Aim : To determine the teaching methods used by residents in paediatric surgery in Nigeria and their exposure to research and conferences. Materials and Methods : A structured questionnaire was administered to trainees in paediatric surgery in Nigeria seeking information regarding different teaching methods used, frequency of use, involvement in research and participation in conferences. Results : There were 11 respondents (91.6%) of 12 questionnaires that were distributed. All of them were training in accredited teaching hospitals in Nigeria. All of them had been involved in teaching medical students. Ten residents were involved in teaching in wards/bedside two times or more in a week and all were involved in teaching at the clinics. Only one resident used audiovisual aid at least once a week to teach students. Eight trainees used tutorial or seminar group discussion as a teaching tool once a week. Four trainees had not used written essay as a way of teaching students while five had never given students lectures in a classroom before. All the respondents had participated in retrospective research while nine had been involved in prospective research. Nine residents had attended conferences nationally while two had attended international conferences. Six trainees presented a paper or more at national conferences while one presented at an international conference. Conclusion : Trainees in paediatric surgery in Nigeria are significantly involved in the teaching of undergraduate medical students and clinical research. This should be encouraged and further enhanced by motivating the trainees to attend international conferences.

Background: Abnormalities of rotation and fixation of the intestines are of intense interest to the pediatric surgeon, as they are frequently associated with volvulus which has catastrophic consequences when diagnosis is delayed or not even considered. This study evaluates the outcomes of surgical management of intestinal malrotation (IM) in children. Materials and Methods: The medical records of all patients with symptomatic malrotation, who underwent surgery between January 2000 and September 2009, were reviewed. Patients' characteristics, management, complications, and survival were evaluated. Results: Nine patients (eight boys and a girl) underwent surgery for malrotation at a median age of 15 days. Eight presented with acute symptoms and one with chronic symptoms. All the patients had symptoms of intermittent or complete upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study in two of them. Volvulus was found at the time of surgery in seven patients, five of whom were neonates. One patient also had associated mesentery cyst. Seven patients were treated by Ladd's operation. One patient with massive bowel gangrene due to volvulus had right hemicolectomy. There was one perioperative death from anastomostic leak. Median length of stay was 9 days. Postoperative bowel obstruction was seen in two patients (one died), resulting in an overall mortality of 22.2%. Conclusions: Bowel gangrene from volvulus contributes to mortality, and small bowel adhesive intestinal obstruction is a cause of morbidity and mortality following surgery for IM. Neonates with bilious vomiting should raise the suspicion of malrotation until proven otherwise and given prompt intervention. There is a need for high index of suspicion in babies with bilious vomiting especially when recurrent to prevent devastating complications when present.

Background: Urethral mucosal prolapse is rare. This condition may be confused with tumour or sexual abuse in girls. This study aims at reporting the pathology presentation and therapeutic options of urethral prolapse in girls. Materials and Methods: A retrospective study was undertaken from January 2000 to December 2008. Authors analysed the clinical features and the treatment options. Results: There were nine cases of urethral prolapse. The ages ranged from 2.5 to 10 years (mean age: 5.08 years). The main presentation was vaginal bleeding (five cases). Physical examination revealed a soft, non-tender mass that bleeds on touch (six cases), with a length ranging from 0.75 to 1 cm. Urine culture in four patients revealed urinary infection that yielded Escherichia coli in three cases and the Staphylococcus aureus in one case. Six patients had surgical treatment while three had medical treatment. In those who had surgery, one had acute urine retention and one had recurrence that was treated successfully without operation. All the nine girls are cured. Conclusion: Urethral prolapse is a disease of the prepubertal girls of low socio-economic group. Diagnosis is clinical. The treatment of choice is surgical.

