ISSN East Cent. Afr. J. surg

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1 1 1 ISSN Eat Cent. Afr. J. urg Title and Author Rahima Dawood Oration. Surgical Competence: Aeing, Acquiring, Maintaining, and Retoring. George G Youngon Colorectal and Anal Malignancie at Tukir Anbea Specialized Hopital, Addi Ababa, Ethiopia D. Zemenfe, B. Kotio Teticular torion in Ethiopia: a cae erie and ytematic review of the ub-saharan African literature M. Derbew, A.D. Laytin Obeity a a Rik Factor for Low Back Pain in a Nigerian Population C.J. Onyemkpa, G.C. Oguzie, D.C. Chukwumam Pattern of Elbow Fracture and Complication of Thoe Seen Late in Children Treated at KCMC in Northern Tanzania M.E. Ngowi, R.Temu, G Maya, A. Mallya Morbidity of Open Tibia Fracture in Lago, Nigeria. G.O. Enweluzo, T.O Adekoya Cole, B.O Mofikoya, S.O. Giwa, O.O. Badmu. Epidemiology of Hand Injurie Seen at Two Teaching Hopital in Southern Nigeria. O. Oluwafemi Awe, O. Ayodeji Oladele, J. Kayode Olabanji, E. Emmanuel Eezobor Injury prevention; Motorcyclit Repone and Practice on the Ue of Helmet in Mwanza, Tanzania S. Kilawa, O.V. Nyongole. The Pattern and Management Outcome of Gatric and Intetinal Foreign Bodie in Children Seen at Muhimbili National Hopital H. L Wella, H. Lituli, R. Bahati, J. Prota Gatric outlet obtruction among adult patient at two Rwandan referral hopital: Etiology, H. pylori infection and outcome M.K. Kabuyaya, R. Sebuufu, B. Aiimwe-Kateera, M. Nyundo, J. Rickard. Pattern and Management Outcome of Neonatal Acute Surgical Condition in Alexandria, Egypt. H.L. Wella, S.M.M. Farahat Compariion of Chlorohexidine Alcohol and Povidone Iodine Skin Preparation Skin Preparation Solution in Orthopaedic and Trauma Surgery at An African Tertiary Hopital H.A. Obamuyide, A.B. Omololu, O.M. Oluwatoin, A.O. Ifeanya, A.N.O Faina Evaluation of the outcome of femoral plate oteoynthei in a teaching hopital in a developing country. O.J. Ogundele, A.I. Ifeanya, A.A. Fakoya, T.O. Alonge Intranaal Endocopic Repair of Bilateral Choanal Atreia in a Male Newborn with Crouzon Syndrome A.D. Dunmade, I.O. Ajayi, B.S. Alabi, O.A. Mokuolu, B.O. Bolaji, O.I. Oyinloye End Stage Achalaia Cardia Maked by Chet Trauma: A Cae Of Diagnotic Mimicry J.I. Ahmad, M.M.Tettey A cae of evere epi following tranrectal protate biopy O.Y. Oluyemi, C.J. Elikwu Page COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

2 2 2 ISSN Eat Cent. Afr. J. urg Hepatic haemangioma: a Cae Report and Review of Literature S. A. Salati, A. Al Kadi Omental Eviceration Following Bicycle Handlebar Injury N.A. Lone, S.A. Salati Unuual Preentation of Invaive Baidiobolu mycoi a a Pelvic Ma in a 3-year-old Child: a Cae Report J. Trudea, G. Mwango, J. Mathaiya, I. Githinji, C. Onyambu, E. Walong. Management of Cholangiocarcinoma in Developing Countrie: Report of Seven Cae and Review of Literature. EBFK Odimba, M. Nthele, P. Phiri, C. Saleh COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

3 3 3 ISSN Eat Cent. Afr. J. urg Rahima Dawood Oration. Surgical Competence: Aeing, Acquiring, Maintaining, and Retoring. Preented at the 14th Annual General Meeting and Scientific Conference of The College of Surgeon of Eat, Central and Southern Africa and The Aociation of Surgeon of Eat Africa 4 December 2013, Harare, Zimbabwe Profeor George G Youngon CBE, MB ChB, PhD, FRCSEd, FRCP Edin Emeritu Profeor of Paediatric Surgery, Royal Aberdeen Children' Hopital, Univerity of Aberdeen, Aberdeen, Scotland AB25 2ZG. Formerly Vice Preident of the Royal College of Surgeon of Edinburgh 2013 Rahima Dawood Travelling Fellow for COSECSA-ASEA. Introduction Acquiition and maintenance of a high level of urgical competence i a goal for every individual urgeon, every urgical intitution, and of concern to every patient undergoing a urgical procedure, in all countrie of the world. The ubiquitou nature of the ubject matter make it entirely appropriate to dicu in the African context where poibly the relative lack of reource to many urgeon, make urgical competence all the more preciou a a commodity, and potentially a more ignificant reponibility for a urgeon practiing in uch an environment. The Rahima Dawood oration wa born out of the deire to pay tribute to the parent of the Foundation originator, - Dr Yuuf Kodwavwala, and thi lecture apire to hare the global challenge faced by urgeon, urgical educator, and urgical college in relation to urgical competence, o that cro juridictional learning can take place. Thi lecture recognie that ome challenge are continent and domain pecific, but many of the olution to the problem outlined, are likely to have more rather than le in common and be of potential interet to all. Amongt the firt et of challenge in conidering urgical competence, are identifying it, defining it, and thereafter determining a cale extending from ufficiency through to excellence. In practice, competence i more eaily identified by it abence rather than noted by it preence,-with the urgically incompetent being more conpicuou than their proficient counterpart. By contraditinction, the choice of any urgeon when faced with the need to identify a colleague to operate on any of their immediate family, - that proce perhap act a COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

4 4 4 ISSN Eat Cent. Afr. J. urg a ueful proxy of identifying thoe urgical attribute that are mot valued by u. Whilt dexterity and precie urgical technique certainly feature in thi lit of deirable attribute, o do the kill of preoperative patient election, intraoperative judgement, ound deciionmaking, communication and leaderhip. However, there i no eaily identified metric that can be applied to that kill et nor a commonly ued gauge which demontrate how cloe to empty our kill et can become. Whilt Africa face the challenge of retricted reource availability, urgeon practiing in countrie in the northern hemiphere by contraditinction face a different form of challenge where a highly critical if not toxic climate of low tolerance of urgical failure, with judicial, ocietal, and media recrimination, reult in the potential for - not only widepread litigation but more recent announcement uch a in the UK where the Health Secretary declared a new offence of wilful mitreatment which will reult in doctor, urgeon, and manager facing five year imprionment if they neglect patient. The take, therefore, for intitution uch a urgical college could not be higher; if the aement procee including examination and conferment of fellowhip and other credential, reult in that urgeon being deemed competent to progre to independent practice, then their liability for ubequent urgical miadventure, if that i deemed to be due to incompetent performance, may well be laid at the feet of the college who deemed thi individual to be competent, rather than the ingular reponibility of the urgeon who perpetrated the error. Additionally, an inceant preoccupation with urgical failure rather than celebration of urgical ucce may produce a erie of unintended conequence with rik averion being one uch product. Whilt good patient election and careful rik aement i to be applauded, undue caution may reult in incomplete or inadequate urgical care and that may reult in a poorer outcome for the patient than would have been the cae if courageou and confident action had been applied. Moreover undue conervatim ha potentially a negative impact upon the development and application of novel technique and new technology if they have a relatively un-proven track record. That i likely to be to the detriment to the progre of urgical reearch and to finding new cure for thoe many urgical dieae and pathologie that remained reitant to current therapy. It i againt thi backdrop therefore, that acquiition, maintenance, and retention of urgical competence become all the more important a a matter for crutiny and tudy. Meauring Surgical Competence It i elf-evident that good urgical technique equate with good outcome but that preumption lack objective upport becaue of the many other influence that accompany the delivery of care and thu influence urgical outcome. Preoperative management with appropriate election procee and timing, pot-operative therapy and intraoperative adjunct and treatment (antibiotic delivery, prophylaxi againt venou thromboembolim, etc) and much more contitute a uite of item that make the unique impact of urgical technique difficult to identify amidt thee many confounding variable. However, a linear relationhip between complication rate and urgical kill rating ha been clearly identified in recent tudie from Ann Arbor Univerity, Michigan 1, where the aement of the video recording of gatric bypa procedure by 20 different urgeon reulted in a very direct invere linear relationhip between rik-adjuted complication rate (which accommodated comorbidity) with the rating of urgical kill that evaluated movement, tempo, expoure, tiue handling, and other apect of intraoperative technical performance. That tudy alo demontrated a relationhip between COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

5 5 5 ISSN Eat Cent. Afr. J. urg urgical kill and even medical complication (chet infection etc) which were preumed to be operative time-dependent and to be important in thee complex and unfit patient. Being a good technician i therefore good for your urgical complication rate and an eential competence. That ame linear relationhip wa alo hown to exit between hopital mortality and the number of doctor within each of the hopital tudied facing anction and warning initiated by the medical regulator (General Medical Council) 2 ; thi tudy howed the ize of hopital not to have any ignificant impact but the greater the number of anction and warning againt doctor within any individual hopital, the greater the mortality rate for each hopital. So competence in technique, although hugely important, i not in itelf a factor that alone will aure good patient outcome and hence other profeional attribute play a hugely important part. Add to that the obervation that the implementation of checklit 3, which of themelve, make no change to the kill et of any individual practitioner in the operating theatre, and yet when properly applied the checklit reult in reduced morbidity and mortality, and we are now facing a more complex picture when attempting to iolate thoe component that actually reult in urgical competence. Acquiition of Surgical Competence The bipartite journey of undergraduate and potgraduate training tart with a rigorou election into medical chool and thi i placed againt the context of a high number of chool leaver in the United Kingdom entering tertiary education. (Figure 1). Succeful entry into medical chool however i even more retrictive with approximately 9 to 10 applicant, all of whom are eligible on the bai of their academic achievement, competing for one place (Table 1.). Specialty choice five year later at exit from medical chool, how urgery to remain a moderately popular choice for many, epecially male, and epecially male who have taken an intercalated degree during their undergraduate coure 4. A highly competitive national election proce at undergraduate graduation permit entry into core urgical training which itelf follow the completion of a two-year foundation attachment where the doctor complete an internhip in ix different medical pecialtie each occupying four month. Core training lat for two year (with the exception of neurourgery and otolaryngology where there are run through program featuring direct entry into the pecialty after foundation year 2). Aement to proceed after core training into pecialty training (pecialty regitrar) i made by a combination of workplace-baed aement and the ucceful completion of the intercollegiate MRCS (memberhip of the Royal College of Surgeon) examination. Competitive entry feature once again in thi paage into pecialty training. Specialty training lat approximately 6 year and i marked again by ucceful completion of work place-baed aement and then ucce in the Intercollegiate Specialty Fellowhip Examination in whichever of the 10 pecialtie the training i entered. The total time in training of fifteen year (five undergraduate year, two foundation, two core and ix pecialty year) hould provide ample opportunity to meet the need of the urgical career. However, whilt ucce rate in the pecialty fellowhip examination (exit examination) are high for UK-baed candidate (approximately 85% ucce rate) they are by COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

6 6 6 ISSN Eat Cent. Afr. J. urg contraditinction ignificantly lower in thoe candidate who enter the training mechanim through alternative route and are uually non-uk baed. The differential pa rate in the econd part of the pecialty board examination i coniderable with only 35% of non-uk trainee finding ucce. Thi difference i worthy of interrogation. Identifying the feature that allow a group of highly elected highly committed and able doctor (prerequiite for ucceful paage through urgical training) to either pa or fail at the final ummative aement would allow better identification of thoe area that need invetment in training and education by urgical college for different cohort of urgical trainee. Figure 1. UK Univerity acceptance Table 1. Application Data from a Sample of UK Medical School, COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

7 7 7 ISSN Eat Cent. Afr. J. urg Maintaining and growing competence Completion of training may be followed by entry into a ub-pecialty Fellowhip program and ubpecialiation i a trend that ha been preent for ome while and i a trend that i on the increae. Thi ha been conidered by ome a detrimental to the proviion of ervice ince they feel that the generality of urgery ha been compromied and in particular the ability for common, nonpecialit, and emergency condition to be dealt with effectively by a workforce which i well vered in the generality of urgery to repond to the need of the community, i becoming limited. While the linear volume/outcome relationhip which pertain to oeophageal, pancreatic, and aortic urgery i well recognied, the expoure requirement for maintenance of kill for many other form of urgical practice ugget that modet number are needed in order to maintain and preerve kill. Identification of the quality of urgical performance i being conveyed in a number of way not leat of which i the publication of mortality data in ome pecialtie (notably cardiac and vacular,) and nationwide comparative performance data i available through a number of dataet that are held either by department of health within government or by bodie deigned to overee quality improvement initiative (e.g. Dr Foter Whilt originally many of thee dataet pertained to outcome held at hopital level, increaingly urgeon pecific outcome data i available for analyi. Aement of competence after completion of training ha been lacking with mot urgeon obtaining a fellowhip not being held to account by any formal proce for the remainder of their career and in the United Kingdom, for the firt time ince the inception of the Medical Regiter by the General Medical Council in 1858, a new proce of competence aurance ha been etablihed and initiated in December Thi proce run a five-year cycle, with each year requiring an appraial of every doctor in the United Kingdom (234,000) by a trained appraier (uually a doctor in the ame pecialty who ha undergone pecific training in a national programme). The ummation of five year worth of annual appraial will allow a enior doctor in the hopital (Reponible Officer ) to make a recommendation to the General Medical Council a to whether or not the doctor hould retain their licence to practice (a licence to practice i required within the United Kingdom to be able to treat patient in any capacity. It i a UK pecific and ha no relevance in other countrie). Thi proce i termed revalidation, and ha become a legilative requirement for clinical practice in the United Kingdom. The component part of the annual appraial include peronal demographic data, an outline of the entire cope of your work, probity and health tatement, a well a upporting information to indicate that you have remained up-to-date. Thi require a decription of the CPD undertaken each year which i recorded againt the categorie of clinical, academic, and profeional development. A minimum of 50 hour per year i required to atify the need of revalidation but more importantly than the actual time pent, a commentary on how that time influence patient care and clinical practice i required through a reflective journal. Compliment and complaint are recorded and their management i dicued at appraial, and once in the five-year cycle, multiource feedback i required from approximately 12 colleague who are anonymou in the proce; imilarly feedback from 25 conecutive patient (random election and not choen by the appraiee) appear in the revalidation proce. Thi proce i an attempt at maintaining tandard uniformly acro the whole of medicine and ha allowed urgical college the opportunity to act a tandard etter in defining the proxie that can be ued a a meaure of urgical competence. The univeral application a an obligatory COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

8 8 8 ISSN Eat Cent. Afr. J. urg mechanim in one nation i a firt and perhap demontrate the way forward for other region in the world in trying to harmonie tandard of care acro and between pecialtie. Performance and Skill Degradation There i a void in the urgical literature in relation to the potential for lo of kill a part of the ageing proce. Thi poibly derive from the fact that thoe bet placed to make commentary, may view it with a conflict of interet but there are data emerging from the United Kingdom which point to a tendency to a lo of competence in the latter tage of the urgical and indeed a medical career 5. Indeed, the number of referral to the National Clinical Aement Service (an agency etablihed to invetigate poor performance in doctor) on account of conduct iue and clinical performance how a teep rie after the age of 60 year 6. The caue for thi are unclear but perhap a reluctance to change practice and modify with paage of time may reult in intranigent poition and refractory attitude which bring enior colleague into conflict with other in the workplace. There are many factor that may diable a urgeon performance and day-to-day variation can be produced by illne, medication, tre, fatigue and even challenge to one' compoure brought about by aggreion and confrontation. Thee little- tudied area comprie human performance limitation which in turn feature in the ocio-technological cience of human factor. The tudy of human factor in the operating theatre i a novel area of interet and one which i being actively explored by the Royal College of Surgeon of Edinburgh in conjunction with the Univerity of Aberdeen in Scotland. Poor and challenging conduct and behaviour a well a exemplary code of conduct, can now be rated uing the NOTSS taxonomy (Non- Technical Skill for Surgeon) 7 where kill categorie include ituation awarene, deciionmaking, teamwork and communication, leaderhip,-all eential ingredient of ound intraoperative performance. Thi program i now being taken up in a range of countrie including the performance aement framework of the Royal College of Autralaia and i in the early phae of implementation in the USA. Concluion Surgical competence i therefore omething of a moaic which i contructed by numerou interdependent piece of kill, behaviour and attitude, a well a thinking procee and a facility for accommodating the unexpected. Diligence, vigilance, intelligence and reilience are competencie which need to be built, nurtured and retained throughout a urgical career. Our current mechanim for evaluating thee area are incomplete and it i important that a urgical educator, college continue to look carefully at the need of the fellow and member o that the delivery of patient care can be met with both urgical preciion but at the ame time with commitment, reponibility and compaion. It i upon thee pillar that urgical fellow will be bet placed to meet the challenge, ome of which may be unique to their domain but at the ame time contribute and commit to COSECSA to enure that your College ha a bright and dynamic future producing the generation of African urgeon to come. Reference 1. Birkmeyer JD, Fink JF, O Reilly A, et al. Surgical kill and complication rate after Bariatric Surgery. NEJM, 2013; 369: The tate of medical education and practice in the UK. General Medical Council. London UK 3. Hayne AB, Weier TG, Berry WR, Lipitz SR, Breizat A-HS, Dellinger EP, et al. A COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

9 9 9 ISSN Eat Cent. Afr. J. urg Surgical Safety Checklit to Reduce Morbidity and Mortality in a Global Population. N. Engl. J. Med Jan 29;360(5): Goldacre MJ, Davidon JM, Lambert TW. Career preference of graduate and nongraduate entrant to medical chool in the UK. Medical Education.2007;41: Donaldon LJ, Panear SS, McAvoy PA.et al.identification of poor performance in a national medical workforce over 11 year: an obervational tudy. BMJ Qual Saf ; 0 : 1-6. Doi /bmjq National Clinical Aement Service. NCS Caework, the firt eight year. London : NCAS, Yule S, Flin R, Maran N, Rowley D, Youngon G, Pateron-Brown S. Surgeon Nontechnical Skill in the Operating Room: Reliability Teting of the NOTSS Behavior Rating Sytem. World J Surg Feb 8;32(4): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

10 10 10 ISSN Eat Cent. Afr. J. urg A Two- year review of Colorectal Cancer at Tikur Anbea Specialized Hopital, Addi Ababa, Ethiopia D. Zemenfe, B. Kotio Addi Ababa Univerity, CHS, SOM, Addi Ababa, Ethiopia Correpondence to: Daniel Zemenfe <danzemen@yahoo.com> Background: Colorectal Cancer i the third mot common caue of admiion and death in the Wet; and till recently it wa thought to be an uncommon dieae in Africa and Aia. Although data from Ethiopia i unavailable, a recent report from Global cancer tatitic center how an increaing incidence in the ub-saharan Africa which i alo our obervation. The objective of thi tudy wa to ae the hopital prevalence, common preenting ymptom, common preenting ign, ite, tage and hitology of colorectal cancer. Method: A retropective cro-ectional tudy deign, by reviewing of patient record collected from 2010 to 2011wa ued. Patient card number with colorectal and anal cancer were retrieved from regitry log book in the department of urgery. Individual patient card wa retrieved from the hopital record office. A total of 120 out of 142 patient card were included in the tudy. Data were entered uing epi-data, verion 3.0 and wa analyzed uing SPSS for window verion 21, and decriptive data analyi uing frequency wa made to anwer the reearch quetion. Reult: The mean age of the tudy ubject wa year, ranging between 18 and 83 year. A third wa below the age of 40 year, 58% were men, nearly half came from Addi Ababa, and 20% preented a an emergency. Study ubject preented with rectal bleeding (63.0%), abdominal pain (54.3%), weight lo (44.9%), tenemu (39.4%), change in bowel habit (48.0%) and ymptom of obtruction (17.3%). The tudy revealed ma on Digital Rectal Examination in 50%, anemia in 24.4%, abdominal ma in 22.8% and ign of obtruction among 11.8% of patient. The common ite of cancer were the rectum in 48.3% of cae followed by caecum (12.5%), igmoid colon (11.5%) and recto-igmoid junction (10.8%). More than half of the tudy ubject had tage III to IV dieae. More than 94% of the patient had hitologically proven adenocarcinoma. Thirty four percent of the cae had either inoperable or unreectable tumor indicative of delayed preentation. The hopital mortality wa 8.0%. Recommendation: Colorectal Cancer i a problem of ignificant magnitude and a the outcome of treatment depend largely on the early detection of cae a detailed reearch hould be done to ee the factor which hamper early detection and referral of cae to the tertiary health facilitie where multidiciplinary management i available. Introduction Cancer i the leading caue of death in the Wet and the econd leading caue of death in developing countrie 1. It i etimated that Cancer will become the caue of over 13 million death a year by 2030 in countrie where traditionally the bigget problem were infection. According to Global Cancer Statitic, the number of new cae with colorectal cancer roe from 12.7 million in 2008 to 14.1 million by the year Colorectal cancer i the 3 rd mot common malignant neoplam worldwide and the 5 th in Sub-Saharan Africa. Colorectal cancer i the 3 rd mot commonly diagnoed cancer in male and the 2 nd in female 2. The life time probability of colorectal cancer diagnoi i 4.1% in women and 5% in men 3. The crude incidence of colorectal cancer in Sub-Saharan Africa for both exe wa found to be 4.04 per 100,000 population (3.69 for women and 4.38 for men) with 1.2:1 male to female ratio 4. There are few paper written on COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

11 11 11 ISSN Eat Cent. Afr. J. urg colorectal cancer in Ethiopia. Teema et al ( ) reported from Tikur Anbea hopital, Addi Ababa, 131 cae in five year time which accounted for 30 % of all GI malignancie 5. The objective of thi tudy wa to ae the hopital prevalence, common preenting ymptom, common preenting ign, ite, tage and hitology of colorectal cancer. Patient and Method Retropective cro ectional tudy deign wa ued. All colorectal cancer cae een in were conidered eligible for incluion. Medical record number of colorectal and anal cancer cae were retrieved from log book in the department of urgery. Uing the medical record number, individual patient card wa retrieved from the hopital record office. Surgical reident were involved for data collection. Data were collected uing a tructured quetionnaire. A total of 120 out of 142 patient card were included in the tudy. Data were entered uing epi-data, verion 3.0 and wa analyzed uing SPSS for window verion 21, and decriptive data analyi uing frequency wa made to anwer the reearch quetion. Proportion and Chi quare were ued a appropriate. Reult There were 142 patient in two year time but the record of only 120(86%) patient could be retrieved for analyi. 69 (58%) were male with a male to female ratio of 1.3:1. Fifty ix (49%) of the tudy ubject were between the age group of 40 and 60, while 44(36.6%) were under the age of 40 year. Sixty one (50.4 %) of the patient were from the capital, Addi Ababa (Table 1). Of the 120 cae 80 % preented a an elective and 20% a an emergency. Bleeding per rectum and vague abdominal pain were the leading ymptom in 63% and 54% followed by change in bowel habit, weight lo and tenemu in 48%, 45% and 39 % repectively. Palpable abdominal ma wa preent in 29(23%) of patient and ma in the rectum wa detected in 60(50%) cae. Twenty four percent of the patient were found to be anemic (Table 2). A demontrated on Table 3, 48.3% of the tumor were located in the rectum. The igmoid and the recto igmoid junction were eat of tumor in12.5% and 10.8% repectively. Hence igmoid, rectoigmoid and rectum combined were the commonet (71.6%) ite involved in thi tudy. Adenocarcinoma (94.8%) wa the mot frequently reported cancer. Of the 92 cae whoe pathological tage of the tumor wa documented only 8.7 % had tage I dieae. It i worth noting that ignificant proportion (41.5%) of the cae had tage II dieae which i amenable for curative urgery. The remaining 16.3 % and 31.5% of the cae were tage III and IV cancer repectively which are late tage (Table 4). According to thi tudy Anterior and Low Anterior Reection combined with Abdomino-Perineal Exciion (38%) were the commonly performed procedure among the elective cae which correlate to the frequently encountered tumor ite. Twenty percent of the tumor were unreectable while 12.5% inoperable. Only 38(65.5%) patient of the rectal cancer cae had tumor amenable for reection while the remaining 20 (34.4%) were either unreectable or inoperable. (Table 5) Age, ex and place of reidence were analyzed with ite of tumour and tage of dieae; and there wa no ignificant aociation which may be attributed to the mall ample ize. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

12 12 12 ISSN Eat Cent. Afr. J. urg Table 1. Socio-demographic characteritic of colorectal cancer cae in Tikur Anbea Hopital (TAH), Feature Frequency Per cent Sex Male 69 58% Female 51 42% Male: Female 1.3:1 Age le than % % % 61 and above 20 17% Addre Addi Ababa % Out of Addi % Table 2. Mode of Preentation 120 Colorectal Cancer cae to TAH, Preentation Frequency Percentage Elective 96 80% Emergency 24 20% Symptom Rectal bleeding 80 63% Abdominal pain 69 54% Bowel habit change 61 48% Wt. lo 57 45% Tenemu 50 39% Obtruction 22 17% Abdominal ma 16 13% Symptom of anaemia 6 5% Sign Ma on DRE 60 50% Preence of anaemia 31 24% Abdominal ma 29 23% Obtruction 15 12% Table 3. Site of tumour in cae of colorectal and anal cancer in TAH, Site of tumour =120 Frequency Per cent Caecum Acending colon Hepatic flexure Splenic flexure Decending colon Sigmoid colon Rectoigmoid Junction Rectum COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

