Egypt University of KwaZulu-Natal Durban, South Africa Charles F.M. Evans, BSc, MBBS, MRCS (Eng), MD Department of Paediatric Surgery Alaa F. Hamza, MD, FRCS, FAAP (Hon) Oxford Children’s Hospital Professor of Pediatric Surgery John Radcliffe Hospital Head of Liver Transplantation Unit Oxford, U .K . Division of Pediatric Surgery Ain Shams University Iyekeoretin Evbuomwan, Professor and Consultant Cairo, Egypt Paediatric Surgeon Department of Surgery Edward Hannon, BSc (Hons), MBChB (Hons), MRCS University of Benin and University of Benin Teaching Hospital Specialist Registrar in Paediatric Surgery Benin, Nigeria Oxford Children’s Hospital Oxford, U .K . Renata Fabia, MD, PhD, FACS Assistant Professor of Clinical Surgery Sameh Abdel Hay, MD The Ohio State University Professor and Chief, Pediatric Surgery Unit Director of Burn Unit Ain Shams University Nationwide Children Hospital Cairo, Egypt Columbus, Ohio, U .S . Hugo A. Heij, MD, PhD Julia B Finkelstein Professor of Paediatric Surgery and Head New York University Langone School of Medicine Paediatric Surgical Centre of Amsterdam New York, New York, U .S . Emma Children’s Hospital AMC and VU University Medical Centre Amsterdam, The Netherlands Andrew P Freeland, FRCS Consultant ENT Surgeon Chris Heinick, Paediatric Surgeon John Radcliffe Hospital Klinik für Kinderchirurgie der Friedrich-Schiller Universität Oxford, U .K . Jena, Germany

Howard B Ginsburg, MD Afua A. J. Hesse, MB .ChB FRCS (Ed), FWACS, FGCS, Director Cert,HMPP (Leeds) Division of Pediatric Surgery, Department of Surgery Associate Professor and Consultant Paediatric Surgeon New York University Langone School of Medicine Head, Department of Surgery New York, New York, U .S . Korle-Bu Teaching Hospital and the University of Ghana Medical School Accra, Ghana John R. Gosche, MD, PhD Chief, Division of Pediatric Surgery Rowena Hitchcock, MB BCh, MA, MD, FRCS Professor of Surgery, Department of Surgery Consultant Paediatric Urologist University of Nevada School of Medicine Oxford Children’s Hospital Las Vegas, Nevada, U .S . Oxford, U .K .

Hugh W. Grant, BSc, MB ChB, MD, FRCS (Edin), FRCS (Eng) Piet Hoebeke, MD, PhD Consultant Paediatric Surgeon Head of Department of Urology John Radcliffe Hospital Paediatric Urology and Urogenital Reconstruction Oxford, U K. . Ghent University Hospital Ghent, Belgium Jonathan I. Groner, MD, FACS, FAAP Professor of Clinical Surgery Sarah Howles, MRCS (Eng), MA The Ohio State University College of Medicine Department of Paediatric Surgery Interim Chief, Department of Pediatric Surgery Oxford Children’s Hospital Trauma Medical Director Oxford, U .K . Nationwide Children’s Hospital Columbus, Ohio, U .S . Amy Hughes-Thomas, BSc (Hons), MBBS, MRCS (Eng) Specialist Registrar Paediatric Surgery Devendra K Gupta, MBBS, MS MCh, FAMS, FRCS, The Children’s Hospital, John Radcliffe NHS Trust DSc (Honoris Causa) Oxford, England Professor and Head, Department of Pediatric Surgery All Institute of Medical Sciences Akanidomo J. Ibanga, BSc, MSc (Clin Psych) New Delhi, India School of Psychology University of Birmingham Ahmed T. Hadidi, MB, BCh, MSc, MD, FRCS (Eng, Glasgow), Birmingham, West Midlands, U .K . FA (Germany), PhD Professor of Pediatric Surgery Hannah B. Ibanga, MBBS, FWACP (Paeds), Child Psychology (Dip) Chairman of Pediatric Surgery Dept . Offenbach Hospital, Offenbach Emergency Department Chairman of Pediatric Surgery Dept ., Emma Hospital, Seligenstadt Birmingham Children’s Hospital Frankfurt, Hessen, Germany Birmingham, West Midlands, U .K .