Background : In some developing countries, many children with intussusception are reported to present late for definitive therapy. This study determines the effect of delayed presentation on clinical parameters, management, and outcome of childhood intussusception in southeast Nigeria. Methods : Comparative analysis of 87 consecutive children with intussusception managed from January 1998 to December 2007 at the University of Nigeria Teaching Hospital, Enugu, was done. Results : Overall, the mean time from onset to presentation was 3.0 days (range 4 hours to 7 days). Thirteen (14.9%) presented within 24 hours of symptoms (group 1) and 74 (85.1%) presented after 24 hours (group 2). Clinical presentations were similar in the children with the exception of bilious vomiting, rectal bleeding, and abdominal distension which were significantly commoner in group 2 children (P < 0.05). Type of intussusception found at operation did not differ in the groups, but cases in group 2 had higher incidence of bowel complications, and greater risk of failed operative reduction and bowel resection than group 1 patients (P < 0.05). Though the postoperative complications did not differ significantly between the two groups, mortality directly related to intussusception occurred only in patients who presented after 24 hours. Conclusion: Significant number of children with intussusception in our setting presented late for definitive treatment. These cases have a higher risk of bowel complications and intestinal resection. Outcome in these patients might be enhanced through improved perioperative care in the short term, or by improving access to, and reducing delays in seeking health care, in the long run.

Background: Anorectal malformation is a common congenital defect and its management has evolved over the years. This is a review of the trend in the management of this condition in a major paediatric surgical centre in Nigeria over two decades. Materials and Methods: A retrospective analysis of 295 patients with anorectal malformations managed from January 1988 to December 2007 was carried out. Results: There were 188 boys and 107 girls aged 1 day-9 years (median 8 years) at presentation. There were 73 (54.5%) and 106 (65.8%) emergency operations in groups A and B, respectively. There were 61 (45.5%) and 55 (34.2%) elective operations in groups A and B, respectively. Regarding treatment, in group A, patients requiring colostomy had transverse loop colostomy, while in group B, sigmoid (usually divided) colostomy was preferred. The definitive surgery done during the two periods were: group A: cutback anoplasty 29 (47.5%), anal transplant 5 (8.2%), sacroabdominoperineal pullthrough (Stephen's operation) 6 (9.5%) and others 21 (34.4%). In group B, posterior sagittal anorectoplasty (PSARP) 46 (83.7%), anal transplant 1 (1.8%), posterior sagittal anorectovaginourethroplasty (PSARVUP) 2 (3.6%) and anal dilatation 6 (10.9%) were done. Early colostomy-related complication rates were similar in the two groups (P > 0.05). The overall late complication rate was 65.5% in group A and 16.4% in group B (P < 0.05). The mortality was 25 (18.6%) in group A compared to 17 (10.6%) in group B (P < 0.05). Conclusion: There have been significant changes in the management of anorectal malformations in this centre in the last two decades, resulting in improved outcomes.

Objective: To report the outcome of commonly used antibiotic combinations in surgical neonates in sub-Saharan African settings. Methods: A retrospective analysis that determines the outcome of commonly combined antibiotics in surgical neonates between January 2006 and December 2008 at two referral paediatric surgical centres in Benin city was carried out. Results: Ampicillin ampiclox, metronidazole, gentamicin, cefuroxime and ceftriaxone were variously combined in the management of 161 neonates with a mean age at presentation of 9.2 ± 2.6 days, mean weight 3.1 ± 1.4 kg and a male:female ratio 1.6:1. Polymicrobial postoperative wound infections and sepsis caused by Staphylococcus aureus, Escherichia coli, Neisseria meningitidis, Klebsiella pneumonia, Pseudomonas aeroginosa and anaerobes, were mainly encountered. The most common aerobes isolated from wound cultures were S. aureus and P. aeroginosa while the ones from that of blood cultures were E. coli and K. pneumonia. Overall postoperative infections recorded were: wound infection 19 (11.8%), sepsis 16 (9.9%) and sepsis-related deaths 6 (3.7%). Conclusion: Combinations of gentamicin/metronidazole/cefuroxime and gentamicin/cefuroxime were adequate for gastrointestinal and extra-gastrointestinal neonatal operations, respectively, in these sub-Saharan African settings, which may be useful in similar regions.