13 13 13 ISSN Eat Cent. Afr. J. urg Table 4. Hitology type and tage of confirmed colorectal cancer cae in Tikur Anbea Hopital, Hitology Type No=97 Frequency Percent adenocarcinoma Carcinoid Lymphoma 1 1 Maltoma\ MALT LYMPHOMA 1 1 Sarcoma 1 1 Stage No=92 I 8 8.7% II % III % IV % Table 5. Type of urgery for 102 elective V 25 emergency cae in TAH Type of Surgery Elective Emergency TOTAL Right Hemicolectomy Extended right Hemicolectomy Left Hemicolectomy Sigmoid Reection AR + primary anatomoi LAR +primary anatomoi LAR +Colotomy 2-2 APR Operated, advanced unreectable tumor Inoperable advanced (EUA) Hartmann colotomy Other TOTAL Dicuion Although prevalence could not be determined due to the limitation of data, it eem that there i an increaing trend of colorectal cancer cae baed on thi tudy which howed 142 cae in jut two year compared to previou tudy from the ame intitute by Teema et al 5 which reported 131 cae over 5 year time. Increaed awarene and improved acce to health ervice might play a role in increaing the number of colorectal cancer een, however thi may COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

14 14 14 ISSN Eat Cent. Afr. J. urg not be the ole explanation a thi might a well be due to the change in life tyle of the population a a whole ince thi ha alo been witneed in other reearche from Africa 6, 7, 8. The mean age of the tudy ubject wa year which i in conitency with the finding of Teema et al, Senait and a tudy from Tanzania which were 47, 47 and 46 year repectively 5,7, 9. However, it i in great diimilarity with report from developed world where elderly population dominate the picture 10. Thirty ix percent of patient were under the age of 40 year which i in line with the tudie from Ethiopia, Nigeria and Tanzania 5,6, 7, 8, 9, but in clear contrat with a tudy from the wet, which reported a much lower prevalence of 2 to 6% among thi age group 11. Thi need further tudy to determine why thi ignificant difference i een between the two geographic location in term of dieae ditribution. In thi tudy a light male preponderance wa een with a male to female ratio of 1.3:1 which i imilar to a tudy done in Tanzania 7 where the ratio i 1.6:1;thi i unlike tudie from the Wet where the male to female ratio i 1:1 with a very little male preponderance for Rectal cancer 10. According to thi tudy the major clinical feature were rectal bleeding, change in bowel habit, abdominal pain and palpable rectal ma on digital rectal examination which i in line with the previou report from the ame hopital and other tudie in Africa 5, 6, 7, 8. Majority (80%) of the cae were operated on elective bae imilar to the tudy from Tanzania where 86.5% of the tudy ubject were operated a an elective 7. On the other hand Hwang from Vernon Jubilee hopital, Canada reported that 43% of hi patient preented a an emergency with obtruction (59%), perforation (9%) and haemorrhage (34%) 12. Obtruction wa the ole caue of emergency admiion in our tudy. The combined involvement of the Sigmoid and rectum (71.6%) i a bit higher than that of Lago 13 and Tanzania 7 whoe report how 54.8%. Thi ditribution further fall down for wetern countrie where there i clear change in ditribution from left to right 14. The reaon for thi anatomical difference among thee countrie i not clear. Adenocarcinoma wa the commonet hitology type (94.8%), thi i imilar to tudie conducted by Teema et al 5 (92%) from Ethiopia and tudie from Tanzania and Nigeria which revealed 98.8% and 84.1% repectively 7, 15. Only 92 patient had a complete pathological diagnoi with only 8.7% preenting a tage I tumour which i in accord with the tudie from African et up (16). In thi tudy, lymph node metatae (tage III) were relatively le (16.3%) compared to ditant metatai (31.5%) which wa mainly liver metatai. Thi i in agreement with the previou report from the ame hopital by Teema et al 5. However, it i in contrat with Chalya et al 7 the finding from Tanzania where lymph node and ditant metatae were encountered in 30.4% and 24.7% repectively. A imilar metatatic pattern to that of Chalya et al 7 wa reported by Yawe et al 17 in Nigeria. The advanced tage definitely make the chance of cure gloomy whatever mean of treatment we utilize. The domination of hematologic route for ditant metatae in our et up i yet to be clarified. The Fact that 32.3% of our patient were either inoperable or had unreectable tumour tell that there wa a ignificant delay in preentation which i imilar to the report from Tanzanian 7. The figure rie to 37% when rectal cancer wa conidered eparately. Late preentation in our erie could be due to lack of awarene, low level of education, and lack of acceibility to health care facilitie which could be an area of future reearch. Some of the cae were being treated a paraitic dieae which further added to the delay. A mot of the tumour in our COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

15 15 15 ISSN Eat Cent. Afr. J. urg erie were located in the rectum, digital rectal examination could have picked ome of them and further delay might have been prevented. Therefore the role of digital rectal examination in adult patient coming with bloody and or mucoid diarrhoea cannot be overemphaized. Early diagnoi could have avoided Abdominoperineal reection with permanent colotomy in ome of the patient. Surgery continue to be the primary treatment option for colorectal cancer patient and reection ha been the tandard procedure for cancer primarily localized to the colon and rectum 16. Complete reection of colorectal cancer with exciion of adjacent lymph node i the only chance of cure in early tage cancer 18. Some 50.2% of our patient had either tage I or II cancer who were candidate for urgery with curative intent. Thi figure wa 33% for the previou tudy in the ame et up by Teema et al 5 which may how that there i ome improvement in early diagnoi. However, it i difficult to tell if thi i due to increaed awarene from the patient ide, improved diagnotic facility in the intitution or a mere chance. Limitation of the tudy The mall ample ize ha made it difficult to ee the ignificance of ome of the tatitic; in addition the data were incomplete from patient medical record. A the tudy relie on the accuracy of written record important data wa not available. Since Tikur Anbea Univerity Hopital i a tertiary hopital with the only oncology ervice in the country advanced cae are more likely to be referred here hence the finding may be difficult to generalize. A a cro ectional tudy: caue and effect cannot be etablihed. Concluion About two third were above 60 year with mean age of 47 year and 58% were men. Fifty percent of the patient preented with a palpable ma on Digital Rectal Examination ignifying the importance of a thorough phyical examination. Nearly half of the tudy ubject had advanced cancer (tage III and IV) which how a big gap on early diagnoi and referral; both at community and facility level. Recommendation Build the capacity of health care provider on early identification and referral of cae, and alo improve the capacity of the health facilitie by availing the much needed diagnotic tool. Create awarene among the community through different media to increae care eeking behavior for improved outcome. Proper documentation of data at all level o a to ue for future reearch, advocacy purpoe and informing policy maker. Further reearch hould alo be done to identify determinant factor of colorectal cancer. Acknowledgement We are very much grateful to the department of urgery, the department of Oncology, Dr Samuel Tefaye, Dr Neguie Deyaa and the OR taff at the Tikur Anbea Hopital. We are alo very much indebted to Mr Tewabech Gebrekirto who went through the manucript and gave u invaluable comment. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

16 16 16 ISSN Eat Cent. Afr. J. urg Reference 1. Alice Graham, Davie Adeloye, Liz Grant, Europi Theodoratou, Harry Campbell Etimating the incidence of colorectal cancer in Sub-aharan Africa. Journal of Global Health; December 2012 vol.2 No pp AhmedinJemal, Freddie Bray, Melia M. Center, Jacque Kerlay, Elizabeth Ward, David Forman, Global Cancer Stattic, CA Cancer J Clin 2011;61: Rebecca Siegel, Carol DeSanti, AhmedinJemal Colorectal Cancer tattic. CA Cancer J Clin 2014;64: Alice Graham, Davie Adeloye, Liz Grant, EvropiTheodoratou Harry Campbel: Etimating the incidence of colorectal cancerin ub-saharan Africa: Aytematic analyij Glob Health Dec; 2(2): doi: /jogh T. Erumo, A Ali ando. Johnon Cancer of the lower GI tract: a five year experience in Ethiopia Eat Afr Med J 1998,Vol.75 No. 6; David M. Irabor. Colorectal Carcinoma: Why i there a lower incidence in Nigerian when compared to Caucaian?, Jounal of cancer epidemiology Vol 2011, article ID Philipo L Chalya,Mabula D Mchembe, Joeph B Mabula, Peter F Rambau, Hyainta J, Mheta K, Eliaa M, and NetoryM: Clinicopathological pattern and challenge of management of colorectal cancer in a reource limited etting: a Tanzanian experience. World Journal of urgical Oncology 2013, 11:88 8. T. Erumo Colorectal adenocarcinoma in young peron: a review of 40 cae. Eat and cent Afri J of Surg vol. 5 No 1; Ahenafi S: Frequency of Large bowel cancer a een in Addi Ababa Univerity, Pathology Ethiop med j 2000, 38(4): Michael RB, Keighley Norman, S. William Surgery of the anu Rectum and Colon Third edition, 2008 vol. 1;p Mitry E, BenhamicheAM, Jouve JL, Clinard F, Finn-Faivre C, Faivre J: Colorectal adenocarcinoma in patient under 45 year of age: comparion with older patient in a well-defined French population. Di colon Rectum 2001, 44(3): Hamih Hwang Emergency preentation of colorectal cancer at a regional Hopital: an alarming trend? BC Medial journal 2012; Vol 54 No Guillem JG, Puig-La Caller Jr,J,CelliniC, Murray VM, Ng J,Fazzari M, Paty PB: Varying feature of early age-of-onet poradic and hereditary nonpolypoi colorectal cancer patient. Di Colon Rectum 1999,42: Takada H, Ohawa T, Iwamoto S, Yohida R, Nakano M, Imada S, Yohioka K, Okuno M, Mauya Y, Haegawa K, Kamano H, HiokiK, Muto T, Koyama Y,: Changing ite ditribution of Colorectal cancer in Japan. Di Colon Rectum 2002, 45; Ponz De Leon M, Marinom, Benatti P, Roi G Menigatti M, Pedroni M, Di GrigarioC, Loi L, Borghi F, Scarelli A, Ponti G, Roncari B, Zengardi G, Abati G, Acari E: Trend of incidence, Sub-ite ditribution and taging of colorectal neoplam in the 15-year experience of a pecialized cancer regitry. Ann Oncol 2004, 15; Cunningham D, Atkin W, Lenz HJ, Lynch HT, Minky B, NordlingerB, Starling N: Colorectal cancer. Lancet 2010, 375: Yawe KT, Bakari AA, Pidiga UH, Mayun AA: Clinicopathological pattern and challenge in the management of colorectal cancer in ub-saharan Africa. J Chinee Clin Med 2007, 2: National comprehenive Cancer Network: NCCN Clinical practice guideline in oncology: colon cancer. V COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

17 17 17 ISSN Eat Cent. Afr. J. urg Teticular torion in Ethiopia: a cae erie and ytematic review of the ub-saharan African literature M. Derbew 1, A.D. Laytin 2 1Addi Ababa Univerity School of Medicine 2Univerity of California San Francico Correpondence to: Miliard Derbew, miliardderbew@gmail.com Background: We report on the preentation, clinical coure and outcome of patient with teticular torion in Addi Ababa, Ethiopia to identify opportunitie for improved care. Method: A retropective review of clinical record of patient with teticular torion preenting to a hopital with pediatric urgical expertie in Addi Ababa, Ethiopia in wa performed and analyzed decriptively. A ytematic review of publihed literature about teticular torion in ub-saharan Africa between wa performed uing the PubMed and African Journal Online databae. Reult: Seven patient aged 5 day to 18 year were diagnoed with teticular torion, ix with acute ymptom and one with chronic, intermittent ymptom. The mot common ymptom were crotal welling and unilateral pain. In 4/6 acute cae, urgical conultation wa delayed to obtain color Doppler ultraound. In 5/6 cae, including all in which ultraound wa obtained, the teti wa nonviable, requiring orchiectomy. Thirteen tudie reported on teticular torion in ub-saharan Africa in the pat 25 year. Concluion: Teticular torion remain an under-appreciated urgical emergency in Ethiopia. Delay in preentation and diagnoi contribute to high level of teticular lo. A high index of upicion i warranted, and urgical conultation hould not be delayed to obtain ultraound confirmation in thi etting. Introduction Teticular torion i a common caue of acute crotal pain, accounting for acutely preenting crotal ymptom in 90% of pot-pubecent boy and 30% of pre-pubecent boy 1. The condition i a urgical emergency, a prolonged ichemia reult in teticular necroi 2. However, timely urgical intervention with detorion and bilateral orchiopexy reulted in a alvage rate of 68% in the United State 3. Color Doppler teticular ultraound ha been widely advocated a a diagnotic adjunct to confirm the preence of torion 4,5. However, there ha been little reearch to ae the prevalence of teticular torion in ub-saharan Africa, or the appropriatene teticular ultraound a a diagnotic technique in thi etting. Delaying urgical conultation and intervention to obtain ultraound imaging in the abence of emergency department phyician with ultraound expertie may contribute to potentially avoidable teticular necroi. Thi tudy wa aimed at invetigating the preentation, clinical coure and outcome of patient with teticular torion preenting to one of the few private hopital with pediatric urgical expertie in Ethiopia to determine current practice and identify ource of delay that may contribute to poor outcome. Patient and Method A retropective review wa performed of the medical record of all patient with final diagnoi of teticular torion preenting to the emergency department of one of the few private hopital with pediatric urgical expertie in Ethiopia, between January 1, 2012 and December 31, Clinical chart were retrieved and data wa extracted regarding patient demographic, nature and duration of ymptom, exam finding, work-up, intra-operative finding and urgical pathology. Thee data were compiled in Microoft Excel and analyzed uing decriptive tatitic. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

18 18 18 ISSN Eat Cent. Afr. J. urg In addition, a ytematic literature review wa performed following the PRISMA guideline 6. The PubMed databae wa queried uing the earch term teticular torion and Africa and the name of all ub-saharan African countrie, a well a the MeSH term teticular torion and Africa. The African Journal Online databae ( wa alo queried uing the earch term teticular torion. All report baed on empirical tudie publihed between for which at leat an abtract wa available were included. Duplicate report were excluded and then abtract were reviewed. Report were then creened and excluded if they were cae report or animal tudie. Finally, report were aeed for eligibility and excluded if they were report of patient population outide ub-saharan Africa, report of pathological examination, report in which teticular torion wa not a main focu of the tudy, or review article. Reult Over a three year period, even patient were treated for teticular torion (Table 1). Age ranged from 5 day to 18 year. Six patient had acute onet of ymptom, while the eventh had over a year of intermittent ymptom. Table 1. Patient treated for teticular torion Age Mon th Preenting Symptom Duration of Symptom Phyical Exam Finding ED Diagnoi Ultraound finding Viabilit y of Teti Operation Performed 13 y Sept crotal pain 12 h unilateral teticular tenderne, welling teticular torion epididymoorchit no orchiectomy, contralateral orchiopexy 5 d June crotal welling 5 d unilateral teticular welling undecended teti teticular torion no orchiectomy, contralateral orchiopexy, circumciion 18 y July crotal pain, welling 37 h unilateral teticular tenderne, elevation teticular torion torion with no flow, no evidence of viability no orchiectomy, contralateral orchiopexy 1.3 y July crotal welling, dicoloration 12 h unilateral teticular tenderne, erythema, elevation undecended teti, poible epididymal torion enlarged and heterogeneou teti, poible germ cell tumor or ubacute or mied torion no orchiectomy, contralateral orchiopexy 2.5 y July crotal pain, welling 4 h unilateral teticular tenderne, welling, hyperemia poible teticular torion not obtained ye bilateral orchiopexy 12 y Apr crotal pain, welling 1 day unilateral teticular tenderne, welling acute epididymoorchiti, poible teticular torion not obtained no orchiectomy, contralateral orchiopexy, circumciion 13 y Apr intermittent crotal pain >1 year nontender, unenlarged tete recurrent teticular torion and detorion not obtained ye bilateral orchiopexy COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

19 19 19 ISSN Eat Cent. Afr. J. urg In the patient with acute preentation, preenting ymptom included crotal welling (5/6), unilateral teticular pain (4/6), and dicoloration (1/6). The duration of ymptom ranged from 4 hour to 5 day at the time of urgical conultation. Five of the ix acute cae occurred between June and September, during the rainy eaon in Ethiopia.. The patient with chronic, intermittent ymptom reported evere unilateral teticular pain that reolved pontaneouly after about one day when ymptomatic Among the patient with acute onet of ymptom, all were afebrile on preentation. Phyical examination finding in the emergency department included unilateral teticular tenderne (5/6), crotal welling (4/6), crotal dicoloration (2/6), and teticular elevation (2/6). In 5/6 cae, patient underwent laboratory evaluation, with normal or mildly elevated white blood cell count (5,000-15,000/microliter) and haematocrit (41-46%). In 4/6 cae, urgical conultation wa delayed to obtain a color Doppler ultraound to confirm the diagnoi. One ultraound tudy wa obtained prior to referral and three were obtained from the radiology department by the phyician taffing the emergency department. Two of the ultraound tudie confirmed a diagnoi of teticular torion, while the other two uggeted alternate diagnoe. In 5 out of the 6 acute cae, including all of thoe in which an ultraound wa obtained, the affected teti wa groly nonviable at the time of crotal exploration and orchiectomy wa performed with contralateral orchiopexy. Teticular alvage wa only poible in one acute cae the patient who had four hour of ymptom and the one chronic, intermittent cae. In thee cae bilateral orchiopexy wa performed, for a teticular alvage rate of 29%. All patient had uneventful pot-operative coure and no urgical complication were noted. Table 2. PRISMA flowchart 77 record identified through databae earch 23 duplicate record removed 54 record creened 19 cae report, 2 review article, and 3 animal tudie excluded 30 tudie aeed for eligibility 13 tudie included in qualitative ynthei 6 report not focuing on teticular torion, 8 report from outide ub- Saharan Africa, and 3 report of pathology report excluded COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

20 20 20 ISSN Eat Cent. Afr. J. urg Seven report were cae erie or cohort tudie of patient with confirmed teticular torion 7-9,13,14,17,18; five report were cae erie or cohort tudie of patient preenting with acute crotal pain 10-12,15,16 and one cohort tudy compared patient preenting with teticular torion and orchiti 19 All report were hopital-baed. One report only included adult patient 9, one only included pediatric patient 15, and the remaining 11 report included all age 7,8,10-14, Study period ranged from two to 18 year, with one multinational tudy preenting data from one French and ix ub-saharan African cohort panning two to eight year. Ten of the report included teticular alvage rate, and ix of thoe were le than 60%. Figure 1. Scrotal Appearance in Acute Teticular Torion. Figure 2. Intra-operative Appearance of Twited Teti Table 3. Report of teticular torion in ub-saharan Africa Author Country Year Publihed Time Range Sample Size Age Range, year (mean) Salvage Rate Muguti et al 18 Zimbabwe <1-32 (17) 36% Magoha 16 Kenya (21) 21% Kuranga 7 Nigeria <1-50 (22.1) 14% Obi and Aghaji 9 Nigeria (22.5) NR Ugwu et al 8 Nigeria (22.7) 61% Mbibu et al 10 Nigeria <1-55 (23) 52% Dakum et al 11 Nigeria NR 72% Gnaingbe 15 Mali <1-15 (4.75) NR Okorie 14 Cameroon NR Maranya 17 Kenya NR 14% Njeze 12 Nigeria (22.7) 75% Baruga an multinational NR 56% Munabi 19 Takure et al 13 Nigeria <1-45 (23.8) 81% * NR = not reported COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

21 21 21 ISSN Eat Cent. Afr. J. urg Dicuion Although it i a well documented clinical entity, there are few publihed report of teticular torion in ub-saharan Africa, and accurate quantification of the incidence and clinical outcome of teticular torion in ub-saharan Africa remain eluive. The only previou report of teticular torion in Ethiopia that we encountered in the publihed medical literature wa a cae report of intrauterine teticular torion from In our tudy, five of the ix cae of acute teticular torion occurred during the rainy eaon, which i the coldet time of year in Ethiopia. Several previou tudie in both the African and international literature have noted alo eaonal variation in the incidence of teticular torion, with torion more common during colder time of year 8,10, Two of our cae were atypical, with one cae of perinatal teticular torion and one cae of intermittent teticular torion. Thee are both rare entitie that are well-documented in the international literature 25. Our tudy finding are imilar to thoe of many of the report identified in our ytematic literature review regarding the demographic of patient with teticular torion, with a wide range of age from infancy to adulthood, a well a their clinical preentation, with evere crotal pain and welling a the mot common ymptom. Our teticular alvage rate of 29% i conitent with the low rate oberved in mot of the reviewed tudie. Several of thee tudie noted delayed preentation and mied or delayed diagnoi a an important factor contributing to teticular lo 10,11,16,18. Becaue none of thee tudie were population-baed, the true prevalence of teticular torion in ub-saharan Africa remain eluive. While the cope of thi problem in ub-saharan Africa ha not been well tudied, one tudy from Nigeria cited teticular torion a the cauative event in 6% of cae of teticular inufficiency 26. Thi tudy ha everal limitation. A a ingle-ite cae erie, we cannot comment on the population prevalence of teticular torion in Addi Ababa. Some patient with teticular torion may have been referred to other urgeon in the city, and it i likely that ome patient with teticular torion never received medical care or urgical conultation. In addition, our literature review wa limited by our inability to acce full manucript for everal of the included report, forcing u to rely on data included in abtract. Logitical challenge prevented u from including grey literature in thi review. Neverthele, we feel that it i important to draw attention to the appropriate diagnoi and management of thi urgical emergency. Traditionally, urgical exploration ha been advocated for all pediatric patient preenting with acute onet of unilateral crotal pain 21,27. More recently author have recommended radiographic evaluation prior to urgery, with color Doppler ultraound a the firt line imaging modality of choice 5, However, thee recommendation generally come from reearch-rich etting where point-of-care ultraound i available in the emergency department. The only article from ub-saharan Africa commenting on the ue of color Doppler ultraound that we encountered wa a review article that only recommended it ue in patient with a low probability of torion with long duration of ymptom or poitive urinalyi 31. None of the tudie from ub-saharan Africa in our review commented on the impact of color Doppler ultraound on diagnoi or delay in intervention in patient with acute crotal pain. Teticular torion remain an under-diagnoed urgical emergency in Ethiopia, and throughout ub-saharan Africa. A low index of upicion and urgent urgical conultation are crucial to improve the rate of teticular alvage. Timely diagnoi of teticular torion i epecially important becaue in addition to the threat to the affected teti, teticular torion poe a threat of auto-antibody mediated damage to the contralateral teti 32. It i important to educate both patient and primary care provider about the erioune of acute crotal pain, welling and dicoloration, and the urgency of early preentation and urgical conultation. In the abence of the equipment and expertie to provide accurate point-of-care color Doppler COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

22 22 22 ISSN Eat Cent. Afr. J. urg ultraonography, urgical conultation and crotal exploration hould not be delayed to obtain radiographic work-up for patient with acute crotum. Source of Support Thi project wa upported by NIH Fogarty International Center (Grant #R25TW009338) under the Global Health Equity Scholar Conortium. The author declare that they have no conflict of interet to dicloe. Reference 1. O Brien M, Chandran H. The acute crotum in childhood. Surgery (Oxford). 2008;26: Vadev N, Chadwick D, Thoma D. The Acute Pediatric Scrotum: Preentation, Differential Diagnoi and Management. Curr Urol. 2012; 6: Cot NG, Buh NC, Barber TD, Huang R, Baker LA. Pediatric teticular torion: demographic of national orchiopexy veru orchiectomy rate. J Urol. 2011;185: Baker LA, Sigman D, Mathew RI, Benon J, Docimo SG. An Analyi of Clinical Outcome Uing Color Doppler Teticular Ultraound for Teticular Torion. Pediatric. 2000;105: Blaiva M, Sierzenki P, Lambert M. Emergency Evaluation of Patient Preenting with Acute Scrotum Uing Bedide Ultraonography. Acad Emerg Med. 2001;8: Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzche PC, Ioannidi JP, et al. The PRISMA tatement for reporting ytematic review and meta-analye of tudie that evaluate healthcare intervention: explanation and elaboration. BMJ. 2009;339:b Kuranga SA, Rahman GA. Teticular torion: Experience in the Middle Belt of Nigeria. Afr J Urol. 2002;8: Ugwu BT, Dakum NK, Yiltok SJ, Mbah N, Legbo JN, Uba AF, et al. Teticular torion on the Jo Plateau. Wet Afr J Med. 2003;22: Obi AO, Aghaji AE. Torion of the Spermatic Cord: I Bilateral Orchidopexy Really Neceary? J Coll Med (Nigeria). 2003;8: Mbibu NH, Maitama HY, Ameh EA, Khalid LM, Adam LM. Acute crotum in Nigeria: an 18-year review. Trop Doct. 2004;34: Dakum NK, Ramyil VM, Sani AA, Kidma AT. The acute crotum: aetiology, management and early outcome-preliminary report. Niger J Med. 2005;14: Njeze GE. Teticular torion: Needle teticular lo can be prevented. Niger J Clin Pract. 2012; Takure AO, Shittu OB, Adebayo SA, Okeke LO, Olapade-Olaopa EO. Torion of the teti and factor that determine the choice of orchidectomy and unilateral orchidopexy. Niger Potgrad Med J. 2013;20: Okorie CO. Unilateral teticular torion with necrotic outcome: dilemma of urgical timing. Urology. 2011;78: Gnaingbe K, Akakpo-Numado GK, Songne-G B, Anoukoum T, Sakiye KA, Kao M, et al. [Acute crotum in children]. Mali Med. 2009;24: Magoha GA. Torion of the teti in African in Nairobi. Eat Afr Med J. 1995;72: Maranya G, Mwero B, Kinyanjui G, Al-Ammary A, Maganga H. Dimal alvage of teticular torion: A call to action! Ann Afr Surg. 2011; Muguti GI, Kalgudi R. Torion of the teti: review of clinical experience in Zimbabwe. Cent Afr J Med. 1994;40: Baruga E, Guyton Munabi I. Cae erie on teticular torion: an educational emergency for ub-saharan Africa. Pan Afr Med J. 2013;14: Bekele Z, Luleged S. Intrauterine-neonatal torion of the permatic cord in an Ethiopian newborn. Ethiop Med J. 1993;31: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