Paediatric Surgery: A Comprehensive Text for Africa vii

Rebecca Inglis, BM BCh, MA (Cantab) Kokila Lakhoo, PhD, FRCS (Eng + Edin), FCS (SA), Junior Research Fellow MRCPCH (U .K .), MBCHB Department of Paediatric Surgery Consultant Paediatric Surgeon and Senior Lecturer John Radcliffe Hospital Children’s Hospital Oxford and University of Oxford Oxford, U .K . Oxford, U .K . African Affiliation: KCMC Tanzania Sha-Ron Jackson, leMD Pediatric Surgery Research Fellow Richa Lal, MS, MCh Children’s Hospital Los Angeles Additional Professor and Head Keck School of Medicine Department . of Pediatric Surgery University of Southern California Sanjay Gandhi Post Graduate Institute of Medical Sciences Los Angeles, California, U .S . Lucknow, Uttar Pradesh, India

Iftikhar Ahmad Jan, MBBS, FCPS, FRCS (Eng + Edin), David A. Lanning, MD, PhD FACS, FEBPS Surgeon-in-Chief, Children’s Hospital of Richmond Professor of Pediatric Surgery Associate Professor of Surgery and Attending Pediatric Surgeon The Children’s Hospital Department of Surgery PIMS Islamabad and National Institute of Rehabilitation Medicine Virginia Commonwealth University School of Medicine Islamabad, Richmond, Virginia, U .S .

Jayaratnam Jayamohan, MBBS, FRCS, BSc Michael Laschat, MD Consultant Paediatric Neurosurgeon Consultant, Paediatric Anaesthesia Oxford Children’s Hospital Children`s Hospital Oxford, U .K . Cologne, Germany

V. T. Joseph, FRCS, MD Mohammed A. Latif Ayad, MD Consultant Paediatric Surgeon Consultant of Pediatric Surgery John Radcliffe Hospital Division of Pediatric Surgery Oxford, U .K . Ain Shams University Cairo, Egypt Jonathan Karpelowsky, MBBCh, FCS (SA), Cert Paed Surg (SA) Senior Specialist John Lazarus, MBChB, FC UROL (SA), MMed (Urology) Department of Paediatric Surgery Paediatric Urologist Red Cross War Memorial Children’s Hospital Red Cross War Memorial Children’s Hospital Cape Town, South Africa University of Cape Town Cape Town, South Africa Brian D. Kenney, MD Assistant Professor of Clinical Surgery Jacob N. Legbo, MBBS, FWACS, FMCS (Nig), FRCSEd, FICS Department of Pediatric Surgery Senior Lecturer and Consultant Plastic and Reconstructive Surgeon Nationwide Children’s Hospital Plastic Surgery Unit, Department of Surgery The Ohio State University Usmanu Danfodiyo University and Usmanu Danfodiyo University Columbus, Ohio, U .S . Teaching Hospital Sokoto, Nigeria John Kimario, MMed Consultant ENT Surgeon Katrine Lofberg, MD Muhimbili National Hospital Surgical Resident Dar es Salaam, Tanzania Oregon Health & Science University Portland, Oregon, U .S . Sharon Kling, FCPaed (SA), MMed (Paed), M Phil Tygerberg Children’s Hospital and Stellenbosch University Muhammad Raji Mahmud, MBBS, FWACS Cape Town, South Africa Lecturer and Consultant Neurosurgeon Division of Neurosurgery, Department of Surgery Sanjay Krishnaswami, MD,FACS, FAAP Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Educational Director, Pediatric Surgical Residency Zaria, Nigeria Assistant Professor, Division of Pediatric Surgery Oregon Health & Science University Amaani K. Malima, MD (Bulgaria), MMed (Orthop-Tumaini), Portland, Oregon, U .S . FCS (ECSA) Head, Department of Surgery Neetu Kumar, MBBS, MRCS Temeke Municipal Hospital Jenny Lind Children’s Department Dar es Salaam, Tanzania Norfolk & Norwich University Hospital Norwich, U K. . N. Marathovouniotis, MD Department of Paediatric Surgery and Paediatric Urology Jean-Martin Laberge, MD, FRCSC, FACS Childrens Hospital Paediatric Surgeon and Professor of Surgery Town of Cologne, Germany Division of Pediatric General Surgery The Montreal Children’s Hospital of the McGill University Health Center Franklin C. Margaron, MD Montreal, Québec, Canada Senior Resident, General Surgery Department of Surgery Virginia Commonwealth University School of Medicine Richmond, Virginia, U .S . viii Paediatric Surgery: A Comprehensive Text for Africa

