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Should the Plastibell Be Removed Twenty- Four Hours After Circumcision?

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Should the Plastibell Be Removed Twenty- Four Hours After Circumcision? SHOULD THE PLASTIBELL BE REMOVED TWENTY- FOUR HOURS AFTER CIRCUMCISION? BY DR. SYLVESTER IKHISEMOJIE MBBS (BENIN). OF THE PAEDIATRIC SURGERY UNIT, DEPARTMENT OF SURGERY LAGOS UNIVERSITY TEACHING HOSPITAL, LAGOS. A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PART FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF THE MEDICAL COLLEGE IN SURGERY, FMCS. MAY 2012 1 DEDICATION This Dissertation is deservedly dedicated to My Parents For the uncompromising principles that guide their lives. My Sisters For the wonderful support they have been And to My Family For making everything worthwhile. 2 TABLE OF CONTENTS Title … … … … … … … … … … … … i Dedication … … … … … … … … … … … ii Table of Contents… … … … … … … … … … iii Attestation… … … … … … … … … … … iv Acknowledgements… … … … … … … … … … v Definitions … … … … … … … … … … … vi Summary… … … … … … … … … … … … vii Chapter One Introduction… … … … … … … … … … … 1 Statement of Problem… … … … … … … … … … 5 Justification… … … … … … … … … … … 6 Scope of the Study… … … … … … … … … … 7 Limitations of the Study… … … … … … … … … 8 Chapter Two Literature Review… … … … … … … … … … 9 Aims and Objectives of Study … … … … … … … … 25 Chapter Three Methodology… … … … … … … … … … … 26 Data Analysis… … … … … … … … … … … 40 Chapter Four Results… … … … … … … … … … … … 41 Chapter Five Discussion … … … … … … … … … … … 54 3 Conclusion … … … … … … … … … … … 58 Recommendations … … … … … … … … … … 59 References … … … … … … … … … … … 60 Proforma … … … … … … … … … … … 65 Appendix 1 … … … … … … … … … … … 66 Appendix 2 … … … … … … … … … … … 67 4 ATTESTATION This is to certify that we have jointly supervised DR. SYLVESTER ONOFE IKHISEMOJIE on the dissertation titled ‘SHOULD THE PLASTIBELL BE REMOVED 24 HOURS AFTER CIRCUMCISION?’ ……………………………………. …………………………………. Christopher Bode. FMCS; FWACS B. O. Mofikoya. FWACS; FMCS Associate Professor/Consultant Paediatric Surgeon Consultant Plastic Surgeon Date…………………… Date……………….. 5 ACKNOWLEDGEMENTS To Prof Chris Bode, I owe a huge debt of gratitude for mentoring and directing the bulk of this work. I am also greatly indebted to Dr Bolaji Mofikoya, Consultant Plastic Surgeon, for his invaluable supervisory role all through the duration of the study. My thanks go to Dr. Adedapo Osinowo, and his wife who provided me with lots of materials and also proof-read some of my work. I wish also to thank Dr. Seyi Olajide for giving me the skeleton upon which I was able to build this work. To Dr. Adesoji Ademuyiwa, Consultant Paediatric Surgeon, who constantly goaded me to complete this dissertation. I am deeply grateful. Dr. Jibola Jeje and Dr. Bisi Ogunjimi, were also very encouraging. I wish also to thank Dr. Ronke Desalu, consultant anaesthesiologist for all her contributions. I owe the completion of this study to you all. Finally, I wish to acknowledge the remarkable family I have been blessed with. They endured my frequent absence from home. Their collective sacrifice was a constant reminder of the importance of completing this work. 6 DEFINITIONS HIV: Human Immunodeficiency Virus. AIDS: Acquired Immune Deficiency Syndrome. LUTH: Lagos University Teaching Hospital. GOMCO: Goldstein Manufacturing Company. FLACC: Face Leg Activity Cry Consolability Test PCV: Packed Cell Volume. EMLA: Eutetic Mixture of Local Anaesthetic SSI : Sample Size Index 7 SUMMARY Although circumcision is the commonest surgical procedure carried out in male neonates using a variety of methods, complications still arise with the use of all the methods. In Africa and much of the Middle East, circumcision is widely practiced mainly for socio-cultural reasons and the rate is almost 100 percent whereas, in Western Europe and North America, circumcision rates have fallen in recent years. Most of the post-circumcision complications referred to the Lagos University Teaching Hospital, LUTH are related to the use of the Plastibell ring. Some of these procedures were performed by relatively low-skilled health- workers. Post-circumcision complications are seen more in areas of the world lacking in adequate health-care personnel. The Plastibell ring is popular among mothers in Lagos. Many of them have no knowledge of its fall-off time, what constitutes prolonged retention and what harm it can cause. Since both doctors and other health workers widely use the Plastibell ring, it became important to examine ways to reduce the complication rate from the use of this method. This study also aimed to determine the benefits of the early removal of the Plastibell ring, or its ill-effects compared with the traditional delayed fall-off time of the device. It also compared the bleeding rates between