23 23 23 ISSN Eat Cent. Afr. J. urg 21. Molokwu CN, Somani BK, Goodman CM. Outcome of crotal exploration for acute crotal pain upiciou of teticular torion: a conecutive cae erie of 173 patient. BJU Int. 2011;107: Lyroni ID, Ploumi N, Vlahaki I, Charii G. Acute crotum -etiology, clinical preentation and eaonal variation. Indian J Pediatr. 2009;76: Srinivaan AK, Freyle J, Gitlin JS, Palmer LS. Climatic condition and the rik of teticular torion in adolecent male. J Urol. 2007;178: Mabogunje OA. Teticular torion and low relative humidity in a tropical country. Br Med J. 1986;292: Gatti JM, Patrick Murphy J. Current management of the acute crotum. Semin Pediatr Surg. 2007;16: Ahmed A, Bello A, Mbibu NH, Maitama HY, Kalayi GD. Epidemiological and aetiological factor of male infertility in northern Nigeria. Niger J Clin Pract. 2010;13: Cavuoglu YH, Karaman A, Karaman I, Erdogan D, Alan MK, Varlikli O, et al. Acute crotum -- etiology and management. Indian J Pediatr. 2005;72: Kapoor S. Teticular torion: a race againt time. Int J Clin Pract. 2008;62: DaJuta DG, Granberg CF, Villanueva C, Baker LA. Contemporary review of teticular torion: new concept, emerging technologie and potential therapeutic. J Pediatr Urol. 2013;9: Yagil Y, Naroditky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler Ultraonography in the Triage of Acute Scrotum in the Emergency Department. J Ultraound Med. 2010;29: Vier AJ, Heyn CF. Torion of the teti and it appendage: Diagnoi and management. Afr J Urol. 2004;10: Vier AJ, Heyn CF. Teticular function after torion of the permatic cord. BJU International. 2003;92: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

24 24 24 ISSN Eat Cent. Afr. J. urg Obeity a a Rik Factor for Low Back Pain in a Nigerian Population C.J. Onyemkpa 1, G.C. Oguzie 2, D.C. Chukwumam 3 1Senior Regitrar (General Surgery) 2 Senior Regitrar (Orthopedic Surgery) 3Conultant Orthopedic Surgeon Department Of Surgery, Federal Medical Center, Owerri, Imo State, Nigeria. Correpondence to: Onyemkpa Chibueze J. chibuezejil@gmail.com Background: Variou rik factor have been implicated in the etiology of Low back pain (LBP) and the role of obeity ha remained contentiou till date. The objective of thi tudy wa to determine if a relationhip exit between obeity and low back pain, and to identify other rik factor. Method: Thi i a cae-referent tudy of patient that preented to the orthopedic clinic from June 2013 to June The cae were patient that preented with LBP during the period of thi tudy, while the referent were randomly elected patient - without a diagnoi of LBP - that alo attended the clinic at the ame time. Body Ma Index wa calculated and broadly claified into obee and non-obee. It wa alo further categorized uing the WHO international claification. Independent t-tet and Chi-quare tet were ued to compare mean and categorical variable repectively. A binary logitic regreion analyi wa carried out to determine independent rik factor. Reult: A total of 332 patient were included in the tudy: 69.6% (n = 231) had LBP and 30.4% (n =101) did not. The mean BMI wa 27.11kg/m 2 ± 4.1. Age, height and weight were tatitically aociated with LBP but gender wa not. The relationhip between obeity and LBP wa null (OR % CI , p 0.079); however, at higher clae of obeity (BMI 35), the relationhip wa ignificant (p 0.000). Concluion: Low back pain i a condition that i commoner in the elderly. Although obeity (BMI >30) wa not identified a a rik factor, individual with BMI 35 are at increaed rik. Age, height and weight were all ignificantly aociated with LBP. Keyword: Low back pain, obeity, aociation, rik factor Introduction Low back pain (LBP) i a ymptom of a wide array of condition that include muculokeletal a well a neurologic pathologie. Over the year, it ha found increaing prevalence in both developing and developed countrie. 1-3 With an etimated lifetime prevalence of 65 80%, it i one of the commonet reaon for clinic viit. 2,4-8 In Africa, it prevalence in adult i etimated at 50%. 2 In a tudy aeing it global burden in 2010, LBP wa firt in diability and 6 th in overall burden with a DALY of $83M. 9 It therefore goe without aying that LBP i a condition with far reaching health and ocioeconomic implication. 1-3,6,8,10 Conidering it burden, undertanding the pathophyiology of LBP and it rik factor have been a major area of reearch. Obeity ha been one of the main variable of interet. In recent time, there ha been an increae in the global rate of obeity 3,6,7,11 and Africa ha not been pared of thi courge. Identified a a rik factor for a number of dieae, it i meaured uing a variety of intrument. The Body Ma Index (BMI) i one of uch tool. A an anthropometric tool, BMI wa deigned to determine weight adjuted for height but ha alo found ue in etimating adipoity With the pathophyiology of LBP hinged on a complex interaction of pychoocial, biomechanical, and tructural influence, obeity if preent i believed to contribute to the interplay of thee procee in the development of LBP. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

25 25 25 ISSN Eat Cent. Afr. J. urg Variou pathway have been potulated to explain the role of adipoity in LBP development - metabolic dyfunction, mechanical tre and inflammation 2. However, there ha been varying reult from cientific tudie to upport a relationhip between obeity and LBP 15.Thi tudy aim to acertain if obeity i a rik factor for LBP. It alo intend to identify other rik factor in the development of low back pain. Patient and Method Thi i a cae-controlled tudy of patient that preented to the orthopedic outpatient from June 2013 to June 2014.Thi tudy wa done at the Federal Medical Centre Owerri (FMCO) which i a tertiary healthcare intitution in Imo tate, Nigeria. FMCO erve a the major referral center for orthopedic cae in the tate.at the time of thi tudy, there were 3 orthopedic team with 5 orthopedic urgeon in the center. Incluion Criteria: The cae were all patient that preented with LBP during the period of thi tudy, while the referent were patient without LBP that alo attended the orthopedic clinic at the ame time. The referent were randomly elected. A total of 332 patient were included in the tudy: 231 had LBP and 101 did not. Cae Definition: Low Back Pain wa defined a pain between the 12th of the rib and the buttock creae. Data Extraction: Patient conent were obtained and demographic profile collected. Weight and height were meaured in kilogram and meter repectively. Body Ma Index wa calculated uing the formula. Outcome Examined: BMI wa claified into obee (BMI 30) and non-obee (BMI<30). It wa further claified uing the WHO international claification a underweight (BMI<18.5), normal weight (BMI ), overweight (BMI ), Cla I obeity (BMI ), Cla II obeity (BMI ) and Cla III obeity (BMI 40). Statitical Analyi: The data wa analyzed uing SPSS verion 21. The ditribution of categorical variable wa repreented in percentage while mean and confidence interval (CI) were ued to repreent ordinal and nominal variable. Mean and categorical variable were compared uing independent t-tet and chi-quare tet. A p value < 0.05 wa tatitically ignificant. A binary logitic regreion model uing LBP a an outcome wa generated and variable independently aociated with LBP were identified. To determine the rik of LBP with obeity, a eparate analyi wa carried out uing BMI a a categorical variable (obee/non-obee). Reult A total of 332 patient were included in the tudy with 207 (62.4%) being female and 125 (37.6%) being male. The mean age of the tudy population wa 57.8 year ± 14.1and the peak age in both gender wa the 6 th decade (Figure 1). The mean BMI of the tudy population wa 27.11kg/m 2 ± 4.1 (95% CI ). Overall mean weight and height were 79.4kg ± 9.57 (95% CI ) and 1.72m± (95% CI ) repectively. In 101 (30.4%) of the patient, no low back pain wa preent while 231 (69.6%) had it. The average age for the control group wa 62.9 year ± and 55.8 year ± for the cae group. Thi difference between age of both group wa tatitically ignificant (t core , p 0.000). 24.8% and COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

26 26 26 ISSN Eat Cent. Afr. J. urg Figure 1. Gender Ditribution in the variou age group Table1. Demographic Characteritic of Patient Characteritic Cae Group Referent Group Number % Number % Gender: Female Male Age Group: year year year year year year year year year BMI Group: Underweight Normal Weight Overweight Obee % of the referent and cae cohort were obee, and the mean BMI were 27.46kg/m 2 ± 5.23 and 27.05kg/m 2 ± 3.5 repectively. The mean weight for the cae group wa 80.07kg ± 8.53 COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

27 27 27 ISSN Eat Cent. Afr. J. urg while that for the control cohort wa kg ± The characteritic of both group are diplayed in Table 1. In the cae cohort, the overall male-to-female ratio wa 1.6:1. Male were however predominant in the 2 nd and 3 rd decade while female were dominant from the 4 th till the 10 th decade. Female had marginally higher mean weight(female kg ±8.92, male kg ± 7.91) and height (female cm ±6.49 and male cm ± 7.02) while male had lightly higher BMI (male ± 3.39 and female ± 3.63).Thee aociation were null.60.9% (n = 42) of the obee cae were male and 39.1% (n = 27) were female. There wa no ignificant relationhip between obeity and gender (p 0.776). Table 2a. Independent rik factor for the entire population irrepective of ex Rik Factor Odd Ratio 95% Confidence Interval P value Age Gender Height Weight BMI Table 2b. Independent Rik Factor for Female Rik Factor Odd Ratio 95% Confidence Interval P value Age Height Weight BMI Table 2c. Independent Rik Factor for Male Rik Factor Odd Ratio 95% Confidence Interval P value Age Height Weight BMI To determine the independent factor aociation with LBP, a binary logitic regreion analyi wa performed, and a ignificant regreion equation wa found (p 0.000, R 2 = 0.161).Age, ex, COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

28 28 28 ISSN Eat Cent. Afr. J. urg weight, height and BMI were the variable included in the model. The Homer-Lemhow goodne of fit howed that the model fit the data (p 0.193). Age, weight, height and BMI were ignificantly aociated with LBP (OR % CI , OR % CI , OR % CI and OR % CI repectively). The aociation between LBP and gender wa null (OR % CI , p 0.597).After controlling for other factor, age, weight, and BMI but not height were rik factor among women. Male, however, had age, weight, height and BMI a independent rik factor (Table 2). With BMI claified either a obee or non-obee and included in a eparate binary logitic regreion model, obeity wa not an independent rik factor (OR % CI , p 0.079). A imilar pattern wa alo oberved when the model wa applied to the different gender with p value and for the male and female cohort repectively. Dicuion During the period of thi tudy, a total of 2132 patient viited the clinic. Since all the patient with low back pain were recruited, the prevalence wa calculated a10%.thi i lower than the 46.8% oberved by Ogunbode et al in their hopital-baed tudy in wetern Nigeria. 16 We found BMI to be independently aociated with LBP in the entire population, a well a the gender ubgroup. However, when categorized a obee or non-obee uing the WHO cut-off point of 30, we found no ignificant relationhip between obeity and low back pain (OR % CI , p 0.079). At a higher cut-off of 35 (Clae II and III obeity), a ignificant interaction wa noted (OR % CI , p 0.000). Garzillo and Garzillo in 1994 had a imilar reult were an aociation wa oberved only in the upper 25 th percent of obeity. 17 Although in agreement with tudie that have hown increaing BMI a a rik factor for LBP, 1,18 our finding place thi rik at value above the tipulated cut-off point for obeity. Thi variation could be attributed to the limitation in the ue of BMI a it ha been purported to give room for miclaification of overweight/obeity. 5 A BMI doe not directly meaure body fat, there i a drawback ineffectively accounting for very high mucle mae which can be mirepreented a obeity/overweight 14. Thi limitation call for the ue of other intrument that directly meaure adipoity 5,10,11. In addition to obeity, we ought to identify other potential rik factor for LBP. One of the variable that we identified i age (OR % CI , p 0.000). More prevalent in the elderly, LBP i aid to tart at a younger age and increae in frequency and everity with age. One explanation for thi high rate of LBP in the elderly have been attributed to the higher rik of degenerating diorder of the pine uch a pondyloi in the older population 1, 8. Although we had a ignificantly older cohort in the referent group, it did not nullify the effect of age a a rik factor on LBP. We, however, oberved that the effect of age wa lot in the moderate and evere obee ubgroup. Gender-baed difference in LBP from our tudy revealed that although we had more female, the difference wa not tatitically different (OR % CI , p 0.597).Thi i imilar to the finding by Kotova and Koleva 19. A plauible reaon for thi gender variation i the health eeking habit of women. Women have been noted to eek healthcare for ailment more than men 20 and thi could be the reaon for the higher prevalence oberved in our tudy. Furthermore, reearche have hown that women are more likely to report pain than their male counterpart 21. Overall, there ha been no agreement on the role of gender in LBP a tudie have yielded differing reult 21. Both exe in our tudy had imilar increae in prevalence with age reaching a peak at year. Although there wa a male cae between 10 year and 20 year, the female cae tarted from age 20 year. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

29 29 29 ISSN Eat Cent. Afr. J. urg Literature on the aociation between height and LBP ha hown a lot of controverie with mot of the relationhip being with dic herniation a a pathology 14, 21. We did note a ignificant aociation between LBP and height (OR % CI , p 0.005). An attempt to identify rik factor unique to each gender revealed that in female, height wa not a rik factor after adjuting for other variable.bmi and weight, however, were. Contrary to the obervation that the aociation between obeity and LBP i higher in women 11, no relationhip wa noted in either ex in our tudy. Converely, the rik of LBP with increaing BMI wa higher in male than female. Weight, on the other hand, had a ignificant relationhip with LBP in both gender, and the entire ample population. Leboeuf-Yde 22 had imilar finding in her tudy in which he concluded that body weight hould be conidered a poible weak rik indicator. 22 On the other hand, Mortimer et al 23 failed to how a clear cut relationhip between a high body weight and low back pain howing a relationhip in male but not in female 23. A major challenge to determining a relationhip between obeity and LBP i the obcurity in definition. A a ymptom and not a dieae, an attempt to link it to obeity might prove difficult due to the large number of poible etiologie hence the variation in reult from tudie done. Interetingly, tudie that have attempted to hone in on a particular diagnoe have alo been faced with the ame debate 6. Limitation of Study: One of the limitation of thi tudy i that it did not effectively eek out other confounding variable, uch a phyical activity or moking which could account for the preence of LBP in the patient. Thee area are apect of the tudy that hould be put into conideration in future tudie. A population baed tudy will alo further elucidate the effect of LBP on the population, a a whole. Concluion Low Back Pain i a condition that motly plague the elderly with majority of the patient in their 6 th decade of life. Age, BMI, height and weight but not gender wa found to be ignificant rik factor. Higher clae of obeity (BMI 35) were alo identified a rik for developing LBP. The ue of an encompaing term a low Back Pain hould be avoided in further tudie a the ambiguity aociated with it might act a a confounding factor. Furthermore, additional reearch i needed to further identify the relationhip between obeity and the variou individual diagnoe reponible for low back pain. Other theorie that examine the relationhip between body fat and LBP hould alo be explored a thi could be caual but in a revere manner: an individual with bout of low back pain may be prone to weight gain due to inactivity or inability to exercie thu increaing their BMI. Or, it might be a confounder for other variable that are reponible for the low back pain. Reference 1. Manchikanti L, Singh V, Falco FJE, Benyamin RM, Hirch JA. Epidemiology of Low back pain in Adult. Neuromodulation 2014; 17: Hu HY, Chen L, Wu CY, Chou YJ, Chen RC, Haung N. Aociation among low back pain, income, and body ma index in Taiwan. The pine journal 2013; 13: Garcia JBS, Hernandez-Catro JJ, Nunez RG, Pazo MAR, Aguirre JO, Jreige A, Delgado W, Serpentegui M, Berenguel M, Cantiani AF. Prevalence of Low Back Pain in Latin America: A ytemic Literature Review. Pain Phyician 2014;17: Daentzer D, Hohl T, Noll Chritine. Ha overweight any influence on the effectivene of conervative treatment in patient with low back pain. Eur Spine J DOI / COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

30 30 30 ISSN Eat Cent. Afr. J. urg 5. Brook C, Siegler JC, Cheema BS, Marhall PWM. No relationhip between body ma index and change in pain and diability after exercie rehabilitation for patient with mild to moderate chronic low back pain. Spine 2013; 38: Samartz D, Karppinen J, Cheung JPY, Lotz J. Dik Degeneration and Low Back Pain: Are they fat-related condition? Global Spine J 2013; 3: Cueta-Varga AI, Gonzalez-Sanchez M. Obeity effect on a multimodal phyiotherapy program for low back pain uffer: patient reported outcome. Journal of Occupational Medicine and Toxicology 2013; 8:13 8. Abanobi OC, Ayeni GO, Ezeugwu CC, Ayeni OA.Effect of ocio-demographic characteritic on low back pain occurrence and moking habit of welder/panel beater in Owerri, outh-eat Nigeria. Wudpecker Journal of Medical Science 2014; 3(1): Hoy D, March L, Brook P, Blyth F, Woolf A, Bain C, William G, Smith E, Vo T, Barendregt J, Murray C, Burtein R, Buchbinder R: The global burden of low back pain: etimate from the Global Burden of Dieae 2010 tudy. Ann Rheum Di 2014;73: Shiri R, Solovieva S, Hugafvel-Purianen K, Telama R, Yang X, Viikari J, Raitakari OT,Viikari-Juntura E. The role of obeity and phyical activity in non-pecific and radiating low back pain: The young Finn tudy. Semin Arthriti 42: Arranz LI, Rageca M, Alegre C. Effect of Obeity on function and Quality of Life in chronic pain condition. CurrRheumatol Rep 2014:390 DOI / Flegal KM, Shepherd JA, Looker AC, Graubard BI, Borrud LG, Ogden CL, Harri TB, Everhart JE, Schenker N: Comparion of percentage body fat, body ma index, wait circumference, and wait-tature ratio in adult. Am J ClinNutr 2009; 89: Luke A, Durazo-Arvizu R, Rotimi C, Prewitt TE, Forreter T, Wilk R, Ogunbiyi OJ, Schoeller DA, McGee D, Cooper RS: Relation between Body Ma Index and Body Fat in Black Population Sample from Nigeria, Jamaica, and the United State. Am J Epidermol 1997; 145: Han TS, Schouten JS, Lean MEJ, Seidell JC: The prevalence of low back pain and aociation with body fatne, fat ditribution and height. Int J ObeRelatMetabDiord 1997; 21: Skinner HB: Current Diagnoi & Treatment in Orthopedic. Lange Medical Book. New York; Adetola M. OgunbodeAM, Adebuoye LA, Alonge TO. Prevalence of low back pain and aociated rik factor amongt adult patient preenting to a Nigerian family practice clinic, a hopital-baed tudy.afr J Prm Health Care Fam Med. 2013; 5(1), Art.# 441, 8 page Garzillo MJ, Garzillo TA: Doe obeity caue low back pain? J Manipulative PhyiolTher 1994, 17: Smuck M, Kao MCJ, Brar N, Martinez-Ith A, Choi J, Tomkin-Lane CC. Doe phyical activity influence the relationhip between low back pain and obeity? The Spine J 2014;14: Kotova V, Koleva M: Back diorder (low back pain, cervicobrachial and lumboacral radicular yndrome) and ome related rik factor. J NeurolSci 2001; 192: Tudiver F, Talbot Y: Why don t men eek help? Family phyician perpective on the help-eeking behavior in men. J FamPract 1999 Jan; 48(1): Manchikanti L: Epidermiology of Low Back Pain. Pain Phyician 2000; 3(2): Leboeuf-Yde C: Body weight and low back pain. A ytematic literature review of 56 journal article reporting on 65 epidemiologic tudie. Spine 2000; 25: Mortimer M, Wiktorin C, Pernol G, Svenon H, Vingard E, MUSIC-Norrtalje tudy group. Muculokeletal Intervention Center: Sport activitie, body weight and moking in relation to low-back pain: a population-baed cae-referent tudy. Scand J Med Sci Sport 2001; 11: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

31 31 31 ISSN Eat Cent. Afr. J. urg Pattern of Elbow Fracture and Complication of Thoe Seen Late in Children Treated at KCMC in Northern Tanzania M.E. Ngowi 1, R.Temu 2, G Maya 3, A. Mallya 4 1Department of orthopedic, Kilimanjaro Chritian Medical Univerity College, P.O.Box 2240, Mohi, Tanzania 2Conultant orthopedic urgeon, Department of orthopedic, Kilimanjaro Chritian Medical Univerity College, P.O.Box 2240, Mohi, Tanzania 3Conultant orthopedic and Head, Department of orthopedic, Kilimanjaro Chritian Medical Univerity College, P.O.Box 2240, Mohi, Tanzania 4Proffeor in orthopedic, Department of orthopedic, Kilimanjaro Chritian Medical Univerity College, P.O.Box 2240, Mohi, Tanzania Correpondence to Dr Mami Evarit; mamievarit@gmail.com Background: Fracture around the elbow in children are common and difficult to diagnoe radiographicaly.there i limited information on fracture pattern around the elbow in children from developing countrie. Thi tudy aim to identify; fracture type around the elbow and midiagnoed fracture by the referring doctor at peripheral health facility and complication on arrival at Kilimanjaro Chritian Medical Centre (KCMC) tertiary hopital. Method: Thi cro ectional record reviewed every child with fracture around the elbow treated at KCMC a outpatient or inpatient during the period of January 2009 to December File and their x-ray film were traced both the orthopedic urgeon and the radiologit dicu the finding and were recorded. Reult: During the tudy period 366 cae were entered into the tudy. Male accounted for 263 (72.1%) of cae. Malunion wa the commonet late complication reported clinically at the time of arrival at KCMC een in (6.8%) patient. The commonet fracture were humeru upracondylar in (82.2%), followed by lateral condyle in (1.9%). Midiagnoed fracture at peripheral health facility were; (5%) upracondylar followed by 3 olecranon and other. Concluion: Fracture around the elbow hould be handed carefully in upiciou cae dicuion between orthopedic urgeon and radiologit i valuable. Refreher coure to the referring doctor from the ditrict will help to improve diagnoi. Introduction Fracture around the elbow in children i common account for 10% of all fracture in America 22.Different tudie have hown fracture around the elbow to be the econd or third commonet from other fracture 17,16,23. Thee fracture in children preent a challenge to orthopedic practitioner in diagnoi due to changing anatomy of their growing keleton. Some are therefore either completely mied or midiagnoed. If not timely diagnoed and treated may reult into grievou complication which include; neurovacular injurie, open fracture, malunion and elbow tiffne 17, 7, 3. Effort ha been made to reduce the chance of miing the fracture where a comparative x-ray of the ound limb were requeted by junior taff to rule out fracture around the elbow. Finally it wa concluded that a review from enior conultant keletal radiologit and orthopedic urgeon wa adequate to diagnoe fracture around the elbow 19. In Ethiopia 10% of the fracture were mied radiologically at the time of injury but diagnoed 2 to 3 week later by follow up x-ray 3. Current literature in mot of the tudie patient were een immediately after injury no late comer. The objective of thi tudy wa to decribe; fracture type around the elbow, midiagnoed fracture by the referring doctor at peripheral health facility and complication on COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

32 32 32 ISSN Eat Cent. Afr. J. urg arrival at KCMC tertiary hopital a baeline information in developing countrie. It i valuable to review elbow fracture with complication which will guide to improve diagnoi in primary health care facilitie and give patient appropriate care in a timely fahion. Patient and Method Thi wa a cro-ectional record review hopital baed tudy done at Kilimanjaro Chritian Medical Centre which i one of the referral, teaching hopital ituated in northern part of Tanzania. The department of orthopedic and trauma ha 3 pecialit and 15 reident. It manage patient both a in patient and out patient. There i alo a department of radiology with, two pecialit and eight reident. Thi make KCMC hopital uitable for thi reearch. All children aged 1-16year treated at KCMC inpatient and outpatient from January 2009 to December Incluion criteria were all children diagnoed to have a fracture or malunion (deformity) around elbow at KCMC hopital. Excluion criteria were thoe patient with miing information pecifically age, ide affected ex and x-ray film. Hopital regitration number of all children with elbow injurie or deformity were obtained from x-ray department regiter, admiion regiter in orthopedic ward and operating theatre regiter. The file and x-ray film were traced for data collection. X-ray film were interpreted. The help of enior conultant orthopedic urgeon or radiologit in thoe cae with ambiguity wa ought. Information wa collected on new fracture, which included thoe firt diagnoed at Kilimanjaro Chritian Medical Centre a well a thoe firt een at other health facilitie for the injury. In addition complication for thoe that preented late were recorded. The data were entered, coded, labeled, and checked for miing value and then analyzed uing the SPSS verion 20 tatitical package. Data were claified and ummarized in ditribution of frequency table, hitogram and the tatitical relationhip between type of fracture and age were teted. Statitical ignificance were conidered when p-value Permiion to conduct the tudy wa ought from the KCMC Reearch Ethical Committee. All confidentiality and regulation of the patient medical information wa followed Reult Three hundred and ixty ix children with fracture around the elbow were included in the tudy. Their x-film were available for analyi. There were 264 (72.1%) male and 102 (27.9%) female (Table 1). The mean age wa 7.3 year and mot of the fracture occurred at 4-10 year of age (Figure 1). Out of 366 injured children the commonet fracture type wa humeru upracondylar in 303 (82.2%), followed by lateral condyle in 7 (1.9%), lateral epicondylar fracture were 6 (1.6%) and medial epicondylar 6 (1.6%), head of radiu 6 (1.6%), olecranon 4 (1.1%), undiagnoed fracture are thoe fracture which came after healing with complication and initial radiological film were not available (Table 2). Table 3 how fracture which were not initially diagnoed at primary health facility of which upracondylar fracture (n=11) wa the commonet. Table 1. Ditribution of ex according to age Age Group of Children Total Sex Under Above 10 No. (%) No. (%) No. (%) No. (%) Male 51(70.8) 175(73.2) 38(69.1) 264(72.1) female 21(29.2) 64(26.8) 17(30.9) 102(27.9) COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