Maurice Mars, MBChB, MD Charles N. Mock, ScB, MPH, MD, PhD, FACS Department of TeleHealth Professor, Department of Surgery, and Professor of Epidemiology Nelson R Mandela School of Medicine University of Washington, Seattle, Washington, U .S . University of Kwa-Zulu Natal Visiting Senior Lecturer Durban, South Africa Department of Surgery School of Medical Sciences/Komfo Anokye Teaching Hospital Ruth D. Mayforth, MD, PhD College of Health Sciences, Kwame Nkrumah University of Consultant Paediatric Surgeon Science and Technology BethanyKids at Kijabe Hospital Kumasi, Ghana Kijabe, Kenya Sam W. Moore, MBChB, FRCS, Doctor of Medicine (MD) Hyacinth N. Mbibu, BSc, MBBS, FWACS Division of Pediatric Surgery Professor and Consultant Urologist Tygerberg Hospital Division of Urology, Department of Surgery University of Stellenbosch Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Tygerberg, South Africa Zaria, Nigeria Paul J. Moroz, MD, MSc, FRCSC, FAAOS Merrill McHoney, MB, BS, FRCS (Paeds), PhD Assistant Professor Academic Clinical Lecturer Department of Pediatric Orthopaedic Surgery Department of Paediatric Surgery University of Ottawa and Children’s Hospital of Eastern Ontario Oxford Radcliffe Hospital Ontario, Ottawa, Canada Oxford, U .K . African affiliation: Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania Vivien M McNamara, BM, BS, FRCS (C/Th), FRCS (Paed Surg) Department of Paediatric Surgery Philip M Mshelbwala, MBBS, FWACS Great Ormond Street Hospital for Children Consultant Paediatric Surgeon and Senior Lecturer London, U .K . Division of Paediatric Surgery, Department of Surgery Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Alice Mears, MBCHB, FRCS Zaria, Nigeria Paediatric Surgery Specialist Registrar Oxford Children’s Hospital and University of Oxford David Msuya, MD, MMED surgery, FCS (ECSA) Oxford, U .K . Consultant Surgeon Kilimanjaro Christian Medical Centre and Tumaini University Donald E. Meier, MD, FACS, FWACS Moshi, Tanzania Professor and Endowed Chairman Division of Pediatric Surgery Evan P. Nadler, MD Texas Tech University Health Sciences Center, El Paso Co-Director, Children’s National Obesity Institute El Paso, Texas, U .S . Children’s National Medical Center Consultant Surgeon Associate Professor of Surgery, Pediatrics, & Integrative Systems Biology Baptist Medical Centre The George Washington University School of Medicine & Health Sciences Ogbomoso, Nigeria Washington, DC, U .S . Honorary Professor of Pediatric Surgery Addis Ababa University Abdulrasheed A. Nasir, MBBS, FWACS Addis Ababa, Ethiopia Consultant Paediatric Surgeon Division of Paediatric Surgery Ronald Merrell, MD University of Ilorin Teaching Hospital Department of Surgery Ilorin, Nigeria Virginia Commonwealth University School of Medicine Richmond, Virginia, U .S . Mark Newton, MD, FAAP Associate Professor of Pediatric Anesthesiology Alastair J.W. Millar, FRCS, FRACS (Paed Surg), FCS (SA), DCH Vanderbilt University Medical Center Charles F .M . Saint Professor of Paediatric Surgery Nashville, Tennessee, U .S . University of Cape Town and Red Cross War Memorial Children’s Consultant Anesthesiologist and Director of Kenya Registered Nurse Hospital, Rondebosch Anaesthetist Program Cape Town, South Africa Kijabe Hospital Kijabe, Kenya Ashish Minocha, MBBS, MS, MCh, DNB, MNAMS, FICS Consultant Paediatric and Neonatal Surgeon Phuong D. Nguyen, MD Jenny Lind Children’s Department Department of Surgery, Division of Pediatric Surgery Norfolk & Norwich University Hospital New York University Langone Medical Center Norwich, U .K . New York, New York, U .S .