Background: Despite the advances in management, congenital diaphragmatic hernia (CDH) has continued to pose a significant challenge to paediatric surgeons. This is amplified in a setting like ours where there is a dearth of facilities to cope with the problem of CDH. This study was undertaken to highlight the peculiarities of the management of CDH in a poor resource setting. Methods: All confirmed cases of CDH were prospectively documented from 2003 till date. Results: Seven children were treated from 2003 till date. The diaphragmatic defect was on the left side in six (83.8%) and on the right side in one (17.7%). All the patients had primary closure of the defect without patch via an abdominal approach. The three patients presenting at birth died while the remaining four patients survived. Conclusion: With inadequate neonatal intensive care facilities, the severe early presenting CDH has a dismal prognosis. In contrast, the late presenting CDH poses more diagnostic challenges; but once identified and appropriate treatment instituted, it has an excellent prognosis. We recommend that physicians should include CDH in the differential diagnosis of patients with birth asphyxia and in patients with chronic respiratory symptoms with failure to thrive.

Background: Femoral shaft fractures are common injuries in childhood. There is paucity of information on their presentation and outcome of the available treatment methods in the African population. This study evaluated the outcome of non-operative methods of treatment of femoral shaft fractures in our centre. Patients and Methods: A retrospective review of the database of children aged 14 years and below with femoral shaft fractures treated non-operatively over a 10-year period. Results: A total of 134 patients with 138 fractures met the study criteria. This consisted of 71 boys (mean age = 6.1 years ± SD) and 63 girls (mean age = 6.5 years ± SD). Pedestrian vehicular accident was the most common cause of femoral shaft fractures in the study population. The midshaft was the most common site of fractures. There were associated injuries to other parts of the body (especially head injury) in 34.3% of the patients. The commonest mode of treatment was skin traction only (87.7%). The mean time to fracture union was 4.9 weeks ± SD (range = 3-15 weeks). The mean length of hospitalisation was 6.7 weeks ± SD (range = 5 days-11 weeks). There was a fairly strong positive correlation between the length of hospitalisation and the presence of associated injuries, especially head injury, upper limb fractures and bilaterality of the fractures. The mean total cost of treatment was #7685 (Naira) or $51.2 (range = $14.2-$190). At the last follow up, 97.8% of the fractures united without significant angulation or shortening. Conclusion: The outcome of non-operative treatment of femoral shaft fractures in our setting is comparable to the results of other workers. Methods of treatment that shorten the length of hospitalisation without unduly increasing cost should be encouraged.

Background: Treatment of varicocoele is aimed at eliminating the retrograde reflux of venous blood through the internal spermatic veins. The purpose of this investigation was to compare laparoscopic varicocoelectomy (LV) with open high ligation technique in the adolescent population. Materials and Methods: We retrospectively evaluated 33 adolescents who underwent varicocoelectomy at our paediatric hospital, between May 2004 and September 2008. Patients were divided into two groups depending on the technique: those who had an LV and those submitted to an open varicocoelectomy (OV). We analysed side, age of surgery, follow-up period and the incidence of recurrence/persistence, hydrocoele formation and wound complication. Results: There were 24 patients in the LV group and 9 in the OV group. All varicocoeles were in the left side. Mean age was 12 years in both groups. Mean follow-up time was 32 months for the LV group and 38 months for the OV group (P = 0.49). There was no significant difference in the incidence of hydrocoele in both the groups (25% versus 22%, P = 0.626). There was no recurrence/persistence on the LV group, while in the OV group there were three cases (P = 0.015). Conclusion: LV seems more efficient than open high ligation technique in the treatment of adolescents' varicocoeles. Larger series are necessary to draw more reliable conclusions.