33 33 33 ISSN Eat Cent. Afr. J. urg Figure 1: Age Ditribution Table 2. Ditribution of elbow fracture according to age. Type of fracture Total (n=366) Age (year) p-value Under 5 (n=72) 5-10 (n=239) Above 10 (n=55) No. (%) No. (%) No. (%) No. (%) Supracondylar 303 (82.8) 62 (86.1) 207 (86.6) 34 (61.8) <0.001 Lateral condyle 7 (1.9) 1 (1.4) 6 (2.5) 0 (0.0) Lateral epicondyle 6 (1.6) 1 (1.4) 4 (1.7) 1 (1.8) Medial epicondyle 6 (1.6) 1 (1.4) 2 (0.8) 3 (5.5) Head of radiu 6 (1.6) 0 (0.0) 3 (1.3) 3 (5.5) Olecranon 4 (1.1) 1 (1.4) 2 (0.8) 1 (1.8) Undiagnoed 10 (2.7) 1 (1.4) 5 (2.1) 4 (7.3) Table 3: Type of midiagnoed fracture Type of fracture Midiagnoi at Referral Centre Total cae referred (n=223) Cae Midiagnoed (n=18) Number Number % Supracondylar Lateral epicondyle Olecranon Medial condyle Head of radiu Table 4: Complication According to Ditrict of Reidence. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

34 34 34 ISSN Eat Cent. Afr. J. urg Ditrict Cubitu varu(25) p-value Other complication(15) p-value Preent Abent Preent Abent No (%) No (%) No (%) No (%) Mohi 11 (5.2) 199 (94.8) 4 (1.9) 206 (98.1) Hai 2 (8.0) 23 (92.0) 1 (4.0) 24 (96.0) Siha 0 (0.0) 16 (100.0) 3 (18.8) 13 (81.2) Same 2 (5.1) 37 (94.9) 0 (0.0) 39 (100.0) Aruha 7 (21.9) 25 (78.1) 2 (6.2) 30 (93.8) Mwanga 2 (12.5) 14 (87.5) 0 (0.0) 16 (100.0) Other 1 (3.6) 27 (96.4) (17.9) 23 (82.1) <0.001 Malunion (cubitu varu) wa the commonet late complication reported clinically more than three week after injury mot of the patient were coming from Mohi urban and rural. Seen in 25 (6.8%) of children. Other complication accounted for 4.1% (n=13) patient. Among other complication, tiffne (n=10) wa the commonet (Table 4). Dicuion In thi tudy male were predominantly affected thi ha alo been found in everal tudie regarding fracture around the elbow. Thi can be explained by the fact that male are the one who are involved in more riky game activitie 2, 17, 10. The mot affected age group in thi tudy wa between 4-10 year of age. Similar reult were alo een in different tudie where by more than three fourth of the fracture happened at around 5-10 year of age. Thi peak i thought to be aociated with the fact that the capule and ligament upporting the elbow have been revealed to have greater tenile trength than the bone itelf, which lead to preferential fracture of the vulnerable humeru upracondylar region when ufficient force i applied acro it 2, 3, 7. The commonet fracture type wa humeru upracondylar een in more than two third, followed by lateral condyle and epicondylar fracture. Similar finding were een in everal tudie 17,3,9 Studie in developed countrie humeru upracondylar fracture were le than two third thi could be due to difference ocial life and ocial tructure example formal play ground1 2,7,10. Fracture not identified initially at primary health care facility mot common were upracondylar which correlate with the number of children referred with humeru upracondylar. Thi i different from other comparative tudie. Other type of fracture include; olecranon, lateral epicondyle, medial condyle, head of radiu. In other tudie the upracondylar fracture were correctly diagnoed. Other fracture type were alo midiagnoed becaue they involve the growth plate which i not o clear on radiograph 3, 19. Malunion (cubitu varu) wa the commonet late complication reported clinically in thi tudy at the time of arrival. Among other complication, tiffne wa the commonet. The remaining four other complication included: chronic Oteomyeliti, compartmental yndrome and fracture bliter. Biruk in hi follow up for mied fracture 2 children preented with malunion (cubitu varu). Other tudie only neurovacular and oft tiue injurie were een. All patient in thee other tudie were een immediately after injurie and 10 week later all had good recovery 7, 17. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

35 35 35 ISSN Eat Cent. Afr. J. urg Concluion Diagnoi of fracture around the elbow hould be handled cautiouly to reduce complication and in upiciou cae patient hould be referred early for dicuion between orthopedic urgeon and radiologit. Recommendation Feedback and refreher coure to the referring doctor will keep them up to date. Thi tudy ha a limitation being a retropective may bia on complication een at arrival. Thi tudy wa intended to guide future tudie. Acknowledgement To o many people whoe help ha been eential in bringing up thi reearch, my heartfelt thank to public health department and radiology at Kilimanjaro Chritian Medical College. Thi paper received financial upport from Minitry of Health and Social Welfare Tanzania. Reference 1. Ahmad Gharaibeh, Ali F. Abu-Lobbad, Motafa H. Ababneh, Marek Lacko, RobertCellar, Stefan Stolfa. The incidence of fracture and dilocation in children at the teaching hopital in northern Jordan.Prevention of accident, poioning and violence 2010; 4(2): Behdad A,Behdad S,Hoeinpour M.Pediatric elbow fracture in major trauma centre in Iran.Arch Trauma Re 2012; 1(4) Biruk L.W. Admaie D& Banchiamlak A. Fracture around child elbow-radiological pattern. Eat and Central African Journal of Surgery 2008;13 (2): Davie M. A & Petteron H. Radigraphic anatomy and interpretation of muculokeletal ytem The WHO manual of diagnotic imaging. 5. Harold E. Clinical Anatomy A reviion and applied anatomy for clinical tudent. Oxford UK: Blackwell; Hart E.S, Tuner A, Albright M. & Grottkau E. B. Common pediatric elbow fracture. Orthop Nur 2011; 30 (1): Houhian S, Mehdi B & Laren M.S. The epidemiology of elbow fracture in children: analyi of 355 fracture, with pecial reference to upracondylar humeru fracture. J Orthop Sci 2001; 6 (4): Jack C.Y.C. & Shen W.Y. Limb fracture pattern in different pediatric age group: A tudy of 3,350 children. Journal of orthopaedic trauma 1993; 7 (1): Jehrani M.K. Elbow injurie at Kenyata National hopital in 1974 Incidence and obervation concerning their management. Eat African Medical Journal 1978; 55 (7): Jidveianu N.H., P. Nicolcecu, and O. Vonica. Elbow fracture in children. Journal of Pediatric Surgical Specialtie 2008; 2 (3): Kifayatullah, Khan H.D, Shah F.A. Fracture in children; ditribution in orthopedic unit at THQ hopital Tangi Charadda NWFP-Pakitan. Profeional Med J 2012; 19(6): Landin L.A & Danielon L.G. Elbow fracture in children. An epidemiological analyi of 589 cae. Acta Orthop Scand 1986; 57 (4): Liyang D. Radiographic Evaluation of Bowmann Angle in Chinee Children and It Clinical Relevance. Journal of Pediatric Orthopaedic 1999; 8 (3): Mbandyo B.S.Conideration on cae of epiphyeal injury oberved at Kenyata National Hopital. Eat African Medical Journal 1979; 56 (9): Micheli, L.J, Santore R & Stanitki, C.L. Epiphyeal fracture of the elbow in children. Am Fam Phyician1980; 22 (5): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

36 36 36 ISSN Eat Cent. Afr. J. urg 16. Minha M.S, Anari I, Khalid, Baig N. & Siddiqui E. Muculokeletal trauma and epidemiology of fracture in children. The journal of Pakitan orthopedic aociation 2011; 23 (1): Ndour O., Ndoye N.A., Alumeti D.M., Fall M., A.L. Faye Fall, Diouf C., Ngom G., Ndoye M. Epidemiology of Elbow Fracture in Children in the African context: About 465 cae.the internet journal of Orthopedic urgery 2012; 199(3) DOI: /2c Pinheiro P.S World report on violence againt children. Geneva, Switzerland, Secretary General Study on Violence againt Children, 2006, ( (acceed 22 nd March 2013) 19. Rickett A. B.& Finlay D.B. An audit of comparative view in elbow trauma in Children. The Britih Journal of Radiology 1993; 66: Solomon L, Warwick D.J, & Nayagam, S.W. Apley Sytem of Orthopedic and Fracture. London: Hodder Arnold; Tandon T, Shaik M & Modi N. Paediatric trauma epidemiology in an urban cenario. Journal of Orthopaedic Surgery 2007;15 (1): Townend D.J & Baett G.S. Common elbow fracture in children. American Family Phyician 1996; 53 (6): Tripathi RB et al. Clinical Epidemiological Study on Pediatric Fracture at Narayani Sub Regional Hopital, Birganj. Journal of GMC Nepal 2009; 2 (2): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

37 37 37 ISSN Eat Cent. Afr. J. urg Morbidity of Open Tibia Fracture in Lago, Nigeria. G.O. Enweluzo, T.O Adekoya Cole, B.O Mofikoya, S.O. Giwa, O.O. Badmu. Department of Surgery, College of Medicine, Univerity of Lago / Lago Univerity Teaching Hopital, Lago, Nigeria. Correpondence to: Dr. G.O. Enweluzo, enweluzog@yahoo.com Background: Open fracture of the tibia are complex injurie of bone and oft tiue. And on account of the open nature ha a tendency to increae morbidity. The main objective of thi tudy wa to determine peculiar iue in the management of open tibia fracture with regard to the pattern, aetiology and management outcome of treatment of open tibia fracture. Outcome meaure included functional outcome, complication, morbidity and cae fatality in our environment Lago; Nigeria. Method: Thi propective tudy wa carried out at Lago Univerity Teaching Hopital (LUTH), Lago Nigeria between July 2011 and June Demographic data, fracture related characteritic, aetiology, location radiologic feature and microbiological culture were collected. Diagnoi of open tibia fracture wa baed on clinical and radiological evaluation. Infection wa diagnoed on the bai of a combination of clinical evidence\microbiological evidence (culture). All cae were followed up till dicharge or death and ubequently in our out patient clinic after dicharge for 12month. Complication ariing in the coure of cae management a well a functional outcome were documented. Reult: A total of 197 patient with open tibia fracture out of 6071 patient preenting to the accident and emergency department over 3 year period were reviewed. Open tibia fracture repreented 3.24% of all preentation. 145 (73.6%) were male, while 52 (26.4%) were female with average age range from 1-90 year (mean 36.9±18.9year). The peak age of incidence wa in the age bracket 21-50year. Vehicular accident accounted for 78.2%, wherea other form of injury accounted for 21.8%. The pattern of fracture wa oblique 93 (47.2%), Tranvere fracture 63(32%). while comminuted, egmental and piral were 22(11.2%), 11 (5.6%) and 8 (4.1%) repectively the mot common leion wa type II (49.2%) injury. The complication rate wa 68 (34.5%) patient with wound infection accounted for 44(22.3%). Other complication oberved included malunion 6.6%; nonunion 3%, four patient (2%) had amputation. Both of whom had Gutilo Anderon type III c Injurie with mangled extremitie everity core greater than even. The functional outcome wa quite atifactory. Concluion: Thi tudy ha hown that open fracture poe ome unique rik beyond thoe encountered with imilar cloed fracture that may occur with imilar amount of force and that wound infection i the commonet complication. It alo how that morbidity i aociated with injury everity. Keyword: Open tibia fracture, Internal fixation, External fixator, Plater of Pari (POP) Introduction Open fracture of the tibia are complex injurie of bone and oft tiue. Open fracture refer to oeou diruption in which a break in the kin and underlying oft tiue communicate directly with the fracture and it haematoma 1. Open fracture are orthopaedic emergencie due to the rik of infection econdary to contamination and compromied oft tiue and ometime vacular upply 1, 2. Open tibia fracture are the mot common open fracture in orthopaedic and are till aociated with ignificant complication 2. At one time, open fracture were a death entence. Today, Orthopaedic urgeon deal motly with infection, non-union and functional deficit 2, 3. Open fracture uually reult from high energy trauma and occur in a third of cae of multiply COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

38 38 38 ISSN Eat Cent. Afr. J. urg injured trauma. 2 The injured extremity i aeed for extent of wound, oft tiue injury, contamination and neurovacular tatu of the limb i alo aeed including excluion of compartment yndrome 3. The ytem of claification of open fracture into three type of increaing everity wa firt introduced by Velikaki 4. Thi concept wa fully developed by Gutilo and Anderon 5. It wa ubequently modified by Gutilo et al 6. Thi claification had an inter-oberver agreement of about 60% a hown by Brombark and Jone in a tudy of claification of tibia fracture by 245 orthopaedic urgeon 7. The high energy nature of mot of thee fracture contribute to the increaed proportion of Gutilo type III injurie 8. In their epidemiological tudy, Court-Brown et al found that nearly 60% of open fracture were Gutilo type III 8. Opinion differ with regard to the method of cloure of the kin and the method of tabilization of uch fracture. Compared with open fracture in other area of the body, open tibia haft fracture poe a more difficult challenge becaue of their high infection rate. The infection rate reported in the literature ha ranged from 2% to 40% 9. Thee high rate are attributed to retricted oft tiue coverage over the tibia and the relatively poor oeou blood upply.while there i agreement that open fracture hould be treated a an emergency, difference of opinion exit with regard to the method of cloure of the kin and the method of tabilization of uch fracture.the principle of treatment remain the ame, but ome of the detail of treatment can reduce the rate of common complication. Becaue a large portion of the tibia i ubcutaneou, and the oft tiue envelope i difficult to treat, pecial care mut be taken in all tage of the management of thee frequent evere injurie. The aim of thi tudy wa to determinepeculiar iue in the management of open tibia fracture with regard to the Pattern, aetiology and Management outcome of treatment ofopen tibia fracture in our Centre. Outcome meaure included functionaloutcome, complication, morbidity and cae fatality in our environment Lago, Nigeria. Patient and Method Thi propective tudy wa carried out at Lago Univerity Teaching Hopital (LUTH), Lago, Nigeria a tertiary reference hopital in Lago metropoli; which admit an average of trauma cae annually. Ethical approval wa received from the LUTHHREC. The tudy wa conducted between July 2011 and June Patient were recruited from cae preenting to the Accident and Emergency Department of LUTH. The incluion criteria were diagnoi of open tibia fracture baed on clinical and radiological evaluation. Cae with pre-morbid bone pathology baed on hitory were excluded. Data documented included baeline demographic data (age, gender), fracture related characteritic, aetiology, location, radiologic feature (e.g. fracture pattern), and microbiological feature. Tibia fracture wa claified baed on the Gutilo claification. In ummary, the criteria claify tibia fracture into three baed on injury everity. Infection wa diagnoed on the bai of a combination of clinical evidence of cellulite or Oteomyeliti, and microbiological evidence (culture) from ample obtained pre-operatively, peri-operatively or pot-operatively. All cae were followed up till dicharge or death and ubequently in our out-patient clinic after dicharge for 12 month. Complication ariing in the coure of cae management were documented. Specifically, the occurrence of non-union, mal-union and amputation were alo noted. In addition, dicharged cae were evaluated at out-patient follow-up clinic to ae functional outcome. Functional outcome wa aeed in relation to Good- return to previou mobility with no impairment, Fair- return to previou mobility with ome impairment and Poor- unable to return to previou mobility due to evere impairment uch a amputation. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

39 39 39 ISSN Eat Cent. Afr. J. urg Reult The tudy included a total of 197 patient out of 6071 patient preenting to the A&E department over the 3yr period. Thu, open tibia fracture repreented 3.24 % of all preentation. 145 (73.6%) were male, while 52 (26.4%) were female, with average age range from 1 90 year (mean year). The male to female ratio wa thu 2.8 to 1. Figure 1. Age/Sex ratio Ditribution Foot note: M: F ratio of tibia fracture overall 2.8 to 1, <20 (2.3 to 1); (4. To 1) and >50 (1 to 1). Table 1. Age and Sex Ditribution of Patient. Age Frequency Total Percentage (%) Male Female < > TOTAL 145(73.6%) 52(26.4%) Table 2. Ditribution in relation to Trauma aetiology Aetiology Frequency Percentage (%) RTA Automobile Motorcycle Tricycle Pedetrian Gunhot Fall from height Indutrial accident Aault Dometic Accident Total COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

40 40 40 ISSN Eat Cent. Afr. J. urg Type 1 Type 2 Type 3a Type 3b Type 3c Figure 2. Ditribution of fracture by the claification of Gutilo and Anderon (P <0.001) Table 4. Type and Frequency of complication aociated with open tibia fracture. Frequency Complication Number Percentage (%) None Infection Malunion Non-union Amputation Death Total Aetiology of Open Tibia Fracture The aetiology of open tibia fracture i hown in Table 2. Overall, vehicular accident accounted for the majority (78.2%) wherea other form of injury accounted for only 21.8%. Fracture characteritic: Pattern and ubtype The right tibia wa the mot frequent location (124 i.e. 69.2%) compared to the left (73 i.e %)The pattern of fracture wa oblique 93(47.2 %), Tranvere fracture 63(32%). While comminuted, egmental and piral were 22(11.2%), 11(5.6%) and 8(4.1%) repectively. Baed on the claification by Gutillo and Anderon (Figure 2), the mot common leion wa type II (49.2%) while the leat frequent wa type I (25%). COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

41 41 41 ISSN Eat Cent. Afr. J. urg Treatment and treatment outcome Treatment protocol included initial debridement in the majority of cae, followed by application of Plater of Pari(POP) for 141 patient (or 71.7%). While 34 (17.3%) had internal fixation with either plate and crew or interlocking nail. Twenty (10.2%) patient had external fixation. Complication were recorded in 68 (34.5%) of the patient. Wound infection accounted for 44 (22.3%). Other complication included mal-union (6.6%) and non-union (3%). Four patient had amputation (all of whom had Gutilo-Anderon type IIIc injurie with mangled extremitie everity core greater than even). There wa one death (Table 4). The mean age of male age wa compared to female ( ). The difference wa tatitically ignificant (P=001). The peak age of incidence wa in the age bracket year overall and in both exe a hown in Figure 1 The functional outcome wa quite atifactory. A total of 124 (62.9%) of the patient returned to pre-morbid work while 56 (28.4%) patient returned to work but had ome limitation which include knee tiffne while 17 (8.7%) of the patient were unable to return to premorbid work a a reult of amputation, ignificant hortening or periting bone infection. Hopital tay ranged from one day to 223 day with a mean of 51.5 day. The majority (63.4%) of thoe that were hopitalized for more than 60 day had aociated wound infection. Dicuion A fracture i well recognized a a break in the continuity of bone. The fracture may be aociated with injurie to blood veel, tendon, nerve and the overlying kin. When the kin i broken, then it become an open fracture, hence there i more to a fracture than jut the broken bone. Patient between 20 year and 50 year of age contituted 61.4% of the cae. Thi i probably becaue they are the active productive age group within the ociety. At the extreme of age (that i le than 10 year and greater than 60 year), open tibia fracture were oberved to be uncommon (21.3% of the cae). Thi i preumably due to the fact that people in thi age group tend to travel le. The male to female ratio 3:1 een in thi tudy had alo been reported by the author 2,10 and thi ugget that the young adult male who are very energetic and active are more prone to open tibia fracture. Road traffic accident caued 78.2% of the cae of which motor vehicle accident accounted for about 45.2% and motor cycle, 22.8% and other mean of tranportation, 10.2%. However, it wa noted that in patient le than 10 year old, pedetrian croing a buy road unaided wa the mot common caue of open tibia fracture. Thi trend ha alo been oberved by other worker 11,12,13. Clinically, the right leg wa more affected with 124(62.9%) of cae while the left wa affected in 73(37.1%) of cae. Thi pattern wa alo oberved by Imran et al in The mot common pattern of the open tibia fracture encountered were oblique 97(47.2%). Type II open fracture formed the majority (49.2%) in conformity with the finding of Gutillo 5, while other author 15,16,17 preented with type III open fractured a mot common. Thi dicrepancy occur due to the effect of variable uch a location of ervice, degree of urbanization, type of etiology and rik factor. Thi may require new comparative tudie of thee variable to better correlate them. In the open tibia fracture, above knee plater of Pari cat wa applied in 141(71.6%) cae compared to external fixation device 20(10.2%) patient. Other 34(17.3%) had primary open reduction and internal fixation. In type I and II open tibia fracture where wound healing i not COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

42 42 42 ISSN Eat Cent. Afr. J. urg a problem, plater of Pari cat i till the maintay of tabilization in developing countrie where external fixation i not readily available 16. It allow the patient to be dicharged home early 17. Prolonged plater of Pari cat application caued joint tiffne and quadricep wating a een in patient limited functional outcome. Similar finding were alo oberved by Ikemet al 11. Re-diplacement of the fracture fragment wa another etback oberved with ue of plater of Pari cat 191(96%) cae reulting to mal-union and non union in mot cae. Nearly all the patient had wound debridement. Meticulou wound debridement and irrigation with copiou fluid are eential for the care of all the patient wound. The aim i to reduce the bacterial load and increae the chance of early primary wound cloure 6,12,15. In thi tudy, the overall wound infection i very high. It occurred in 44(22.3%) cae of open tibia fracture. The literature report infection rate in open tibia fracture between 2% and 40% 9. Often in thee erie, it i not certain whether the figure refer to all wound infection or only deep infection involving bone. Our erie include both uperficial and deep infection. The everity of injurie wa found to be an important prognotic indicator of infection a majority of wound infection occurred in type III fracture. Only 4 (2%) f our patient had amputation and all of them had Gutilo-Anderon type IIIc injury with mangled extremity injury everity core greater than even. Helfet et al in their tudy howed that all patient with mangled extremity everity core of >7 had amputation 10. The functional outcome wa good depite univeral prevalence of tiffne and malunion in many of the patient with open fracture. In pite of thi, many of the patient returned to the premorbid occupation depite having varying degree of limitation. Concluion Thi tudy ha hown that open fracture poe ome unique rik beyond thoe encountered with imilar cloed fracture that may occur with imilar amount of forceand that wound infection i the commonet complication in open fracture. It alo how that morbidity i aociated with injury everity. Thee tatitic call for determined effort on the part of the government to curb the incidence of road traffic crahe in our ociety. However functional outcome i relatively atifactory. Reference 1. Chapman MW open fracture of the haft of the tibia. Wet. J med. 1998;168: Canale Terry S. General principle of fracture treatment. Campbell operative Orthopaedic. 9 th ed. Moby. 1998; Blick SS, Brumback RJ, Poka A, Burgre A, Ebraheim NA. Compartment yndrome in open tibia fracture. J Bone joint urg. Am 1986; 68: Velikaki KP. Primary internal fixation in open fracture of the tibia haft. The problem of wound healing. J bone joint urg Br 1959; 41: Gutilo RB, Anderon JT. Prevention of infection in the treatment of one thouand and twenty five open fracture of long bone: retropective and propective analyi. J bone joint urg. AM. 1976; 58(4): Gutilo RB, Mendoza RM, William DN. Problem in the management of type III open fracture. A new claification of open fracture. J trauma 1984; 24: Brumback RJ, Jone AL. Interoberver agreement in the claification of open fracture 8. Court-Brown CM,Rimmer S, Prakah U, Mc Queen MM. The epidemiology of long bone fracture. Injury. 1998; 29: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

43 43 43 ISSN Eat Cent. Afr. J. urg 9. Gutilo RD. Management of open fracture in Orthopaedic infection. Diagnoi and treatment. Philadelphia; Saunder; P Helfet DL, Howery T, Saunder R, Johanen K. Limb alvage veru amputation; preliminary report of the mangled extremity everity core. Clin. Orthop. 1990; 256: I.C.Ikem, LM Oginni and JD Ogunlui. Determinant of management outcome in open tibia fracture in Ile-Ife. Nigerian journal of urgical reearch 2006; 8 (1-2): Seligon D, Henry SL. Treatment of compound fracture. AM J Surg. 1990; 161: Onabowale BO, Onumimya JE, Eien IAJ, Ukegbu ND. The management of open tibial haft fracture. The National Orthopaedic Hopital EyperNig J Surg 1995; 2: Imran Y, Vihuanathan T. Doe right leg require extra protection; Five year review of type III open fracture of the tibia. Singapore med. J 2004; 46(6): Grimard G, Nauche D, Laberge L.C, Hamdy RC. Open fracture of the tibia in children. Clinorthop. 1996; 332: Ikem IC, Oginni IM, Bamgboye EA. Open fracture of the lower limb in Nigeria. International orthopaedic (SICOT) 2001; 25: Gopal S, Giannoudi PV, Murray A, Mathew SJ, Smith RM. The functional outcome of evere open tibia fracture managed with early fixation and flap coverage, J. Bone joint urg (BV) 2004; 86-8: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