Catherine Mngongo, MMED Surg (KCMC), MBBCH (Tanzania) Paul T. Nmadu, FMCS (Nig), FWACS, FICS Consultant Surgeon Professor and Consultant Paediatric Surgeon Tumaini University Division of Paediatric Surgery, Department of Surgery Kilimanjaro Christian Medical Centre Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Kilimanjaro Moshi, Tanzania Zaria, Nigeria

Paediatric Surgery: A Comprehensive Text for Africa ix

Peter M. Nthumba, MBChB, MMed (Surgery), FCS (ECSA) Iyore A. Otabor, MD, MALD Plastic, Reconstructive and Hand Surgeon Clinical Instructor and Research Fellow AIC Kijabe Hospital Department of Pediatric Surgery Nairobi, Kenya Nationwide Children’s Hospital The Ohio State University Alp Numanoglu Columbus, Ohio, U .S . Red Cross War Memorial Children’s Hospital Cape Town, South Africa Dakshesh Parikh, MBBS, MS, FRCS (Paed), MD Consultant Paediatric General and Thoracic Surgeon Benedict C. Nwomeh, MD, MPH, FRCS (Eng, Ed, Glas), FACS, Birmingham Children’s Hospital NHS Foundation Trust FAAP, FWACS Birmingham, U .K . Associate Professor of Clinical Surgery The Ohio State University Graeme Pitcher, MBBCh, FCS (SA) Director of Surgical Education Adjunct Professor Department of Paediatric Surgery Department of Surgery Nationwide Children’s Hospital University of the Witwatersrand Columbus, Ohio, U .S . Head, Paediatric Surgery Chris Hani Baragwanath Hospital Andrew Gustaf Nyman, MBBCh, MRCPCH Johannesburg, South Africa Paediatric Intensive Care Registrar Oxford Children’s Hospital Dan Poenaru, MD, MHPE, FRCSC, FACS, FCS (ECSA) Oxford, U .K . Consultant Paediatric Surgeon BethanyKids at Kijabe Hospital Modupe Odelola Kijabe, Kenya Imperial College NHS Trust Honorary Professor of Surgery St . Mary’s Hospital Aga Khan University Praed Street Nairobi, Kenya London Adjunct Professor of Surgery and Paediatrics Queen’s University Michael O. Ogirima, FMCS, FWACS, FICS, FAOI Kingston, Ontario, Canada Associate Professor and Chief Consultant Department of Orthopaedics and Trauma Surgery Jean Heuric Rakotomalala, MD Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Paediatric Surgery Fellow (COSECSA) Zaria, Nigeria BethanyKids at Kijabe Hospital Kijabe, Kenya G. Olufemi Ogunrinde, MBBS, FWACP Senior Lecturer and Consultant Paediatrician Ashley Ridout, BM BCh, MA (Oxon), MRCS (Eng) Department of Paediatrics Oxford Deanery School of Surgery Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Oxford, U .K . Zaria, Nigeria Dorothy V. Rocourt, MD Adekunle O. Oguntayo, MBBS, FWACS, FICS Chief Fellow in Pediatric Surgery Senior Lecturer and Consultant Obstetrician and Gynecologist Nationwide Children’s Hospital Gynaecologic Oncology Unit The Ohio State University Department of Obstetrics and Gynecology Columbus, Ohio, U .S . Ahmadu Bello University Teaching Hospital Zaria Nigeria Bankole S. Rouma, MD Professor, Pediatric Surgery Philemon E. Okoro, MBBS, FWACS University Hospital of Treichville Lecturer and Consultant Paediatric Surgeon Abidjan, Côte d’Ivoire University of Port Harcourt and Port Harcourt University Teaching Hospital Port Harcourt, Nigeria Avraham Schlager, MD Division of Pediatric Surgery, Department of Surgery Peter F. Omonzejele, PhD New York University School of Medicine Department of Philosophy New York, New York, U .S . University of Benin Benin-City, Nigeria Kant Shah, MBBS MRCS Research Fellow Richard Onalo, MBBS, FMCP Department of Paediatric Surgery Consultant Paediatrician Oxford Children’s Hospital Department of Paediatrics Oxford, U .K . Ahmadu Bello University Teaching Hospital Zaria, Nigeria Shilpa Sharma, MBBS, MS, M .Ch, DNB, Ph .D Assistant Professor G. Ifeyinwa Onimoe, MBBS, FAAP Department of Pediatric Surgery Clinical Fellow Post Graduate Institute of Medical Education and Research Department of Hematology/Oncology/Bone Marrow Transplant Dr RML Hospital Nationwide Children’s Hospital New Delhi, India Ohio State University Columbus, Ohio, U .S . x Paediatric Surgery: A Comprehensive Text for Africa