Background: Hirschsprung's disease (HD) is a common cause of intestinal obstruction in children. Definitive treatments consist of excision of the aganglionic segment and anastomosing the normal colon to the anal remnant. The outcome of this approach in Nigerian children is not known. The aim of this study was to analyze the short to mid-term outcome of children who have undergone the Swenson Procedure (SPT) as a treatment of HD over a period of 10 years. Patients and Methods: The clinical data of biopsy-proven cases of HD managed at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria, between 1998 and 2007 were reviewed. Results: There were 33 children 28 were males and five were females (M 5.6: F = 1). The median age at presentation was eight months (range three days to 11 years). Eighteen (54.5%) patients had primary pull-through without colostomy while 15 (45.5%) patients had a two-staged operation. The operation was carried out at a median age of 14 months with a range of seven weeks to 11 years, four months. Twenty-one (64%) of the patients were older than one year at the time of surgery. The level of aganglionosis was in the recto-sigmoid area in 30 (91%) patients. The commonest post-SPT complication was intestinal obstruction from adhesions. Bowel opening varied from once daily to eight times daily, median thrice daily. Conclusion: The Swenson's Procedure is an effective procedure in the treatment of HD in children in Ile Ife, Nigeria.

Introduction: The challenge of management with bilateral Wilms' tumours is the eradication of the neoplasm, while at the same time preserving renal function. Surgical management with a variety of nephron-sparing techniques, combined with chemotherapy and occasionally supplemented by transplantation has evolved over the last 30 years to achieve remarkable success. We document the experience of a single centre in a developing country. Material and Methods: Twenty-three bilateral Wilms' tumours were seen in our service between 1981 and 2007. Treatment was, in most cases, according to National Wilms' Tumour Study Group protocols, with initial bilateral biopsy, neoadjuvant chemotherapy, and tumourectomy. Technique of nephrectomy included full mobilization of the tumour-involved kidney, topical cooling with slush ice, vascular exclusion, tumour resection and reconstruction of the remnant kidney. Results: Twelve patients are alive and free of disease one to 15 years after treatment, all with well-preserved renal function (lowest glomerular filtration rate was 65 ml/min per (1.73 m ² ). None of the survivors have hypertension. Eleven have died (two of unrelated disease) including six of the seven with spread outside the kidney. All three with unfavourable histology are alive. Four of the five metachronous presentations are alive, as are eight of 12 patients with synchronous bilateral tumours who presented since 2000. Conclusions: Appropriate chemotherapy and nephron-sparing surgery can achieve good results with preservation of adequate renal function in nearly all cases. Unfavourable histology did not have a reduced survival in our series. Metastatic spread outside the kidney had a poor prognosis.

Background: It is believed that intensive care greatly improves the prognosis for critically ill children and that critically ill children admitted to a dedicated Paediatric Intensive Care Unit (PICU) do better than those admitted to a general intensive care unit (ICU). Methods: A retrospective study of all paediatric (< 16 years) admissions to our general ICU from January 1994 to December 2007. Results: Out of a total of 1364 admissions, 302 (22.1%) were in the paediatric age group. Their age ranged from a few hours old to 15 years with a mean of 4.9 ± 2.5 years. The male: female ratio was 1.5:1. Postoperative admissions made up 51.7% of the admissions while trauma and burn made up 31.6% of admissions. Medical cases on the other hand constituted 11.6% of admissions. Of the 302 children admitted to the ICU, 193 were transferred from the ICU to other wards or in some cases other hospitals while 109 patients died giving a mortality rate of 36.1%. Mortality was significantly high in post-surgical paediatric patients and in patients with burn and tetanus. The length of stay (LOS) in the ICU ranged from less than one day to 56 days with a mean of 5.5 days. Conclusion: We found an increasing rate of paediatric admissions to our general ICU over the years. We also found a high mortality rate among paediatric patients admitted to our ICU. The poor outcome in paediatric patients managed in our ICU appears to be a reflection of the inadequacy of facilities. Better equipping our ICUs and improved man-power development would improve the outcome for our critically ill children. Hospitals in our region should also begin to look into the feasibility of establishing PICUs in order to further improve the standard of critical care for our children.