44 44 44 ISSN Eat Cent. Afr. J. urg Epidemiology of Hand Injurie Seen at Two Teaching Hopital in Southern Nigeria. O. Oluwafemi Awe 1, O. Ayodeji Oladele 2, J. Kayode Olabanji 2, E. Emmanuel Eezobor 1. 1Department of Surgery, Irrua Specialit Teaching Hopital, Irrua, Edo State and Department of Surgery, Faculty of Clinical Science, Ambroe Alli Univerity, Ekpoma, Edo State, Nigeria. 2Department of Surgery, Faculty of Clinical Science, College of Medicine, ObafemiAwolowo Univerity, Ile-Ife, Oun State, Nigeria. Correpondence to: Dr. Awe OluwafemiOlaupo, Background: Hand injurie are very devatating to the patient and can ruin patient ability to function a an independent human. Thi could alo lead to depreion and ocial iolation. It i a very common preentation at the emergency room. The incidence i on the increae worldwide. Method: Thi i a retropective clinical audit of patient with hand injurie to the Platic Unit of both Irrua Specialit Teaching Hopital (ISTH) and ObafemiAwolowo Univerity Teaching Hopital (OAUTH) from September 2011 and Augut All data were obtained from the patient cae-file and analyzed. Reult: 235 hand cae preented to the two Teaching Hopital during the period tudied and hand injurie account for 54.4%. Male to female ratio wa 4.5:1 with right-hand dominance. Hand injurie due to aault were high in thi tudy Concluion: We oberved that the incidence of hand injurie, wa high in thee hopital epecially thoe due to aault. Behavioral change and re-orientation of the people will reduce the preentation. There i need for hand unit in thi region. Keyword: Hand injurie, preentation, aault, Nigerian hopital. Introduction The hand i very vulnerable to injury becaue it i involved in almot all activitie of daily living. It i at rik of evere injury from a number of caue. Example are road traffic accident, occupational hazard, porting and dometic activitie, and aault. The hand injurie pattern in a community commonly reflect their commercial, indutrial, ocial, occupational or recreational activitie 1-4. A even year propective tudy of 136 children and adolecent with hand injurie in Saudi Arabia, oberved that the mot common type of injury wa cruh injurie by door at home and recommended hydraulic automatic door cloure to prevent thi injury 5. There wa alo a tudy of 560 worker with traumatic hand injurie treated in 11 hopital in three economically active citie in the People Republic of China over a two year period. They concluded that working in manufacturing indutrie and uing powered machine were primary ource of evere hand injurie 6. An injury to the hand can immediately compromie and chronically debilitate the patient ability to perform the activitie of daily living. The prevention of thee injurie will help in reducing diability and hence increaing productivity of the individual, family and the ociety a a whole. Mot of the hand injurie from the developing countrie are uually preventable while thoe of the developed world are motly congenital or a reult of heavy machine mihap. It i important that an acutely injured hand i managed adequately to prevent infection, alvage the injured part, promote healing and retore function 7. Thi required ingeniou urgical kill for correction, uch a provided by recontructive hand urgery. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

45 45 45 ISSN Eat Cent. Afr. J. urg Patient and Method Thi i a retropective clinical audit of patient with hand injurie that preented to the Platic Unit of both Irrua Specialit Teaching Hopital (ISTH) and ObafemiAwolowo Univerity Teaching Hopital (OAUTH) from September 2012 and Augut Thee two teaching Hopital are elected becaue both of them are ituated in ub-urban area of Nigeria. Irrua Specialit Teaching Hopital (ISTH) i ituated in Ekpoma, Edo State in the South-South Region of the country. Ekpoma ha only the Teaching Hopital and the State Univerity (Ambroe Alli Univerity) a the main etablihment. Other are few mall and medium cale enterprie and farmer. Thi i almot perfectly imilar to that of ObafemiAwolowo Univerity Teaching Hopital (OAUTH) in Ile-Ife Oun State in the South- Wet Region of the country. Ile- Ife alo ha only the Obafemi Awolowo Univerity and it Teaching Hopital a main the etablihment. However, the Platic urgery unit of the OAUTH ha been operational ince 1997 while that of ISTH i jut above five year in operation. All patient with traumatic injurie dital to the writ entered into the tudy. Data were retrieved from the patient cae-note from the Medical Record Department of both Teaching Hopital involved, and thereafter analyzed with SPSS verion 16 (SPSS, Chicago). Reult A total of 235 patient preented to both intitution with hand cae during the period under review. However, only 54.4%(n = 127) of thee patient were due to trauma from thee intitution. Their age range from 1-65 year; the mean age wa 32.4yr ± 4.8 (SD). The age ditribution i a hown below (Figure 1). The majority of the patient, 63% (n = 80) were in the third and fourth decade. The right hand wa the dominant hand in about 90% and the dominant hand wa involved in about 75% of thee cae. Of thee patient with hand injurie, 104 (82%) were male while 23 (18%) were female. The male to female ratio wa 4.5:1. The hand injurie cae were claified on the bai of the etiology of injury (Table 1). Gunhot accounted for 32 (25.2%) of the hand injurie. The type of injury (wound) preented by thee patient varie from minor laceration to cruh injurie and amputation. Thi i very important becaue the treatment modality for thee patient depend type of the injury and the duration before preentation. Figure 1. The Age Ditribution of the Patient with Hand Injurie COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

46 46 46 ISSN Eat Cent. Afr. J. urg The modalitie of treatment range from dreing only, Kirchner wire, plit thickne kin graft to flap cover which wa ued in both intitution for imilar type of injury. The modality ued depend on the type of the injury and the everity which wa claified according to Buchler and Hating [8] a follow; 1. Iolated injury (ingle hand tructure) 2. Combined /Complex injury (more than one important hand tructure) Table 1. Etiology of Hand Injurie Etiology of Injury No of Patient Percentage (%) Gunhot Machine Road traffic injury Machete/ bottle Human bite Snake bite Total Fig. 2 Fig. 3 Fig. 4 Fig. 5 COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

47 47 47 ISSN Eat Cent. Afr. J. urg Dicuion The importance of the hand for urvival and economic purpoe called for appropriate and efficient care for all hand injurie to limit dyfunction to the baret minimum. Thee injurie require the application of principle of recontruction preently in the armamentarium of the platic and recontructive urgeon. It i alo known that any delay in preentation and, or initial inappropriate treatment will almot invariably woren the outcome. It i preferable that all hand injurie hould be referred to pecialit a oon a haemotai i ecured with aid of preure parking 9. The preence of many delicate tructure in the hand, demand for early and appropriate treatment or manipulation, if a deirable outcome i going to be achieved. In thi tudy, the incidence of hand injurie i high though the incidence of injurie due road traffic accident i till the main caue.. The age range of the patient were from 1 to 65 year with mean age of 32.4yr ± 4.7 (SD). The majority of thee patient were in their third and fourth decade of life, which accounted for 63.0% (n = 80). Thi age group actually repreent the active young adult in the mot productive period of their life. Thi i tandem with the tudie in China, Sweden and Ghana 4.6,7. The road traffic accident ha been the leading caue of hand injurie in mot tudie from the developing countrie, which i the ame in our tudy. Report from the developed world have different factor a leading caue of thee injurie, depending on the level of indutrialization. Thi i cloely followed by machine injurie, becaue of the ue of locally fabricated caava milling machine in thi area where the mot taple food i caava meal which predipoed them hand injury 3. The other caue of injury include gunhot, machete cut and human bite which were uually due to aault. There were five cae of hand injury following gunhot which reulted from peronal gun while firing cannon during burial 10,11. Mot of the machete cut and human bite in the hand follow trivial quarrel between friend, colleague or rival. When all thee are put together, a hand injurie reulting from aault, it become the ingle mot important caue of hand injurie in thi tudy (41.7%, n = 53). The only patient with nake bite wa a 7-year old girl who carried a live nake with bare hand and had extenive myo-necroi of the affected hand with renal failure 7. Laceration are the commonet type of injury in patient with hand injurie 12, they are uually manage with primary cloure if preented early and ubequently dreing on alternate day bai except in cae when the dreing become oaked earlier. Thi i cloely followed by cruh injurie. Both cloe and open fracture of the hand were tabilized with Kirchner wire which i maintained for at leat two week. Serial wound exciion were done for patient with cruh injurie, until all the dead tiue had been excied and delay primary oft tiue cover either with kin graft or flap. Thi ha been documented a tandard mode of treatment in previou tudie. It i apparent from thi tudy that the hopital incidence of hand injurie i common in teaching hopital and the proportion due to aault i of much ignificance. Concluion The high incidence of hand injurie, epecially thoe due to aault in the outhern Nigeria actually called for reorientation of the populace in thi area. The ociety hould encouraged people to report any offence to the law-enforcement agent, rather than getting involved in jungle jutice. There i need to reduce the unemployment rate, o a to reduce incidence of armed robbery. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

48 48 48 ISSN Eat Cent. Afr. J. urg Every hand injury hould be managed with utmot care o a to reduce reidual morbidity to the baret minimum. It i advied that all hand injurie a much a poible and a early a poible be referred to a pecialit (hand) urgeon. Reference 1. Ahmed E, Chaka T. Propective tudy of patient with hand injury in TikurAnbea Univerity Teaching Hopital, Addi Ababa. Ethiop Med J 2006; 44: McMinn RM. Upper limb in: Lat Anatomy, Regional and Applied 9 th Ed. Edinburgh. Churchill Livingtone Eezobor EE, Awe OO, Onuminya JE, Dongo AE, Nwokike OC, Abikoye FO, Edomwonyi EO, Aigbonoga QO. Hand injurie from caava milling machine in ub-urban Nigeria. Afr J Trauma 2014; 3: Roberg HI, Dahim IB. Epidemiology of hand injurie in a middle ized city in Southern Sweden.: a retropective comparion of 1989 and Scand J PlatRecontrSurg Hand Surg 2004; 38: Mirdad T. Pattern of hand injurie in Children and Adolecent in a Teaching Hopital in Abha, Saudi Arabia. J R Soc. Promot Health 2001; 121: Jin K, Lombardi DA, Courtney TK, Sorock GS, Li M, Pan R, Wang X, Lin J, Liang Y, Peny MJ. Pattern of work-related traumatic hand injury among hopitalized worker in People Republic of China. InjPrev 2010; 16: Adu EJK. Management of Hand injurie: a ix year experience from KomfoAnokye Teaching Hopital, Kumai, Ghana. Potgr. Med. J Ghana 2013; 2(2): 8. Buchler U, Hating H. Combined injurie in: Green DP (ed) Operative Hand Surgery 4 th Ed. Churchill Livingtone Philip E, Wright II. Acute hand injurie in: Canale ST (ed) Campbell Operative Orthopeadic 9 th Ed. St Loui Moby 1999: Turker T et.al. Management of Gunhot wound to the hand: a literature review. J Hand Surg Am 2013; 38(8): Awe OO, Edomwonyi EO, Eezobor EE, Aigbonoga QO. Multiple wound to both Upper Limb from Accidental dicharge of a peronal gun: A cae report. Ann Med Re 2015; 12. Trybu M, Lorkowki J, Brongel L, Hladki W. Caue and Conequence of Hand injurie. Am J Surg 2006; 192: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

49 49 49 ISSN Eat Cent. Afr. J. urg Injury prevention; Motorcyclit Repone and Practice on the Ue of Helmet in Mwanza, Tanzania S. Kilawa 1, O.V. Nyongole 2. 1Medical tudent, School of Medicine, Muhimbili Univerity of Health and Allied Science 2Department of Surgery, School of Medicine, Muhimbili Univerity of Health and Allied Science Correpondence to: Obadia V Nyongole, onyongole@yahoo.co.uk Background: Regarding rik factor for motorcycle injurie, the non-ue of helmet ha been identified a a pecific factor leading to head injurie and fatalitie reulting from motorcycle crahe. Helmet a a protective meaure have been identified to be effective toward head injury prevention. Objective: Thi tudy aimed to determine the knowledge, attitude and practice among motorcyclit on helmet ue in Mwanza region, Tanzania. Method: Thi wa a decriptive cro-ection tudy conducted in Mwanza region at different motorcyclit parking point, uing a tandardized tool, collected data were cleaned, analyzed and proceed by uing SPSS 16. Reult: A total of 200 motorcyclit were involved in the tudy. Knowledge on helmet ue wa high in mot of them (91.5%) with lightly low poitive attitude (87.5%) on helmet ue although poeion of helmet wa good of which 97.5% of them had helmet. Mot of thoe motorcyclit 156(85.2%) with high knowledge had poitive attitude on helmet ue (P-value =0.000 indicating trong aociation between knowledge and attitude. Practice on helmet ue every day at every trip wa alo influenced by knowledge. Thi relationhip i further upported by p-value (0.00), indicate that there i trong aociation. (The chiquare i 0.00) Concluion: The tudy how that majority of motorcyclit in Mwanza region are young adult with formal education, with mot of them having high knowledge and poitive attitude on helmet ue.the conitency of helmet ue in our tudy ubject eem to be influenced poitively by level of education. Key word: Knowledge, attitude, practice, motorcyclit, helmet Introduction Road traffic injurie (RTI) are a leading caue of diability and fatality globally. Motorcyclerelated injurie, mainly head injurie, and related death and diabilitie are a ignificant contributor to the burden of dieae in low- and middle-income countrie (LMIC).Motorcycle accident a among other type of road accident form a fatal category of motor traffic accident. Thi i becaue motorcyclit are more at rik of utaining injury than motor vehicle driver; per mile travelled, motorcycle rider have a 34 time rik of death than the driver of other type of vehicle. They are alo 8 time more likely to be injured 1-4. Road traffic injurie form a ignificant amount of injury related mortality and morbidity around the world with an etimated 1.2 million people killed and about million injured on the road annually, motorcyclit death and injurie are an important public health of concern. Motorcycle uer are vulnerable on the road and repreent an important group to target from reducing road traffic injurie 5-6. In middle and low-income countrie, motorcycle form a common mean of tranport. Motorcyclit form ignificant road traffic accident, due to the rapidly increaing number of motorcycle from 6,700 in 2007 to 85,000 in 2009, and13 fold increae in the period of 2 year 7-8. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

50 50 50 ISSN Eat Cent. Afr. J. urg Commercial motorcycle are old at relatively cheaper price than other vehicle and good earning from the motorcycle taxi buine which encourage more people epecially youth to join thi buine and increae the number of motorcycle. Motorcycle in low- and middleincome countrie account for the majority of thee injurie. Nearly 85% of the global burden of road traffic injurie i accounted for by thee countrie. The road traffic injury mortality rate i highet in Africa, 28.3 per 100,000 population when corrected for underreporting, compared with 11.0 in Europe.The rate of road traffic death in Sub-Saharan Africa i 40% higher than that in all other low- and middle-income countrie (28.3 compared to 20.2 per 100,000) and 50% higher than the world level (28.3 compared to 19.0 death per 100,000 population) making traffic injurie the 10th leading caue of death in the region. The majority of the motorcyclit don t wear any protective gear, hence aggravating the rik of getting evere head injurie5, 8-9. Regarding rik factor for motorcycle injurie, the non-ue of helmet ha been identified a a pecific factor leading to head injurie and fatalitie reulting from motorcycle crahe. Helmet a a protective meaure have been identified to be effective toward head injury prevention and reduce the fatality of motorcycle rider. 8 To protect themelve from head injury, motorcyclit need to conitently and properly wear helmet according to the precribed tandard. Depite their effectivene, helmet are not a widely ued a they hould be and when ued, they are not ued properly. 10 Some reaon for non-adherence and non-ue of helmet include feeling of dicomfort due to heat during the hot weather, and lateral viion and hearing ability impairment. 11 According to tudie done in Vietnam, Nigeria and USA, low rate of helmet ue have been evident depite the enactment of helmet law. 23.8% had a helmet on at the time the tudy wa conducted. The majority (67.3%) favoured the enforcement of crah helmet while other would reject the idea. In Eat Africa, The motorcycle, commonly called boda boda in Uganda and Kenya 11. Tanzania and Kenya account for more road traffic death with 34.3 and 34.4 death per 100,000 population repectively. Burundi, Uganda and Rwanda account for 23.4, 24.7 and 31.6 death per 100,000 population repectively 12. Motorcycle accident have drawn great attention from the Tanzanian government authoritie. For example, 2010 Road Safety Week had a theme of Dicourage High Speed; Cyclit Wear Helmet; Accident Kill, Injure 13. Motorcycle ha recently become increaingly popular in Tanzania a a mean of commercial tranport but their operation i characterized by nonhelmet ue by rider and their paenger, paenger overload, lack of certified driver training and valid licening, over peed and reckle driving, poor regulation and law enforcement and poible ue of alcohol and drug a ten year epidemiological appraial urvey done in Tanzania 14 Between 1990 and 2000 road accident roe by 44% for a cumulative total of 10,107. However due to the rapid importation of motorcycle, the contribution of motorcycle to road accident cannot be ignored; in the firt three month of the year 2010, 181 people died in motorcycle accident. 7 Reported that by the end of 2007 will be that peron killed in accident will increae by 30%, the number of reported injurie will increae by 35%, and the cot of reported accident and caualitie will a well increae by 30 % (Tanzania Annual Road convection Report, 2005). Thi tudy aimed to ae the knowledge, attitude toward, and the practice of helmet ue among motorcyclit in Mwanza, Tanzania. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

51 51 51 ISSN Eat Cent. Afr. J. urg Method Thi wa a decriptive community baed cro ectional tudy which wa conducted in randomly elected commercial parking point by interviewing commercial motorcyclit in Mwanza uing a tandardized data collecting tool. Included in the tudy were all commercial motorcyclit with a motorcycle at the parking point with and /or without a cutomer to be ridden. Excluded from the tudy were commercial motorcyclit whom did not conent to be part of tudy. Permiion to conduct the tudy wa ought from Muhimbili Univerity of Health and Allied Science (MUHAS), region adminitration and the motorcyclit at parking point. Conent wa ought from the motorcyclit. Data cleaning wa done before feeding it into the computer for analyi, data wa analyzed uing SPSS 16.0 program. Cro-tabulation were generated, and where comparion were made, ignificance wa conidered at p-value of le than Study Limitation Sample drawn may not be repreentative of the tudy population, reluctance of ome motorcyclit to be part of tudy. Limited reource for the tudy and hort tudy period. Reult A total of 200 motorcyclit were involved. Majority were at age group (62.5%) year. Mot of thoe motorcyclit 156(85.2%) with high knowledge had poitive attitude on helmet ue while 6 (75%) of motorcyclit with low knowledge had negative attitude on helmet ue with (P-value =0.000 indicating trong aociation between knowledge and attitude. Majority 71.6% of the motorcyclit who had high knowledge were uing helmet every day at every trip while 75% of thoe who had low knowledge never ued helmet. Thi relationhip i. further upported by p-value (0.00), indicate that there i trong aociation. (The chi- quare i 0.00) (Table 1). Table 1. Ditribution of Study Population by Age Age Number Frequency Percentage % % % % % > % TOTAL % COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

52 52 52 ISSN Eat Cent. Afr. J. urg Table 2. Ditribution of Study Population by Level of Knowledge Level of Knowledge Number Frequency Percentage Low 8 4% Moderate 9 4.5% High % T0TAL % Table 3. Attitude on Helmet Ue among Motorcyclit in Mwanza Attitude Number Frequency Percentage Poitive % Negative % Total % Table 4. Cro Tabulation Between Knowledge and Attitude Attitude Knowledge Low Moderate High Total Poitive 2 (25%) 8 (89%) 156 (85.2%) 166 (83%) Negative 6 (75%) 1 (11.1%) 27 (14.8%) 34 (17%) Total 8 (100%) 9 (100%) 183 (100%) 200 (100%) Among 200 motorcyclit in Mwanza, majority had completed primary chool 82 (41%) while only 0.5% of our tudy population never went for formal education. Majority of them had high knowledge on helmet ue 183 (91.5%) (Table 2). Majority had the helmet; they ue by (95.5%). Mot of them ued helmet every day at every trip 136 (68%).Small majority of paenger ue helmet every day at every trip 63 (31.5%) and when they anticipate meeting policeman 52 (26%). Mot (85.2%) of thoe motorcyclit with high knowledge had poitive attitude on helmet ue while 6 (75%) of motorcyclit with low knowledge had negative attitude on COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

53 53 53 ISSN Eat Cent. Afr. J. urg helmet ue. The p value indicate trong aociation between knowledge and attitude (P-value =0.00) (Table 4). Table 5. Cro tabulation of Knowledge and Practice of Helmet Ue among Motorcyclit Do you Wear Helmet? Knowledge Low Moderate High Total Ye 2 (25%) 9 (100%) 180 (98.4%) 191 (95.5%) No 6 (75%) 0 (0%) 3 (1.6%) 9 (4.5%) Total 8 (100%) 9 (100%) 183 (100%) 200 (100%) Table 6. Knowledge and Conitency on Ue of Helmet How Often Do you Wear Helmet? Knowledge Low Moderate High Total Every day at every trip 1 (12.5%) 4 (44.4%) 131 (71.6%) 136 (68%) Every day but not every trip Every long trip not hort trip When anticipate meeting policemen 0 (0%) 2 (22.2%) 26 (14.2%) 28 (14%) 1 (12.5%) 0 (0%) 6 (3.3%) 7 (3.5%) 0 (0%) 3 (33.3%) 17 (9.3%) 20 (10%) Never 6 (75%) 0 (0%) 3 (1.6%) 9 (4.5%) Total 8 (100%) 9 (100%) 183 (100%) 200 (100%) The majority (87.5%)of our participant had poitive attitude on helmet ue. A total of 195 (97.5%) of motorcyclit had helmet (Table3). Mot (98.4%) of motorcyclit with high knowledge ued helmet while 75% of motorcyclit with low knowledge were not uing helmet. Thi relationhip i more upported by p-value, which indicate trong aociation between knowledge and practice of wearing helmet (p value=0.00) (Table 5). COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

54 54 54 ISSN Eat Cent. Afr. J. urg Majority (71.6%) of the motorcyclit who had high knowledge ued helmet every day at every trip while 75% of thoe who had low knowledge never ued helmet. Thi relationhip i further upported by p-value (0.00), indicate that there i trong aociation. (The chi- quare i 0.00) (Table 6). Dicuion Our tudy aimed to determine the knowledge, attitude and practice among motorcyclit on helmet ue in Mwanza region, Tanzania. Our reult how majority (62.5%) of motorcyclit were at the age group between 20 to 25 year which i imilar to 66.5% the tudy done by Mwakalaa in Tanzania 15. Forty one percent of our participant had primary chool education thi i lightly low compared to what wa found in other tudie. Majority of motorcyclit had low level of education that partly attributed to the fact that they had limited chance of getting other job and thu engage into motorcycling buine a a lat option following unemployment regardle of being a riky job Thi tudy demontrated that 87.5% of our client had poitive attitude on helmet ue, Alo 97.5% of thoe with poitive attitude had helmet, with 95.5% of them uing helmet and mot of them 68% uing helmet conitently at every trip. Thi wa high compared to what wa oberved in one local tudy. 15 Thi wa alo reflected by 85.2% of motorcyclit with high knowledge having poitive attitude on helmet ue. In our tudy, 98.4% of motorcyclit who had high knowledge owned helmet and 71.6% of them were uing helmet every day at every trip. Mot 75% of motorcyclit with low knowledge didn t poe helmet and never ued thi i imilar to what wa reported in other tudy 2. The majority of our participant 95% perceived wearing helmet a neceary even without law reinforcement, Mot of client 98.5% perceived helmet ue a important for both driver and paenger afety although they mentioned a number of limitation uch a hot weather, wearing helmet reduce peripheral viion Concluion The tudy how that majority of motorcyclit in Mwanza region are young and young adult with formal education which influenced poitively their knowledge, attitude and practice on helmet ue. The conitency of helmet ue wa found to be aociated with level of education, knowledge and poitive attitude toward helmet ue. We recommend to provide education on proper and conitency ue of helmet all over the country. Acknowledgement We would like to thank the chairperon of motorcyclit union of Mwanza region a well all motorcyclit who participated in our tudy.we alo thank the Management of the School of Public Health and Social Science of Muhimbili Univerity and allied cience and all taff member for organizing the tudy. Reference 1. National Highway Traffic Safety Adminitration (2007). Traffic Safety Fact 2005: Motorcycle, Wahington, DC. National Highway Traffic Safety Adminitration (2004). 2. Brown V, Hejl K, Bui E, Tip G, CoopwoodB. (2009). Rik factor for riding and crahing a motorcycle unhelmeted. The journal of emergency medicine. 3. Chang, H.L., &Yeh, T.H. Motorcyclit accident involvement by age, gender and rik behaviour in Taipe; Taiwan. Tranportation reearch.2006; COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

55 55 55 ISSN Eat Cent. Afr. J. urg 4. Hung, D., Stevenon, M., Iver, R. Barrier to, and factor aociated, with oberved motorcycle helmet ue in Vietnam. Accident analyi and prevention.2008; 40, Peden, M., Scurfield, R., Sleet, D., Mohan, D., Hyder, A., Jarawan, E. (2004). World report on road traffic injury prevention Geneva: WHO. 6. Solagberu, B.A., Ofoegbu, C.K.P., Nair, A.A.,Ogundipe, O.K., Adekanye, A.O. &Abdur- Rahman, 7. L.O. Motorcycle injurie in a developing country and the vulnerability of rider, paenger, and pedetrian. Injury prevention.2006; 12, Nkwame, M. (2010). Motorcycle accident claim 181 live in four month. The daily new. Retrieved July 23, 2010.from new.co.tz. 9. World Health Organization (2006). Helmet: A Road Safety Manual for Deciion-maker and Practitioner. WHO, Geneva, Switzerland. 10. Naddumba, E.K. A cro ectional retropective tudy of boda-boda injurie at Mulago Hopital in Kampala, Uganda. Eat and Central African Journal of urgery.2004; 9, Li, L., Li, G., Cai, Q., Zhang, A., Lo, S. Improper motorcycle helmet ue in provincial area of a developing country. Accident analyi and prevention.2008; 40, Dandona, R., Anil G., Dandona. L. Riky behaviour of driver of motorized two wheeled vehicle in India. Journal of afety reearch.2005; 37 (2), Peltzer, K. Road ue behaviour in Sub-Saharan Africa. Public Health.2011; 122 (12). 14. Mutapha, S. (2010). 64 killed in motorcycle accident by June. The Daily New. Retrieved October 15. Mueru, L., Mcharo, C., Lehabari, M. Road Traffic Accident in Tanzania: A Ten Year Epidemiological Appraial. Eat and Central Africa Journal of urgery.2002; 7 (1), Mwakalaa, E.G. (2011).Attitude and knowledge among commercial motorcyclit in Dar e alaam Tanzania 17. Iribhogbe, P., Odai, E. Driver-related rik factor in commercial motorcycle (okada) crahe in Benin City, Nigeria. Pre-hopital Diater Medicine.2009; 24(4): Keng S. Helmet ue and motorcycle fatalitie in Taiwan. Accident analyi and prevention.2005; 31, Brandt, M., Ahrn, K, Corpon, C. Hopital cot i reduced by motorcycle helmet ue. Journal of Trauma.2002; 53, COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