Alison Shefler, MD, FRCP (C) Ralf-Bodo Troebs, MD Consultant in Paediatric Intensive Care Professor of Pediatric Surgery Oxford Children’s Hospital Department of Pediatric Surgery Oxford, U .K . Catholic Foundation Marienhospital Herne Ruhr University of Bochum Bello Bala Shehu, MBBS, FRCS, FACS, FWACS Herne, Germany Professor and Consultant Neurosurgeon Chief, Regional Centre for Neurosurgery Nyaweleni Tshifularo, MBChB, FCS (SA) Usmanu Danfodiyo University Teaching Hospital Tygerberg Hospital Sokoto, Nigeria University of Stellenbosch Stellenbosch, South Africa Daniel Sidler, MD, M .Phil, FCS (SA) Associate Professor of Paediatric Surgery and Senior Lecturer Francis Aba Uba, MB ChB, FMCS, FWACS Department of Paediatric Surgery Associate Professor of Surgery and Consultant Paediatric Surgeon Tygerberg Children’s Hospital, Stellenbosch University Paediatric Surgery Unit, Department of Surgery Cape Town, South Africa University of Jos and Jos University Teaching Hospital Jos, Nigeria Michael Singh, MBBS; FRCS (Paed) Consultant Paediatric General and Thoracic Surgeon Jeffrey S. Upperman, MD, FACS, FAAP Birmingham Children’s Hospital NHS Foundation Trust Associate Professor of Surgery Birmingham, U .K . Keck School of Medicine University of Southern California Saurabh Sinha, MBBS,FRCS Director of Pediatric Trauma Fellow in Neurosurgery Children’s Hospital of Los Angeles Oxford Children’s Hospital Los Angeles, California, U .S . Oxford, U K. . Usang E. Usang, FWACS, FMCS (Nig), FICS Oludayo Adedapo Sowande, MBChB, FRCSEd, FWACS Lecturer and Consultant Paediatric Surgeon Senior Lecturer and Consultant Paediatric Surgeon University of Calabar and Calabar University Teaching Hospital Paediatric Surgery Unit, Department of Surgery Calabar, Nigeria Obafemi Awolowo University Teaching Hospital Ile Ife, Nigeria A.B. (Sebastian) van As, MBChB, MMed, MBA, FCS (SA), PhD Professor and Head, Trauma Unit Helen Sowerbutts, BA, BABCh Oxon Red Cross War Memorial Children’s Hospital Speciality Trainee (ST1) in Paediatrics Department of Paediatric Surgery Northwick Park Hospital School of Child and Adolescence Health, University of Cape Town London, U .K . Cape Town, South Africa