Aim: The aim of this study was to review 10 years of experience in the management of children with acute intestinal conditions requiring exploratory laparotomy. Patients and Methods : This retrospective study included 334 children (244 boys and 90 girls) who underwent laparotomy for acute intestinal conditions between Jan 1, 2000 to Dec 31, 2009. Patients were grouped into two categories: group A (n = 44) included patients who needed laparotomy with terminal ileostomy and group B (n = 290) included patients who needed laparotomy without terminal ileostomy. We excluded neonates and patients with jejunoileal and colonic atresias, anorectal malformations, congenital pouch colon, neonatal necrotising enterocolitis, Hirschsprung's disease, appendicitis, abdominal trauma and gastrointestinal tumours. Results : During the last 10 years, 334 laparotomies were performed in children under 12 years: 59.88% for intestinal obstruction and 40.11% for perforation peritonitis. Causes in order of frequency were: ileal perforations 34.13%; intussusceptions 26.34%; Meckel's obstruction 10.17%; congenital bands and malrotation 6.88%; postoperative adhesions 5.98%; miscellaneous peritonitis 5.68%; miscellaneous intestinal obstructions 4.79%; abdominal tuberculosis 4.19% and roundworm intestinal obstruction 1.79%. Ileostomy closures (n = 39) was tolerated well by all except one. The mortalities were 28 (8.38%) in group B and 6 (1.79%) in group A. Conclusions: The need for re-exploration not only increases the morbidity but also increases mortality as well. Diverting temporary ileostomy adds little cumulative morbidity to the primary operation and is a safe option for diversion in selected cases. The best way to further reduce the mortality is to create ileostomy at first operation.

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a quite rare congenital and fatal disease. The disease is three to four times more prevalent in females than males. Most of the cases die within the early months of their lives. We present the case of a newborn male with antenatal ultrasound suggesting the diagnosis of MMIHS. The case was admitted for perforation complicated with prematurity after birth. This case is th e only one where MMIHS presented as perforation.

Epidermolysis bullosa (EB) is a rare disorder that presents with urological complications. We present a 6-year-old boy admitted with urological symptoms that revealed an inherited EB misdiagnosed. We also review the literature on this disorder and management of the common urological complications.

Transmesenteric hernias are extremely rare. A strangulated hernia through a mesenteric opening is a rare operative finding. Preoperative diagnosis still is difficult in spite of the imaging techniques currently available. The authors describe two cases of paediatric patients presenting with bowel obstruction resulting from a congenital mesenteric hernia. The first patient had a 3-cm wide congenital defect in the ileal mesentery through which the sigmoid colon had herniated. The second patient is a newborn infant who presented with symptoms and radiographic evidence of neonatal occlusion. At surgical exploration, a long segment of the small bowel had herniated in a defect in the ileal mesentery. A brief review of epidemiology and anatomy of transmesenteric hernias is included, along with a discussion of the difficulties in diagnosis and treatment of this condition.

Gastric perforation in neonates is a rare, serious and life-threatening problem. The precise aetiology is obscure in most cases. By virtue of its high mortality rate, it requires prompt recognition and surgical intervention. We report three cases of neonatal gastric perforation managed by early resuscitation and primary repair.

Alveolar soft-part sarcoma (ASPS) is a rare soft tissue tumour of uncertain cellular origin. It accounts for only 1% of all sarcomas, which themselves represent only a small proportion of human tumours. ASPS can arise in any soft tissue of the body, but there is an unexplained predilection for the right side. The most common site for paediatric ASPS is in the head and neck region, although involvement of the orbit is rare, with fewer than 30 reported cases. A case of a 5-year-old Kenyan boy with left-sided orbital ASPS is reported and the difficulties of diagnosing rare tumours are discussed.