56 56 56 ISSN Eat Cent. Afr. J. urg The Pattern and Management Outcome of Gatric and Intetinal Foreign Bodie in Children Seen at Muhimbili National Hopital H. L Wella 1, H. Lituli 2, R. Bahati 2, J. Prota 3 1Fellow Paed Surg (reident-currently in Alexandria Univerity, Egypt). 2Department of Surgery, Muhimbili National Hopital 3Department of Community Health Nuring, Hubert Kairuki Memorial Univerity Addre for Correpondence: DR. Herman L. Wella, E- mail: her_w2002@yahoo.com Background: Finding an ingeted ub-diaphragmatic foreign body in paediatric i common and repreent a coniderable nervoune to parent. The vat majority i expelled uneventfully within one week of ingetion, however, ometime can lead to complication and mortality. The purpoe of thi tudy wa to explain the pattern of ingeted gatric and intetinal foreign bodie, it management and outcome in children at Muhimbili National Hopital. Method: A propective cro-ectional tudy wa conducted in the paediatric urgery unit from April 2012 to October 2013 to children below 10 year of age uing a tructured quetionnaire. Symptom free children were dicharged for obervation at home and ymptomatic children or with riky object were planned to be cared in the hopital. Reult: A total of 33 children were tudied, Boy being 72.7% (24/33), M: F=2.7:1. The under 5-year were the majority (78.8%, 26/33). The commonet ingeted foreign bodie were Coin (42.4%, 14/33), Nail (18.2%, 6/33) and crew (12.1%, 4/33). The mean length of ingeted foreign bodie wa 2.47 centimeter (±0.56 SD). The tranient time wa le than one week in the majority of children (90.9%, 30/33). The average tranient time wa 4.1±0.05 SD day. All children paed their foreign bodie under obervation at home uneventfully. Concluion: Foreign bodie rik of ingetion i high in under five and conervative obervational treatment i ucceful in the majority. Key word: Foreign body, paediatric, gatric, intetinal, management, outcome. Introduction Ingetion of a foreign body i a frequent condition occurring in the paediatric age group a children tend to explore object by tating and wallowing them (1,2). It poe a great anxiety to parent (3,4). Foreign body ingetion among children i uually accidental, the incidence i greatet in children aged between 6 month and 6 year (3,5,6) and equal amongt male and female (2,7,8).The majority of foreign bodie once they reach the tomach pa un eventfully through the ret of the gatrointetinal tract in 4 to 6 day (4,5,6). However, ome may be impacted, caue obtruction, bleeding and perforation and require immediate flexible endocopic or urgical intervention (2,9). Children inget ignificantly different type of foreign bodie and the type of ingeted foreign bodie differ by geographic region and cultural practice (6,10). Thi tudy wa performed to explain the pattern, management and outcome of gatric and intetinal object in paediatric and enlit area of improving care in our environment. Patient and Method Thi one and a half year propective cro-ectional urvey wa done at Muhimbili National Hopital between April 2012 and October 2013 in children under 10 year of age (the upper age limit for paediatric urgery patient) with gatric and intetinal foreign bodie proven by hitory and abdominal x-ray who were een at firt in the Emergence department and referred to paediatric urgery unit for further care. All cae were reviewed and ymptom free children COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

57 57 57 ISSN Eat Cent. Afr. J. urg with le riky object were dicharged home immediately under conervative treatment (watch full waiting) until the exit of the foreign body while at home. Mobile phone follow up wa applied to monitor the child progre every two day. However parent/guardian were advied to oberve for ign of complication like abdominal pain, fever, abdominal ditention and bring back the child immediately to hopital if thee ymptom develop. The plan for ymptomatic patient or with highly rik object like dic batterie or magnet, narcotic packet of illegal drug and long harp object were to be followed and managed with laxative or urgery if needed in the ward. Information collected included: Age, ex, parent telephone number, time and date of ingetion of a foreign body, clinical feature, ite of a foreign body in the gatric-intetinal tract at firt x-ray, type, length and width of the foreign body, time and date of expel of a foreign body, complication, type of management and outcome, home addre. Analyi of data uing the computer tatitical package SPSS verion 20 wa done and Fiher` exact tet wa ued to compare proportion. A P value of 0.05 wa conidered tatitically ignificant. Reult During one and a half year, 33 children were tudied. Male outnumbered female by being 72.7% (24/33) of the tudy population, M: F=2.7:1. Mot of cae aged below 5 year (78.8%, 26/33) and the peak age wa between 3 and 5 year (57.6%, 19/33). The mean age wa 4.7±0.23 SD year with the range of year (median 4.2 year). Coin (including 3 two hundred, 5 one hundred and 6 fifty hilling coin) wa the mot common ingeted foreign body found in 42.4% (14/33) of cae followed by Nail (18.2%, 6/33) and crew (12.1%, 4/33), Table 1. Table1. Foreign Bodie' Ditribution by Age and Sex. Type of foreign bodie Age (Year) Total (%) Sex Total (%) 1-3 (%) >3-5(%) >5-10(%) Male (%) Female(%) coin 5(35.7) 7(50.0) 2(14.3) 14(42.4) 11(78.6) 3(21.4) 14(42.4) Nail 1(16.7) 3(50.0) 2(33.3) 6(18.2) 5(83.3) 1(16.7) 6(18.2) Screw 1(25.0) 3(75.0) 0(0.0) 4(12.1) 2(50.0) 2(50.0) 4(12.1) Pin 0(0.0) 0(0.0) 3(100.0) 3(9.1) 1(33.3) 2(66.7) 3(9.1) Metal 0(0.0) 2(100.0) 0(0.0) 2(6.1) 2(100.0) 0(0.0) 2(6.1) bar Other 0(0.0) 4(100.0) 0(0.0) 4(12.1) 3(75) 1(25) 4(12.1) Total 7(21.2) 19(57.6) 7(21.2) 33(100.0) 24(72.7) 9(27.3) 33(100.0) ǂ. Other include: Necklace (1), piece of gla (1), Hook crew (1), Metal dic (1) Fiher` exact tet 15.59, P=0.26 for the age Fiher` exact tet 7.90, P =0.38 for ex The median time between object ingetion and preentation to hopital wa 6 hour (range hour). Mot of children preented to the hopital within 6 hour of ingetion of foreign body, 60.6 % (20/33) and all cae were ymptom le at preentation. There wa no child with a previou hitory of gatro-intetinal urgery or co-morbidity and no child ingeted more than one or one kind of object. Mot of the object were in the tomach (54.5%, 18/33) at preentation, followed by mall bowel (24.2%, 8/33), Table 2. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

58 58 58 ISSN Eat Cent. Afr. J. urg The mean length of the ingeted foreign bodie wa 2.47 ±0.56 SD centimeter and the range wa 1.5 to 4 centimeter, the width/thickne average wa 0.2±0.07 SD centimeter ranging between centimeter. The tranient time (time between ingetion and exit of foreign body) wa le than 7 day in the majority of children (90.9%, 30/33) with the peak tranient time being from 1 to 3 day (63.6%, 21/33). Eight out of the 9 female paed their foreign bodie within 3 day of ingetion and thi obervation wa tatitically ignificant (P= 0.02), Table 3. The average tranient time wa 4.1±0.05 SD day (range day). Table 2. Site of foreign bodie at preentation to hopital. Type of a foreign body Stomach Site of a foreign body at preentation Small intetine Colon Rectum Total (%) Coin 8(57.1) 3(21.4) 2(14.3) 1(7.1) 14(42.4) Nail 2(33.3) 2(33.3) 2(33.3) 0(0.0) 6(18.2) Screw 2(50.0) 2(50.0) 0(0.0) 0(0.0) 4(12.1) Pin 2(66.7) 0(0.0) 1(33.3) 0(0.0) 3(9.1) Metal bar 2(100.0) 0(0.0) 0(0.0) 0(0.0) 2(6.1) Other 2(50.0) 1(25.0) 1(25.0) 0(0.0) 4(12.1) Total 18(54.5) 8(24.2) 6(18.2) 1(3.0) 33(100.0) Fiher` exact tet, Value , P= Table 3. Age and ex ditribution according to tranient time of foreign bodie Tranient time of foreign bodie (Day) 1-3(%) Age (Year) >3- >5-5(%) 10(%) Total (%) Male (%) Sex Total (%) Female (%) 1 2(33.3) 3(50.0) 1(16.7) 6(18.2) 6(100.0) 0(0.0) 6(18.2) >1-3 1(6.7) 10(66.7) 4(26.7) 15(45.4) 7(46.7) 8(53.3) 15(45.4) >3-7 3(33.3) 5(55.6) 1(11.1) 9(27.3) 8(88.9) 1(11.1) 9(27.3) >7 1(33.3) 1(33.3) 1(33.3) 3(9.1) 3(100.0) 0(0.0) 3(9.1) Total 7(21.2) 19(57.6) 7(21.2) 33(100.0) 24(72.7) 9(27.3) 33(100.0) Fiher` exact tet 5.212, P=0.64 for the age Fiher` exact tet 8.043, P =0.02 for ex There wa a light more delay (>3 day) in the paage of coin (50.0%, 7/14) than that for other object, Table 4. All children were managed conervatively with a cloe watchful waiting at their home and no complication (like rectal bleeding, bowel perforation or intetinal COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

59 59 59 ISSN Eat Cent. Afr. J. urg obtruction) occurred to any child. But three children who had foreign bodie for more than 7 day were given laxative to peed expel. Table 4. Foreign bodie' ditribution according to tranient time Type of foreign bodie Tranient time of foreign bodie (Day) Total (%) 1 (%) >1-3 (%) >3-7 (%) >7(%) coin 3(21.4) 4(28.6) 5(35.7) 2(14.3) 14(42.4) Nail 2(33.3) 2(33.3) 2(33.3) 0(0.0) 6(18.2) Screw 0(0.0) 4(100.0) 0(0.0) 0(0.0) 4(12.1) Pin 0(0.0) 2(66.7) 0(0.0) 1(33.3) 3(9.1) Metal 0(0.0) 2(100.0) 0(0.0) 0(0.0) 2(6.1) bar Other 1(0.0) 1(100.0) 2(0.0) 0(0.0) 4(12.1) Total 6(18.2) 15(45.4) 9(27.3) 3(9.1) 33(100.0) Fiher` exact tet 24.36, P =0.39 Dicuion Foreign body ingetion in children i common and in the majority of cae watchful waiting for the paage i ufficient. Thi urvey revealed the preponderance of ingetion of foreign bodie in boy a imilarly found in other tudie (11-14). Thi male` dominance may be due to their more activene in curioity or their le carefulne peronality. The finding of under five being the majority in thi tudy correponded to report of other author (11-14).Thi i probably due to children in thi age group are more unaware of the hazardou behaviour or riky object and o they require much cloe parental/guardian care and le expoure to mall ingetible object. In thi tudy coin wa the mot frequent wallowed object likewie in other tudie done by Panieri et al (11), Kaewwichian et al (12), and Melek et al (14). However, Amin-Ranjbar (9) and Branavan et al (13) reported Button batterie from toy to be commonly ingeted. Thi depict the diparity in expoure to kind of object in children among different ocietie and culture. There wa a light prolonged time between ingetion of a foreign body and preentation to hopital in the other urvey done in Thailand (12) unlike in thi tudy. Thi variation may be due to prolonged referral ytem in the other tudy etting. However, imilar duration of 6 hour from ingetion to preentation in the majority of participant wa reported by another author (15), probably reflecting the reemblance in the functioning of the health care referral ytem in thee area. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

60 60 60 ISSN Eat Cent. Afr. J. urg In thi urvey tomach wa the mot common ite of the foreign body at admiion a equally reported by other (11, 12) whereby coin formed the majority of wallowed object. Unlike in other tudie (9, 11) where mall intetine wa the commonet ite and dic batterie being the mot frequent ingeted foreign body. Thi reflect the fact that mall/hort object are likely to pa eaier and fat through the gatric-intetinal tract than the large/long one a it ha alo been revealed in thi urvey. The tranient time of le than one week in the majority of cae in thi tudy wa the ame a it wa found in the tudy done by Melek et al (14) and the related mean tranient time wa oberved in other tudie (12,15). One probable reaon for thi likene and need more reearch could be due to imilarity in bowel object propulion ability among children of different ocietie or general imilarity in the ize of ingeted object. In thi analyi mot of female had horter tranient time (<3 day) than male and thi obervation wa tatitically ignificant. However, thi alo require a large detailed urvey.. All cae were managed conervatively with watchful waiting for the exit of the object without complication. Except for three cae that did not pa a foreign body after one week received laxative to haten the excretion. Same treatment and outcome wa reported in one previou tudy (11). In contrat to other tudie (12-14) flexible endocopic intervention occurred due to the nature of the ingeted object being longer than 5centimeter and harp and o difficult to negotiate through the curve of the duodenum and ileocaecal valve and high rik of bowel perforation. Alo high rik of rupture or attraction to each other and caue bowel perforation a for the ingeted dic batterie and magnet repectively and their prolonged tay in the tomach for more than 48 hour were the indication for flexible endocopic removal. Surgical intervention wa applied in cae ended up with bowel perforation, obtruction, prolonged tay of dic batterie in mall bowel for more than 5 day or feature of rupture and rupture(on x-ray) of narcotic capule of illegal drug. No child underwent endocopic removal of a foreign body in thi tudy on the other ide due to lack of paediatric flexible endocope and their acceorie in our etting. Concluion Children under five year are at higher rik of ingeting foreign bodie. Coin were the commonet ingeted foreign body. Stomach wa the commonet location of object at preentation. Mot of children paed their foreign bodie within 3 day of wallowing. And all cae received conervative treatment with cloe follow up at home uccefully. Therefore it i important for parent /guardian to take extra care for the under five to enure le expoure to ingetible object. Watchful waiting management i ueful; however, enuring the availability of paediatric flexible endocopic ervice i vital for cae that might require uch intervention in future. Acknowledgement The author would like to thank the MNH adminitration for giving permiion to carry out thi analyi. Reference 1. Yalcin S, Karnak I, Ciftei A O, Senocak M E, Tanyel F C, Buyukpamukcu N. Foreign body ingetion in children:an analyi of paediatric urgical practice. Paediatr Surg Int. 2007;23(8): A-Kader H H. Foreign body ingetion: Children like to put object in their mouth. World J Pediatr. 2010;6(4): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

61 61 61 ISSN Eat Cent. Afr. J. urg 3. Awe JAA. Overview of the Management of Swallowed Gatrointetinal Tract Foreign Body. Glob Adv Re J Microbiol. 2013;2(6): Macgregor D, Ferguon J. Foreign body ingetion in children: an audit of tranit time. J Accid Emerg Med. 1998;15(6): Ikenberry S O, Jue T L, Anderon M A, Appalaneni V, Benerjee S, Ben-Menachem T, et al. Management of ingeted foreign bodie and food impaction. Gatrointet Endoc. 2011;73(6): Chung S, Forte V, Campi P.A review of paediatric foreign body ingetion and management.clinical paediatric emergence medicine ;11(3): Kumar N, Minocha A, Muya D. Aerodigetive Foreign Bodie in Children Chapter 52. In Ameh E A, Bickler S W, Lakhoo Kokila, Nwomeh BC, Poenaru D, ed. Paediatric urgery:acomprehenive text book for Africa.Firt eddition,volume I. Global HELP Organization; p Kramer R E, Lener D G, Lin T, Manfreid M, Shah M, Stephene T C, et al. Management of ingeted foreign bodie in children: A clinical report of the NASPGHAN endocopy committee.jpgn. 2015;60(4): Amini-Ranjbar S. Foreign body ingetion in Iranian children:a 4 year obervational tudy. Ru Open Med J. 2012;1(307): Kay M, Wyllie R. Paediatric foreign bodie and their management. Curr Garoenterology Report. 2005;7(3): Panieri E, Ba D H. The management of ingeted foreign bodie in children- a review of 663 cae.. Eur J Emerg Med. 1995;2(2): Kaewwichian W, Tantiyaawadikul V, Areemitr S. Experience of Pediatric Foreign Body Ingetion in Srinagarind Hopital, Khon Univerity. Srinagrind Med J. 2012;27(Suppl): Branavan B, Dia R, Kumari T, Samarainghe M. Foreign body ingetion in children : Single intitutional experience in Sri Lanka. 2014;43(2): Melek M, Cobanoglu U, Bilici S, Beger B, Kazilyidiz B S, Melek Y. Management and treatment of foreign bodie ingetion in childhood. Eat J Med. 2011;16(3): Antoniou D, Chritopoulo-Geroulano G. Management of foreign body ingetion and food bolu impaction in children: A retropective analyi of 675 cae. Turk J Pediatr. 2011;53(4): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

62 62 62 ISSN Eat Cent. Afr. J. urg Gatric outlet obtruction among adult patient at two Rwandan referral hopital: Etiology, H. pylori infection and outcome M.K. Kabuyaya 1, R. Sebuufu 2,3, B. Aiimwe-Kateera 3, M. Nyundo 1,3, J. Rickard 1,4. 1Univerity Teaching Hopital of Kigali, 1024 Rue de la Paix, Kigali, Rwanda 2Univerity Teaching Hopital of Butare, PO Box 254Huye, Southern Province, Rwanda 3Univerity of Rwanda, College of Medicine and Health Science, PO Box 3286, Kigali, Rwanda 4RwandaHumanReource for Health Program, PO Box 84, Kigali, Rwanda Correpondence to: Kabuyaya K. Médard, Background: Gatric outlet obtruction (GOO) i characterized by peritent non-biliou vomiting due to obtruction at the pyloru. GOO i aociated with Helicobacter pylori through both malignant and benign procee. The objective of thi tudy wa to determine the epidemiology of gatric outlet obtruction in Rwanda. Method: A cro-ectional decriptive tudy wa undertaken on patient with GOO een over a 12-month period. Patient demographic, hitopathology, H.pylori infection and mortality, were analyzed uing Chi-quare (χ2) tet and logitic regreion. Mortality wa aeed with a minimum follow up of 3 month. Reult: A total of 82 patient preenting with GOO were tudied. The rate of H.pyloriinfection wa 61%. Malignant hitopathology wa found in 67% of patient. Bivariate analyi howed that pylori infection wa aociated with a benign hitopathology (X 2 =4.77, p=0.029). Logitic regreion howed that malignant hitopathology wa aociated with decreaed urvival (Odd Ratio = 0.072, 95% Confidence Interval = , p< 0.001). There wa no tatitically ignificant difference in mortality between urgical and non-urgical patient with malignant hitopathology (X 2 =1.41, p= 0.495). Concluion: Malignancy i a common caue of GOO in Rwanda and i aociated with increaed mortality whether treated urgically or non-urgically. Over 50% of patient with GOO in Rwanda were infected with H pylori. Introduction Gatric outlet obtruction (GOO) decribe a clinical condition repreented by any dieae proce cauing mechanical obtruction to gatric emptying, including both benign or malignant condition 1.The incidence of GOO i not preciely known but in developed countrie it ha been etimated at 5% among patient with benign condition and in peripancreatic malignancy it ha been reported at 15-20% 2. GOO in developed countrie i predominantly aociated with malignancy 3. However, in developing countrie uch a Ethiopia, the majority of tudie report a benign aetiology 4. Helicobacter pylori infect the tomach and produce an inflammation that may contribute to complete or incomplete obtruction of the dital tomach, pyloru or proximal duodenum 5. The prevalence of H. pylori infection among patient with GOO in developed countrie i approximately 69% 6. In Rwanda the prevalence of H.pylori among patient undergoing endocopy wa 75% 7. The majority of patient with GOO often eek medical care late when the patient i dehydrated and nutritional tatu i compromied(4). A tudy conducted in Netherlandon patient with advanced malignant GOO reported a pot-operative mortality rate of 95%(8). GOO in Rwanda i a common medical condition. However, the caue of GOO and hort-term outcome of urgery have not been adequately tudied. Further information i needed to addre thi public health The aim of thi tudy wa to identify the etiology of GOO, the rate of H.pylori infection in patient with GOO and the hort-term outcome for thoe undergoing urgery at the Univerity Teaching Hopital of Kigali and Butare. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

63 63 63 ISSN Eat Cent. Afr. J. urg Patient and Method Thi wa a decriptive cro-ectional tudy involving patient with a clinical diagnoi of GOO conducted at the Univerity Teaching Hopital of Kigali and Butare over a twelve-month period (April 2013 to March 2014). All patient with a diagnoi of GOO confirmed by endocopy or laparotomy were included. Pediatric patient (<15 year old) and thoe without biopy reult were excluded from the tudy. The Univerity Teaching Hopital of Kigali (CHUK) and Butare (CHUB) are national referral and teaching hopital in Rwanda. CHUK ha a bed capacity of 586 with a catchment area of more than 11 million people. CHUB ha a bed capacity of 329 and a catchment area of more than 2 million people. A trained phyician performed all endocopic procedure. GOO wa uggeted by the inability to progre the endocope through the pyloru or intubate the duodenal bulb. For patient who underwent laparotomy, the diagnoi of GOO wa made by the urgeon noting a protruding ma in the antrum, a cicatrized firt part of duodenum, or a pyloru with a dilated and thickwalled tomach. To identify the underlying caue of GOO two biopie were taken from the antral ma and two more away from the leion. Biopy pecimen were immediately fixed in 20% formalin and ent for hitopathological analyi. Specimen were analyzed at the King Faial Hopital, Univerity of Rwanda Pharmaceutical Reearch Laboratorie in Rwanda and/or and the Brigham and Women Hopital USA. H.pylori infection wa diagnoed immediately at endocopy by performing a modified rapid ureae tet (MRUT) to freh biopie taken from the mucoa of the tomach, ditant from the antral ma. The MRUT tet material were frehly made following the decription of Katelari et al, who found a tet enitivity of 97% and pecificity of 95%(9). After endocopy, patient were either placed on the theatre waiting lit or underwent immediate laparotomy. The choice of urgical procedure wa at the dicretion of the operating urgeon. The mot common urgical procedure wa gatrojejunotomy with one patient undergoing antrectomy and gatrojejunotomy (Billroth II).All patient were telephoned at leat once per month for a minimum of three month for follow up and document the patient tatu. Statitical analyi wa performed uing the Statitical Package for Social Science (SPSS) verion 16.0 for Window. Frequencie and percentage were reported for categorical variable. Age wa evaluated a a categorical variable. Factor aociated with benign or malignant etiologie of GOO were aeed uing the Chi-quared tet. Bivariate analyi of factor aociated with mortality wa performed uing the Chi-quared tet. A p value <0.05 wa conidered to be tatitically ignificant. For thoe patient who urvived, data from the date of lat contact wa ued. Ethical approval wa obtained from the School of Medicine, College of Medicine and Health Science at the Univerity of Rwanda a well a from the Ethical Review Board at the Univerity Teaching Hopital of Kigali. Informed conent wa obtained from all patient or the witne of patient enrolled in the tudy. Reult Eighty-two (82) patient were diagnoed with GOO. The majority (76%) were farmer. 54 (66%) patient were older than 50 year of age and 58% were male (Table 1). 50% completed primary chool education. Mot patient (98.8%) reported epigatric pain, intermittent non biliou potprandial vomiting, and weight lo. The mean duration of epigatric pain wa 27.5 month (SD: 36.8).Sixty-even percent (67%) of patient reported uing a combination of modern (antibiotic and proton-pump inhibitor) and traditional medicine prior to preentation. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

64 64 64 ISSN Eat Cent. Afr. J. urg Table 1. Characteritic of patient preenting with gatric outlet obtruction Frequency Percentage Demographic Age <50 year >50 year Gender Male Female Aetiology Malignant Intetine Diffue Benign Chronic gatriti Eroive gatriti Other H. pylori Poitive Negative Management Non operative Benign Malignancy Surgery Benign Malignancy Outcome Survival Mortality Table 2. Factor aociated with etiology of GOO Benign Malignant X 2 P value Age <50 year 12 (14.7%) 17 (20.7%) >50 year 15 (18.3%) 38 (46.3%) Gender Male 18 (21.9%) 30 (36.5%) Female 9 (10.9%) 25 (30.5%) H.pylori Poitive 21 (25.6%) 29 (35.4%) Negative 6 (7.3%) 26 (31.7%) Overall, 55(67.1%) cae of GOO were aociated with malignancy, while 27(32.9%) cae had a benign etiology. Chronic gatriti wa the mot common diagnoi in benign dieae, accounting for 21(25.6%) cae of GOO. Intetinal type accounted for the mot common malignant etiology COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