Emily Stamell Stefan Wolke Division of Pediatric Surgery, Department of Surgery Clinic of Paediatric Surgery New York University School of Medicine Jena University Hospital New York, New York, U S. . Friedrich Schiller University of Jena Jena, Germany Ronald S. Sutherland, MD, FACS, FAAP Pediatric Urology George G. Youngson, CBE, PhD, FRCS Ed Professor of Surgery & Pediatrics (Clinical) Professor and Consultant Paediatric Surgeon University of Hawaii, John Burns School of Medicine Department of Paediatric Surgery Honolulu, Hawaii, U .S . Royal Aberdeen Children’s Hospital Aberdeen, Scotland Atonasio Taela African affiliation: External Examiner, University of Malawi Department of Surgery Eduardo Mondlane University Nathan R. Zilbert Maputo Central Hospital Division of Pediatric Surgery, Department of Surgery Maputo, Mozambique New York University School of Medicine New York, New York, U .S . Erin A. Teeple, MD Bariatric/Minimally Invasive Surgery Fellow Department of Pediatric Surgery Nationwide Children’s Hospital The Ohio State University Columbus, Ohio, U S. .

Paediatric Surgery: A Comprehensive Text for Africa xi

Foreword

Paediatric surgery has come of age with the publication of this landmark textbook directed to the African continent. A comprehensive textbook of this nature is long overdue and undoubtedly will serve as a basic reference tome, practical manual, and stimulus for innovative research for generations to come. Most current textbooks are written with an emphasis on surgical conditions and remedies commonly encountered in the developed world. However, in many developing countries, the aetiology, incidence, pathogenesis, clinical manifestations, investigations, treatment, and outcomes for common diseases, as well as diseases endemic to these regions, are different. Hence the need for a textbook to look beyond current texts and address diseases in a more comprehensive way. The development of paediatric surgery as a speciality in Africa is relatively recent. In many areas, it is still compromised by a lack of demographic information, infrastructure, and trained surgeons familiar with the special needs of children, as well as limited anaesthetic services and fiscal deficiencies. Life for children on the African continent is therefore not easy. It is a constant battle against poverty, parasitic and other infections and diseases, trauma, debilitating congenital and central nervous system abnormalities, and many other factors impairing their growth and development. Many of the same surgical diseases seen in the developed world must be diagnosed and treated in Africa under substantially less favourable and often adverse circumstances. The morbidity and mortality rates remain unacceptably high, with wide disparities between countries as well as between urban and rural communities. It is in this setting that this textbook will make a valuable contribution toward expanding knowledge and achieving improved surgical outcomes for all children. Authorship was wisely chosen: each chapter is written by an acknowledged international expert and an African counterpart who has extensive experience. This daunting task is an affirmation of the specific need to address the often neglected surgical diseases of the region and their special circumstances. This collaboration also recognises the important contributions made by surgeons from Africa. They have a breadth of knowledge and experience to help unlock the doors of ignorance and to contribute to setting a standard of quality care. Many of the authors have earned national and international professional distinction as surgeons, teachers, innovative researchers, and leaders. People often question the relevance of surgery on a continent where so many other issues are a priority. The estimated accumulative risk for a child to have a condition requiring surgical input is 85% by the age of 15 years, making it a significant public health problem. Obstacles to improve paediatric surgical care include a general lack of interest in surgical conditions affecting children, its poorly defined role, and a lack of political commitment. Surgical training in Africa is also very variable and beset with multiple challenges, which further compound the already suboptimal standard of surgical care. Sick children therefore are found on the doorsteps of workers, but the only way they can get their rightful due is to have knowledgeable and skilled surgeons caring for them. This textbook, as a rich source of information, will consequently contribute significantly to paediatric surgical education in Africa, combining home-grown knowledge on the care of children with surgical conditions. Although this book is directed to the needs of surgeons working in Africa, it may also be of great help to those treating children from Africa somewhere in the developed world. Diseases know no boundaries.