subjects who underwent early removal of the Plastibell and a control group whose devices were left to fall off on their own. A total of sixty consecutive male neonates were recruited for this study and all of them underwent circumcision with the Plastibell device. Thirty patients were assigned to the Subject Group, in whom the Plastibell ring was removed by the investigator at 24 hours while the other thirty constituted the Control Group whose Plastibell rings were allowed to fall off on their own. Both were selected by closed balloting. The patients selected were aged between 7 and 28 days, with a mean age of 11.3 ± 5.3 days. The modal age was 8 days with 28 ( 46.7%) babies presenting for circumcision on that day. The age, weight and PCV of both the subjects and controls were comparable. There was minor haemorrhage in 3 of the 30 Subjects and in 1 of the 30 Controls (P = 0.3006). Similarly, wound infection rates were comparable between both groups with only 1 wound being infected among the Controls and none among the Subjects (P=1). In both groups, reported discomfort from circumcision was incomparable as there was no reliable, complete data. The mean duration of complete wound healing was 6.2 ± 0.8 days in the Subject Group 8 and 9.4 ± 1.7 days in the Control Group (p<0.005). The mean duration of wound healing was 7.8 ± 2.1 in the entire study group so that it took a significantly longer number of days to achieve complete wound healing in the Control Group. The fall-off time of the Plastibell ring in the Control Group ranged from 1-7 days with a mean of 4.6 ± 1.6 days. The modal day was Day 6 when 11 of the Plastibell rings fell off. This was statistically significantly prolonged when compared with the 1 day in which the devices in the Subject Group were removed. In conclusion, early removal of the Plastibell at twenty-four hours following circumcision was not attended by any significant haemorrhage, infection or discomfort. Rather, it appeared to promote wound healing. These findings remain to be validated in a wider study. It is hereby recommended from this study that the Plastibell circumcision ring could be removed twenty-four hours after circumcision without significant complications. CHAPTER ONE INTRODUCTION Circumcision, the partial or complete removal of the foreskin on the male genitalia, has been practiced for thousands of years and was initially thought to have originated in ancient Egypt as a means of marking male slaves1. It is now believed to have been copied from the Babylonians or from the Negroes of West Africa, most probably the latter, which may be why it is a cultural practice in the two sub-regions2. However, there is evidence even from ancient civilizations that circumcision may have been practiced as early as 5000 BC1,2,3,4. The Jews trace their ritual circumcisions to Abraham4,5,6. Since the days of Moses, it became a prerequisite for asserting the Jewish identity. This operation has been carried out for millennia for both religious and cultural reasons7,8,9. It is also widely practiced in North America with about 1.3 million circumcisions in the United States in 1997, constituting 65 percent of all newborn males but less than the 90 percent circumcision rate reported a decade earlier10. It is much less practiced in Europe and seldom seen in the Indian sub-continent and 9 the Orient because Buddhism abhors bodily mutilation. In many other cultures, especially in Africa, it has simply been a means of cultural identity and a rite of passage into manhood9,11. It is the most common surgical operation carried out in new-born males worldwide and is universally practiced in the West African sub-region. The medical indications for performing circumcisions are few and include such problems as phimosis, paraphimosis and recurrent balanitis. These indications constitute less than 1 percent of all circumcisions12,13,14. Advocates of this widely practiced procedure list a number of its advantages as increased levels of genital cleanliness, diminished rates of penile cancer, reduced incidence of cervical cancer among the partners of circumcised men14,15,16,17. Most recently, a reduced rate of heterogenous transmission of the Human Immunodeficiency Virus (HIV), the virus which causes the Acquired Immune Deficiency Syndrome (AIDS) has been credited to routine male neonatal circumcision18,19. Opponents of circumcision cite the scant evidence in support of the claim that circumcised males are cleaner or healthier than the uncircumcised20. The British Paediatric Association16,17 recently issued an official statement which states that ‘even though evidence exists suggesting that there are certain health benefits deriving from circumcision, such benefits are not of a sufficiently general nature to recommend routine neonatal circumcision’. Those who anchor their arguments on health
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