65 65 65 ISSN Eat Cent. Afr. J. urg with 48(58.5%) cae of GOO. H.pylori wa detected in 50 (61%) patient. Bivariate analyi howed H.pylori infection to be ignificantly aociated with a benign etiology of GOO (χ2 =4.77, p=0.029) (Table2). A total of 35 (43%) patient underwent urgical treatment for GOO. Of thee, 23 (66%) had a malignant etiology while the remainder were benign. Mot patient (97%) underwent gatrojejunotomy with only one patient undergoing antrectomy and gatrojejunotomy (Billroth II). Table 3. Outcome and relationhip to epidemiologic and clinical characteritic Survival Mortality OR 95% CI P value Age < 50 year 19 (25.6%) 8 (10.8%) > 50 year 22 (29.7) 25 (33.7%) Gender Male 23 (31.1%) 19 (25.6%) Female 18 (24.3) 14 (18.9) Aetiology Malignant 17 (20.2%) 30 (49.5%) <0.001 Benign 24 (32.4%) 3 (3.85%) Management Non operative 23 (31.1%) 16 (21.6%) Surgery 18 (24.3%) 17 (22.9%) A follow up period of at leat three month wa poible in 74 of 82 (90%) patient with GOO. The eight patient (10%) lot to follow up all had malignant dieae. The overall mortality rate at three month of follow up wa 44.5% (Table 1).Bivariate analyi howed that age greater than 50 year (χ2=3.85, p= 0.050) and malignant etiology of dieae (χ2= 19.29, p<0.001) were aociated with increaed mortality. Multivariate logitic regreion revealed that a malignant aetiology of GOO wa aociated with decreaed urvival compared to benign caue (OR= 0.072, 95%CI= , p<0.001) (Table 3).In patient with malignancy, the 3-month urvival wa not tatitically different between thoe operated on and thoe not (χ2=1.41, p=0.495) (Table 3). Dicuion GOO i a common urgical problem in Rwanda and poe many challenge to the general urgeon. A recent tudy in Rwanda of 961endocopie found the prevalence of GOO to be relatively high at 10%, compared with other etting 7. The current tudy wa conducted to identify common etiologie of GOO, the rate of H.pylori infection in patient with GOO and the hort-term outcome for thoe undergoing urgery. To date, thee problem have not been adequately tudied in Rwanda. Two third of patient were found to have a malignant etiology of GOO. Thi finding i imilar to other tudie in developing countrie uch a Tanzania, Pakitan and India 10, 11, 12. It contrat with tudie in Nigeria and Ethiopia 13, 14. Rwanda i ituated in the Great Lake region of Africa where the incidence of gatric cancer i high (3.2 per 100,000) and previou tudie have hown that Rwanda ha a high incidence of gatric cancer (13 to 15 per 100,000) 14.In developed countrie, the predominance of malignancy i theorized to be due to a declining rate of benign etiologie econdary to the early identification and treatment of H.pylori and the ue of proton COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

66 66 66 ISSN Eat Cent. Afr. J. urg pump inhibitor 3. However, it i unknown whether the ame principle applie in ub-saharan Africa. Of malignant pecimen in our tudy, 87% howed intetinal type dieae. Thi type ha been frequently identified in dital gatric biopie and in population at high rik for gatric cancer 15. Similar finding of intetinal type were predominant (62.9%) in a tudy conducted in Japan 16. In Uganda, intetinal metaplaia wa oberved in the majority of Nyarwanda and Nkole tribe 17. In contrat, in China a tudy examining the biopie of gatric carcinoma revealed 47.8% of patient had diffue-type 18. The increaed rate of intetine -type dieae found in Rwanda could be attributed to the high rate of H. pylori infection (61%), which i a known rik factor. A metaanalyi conducted in Japan reported that each year, 5% of H.pylori poitive patient develop gatric cancer 19. In thi tudy, the prevalence of H. pylori among patient with GOO wa 61%. Previou endocopic tudie conducted in Rwanda howed a prevalence of H.pylori of 75% in all patient (9, 20). In developed countrie the variation in prevalence of H.pylori infection among patient with GOO range from 33 to 69% 6, 21. The diparity in prevalence rate could be related to variation in the enitivity of the tet ued and the underlying caue of GOO. Kate et al found the prevalence of H.pylori to be 91% after uing multiple teting including erology, hitology and rapid ureae tet among patient with GOO and active ulcer in the duodenum 22. Our finding are imilar to previou data reported in Rwanda and confirm prior report that H. pylori infection i ignificantly aociated with benign etiology of GOO 23. There wa no tatitically ignificant aociation between malignant etiology of GOO and H.pylori infection. H.pylori i one of many independent factor in gatric carcinogenei which ha been reported in everal cae-control tudie 24.Other factor uch a genetic, dietary, and environmental factor play a major role in development of gatric malignancy among patient with negative H.pylori teting 25. Many of thee independent factor were not evaluated in thi tudy. The lack of tatitical difference between H.pylori infection and malignant aetiology of GOO could be due to prior medical treatment. H pylori infection may alo be underetimated becaue of the laboratory method ued to diagnoe H.pylori. By combining immunohitologic biopy pecimen with antibodie againt H.pylori, ome tudie have detected a prevalence of H.pylori in gatric cancer of 98% 26. In thi tudy, the highet frequency of patient with GOO wa in the group age over 50 year. Similar reult were reported by Kotio in Ethiopia 4. A retropective tudy conducted on patient with GOO in developed countrie reported a mean age of 61 year 10. Additionally the majority of death (75%) occurred in patient aged greater than50 year. Bivariate analyi revealed that independent factor for mortality were age greater than 50 year and malignancy. Jaka et al 10 found that patient age greater than 60 year and malignant caue of GOO were ignificantly aociated with higher mortality rate 10. However, on multivariate analyi malignancy alone wa aociated with mortality. The high mortality in our etting may be due to delayed patient preentation. Mot patient had a mean duration of ymptom of 27.5 month (SD=36.8 month) prior to evaluation at a referral hopital. Patient may delay at home while receiving treatment and medicine from traditional healer. There may alo be delay within the healthcare ytem reulting in delayed referral to a tertiary hopital. Thi tudy ha everal limitation. Many invetigation were not routinely available due to financial contraint. The tage of malignancy at time of preentation influence overall mortality reult a well a the choice of operation. Alo, many patient do not routinely ee a phyician, o there i limited data on co-morbiditie, which could influence mortality. Further tudie would be needed to include thee factor in the analyi. Depite thee limitation, the COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

67 67 67 ISSN Eat Cent. Afr. J. urg tudy provide local data that can be ued by health care provider to plan for preventive trategie a well a intitute management guideline for thee patient. Concluion GOO i a common urgical problem in our etting with malignancy accounting for the majority of cae. Malignant etiology wa aociated with increaed mortality but the mortality rate wa imilar in urgical and non-urgical patient. H.pylori infection i aociated with a benign etiology of GOO. Provider at the health center and ditrict hopital hould be educated about GOO and refer patient early to optimize outcome. Acknowledgement We are grateful to the Brigham and Women Hopital for performing hitopathology analyi of a number of biopy pecimen and we acknowledge the endocopy taff of the Univerity Teaching Hopital of Kigali and Butare Reference 1. Appaani S, Kochhar S, Nagi B, Gupta V, Kochhar R. Benign gatric outlet obtruction-- pectrum and management. Tropical gatroenterology : official journal of the Digetive Dieae Foundation. 2011;32(4): Tendler DA. Malignant gatric outlet obtruction: bridging another divide. The American journal of gatroenterology. 2002;97(1): Shone DN, Nikoomaneh P, Smith-Meek MM, Bender JS. Malignancy i the mot common caue of gatric outlet obtruction in the era of H2 blocker. The American journal of gatroenterology. 1995;90(10): Kotio B. Gatric outlet obtruction in Northwetern Ethiopia. Ecit and Central African Journal of Surgey. 2007;5(2): Yamaoka Y. Pathogenei of Helicobacter pylori-related Gatroduodenal Dieae from Molecular Epidemiological Studie. Gatroenterology reearch and practice. 2012;2012: Gibert JP, Pajare JM. Review article: Helicobacter pylori infection and gatric outlet obtruction - prevalence of the infection and role of antimicrobial treatment. Alimentary pharmacology & therapeutic. 2002;16(7): Walker TD, Karemera M, Ngabonziza F, Kyamanywa P. Helicobacter pylori tatu and aociated gatrocopic diagnoe in a tertiary hopital endocopy population in Rwanda. Tranaction of the Royal Society of Tropical Medicine and Hygiene. 2014;108(5): Van Hooft JE, Dijkgraaf MG, Timmer R, Sierema PD, Focken P. Independent predictor of urvival in patient with incurable malignant gatric outlet obtruction: a multicenter propective obervational tudy. Scandinavian journal of gatroenterology. 2010;45(10): Katelari PH, Lowe DG, Norbu P, Farthing MJ. Field evaluation of a rapid, imple and inexpenive ureae tet for the detection of Helicobacter pylori. Journal of gatroenterology and hepatology. 1992;7(6): Jaka H, McHembe MD, Rambau PF, Chalya PL. Gatric outlet obtruction at Bugando Medical Centre in Northwetern Tanzania: a propective review of 184 cae. BMC urgery. 2013;13: Samad AK, TW; Shoukat I. Gatric Outlet Obtructuion: Change in Etiology. Pakitan Journal of Surgery. 2007;23(1): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

68 68 68 ISSN Eat Cent. Afr. J. urg 12. Mira SP, Dwivedi M, Mira V. Malignancy i the mot common caue of gatric outlet obtruction even in a developing country. Endocopy. 1998;30(5): Dogo D, Yawe T, Gali BM. Gatric outlet obtruction in Maiduguri. African journal of medicine and medical cience. 1999;28(3-4): Newton R, Ngilimana PJ, Grulich A, Beral V, Sindikubwabo B, Nganyira A, et al. Cancer in Rwanda. International journal of cancer Journal international du cancer. 1996;66(1): Volk J, Paronnet, J. Epidemiology of gatic cancer and Helicobater pylori. In: T. Wang JF, A. Giraud, editor. The Biology of Gatric Cancer: Springer; p Sakitani K, Hirata Y, Watabe H, Yamada A, Sugimoto T, Yamaji Y, et al. Gatric cancer rik according to the ditribution of intetinal metaplaia and neutrophil infiltration. Journal of gatroenterology and hepatology. 2011;26(10): Wabinga H. Helicobacter pylori and hitopathological change of gatric mucoa in Uganda population with varying prevalence of tomach cancer. Afr Health Sci. 2005;5(3): Qiu MZ, Cai MY, Zhang DS, Wang ZQ, Wang DS, Li YH, et al. Clinicopathological characteritic and prognotic analyi of Lauren claification in gatric adenocarcinoma in China. Journal of tranlational medicine. 2013;11: Aaka M ST, Nobuta A, Kato M, Takeda H, Graham DY. Atrophic gatriti and intetinal metaplaia in Japan: reult of a large multicenter tudy. Helicobacter. 2001;6(4): Rouvroy DB, J; Nengiumwa, O; Omar, M; Veraille, L; Haot, J. Campylobacter pylori, gatriti, and peptic ulcer dieae in Central Africa. Br Med J. 1987;295(1174). 21. Gibon JB BS, Fabian TC, Britt LG. Gatric outlet obtruction reulting from peptic ulcer dieae requiring urgical intervention i infrequently aociated with Helicobacter pylori infection. J Am Coll Surg. 2000;191(1): Kate V AN, Badrinath S, Amarnath SK, Ratnakar C. Helicobacter pylori infection in duodenal ulcer with gatric outlet obtruction. Tropical gatroenterology : official journal of the Digetive Dieae Foundation. 1998;19(2): Takin V GI, Ozyilkan E, Sare M, Hilmioglu F. Effect of Helicobacter pylori eradication on peptic ulcer dieae complicated with outlet obtruction. Helicobacter. 2000;5(1): Muñoz N FS. Epidemiology of gatric cancer and perpective for prevention. Salud Publica Mex. 1997;39(4): Correa P PM, Camargo MC. Etiopathogenei of gatric cancer. Scandinavian Journal of Surgery. 2006;95(4): Enomoto H WH, Nihikura K, Umezawa H, Aakura H. Topographic ditribution of Helicobacter pylori in the reected tomach. Eur J Gatroenterol Hepatol. 1998;10(6): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

69 69 69 ISSN Eat Cent. Afr. J. urg Pattern and Management Outcome of Neonatal Acute Surgical Condition in Alexandria, Egypt. H.L. Wella 1, S.M.M. Farahat 2, 1Currently a paediatric urgery trainee Department of Paediatric Surgery-Alexandria Univerity 2Houe officer- Alexandria Univerity Hopital. Correpondence to: Dr. Herman Landolin Wella, her_w2002@yahoo.com Background: Neonatal acute urgical condition ignificantly contribute to high morbidity and mortality among neonate particularly in low reource etting.the main objective of thi tudy wa to determine the pattern and management outcome of acute urgical condition in neonate. Method: A one year propective tudy wa conducted at El Shatby hopital, Alexandria, Egypt between February 2014 and January Only neonate who were operated for acute urgical condition were included in the tudy. Reult: A total of 156 neonate were tudied. The male accounted for 103 (66.0%) for the cae. The M: F ex ratio wa 1.9:1(P=0.02). The age ranged from 5 hour to 30 day. The median age wa 6 day. The majority had normal birth weight ( 2.5 kg), 84.0% (131) (mean 2.9 (± 0.5SD) kg), P=0.03. The mot common condition were oeophageal atreia 15.4% (24), anorectal malformation 13.5% (21) and intetinal atreia 12.8% (20). Overall 17.9 % (28) of neonate had potoperative complication with wound epi being the commonet potoperative complication. The mortality wa 20.5% (32) with high mortality een among low birth weight neonate, P= 0.00, and in thoe with other medical condition, P=0.04. Concluion: High morbidity and mortality occur among neonate with acute urgical condition and o adequate maternal health care, facilitie and peronnel are eential for the bet out come. Key word: Neonate, Acute urgical condition, Management, Outcome. Introduction Newborn acute urgical pathologie occur in 1 in 5000 live birth and contribute coniderably to high morbidity and mortality among neonate 1 3. When compared to older children, neonate have a wide divergence in phyiology, anatomy, immunity and repone to tre and when they have urgical illne they are further compromied by the condition itelf which predipoe them to electrolyte derangement, repiratory ditre, epi and unpleaant effect of anaetheia and urgery 1,4,5. The ultimate goal in newborn urgical care i every neonate undergoing urgery hould live and therefore effective and cloe interdiciplinary collaboration between community health worker, paediatric urgeon, paediatrician, anaetheiologit, nure, radiologit, pathologit, biochemit and technician i eential for the bet outcome 1,6,7. Thi analyi wa conducted to find out the pattern and outcome of emergency newborn urgerie and provide baeline data for future tudie. Patient and Method. Thi one year propective tudy wa conducted at the paediatric urgery department, El Shatby hopital in Alexandria Egypt from February 2014 to January Only neonate (newborn 30 day of age) who undergone emergency Surgery were recruited into the tudy after obtaining verbal conent from parent. Data collection wa done by uing a tructured quetionnaire during admiion, urgery, potoperative care in the ICU/ward and the out patient clinic viit after dicharge. Mobile phone communication wa ued to get maternal information and follow up of patient while at home. Information collected included age, ex, birth weight, getational age at birth, aociated maternal co morbiditie, mode of delivery, type COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

70 70 70 ISSN Eat Cent. Afr. J. urg of getation, maternal age, tatu of parent conanguinity, duration of ymptom, clinical feature, diagnoi, other aociated anomalie and medical condition, time interval between admiion and urgery, urgical treatment, pre and pot operative treatment, pot operative complication and outcome at dicharge. Data collected were cleaned and analyed uing the SPSS verion 20. Categorical data were analyzed uing fiher` exact and chi-quare tet and a P value 0.05 wa conidered a ignificant. Continuou data were expreed in mean and median. Permiion to carry out thi tudy wa obtained from the hopital management. Reult A total of 156 newborn were tudied. The male contributed 103 (66.0 %) of the cae with a Male to Female ratio of 1.9:1(P=0.02).Their age ranged from 5 hour to 30 day with the overall median being 6.0 day. The majority had birth weight greater than 2.5 kilogram (Kg), 131 (84.0%), (P=0.03). Birth weight ranged between 1.5 Kg and 5.5 Kg with the overall average being 2.9(±0.5 SD) Kg. The majority were delivered at term ( 37 week of getation), 87.8% (137/156), P=0.44. Table 1. Ditribution of patient by demographic characteritic and ex Patient` Sex Total (%) characteritic Male (%) Female (%) Age (day) (67.4) 29(32.6) 89(57.1 ) (39.1) 14(60.9 ) 23( 14.7) (82.4) 3(17.6) 17(10.9 ) (74.1) 7(25.9 ) 27( 17.3) Total 103(66.0 ) 53(34.0) 156( 100.0) Birth weight(kilogram) (33.3) 6(66.7) 9(5.8 ) (43.8) 9(56.2 ) 16(10.2 ) (68.2 ) 14(31.8) 44( 28.2) 3 63(72.4) 24(27.6 ) 87(55.8 ) Total 103(66.0) 53(34.0 ) 156( 100.0) Getational age at birth(week) <37 11(57.9) 8(42.1) 19(12.2) 37 92(67.2) 45(32.8) 137(87.8) Total 103(66.0) 53(34.0) 156(100.0) Maternal age (year) <20 5(83.3) 1 (16.7) 6(3.8) (68.7) 42(31.3) 134(85.9) (57.1) 6(42.9) 14(9.0) >40 1(50.0) 1(50.0) 2(1.3) Total 103(66.0) 53(34.0) 156(100.0) Preence of conanguinity Not preent 82(67.8) 39(32.2) 121(77.6) Preent 21 (60.0) 14(40.0) 35(22.4) Total 103(66.0) 53(34.0) 156(100.0) Fiher` exact tet, P=0.02 for the age, Fiher` exact tet, P=0.03 for the birth weight, Chi-quare Value 0.60, df=1, P=0.44 for getational age, Fiher` exact tet, P= 0.68 for the maternal age, Fiher` exact tet, P= 0.68 for conanguinity COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

71 71 71 ISSN Eat Cent. Afr. J. urg The getational age ranged from week and the overall mean wa 38.0 (±1.6 SD) week. Fifty (32.1%) and 49 (31.4%) of neonate were econd or third born repectively, followed by 27 (17.3%) firt born group, P=0.43. Ninety two (58.9%) of the newborn were delivered by caearean ection. The overwhelming majority (96.8%) were ingle ton. The age of the mother ranged from 16 to 41 year with a mean of 24.9 (±4.3 SD) year. A total of 134 (85.9%) of the mother were in the 20-30year age group. Conanguinity wa preent in 35 (22.4%) of couple (Table 1). Twenty (12.8 %) of the neonate were delivered from mother with other maternal co morbiditie (P= 0.49), which included premature rupture of membrane occurring in 7 (4.5%) of the mother, pre-eclampia in 6 (3.8 %), anaemia in 5 (3.2 %), getational diabete in 3 (1.9 %) and cardiomyopathy in 1 (0.6%) of the 156 mother. Aociated maternal morbid condition were common in neonate aged below 7 day at admiion, P= 0.28, in female, P=0.29, in low birth weight (<2.5 Kg), P=0.09, and in preterm deliverie, P=0.46. A half of cae, 50.0% (78/156) preented late to hopital (> 2 day of ymptom). Mot of male, 51.5% (53/103), normal birth weight neonate ( 2.5 Kg birth weight), 52.7% (69/131) and mot of thoe born at term, 51.8% (71/137), preented late to hopital. The overall median duration of ymptom wa 2.0 day (range 4hour-29 day). The mot frequent reaon for delay wa midiagnoi, 60.3% (47/78), followed by delayed invetigation at the initial health centre, 33.3% (26/78). Table 2. Ditribution of neonate by urgical condition and ex Primary Diagnoi Sex Total (%) Male (%) Female (%) Oeophageal atreia 15(62.5) 9(37.5) 24(15.4) Anorectal malformation 17(81.0) 4(19.0) 21(13.5) Intetinal atreia 9(45.0) 11(55.0) 20(12.8) Hypertrophic pyloric tenoi 14(87.5) 2(12.5) 16(10.2) Peritoniti 9(60.0) 6(40.0) 15(9.6) Hirchprung` Dieae 10(76.9) 3(23.1) 13(8.3) Intetinal malrotation 5(50.0) 5(50.0) 10(6.4) Diaphragmatic hernia 5(55.6) 4(44.4) 9(5.8) Obtructed inguinal hernia 4(100.0) 0(0.0) 4(2.6) Exomphalo minor 1(25.0) 3(75.0) 4(2.6) Intetinal web 2(50.0) 2(50.0) 4(2.6) Gatrochii 3(100.0) 0(0.0) 3(1.9) Meconium ileu 2(100.0) 0(0.0) 2(1.3) Midgut volvulu 1(50.0) 1(50.0) 2(1.3) Ileal duplication cyt 2(100.0) 0(0.0) 2(1.3) Intetinal obtruction econdary to primary 1(50.0) 1(50.0) 2(1.3) adheion Annular pancrea 2(100.0) 0(0.0) 2(1.3) Other 1(33.3) 2(66.7) 3(1.9) Total 103(66.0) 53(34.0) 156(100.0 ) Fiher` exact tet, Value , P=0.08 *Other included: intetinal obtruction econdary to twited Meckle` diverticulum (1), Intetinal obtruction econdary to colonic tumour (1), eventration (1). COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

72 72 72 ISSN Eat Cent. Afr. J. urg Table 3. Ditribution of Cae by Aociated Anomalie and Sex Aociated Anomalie Sex Total (%) Male (%) Female (%) Abent 90(66.2) 46(33.8) 136(87.2 ) Preent 13(65.0) 7(35.0) 20(12.8) Total 103(66.0) 53(34.0) 156(100. 0) Muculokeletal Dactyl anomalie 2(50.0) 2(50.0) 4(11.4) anomalie Club foot 2(66.6) 1(33.3) 3(8.6) colioi 1(100.0) 0(0.0) 1(2.9) Hemivertebral 1(100.0) 0(0.0) 1(2.9) Cardiac anomalie ASD&VSD 6(85.7) 1(14.3) 7(20.0) Genital urinary Undecended teti 3(100.0) - 3(8.6) anomalie Hypopadia 1(100.0) - 1(2.9) Abnormal labia majora - 1(100.0) 1(2.9) hydrocoele 1(100.0) 0(0.0) 1(2.9) Anorectal anomalie 3(75.0) 1(25.0) 4(11.4) Gatrointetinal Situinveru 1(50.0) 1(50.0) 2(5.7) anomalie Intetinal malrotation 1(50.0) 1(50.0) 2(5.7) Renal anomalie Hypoplatic kidney 1(100.0) 0(0.0) 1(2.9) Aplatic kidney 1(100.0) 0(0.0) 1(2.9) Cranial facial anomalie Microcephaly 1(50.0) 1(50.0) 2(5.7) Down yndrome 1(100.0) 0(0.0) 1(2.9) Total 26(74.3) 9(25.7) 35(100.0) Chi-quare Value 0.007, df=1, P=0.93 Table 4. Ditribution of Surgical Condition and Statu of Potoperative Complication Primary diagnoi Statu of Potoperative complication Total (%) Preent (%) Abent (%) Oeophageal atreia 3(12.5) 21(87.5) 24(15.4) Anorectal malformation 2(9.5) 19(90.5) 21(13.5) Intetinal atreia 4(20.0) 16(80.0) 20(12.8) Hypertrophic pyloric tenoi 1(6.2) 15(93.8) 16(10.2) Peritoniti 7(46.7) 8(53.3) 15(9.6) Hirchprung` dieae 2(15.4) 11(84.6) 13(8.3) Intetinal malrotation 1(10.0) 9(90.0) 10(6.4) Diaphragmatic hernia 2(22.2) 7(77.8) 9(5.8) Obtructed inguinal hernia 0(0.0) 4(100.0) 4(2.6) Exomphalo minor 0(0.0) 4(100.0) 4(2.6) Intetinal web 1(25.0) 3(75.0) 4(2.6) Gatrochii 0(0.0) 3(100.0) 3(1.9) Meconium ileu 2(100.0) 0(0.0) 2(1.3) Midgut volvulu 1(50.0) 1(50.0) 2(1.3) Ileal duplication cyt 1(50.0) 1(50.0) 2(1.3) Intetinal obtruction econdary to 0(0.0) 2(100.0) 2(1.3) primary adheion Annular pancrea 1(50.0) 1(50.0) 2(1.3) Other 0(0.0) 3(100.0) 3(1.9) Total 28(17.9) 128(82.1) 156(100.0) Fiher` exact tet, Value , P= 0.02 COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