Emeritus Professor Heinz Rode Red Cross War Memorial Children’s Hospital University of Cape Town, South Africa xii Paediatric Surgery: A Comprehensive Text for Africa

A Note from the Publisher Preface

We are very pleased to partner with the authors to publish this entirely Paediatric surgery has become an established specialty in many parts new and important book: Paediatric Surgery: A Comprehensive Text of Africa and other developing countries. However, the surgical care For Africa. This is a major achievement resulting from the contribu- of children continues to pose significant challenges in these settings, tions of many individuals. due partly to the enormous disparity between the large volume of All of the authors contributed their time, experience, and expertise, patients and the few available paediatric surgical specialists. In addi- and for busy clinicians, writing is done at great personal sacrifice. tion, many patients present late, frequently with advanced diseases, Only by knowing the importance of a project do physicians elect and, unfortunately, available medical facilities are often suboptimal. to allocate such time for new material. We acknowledge the special Although a number of good paediatric surgical textbooks are contribution of Dr. Emmanuel Ameh for initiating and coordinating currently in use worldwide, few address the peculiar needs of surgeons the entire undertaking. Please review the list of the text’s contributors in the developing world. Even though most aspects of paediatric and note their diversity and impressive credentials. surgical care are standard worldwide, in many cases, the approach, Our staff also made this publication a priority. Deborah Cughan methods, and techniques described in Western textbooks may not be organized the project and used her graphic skills to integrate the applicable to the African setting. Most existing textbooks are written text and illustrations for publication as well as to design the cover. by surgeons who assume a Western audience in their discussion of Sandy Rush edited and indexed the book at a reduced non-profit rate. incidence rates, demographics, and socioeconomic aspects. Discussion Additionally, Dean Carlson, our manager and web-master, helped to of available treatment options and reference to “standard of care” facilitate all aspects of the project. assume a Western level of technology. Understandably, conditions Friends of the Global HELP Organization covered the cost of common in Western countries are treated with greater emphasis while producing this book. Expenses include editing, indexing, formatting, those commonly seen in Africa may not be discussed at all. This book web-site management, CD-Rom Library duplication, and hardcopy presents a comprehensive overview of paediatric surgery that is most printing. Scores of generous people made donations and the major relevant to African children and their surgeons. When used along contributors were Henry & Cindy Burgess, George Hamilton, Paul & with the already available textbooks, it will provide a more balanced Suzanne Merriman, and Lana & Lynn Staheli. perspective to anyone interested in paediatric surgery in Africa We plan to distribute this publication as widely as possible. The authors of this book are primarily reputable paediatric Along with the printed version, the full text is available on low-cost surgeons with vast experience working in Africa, but also include CD-Roms and may be downloaded in PDF format from our web-site those from developed countries, whose contributions will add the without charge or restrictions. expertise gained from experience in state-of-the-art facilities. It is hoped that this collaboration will provide the reader with a safe For any new editions of the publication, please visit our web-site approach to surgical care of children under difficult situations as well at www.global-help.org. as up-to-date information on various aspects of paediatric surgery. Africa is currently experiencing a severe shortage of paediatric surgical specialists, and a significant proportion of surgery on African children is still performed by general surgeons. Therefore, Lynn Staheli, MD, 2011 this book is targeted at trainees in both paediatric surgery and Founder and Volunteer Director, general surgery in Africa and similar settings as well as practising Global HELP Organization surgeons. Undergraduate medical students, paediatricians, and other Paediatric Orthopaedist paediatric health care practitioners will also find this book a useful Professor Emeritus, University of Washington reference. The recent increase in the numbers of charitable medical Seattle, Washington, USA missions from Western countries will continue to bring surgeons from developed countries to Africa. These much-needed doctors will find the book an essential accessory to their work in Africa. Ultimately, we hope the children of Africa will be the final beneficiaries.

The Editors, E. A. Ameh, Zaria, Nigeria S. W. Bickler, San Diego, California, USA K. Lakhoo, Oxford, UK B. C. Nwomeh, Columbus, Ohio, USA D. Poenaru, Kijabe, Kenya Paediatric Surgery: A Comprehensive Text for Africa xiii

Every effort has been made to confirm the accuracy of the presented information. The authors and publisher are not responsible for errors of omission or for any consequences from the application of the information in this book, and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of this publication. Application of this information in a particular situation remains the professional responsibility of the practitioner.

Paediatric Surgery: A Comprehensive Text for Africa is published by the Global HELP Organization.

Seattle, WA, USA

© 2011 All rights reserved

ISBN 978-1-60189-091-7