Cystic hygroma is the cystic variety of lymphangiomas. Its common site is cervico-facial region, followed by axilla, superior mediastinum, mesentery and retroperitoneal region. Its occurrence in upper extremity is rarely reported, whereas its location at sternum has not been reported before. We report two cases of cystic hygroma occurring at unusual sites.

Anterior urethral valve (AUV) is a long known but rare anomaly, which is occasionally encountered in boys with obstructive uropathy. We present a case of AUV with a diverticulum which was misdiagnosed at other center as neurogenic bladder resulting in chronic renal failure. The case was further complicated by breakage of tip of the catheter used for clean intermittent catheterization (CIC) in the diverticulum presenting as a foreign body in the urethra. This article highlights the frequently missed diagnosis of AUV by most practitioners wrongly labeling it as neurogenic bladder, leading to improper management and renal failure in young boys.

We present a case of incomplete duodenal obstruction having a delayed presentation, making diagnosis and early intervention more challenging. Failure of recanalization of the duodenal lumen during the eighth to tenth week of gestation, results in duodenal atresia. Incomplete recanalization can lead to duodenal stenosis or the presence of a duodenal web. In the absence of other serious anomalies or prematurity, the overall survival for duodenal stenosis or atresia is nearly 100%.

Embryonal rhabdomyosarcoma (sarcoma botyroides) of the cervix, which is rare, is described in a 16-year-old. The combined use of chemotherapy, radiotherapy and surgery has markedly improved survival in those with this condition. However, our patient did not benefit from this treatment modality due to late presentation and loss to follow-up.

A 12-year-old girl presented with a large congenital splenic cyst complicated by Salmonella organisms. After failure of conservative management and percutaneous drainage, a splenectomy was performed. An incidental splenunculus was preserved. On follow up the splenunculus had increased to normal splenic size and there was no evidence of Howell-Jolly bodies, suggesting normal splenic function.

South Africa has a high level of violence, as more people are killed by gunfire each year than in motor vehicle accidents, and the numbers are increasing. Regrettably, children are affected most by this epidemic. During 1997, a total of 142 children aged less than 14 years died from gunshot injuries while many more were injured. Here we present the case of an 11-year-old male street child who sustained a gunshot to the face, and illustrate the magnitude of the problem. The escalating epidemic of firearm-related injuries and deaths among children and adolescents in Cape Town, like in many other parts of the world, calls for concern. Further research is needed to understand firearm-related injuries among children and adolescents in South Africa, and to develop policies and programmes for effective prevention of situations such as this.

We present a case of combined avulsion fracture of the tibial tubercle (AFTT) and avulsion of the patellar ligament in a 15-year-old boy. This injury was treated by open reduction and fixation of both lesions using staples with satisfactory results. This constellation of injury is rare but a high index of suspicion is needed when faced with a displaced AFTT. Open reduction and internal fixation should be the treatment of choice.

A 3-month-old girl presented with total urinary incontinence along with small bladder and bilateral single-system vaginal ectopic ureters [BSSVEU]. Bladder augmentation was done with dilated ureters (ureterocystoplasty) based on proximal blood supply of the ureters.

Pediatric hernia surgery is the most common operation done by pediatric general surgeons and it is a core competency for general surgeons in the developing world. Herniotomy is performed for the surgical repair of hernia and along with orchiopexy for the closure of associated patent processus vaginalis. Traditionally, ligation of hernial sac during orchiopexy is considered mandatory to prevent postoperative development of hernia. The present report was designed to study the results of non-ligation of the hernial sac during orchiopexy. It was found that non-ligation has no untoward effect on early complications and recurrence rate on long-term follow-up. It is suggested that it is not necessary to ligate the hernial sac during orchiopexy in children.