73 73 73 ISSN Eat Cent. Afr. J. urg Table 5. Ditribution of Surgical Condition by Potoperative Complication Primary diagnoi Wound epi (%) Potoperative complication Total (%) Wound Burt Anatomoi dehicence abdomen leak/breakdown (%) (%) (%) Oeophageal 3(60.0) 1(20.0) 0(0.0) 1(20.0) 5(9.6) atreia Anorectal 2(50.0) 2(50.0) 0(0.0) 0(0.0) 4(7.7) malformation Intetinal 4(44.4) 4(44.4) 0(0.0) 1(11.1) 9(17.3) atreia Hypertrophic 1(50.0) 0(0.0) 1(50.0) 0(0.0) 2(3.8) pyloric tenoi Peritoniti 7(53.8) 4(30.8) 2(15.4) 0(0.0) 13(25.0) Hirchprung` 2(66.7) 0(0.0) 1(33.3) 0(0.0) 3(5.8) Dieae Intetinal 1(50.0) 1(50.0) 0(0.0) 0(0.0) 2(3.8) malrotation Diaphragmati 2(100.0) 0(0.0) 0(0.0) 0(0.0) 2(3.8) c hernia Intetinal web 1(100.0) 0(0.0) 0(0.0) 0(0.0) 1(1.9) Meconium 2(66.7) 1(33.3) 0(0.0) 0(0.0) 3(5.8) ileu Midgut 1(33.3) 0(0.0) 1(33.3) 1(33.3) 3(5.8) volvulu Ileal 1(33.3) 1(33.3) 0(0.0) 1(33.3) 3(5.8) duplication cyt Annular 1(50.0) 0(0.0) 1(50.0) 0(0.0) 2(3.8) pancrea Total 28(53.8) 14(26.9) 6(11.5) 4(7.7) 52(100.0) The mot common urgical condition were Oeophageal atreia, 15.4% (24/156), followed by Anorectal malformation, 13.5% (21/156) and intetinal atreia, 12.8% (20/156), (Table 2). Mot of neonate ( 50.0%) in each condition weighed 2.5 Kg birth weight, P=0.001 and alo ( 66.0%) were delivered at term, P=0.19. High conanguinity wa een in cae with hirchprung` dieae, 46.2% (6/13) and intetinal malrotation, 40.0% (4/10), P=0.58. Mot of maternal co morbid condition occurred in Oeophageal atreia, 25.0% (5/20) and Intetinal atreia, 18.8 %( 3/16), P= Aociated anomalie were found in 12.8% (20/156) of newborn, P=0.93. Muculokeletal aociated anomalie were the commonet accounting for 25.7% (9/35), followed by cardiac anomalie, 20.0% (7/35) and genital urinary ytem anomalie, 17.1% (6/35), (Table 3). Mot of the aociated anomalie were een in oeophageal atreia cae, 34.3% (12/35), Diaphragmatic hernia neonate, 14.3% (5/35) and Anorectal malformation cae, 11.4% (4/35). Mot of cae, 51.9% (81/156), had other aociated preoperative medical condition and thee included: epticaemia occurring in 35.9% (56/156), Pneumonia, 22.4% (35/156), neonatal jaundice, 17.9% (28/156) and hypothermia in 16.7% (26/156) of the neonate. Thee were common in female, 58.3% (31/53), P=0.26, among newborn aged le than a week, 55.1% (49/89), P=0.72, in low birth weight (<2.5kg) neonate, 84.0% (21/25), P= 0.04, and in preterm babie (<37 week of getation), 68.4% (13/19), P= Mot of other COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

74 74 74 ISSN Eat Cent. Afr. J. urg medical condition were more frequent in Oeophageal atreia cae, 31.9% (38/119), Intetinal atreia neonate, (15.1%) 18/119, Diaphragmatic hernia, 13.4% (16/119) and 8.4 %( 10/119) in peritoniti and alo in intetinal malrotation babie. The overall median duration between time of admiion and time at the tart of urgery wa 1.0 day (range 4hour-21 day). About 79.5% (124/156) of babie ued incubator, 26.3% (41/156) ued neonatal ventilator in which mot were cae involved thoracic urgery like Oeophageal atreia, 70.8% (17/24) and Diaphragmatic hernia, 66.7% (6/9).Twelve cae, 7.7% (12/156) ued parenteral nutrition. Potoperative complication were oberved in 17.9% (28/156) of newborn, P=0.02, (Table 4). The mot frequent potoperative complication wa wound epi, 53.8% (28/52), followed by wound dehicence, 26.9 (14/52) and burt abdomen 11, 5% (6/52), (Table 5). Overall potoperative complication were common in female, 22.6% (12/53), P=0.27, in neonate with le than 2.5 Kg birth weight, 20.0% (5/25), P= 0.726, in preterm neonate, 21.1% (4/19), P= 0.65, and in neonate aged above one week, 20.9% (14/67), P=0.68. Potoperative complication alo occurred frequently among neonate with aociated maternal co morbiditie, 35.0% (7/20), P=0.36, in thoe from conanguineou couple, 25.7% (9/35), P=0.19, among thoe with aociated anomalie, 20.0% (4/20), P=0.75, in thoe who preented late to hopital, 32.1% (25/78), P=0.76, among urvivor, 18. 5% (23/124), P=0.70 and in thoe with other preoperative medical condition, 18.5% (15/81), P=0.71. Table 6. Ditribution of neonate by urgical condition and outcome Primary diagnoi Outcome Total (%) Survived (%) Died (%) Oeophageal atreia 15(62.5) 9(37.5) 24(15.4) Anorectal malformation 19(90.5) 2(9.5) 21(13.5) Intetinal atreia 13(65.0) 7(35.0) 20(12.8) Hypertrophic pyloric tenoi 16(100.0) 0(0.0) 16(10.2) Peritoniti 11(73.3) 4(26.7) 15(9.6) Hirchprung` Dieae 11(84.6) 2(15.4) 13(8.3) Intetinal malrotation 9(90.0) 1(10.0) 10(6.4) Diaphragmatic hernia 6(66.7) 3(33.3) 9(5.8) Obtructed inguinal hernia 4(100.0) 0(0.0) 4(2.6) Exomphalo minor 4(100.0) 0(0.0) 4(2.6) Intetinal web 3(75.0) 1(25.0) 4(2.6) Gatrochii 2(66.7) 1(33.3) 3(1.9) Meconium ileu 1(50.0) 1(50.0) 2(1.3) Midgut volvulu 2(100.0) 0(0.0) 2(1.3) Ileal duplication cyt 2(100.0) 0(0.0) 2(1.3) Intetinal obtruction econdary to 2(100.0) 0(0.0) 2(1.3) primary adheion Annular pancrea 2(100.0) 0(0.0) 2(1.3) Other 2(66.7) 1(33.3) 3(1.9) Total 124(79.5) 32(20.5) 156(100.0 ) Fiher` exact tet, Value , P= 0.20 The overall mortality wa 20.5% (32/156) with highet mortality een in oeophageal atreia neonate, 37.5% (9/24), in intetinal atreia babie, 35.0% (7/20), and in one meconium ileu cae, P=0.20 Table 6. Mortality wa higher in girl, 26.4% (14/53), P=0.20, among thoe in the firt week of life, 30.3% (27/89), P=0.01, in low birth weight children (< 2.5 Kg), 56.0% (14/25) COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

75 75 75 ISSN Eat Cent. Afr. J. urg and it wa decreaing with increaing birth weight, P=0.00, alo it wa high in preterm children, 31.6% (6/19), P=0.18, among early preenter ( 2 day of ymptom), 25.6% (20/78), P= 0.17, in newborn with aociated anomalie, 35.0% (7/20), P=0.09, and in the group of patient with other preoperative medical condition, 27.5% (22/71), P= Mortality wa lower in neonate delivered from conanguineou marriage, 6.6 %( 2/30) than in the counterpart group, 11.3 % (12/106), P= Mortality wa almot equal among neonate with aociate maternal morbid condition and thoe without, 11.8 %( 2/17) veru 10.9 %( 13/119), P= 0.00.The overall median duration of hopitalization wa 8.0 day (range 1-25 day) with ileoduplication cyt and Meconium ileu condition having prolonged hopitalization, median of 47.5 day and mean of 28.0 (±0.00 SD) day repectively. Dicuion Neonatal urgical emergency condition contribute coniderably to mortality among newborn a they are till in the tranition of phyiologic adjutment needed for extra uterine life 8. In the current tudy boy formed a predominant group comparably to the reult obtained by other author 9 11 poibly becaue Y-chromoome provide le protection againt genetic uceptibility for developing congenital anomalie and alo probably due to male embryo being highly vulnerable to teratogenic agent. The overall median age at preentation in thi urvey wa almot one week a imilarly reported by Sowende et al 12. Lower age at preentation wa oberved in other tudie 2,13,14. However, Oifo et al 15 found the mean age at preentation to be more than a week. Early preentation age may denote good clinical acumen among health peronnel in the initial hopital and early referral or poibly due to the tertiary centre being the only reliable facilitie for tabilizing a newborn, invetigating and providing urgical care in thoe environment o once diagnoed neonate are referred there. Delayed age of preentation for a week or more including in thi tudy may be due to high midiagnoi or due to preence of many other centre that can provide early tabiliation and diagnotic invetigation to a neonate before referral for a pecific urgical care. The majority of newborn had normal birth weight a ame a it wa een in other etting 3,6 illutrating low birth weight not to be directly a rik for developing urgical anomalie. Nonethele Singh et al 16 reported a higher prevalence of congenital anomalie in low birth weight children. The finding of mean birth weight more than 2.5kg correponded to the reult in other report 10,13,14. But Gangopadhyay et al 17 obtained low average birth weight probably reflecting inadequate maternal nutrition tatu and health care in their environment. Neonate born at term accounted for the majority comparably to the finding given by other author 3,11 denoting preterm delivery not to be directly aociated with development of congenital urgical anomalie. On the other hand Singh et al 16 found a high prevalence of congenital anomalie among preterm babie. Term mean getational age wa found in thi urvey likewie the reult of other (10,13). On the contrary, Bhatti et al 14 obtained preterm mean getational age due to having a coniderable proportion (32.6%) of preterm neonate in their urvey and o probably indicating a coniderable preterm birth rate in that area. Majority of neonate were econd parity and more, imilar obervation wa reported in one prevalence tudy 16 whereby a high prevalence of congenital anomalie wa een among newborn of multiparou women ignifying increaed rik for congenital urgical anomalie after firt delivery/pregnant. Yet thi obervation wa tatitically inignificant in thi tudy. Majority of mother were under 30 year of age the ame a it wa reported by Singh et al 16 reflecting thi to be the age period of maximum delivery in thee area and high maternal age not to be a direct rik of developing a urgical anomaly in a newborn. However, High prevalence of congenital anomalie had been reported to be among deliverie at above 30 year of maternal age 16. Conanguinity i a known rik for developing congenital malformation. In thi tudy conanguinity wa 22.4%, lower than 45.8% obtained in one tudy in Egypt 18. Thi COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

76 76 76 ISSN Eat Cent. Afr. J. urg reveal conanguinity generally to have relatively low rik for delivering a child with congenital urgical anomalie. But thi obervation wa not tatitically ignificant in thi tudy. However, the prevalence of congenital anomalie i high among conanguineou marriage 19. They were fewer cae with maternal co-morbiditie in thi tudy when compared to a tudy done by Bhatti et al 14 indicating the difference in maternal wellbeing in different environment. However, thi obervation wa not tatitically ignificant in thi tudy. Half of neonate preented early in thi urvey unlike Ugwu et al 2 who reported a lower proportion of early preenter poibly due to a better clinical acumen among clinician and adequate ue of antenatal ultraound in the diagnoi and early referral of cae in the environment of thi tudy. Midiagnoi and delayed invetigation were the major reaon for delayed preentation, in contrat to the finding in another tudy 15 where ignorance, upertition belief and financial contraint were the predominant reaon. Thi indicate good heath eeking behaviour and acceibility to health care ervice in the etting of the current tudy. Oeophageal atreia wa the mot common condition in thi tudy a ame a it wa found in India 13, Oman 14, and Iran 19. Unlike in other tudie done in Portugal 10 and Saudi Arabia 11 where Diaphragmatic hernia wa the commonet condition and Anorectal malformation wa the mot frequent condition in Kenya 6, Korea 7 and India 17. The variability in the occurrence of condition ignifie the difference in rik factor of congenital urgical anomalie in different ocietie and environment. About one eighth of cae had aociated anomalie and muculokeletal anomalie were the frequently aociated anomalie; however, Homa et al 3 and Cho Y et al 7 in their tudie oberved cardiac anomalie to be the commonet aociated anomalie. In thi tudy a high frequency of aociated anomalie wa noted in among neonate with Oeophageal atreia contrary to the finding in another tudy in Korea 7 whereby aociated anomalie were commonet among anorectal malformation babie. Thi inconitence implie the difference in type of rik of expoure between different location and ocietie. A coniderable proportion of neonate preented with epi in thi urvey the ame a it wa reported in other tudie 2,12,15 indicating the importance preoperative adequate aement and appropriate medication a mot of neonate are liable to have epi due to their exiting acute urgical condition and weak body immunity. There wa a horter interval between admiion and urgical intervention in thi tudy than in other tudie 9,11 may be due to active reucitation, fat invetigation reult availability, and neonate reporting relatively in le evere ill condition due to early preentation and adequate reucitation in the initial health care facilitie in thi area. Potoperative complication occurred in 17.9% of newborn in thi urvey. Other author 7,11 reported very low occurrence of potoperative complication. However, Ugwu et al 2 oberved high pot operative complication rate. Thi diimilarity may be explained by difference in length of time of illne before preentation to hopital, adherence to aeptic technique and in type and adequacy of medication given. Potoperative complication in thi tudy were mainly wound complication which were common among urvivor indicating that wound complication are not directly related to mortality. Wound epi wa the commonet pot operative complication likewie in other tudie 2,7. But very low wound epi rate compared to that in thi tudy wa oberved by Sherif et al 11 and Bhatti et al 14 and the higher rate wa reported by Ugwu et al 2. The difference may be due to difference in type of urgical cae commonly een and their condition at admiion and may be indicating the difference in quality of medication and adherence to aeptic technique in different etting. Low birth weight, preterm delivery, and delayed preentation were aociated with high complication rate a imilarly reported by other 10,12,15 treing thee to be major rik factor for developing potoperative complication a babie in thee condition have immature organ function, low body immunity, and are in evere eptic condition due to late preentation. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

77 77 77 ISSN Eat Cent. Afr. J. urg Potoperative complication were frequently oberved among neonate from conanguineou couple and in thoe with aociated maternal co morbid condition, but thee finding were not tatitically ignificant. Late preentation wa aociated with high pot operative complication rate a imilarly noted by other 12,15 indicating the importance of early diagnoi and referral to tertiary centre a delay exacerbate epi and delay reucitation cauing a neonate to preent in moribund tate. Mortality wa 20.5% in thi analyi, but Abdalla et al 8, Sharif et al 11 and Bhatti et al 14 obtained lower mortality. On contrary Ilori et al 9, Manchanda et al 13 and Gangopadhyay et al 17 reported a higher mortality than in thi tudy. Lack or inadequate facilitie for neonatal urgical care like neonatal ICU, neonatal ventilator, incubator, parenteral nutrition and hortage of killed peronnel contribute to high mortality. Mortality wa high among children aged le than a week due to more eriou condition being in thi group. A high mortality occurred in low birth weight, preterm babie, and neonate with aociated anomalie a equally oberved in the earlier tudie 10,12,13 howing thee to be important contributor of mortality in an acute urgical neonate a mot of thee neonate cannot withtand the tre of urgery, have immature organ ytem and low body immunity. However, high mortality wa oberved in early preenter in thi urvey different from previou tudy finding 8,9,15 probably becaue mot of them were under weight, preterm with multiple aociated anomalie and alo had high rik type of condition like oeophageal atreia and intetinal atreia. But in thi analyi thi finding wa not tatitically ignificant. Mortality wa low among newborn from conanguineou marriage and thi finding wa tatitically ignificant indicating conanguinity to have no rik for death in acute urgical neonate. Aociated maternal morbidity occurred le frequently in thi urvey than in one previou tudy 14 and mortality wa the ame between babie from mother with co morbid condition and thoe without. Thi obervation wa tatitically ignificant. Thi reflect the difference in maternal health tatu between different ocietie and maternal co morbiditie not to be direct rik of mortality in acute urgical neonate. Preence of aociated anomalie wa aociated with high mortality a reported by Cantre et al 10 and Manchanda et al 13. Thee anomalie particularly cardiac anomalie can lead to death unrelated to the actual urgical anomaly under treatment and alo can be precipitated by anaetheia and urgical tre leading to death 13. But in thi urvey thi obervation wa not tatitically ignificant. Other aociated medical condition did not increae the rik of developing potoperative complication, however, contributed ignificantly to mortality the ame a it wa reported by Homa et al 3, Abdalla et al 8, Sharif et al 11, indicating the importance of adequate preoperative evaluation and appropriate medical treatment of neonate. The duration of hopitalization wa horter than in other preceding report probably in thi tudy mot of cae were in relatively le ill condition. Concluion Acute neonatal urgical condition are common in male. The majoritie of newborn with acute urgical emergencie are delivered at term, had normal birth weight and were from maltiparou mother. Oeophageal atreia wa the commonet acute urgical condition and muculokeletal anomalie were the mot common aociated anomalie. A coniderable proportion of neonate had other aociated medical condition. Midiagnoi wa the mot frequent reaon for delay and wound epi wa the mot common potoperative complication. Pot operative complication are common in urgical neonate. Mortality wa alo high mainly in low birth weight babie and in thoe with other preoperative medical condition. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

78 78 78 ISSN Eat Cent. Afr. J. urg Recommendation It i recommended that a pecial attention to be paid to multigravida/ multiparou mother during antenatal obtetric ultraound eion and firt neonatal creening for urgical anomalie for early diagnoi and referral. Adequate aement and management of other aociated medical condition i important for better outcome. Special attention hould be conidered for low birth weight babie, and thoe with other aociated medical condition a they are at a higher rik of mortality. It i important to improve community maternal health to reduce incidence of preterm and low birth weight deliverie a they are rik factor for poor outcome in acute urgical neonate. Acknowledgement Author would like to thank the Alexandria paediatric urgery department for the permiion to conduct thi tudy and appreciate the aitance in data analyi from Dr. Aem Abdelmoaty (Alexandria Univerity-Egypt) and MS. Joyce Prota (Hubert Kairuki Memorial Univerity- Tanzania). Alo we would like to thank the ICU nure for their appreciably upport during thi urvey. Reference Ameh E A. Challenge of Neonatal Surgery in Sub-aharan Africa. African J Paediatr Surg. 2004;1(1): Ugwu RO, Okoro PE. Pattern, outcome and challenge of neonatal urgical cae in a tertiary teaching hopital. 2013;10(3): Homa B, Ahmadipour S H, Mohamadimoghadam J, Mohenzadeh A. The Study of Newborn with Congenital Gatrointetinal Tract Obtruction. JKIMSU. 2014;3(2): Sheikh A. Prognoi of urgical neonate. J neonatal Surg. 2012;1(1): Rowe MI, Rowe SA. The Lat Fifty Year of Neonatal Surgical Management. The American Journal of Surgery. 2000;180(5): Tenge-Kuremu R, Kituyi P W, Tenge CN, Kerubo J. Neonatal Surgical Emergencie at Moi Teaching and Referral Hopital in Eldoret -Kenya. Eat Cent African J Surg. 2007;12(2): Cho Y, Haeyoung K, Sanghyup L, Miran K. Analyi of Neonatal Surgery during a 5-year Period. J Korean Surg Soc. 2009;77(6): Abdalla AR, Karani S H A. Pattern of Neonatal Surgical Preentation and Outcome in Sinnar. 2014;14(4): 16-22) Ilori I U, Ituen A M, Eyo C S. Factor aociated with mortality in neonatal urgical emergencie in a developing tertiary hopital in Nigeria. Open J Paediatr. 2013;3(3): Cantre D, Lope M F, Madriga A, Oliveiro B, Viana J S, Cabrita AS. Early mortality after neonatal urgery : analyi of rik factor in an optimized health care ytem for the urgical newborn. Rev Bra Epidemiol. 2013;16(4): Sharif M, Abood H, Eliddig I E, Atwan F. Pattern and Outcome of Neonatal Surgery: Experience at King Fahad Hopital Al-Baha. Pakitan J Med Heal Sci. 2014;8(2): Sowande O A, Ogundoyin O O, Adejuyigbe O. Pattern and factor affecting management outcome of neonatal emergency urgery in Ile-Ife, Nigeria. Surg Pract. 2007;11(2): Manchanda V, Sarin Y K, Ramji S. Prognotic factor determining mortality in urgical neonate. J neonatal Surg. 2012;1(1):3 9. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

79 79 79 ISSN Eat Cent. Afr. J. urg Bhatti K M, Al-Baluh Z N, Sherif M H, Al-ibai S M, Khan A A, Mohammed M A et al. Factor reponible for the prolonged tay of urgical neonate in inteive care unit. SQU Med J. 2015;15(1): Oifo O D, Ovueni M E. The Prevalence, Pattern, and Caue of Death of Surgical Neonate at Two African Referral Pediatric Surgical Center. Ann Paediatr Surg. 2009;5(3): Singh K, Krihnamurthy K,Camille G, Kandamaran L, Nielen A L, Kumar A. Major Congenital Malformation in Barbado : The Prevalence, the Pattern, and the Reulting Morbidity and Mortality. ISRN Ob Gynaecol. 2014;2014(2014): Gangopadhyay A N, Upadhyay V D, Sharma S P. Neonatal urgery: A ten year audit from a univerity hopital. Indian J Pediatr. 2008;75(10): Shawky R M, Sadik D I. Congenital malformation prevalent among Egyptian children and aociated rik factor. Egypt J Med Hum. 2011;12(1): Al-Ani Z R, Al-Haji S A, Al-Ani, M M, Al-Dulaimy K M, Al-Maraie AK, Al-Ubaidi B K. Incidence, type, geographical ditribution, and rik factor of congenital anomalie in Al-Ramadi Maternity and Children Teaching Hopital, Wetern Iraq. Saudi Med J. 2012;33(9): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

80 80 80 ISSN Eat Cent. Afr. J. urg Comparion of Chlorhexidine Alcohol and Povidone Iodine Skin Preparation Skin Preparation Solution in Orthopaedic and Trauma Surgery at An African Tertiary Hopital H.A. Obamuyide 1, A.B. Omololu 1, O.M. Oluwatoin 2, A.O. Ifeanya 1, A.N.O Faina 3 1Department of Orthopaedic and Trauma, Univerity College Hopital, Ibadan, Nigeria 2Department of Platic, Recontructive and Aethetic Surgery, Univerity College Hopital, Ibadan 3Department of Medical Microbiology and Paraitology, Univerity College Hopital, Ibadan Correpondence to: Dr Henry A. Obamuyide, bayo_obamuyide@yahoo.com Background: The aim of thi tudy wa to compare the efficacy of Povidone-Iodine (PI) and Chlorhexidine-Alcohol (CHG-A) kin preparation olution in orthopaedic and trauma urgery. Method Thi propective randomied tudy decribed the bacterial kin flora and compared the bacterial clearance rate by PI and CHG-A in patient undergoing clean orthopaedic urgery at an African tertiary hopital. Reult: There were 50 patient in each group. A baeline poitive culture rate of 76.8% wa found. Coagulae-negative taphylococcu wa the commonet aerobe (42.9%) while Propionibacterium pecie wa the commonet anaerobe (17.3%). The aerobic poitive culture rate reduced from 60% to 22% after PI preparation and from 49% to 6.2% after CHG-A preparation (p=0.026). The anaerobic culture rate reduced from 54% to 44% after PI preparation and from 53.1% to 43.8% after CHG-A preparation (p=0.435).the mean log pre-preparation and pot-preparation aerobe count were 7.85/cm2 and 7.50/cm2 repectively in the PI group and 7.62/cm2 and 7.65/cm2 repectively in the CHG-A group (p=0.715). The mean log pre-preparation and pot-preparation anaerobe count were 8.06/cm2 and 7.96/cm2 repectively in the PI group and 7.86/cm2 and 7.84/cm2 repectively in the CHG-A group (p=0.335). Concluion: Thi tudy did not demontrate an overall uperiority of chlorhexidine-alcohol over povidone-iodine kin preparation olution or vice vera. Keyword: Chlorhexidine-Alcohol, Povidone-Iodine, Skin Antieptic, Orthopaedic, Trauma Introduction Infection following orthopaedic procedure can be frutrating to the urgeon and devatating to the patient, with both long term and expenive conequence 1-3. In developed countrie, urgical ite infection (SSI) rate in orthopaedic i reducing but o alo i the number of procedure performed with value ranging between 1.6% and 2.1% 3,4.In Nigeria, the reported rate of SSI in orthopaedic ranged between 4.6% and 9.9% 5-7. Several factor may contribute to the rik of developing potoperative SSI. Thee include moking, obeity, diabete, long preoperative tay, corticoteroid ue, HIV infection, alcohol-abue, malnutrition, prolonged operative time and blood lo 7.Bacterial contamination at urgery ha been identified a a contributor to urgical ite infection and the patient kin i a major ource of thee wound contaminant Thu, one major potential rik factor for SSI i the amount of bacterial flora preent at the operative ite at the time of kin inciion. Many trategie have been employed in minimiing thi particular rik, including the ue of perioperative antibiotic, antibiotic impregnated incie drape and preoperative kin preparation 11. Skin preparation with an effective antimicrobial olution prior to urgery i eential to reduce contamination of the urgical wound and ultimately urgical ite infection. Variou kin antieptic have been tudied, epecially chlorhexidine alcohol and povidone iodine, but the concluion have been controverial COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

81 81 81 ISSN Eat Cent. Afr. J. urg The aim of thi tudy were to identify the common bacterial flora on the kin of orthopaedic patient undergoing clean urgery and to evaluate the efficacy of chlorhexidine-alcohol and povidone-iodine in the eradication of bacterial pathogen from the urgical ite following kin preparation. Material and Method Thi propective randomied controlled tudy wa carried out at the orthopaedic and trauma department of an African teaching hopital. The participant were recruited from all patient aged 10 and above cheduled for urgery who had urgical wound categoried a clean between May 2011 and April Ethical review committee approval wa obtained and written informed conent obtained from all patient or their guardian. Patient were excluded if they had wound at the ite or vicinity of the planned urgery, epi near the ite or anywhere. A proforma wa completed by each patient or guardian to identify any confounding variable uch a diabete mellitu, HIV infection or chronic corticoteroid ue. All patient who had implant urgery had perioperative antibiotic and a non-antibiotic impregnated drape wa ued for all. Sample ize requirement were baed on the finding of two propective tudie evaluating the rate of poitive culture from the ankle and foot 13 and the houlder 14. On the bai of the aumption that a 20% difference inpoitive culture rate would be clinically relevant, the calculated number of patient required to achieve 80% power at alpha 0.05 wa 41 per group. Each patient wa randomied to one of two arm in a 1:1 ratio. Arm A wa prepared with 2% Chlorhexidine in 70% alcohol olution (CHG-A) while arm B wa prepared uing 10% Povidone Iodine olution(pi). The agent to be ued for each particular patient wa determined jut immediately before the commencement of kin preparation by opening a ealed randomly aigned envelope. No pecific home or ward cleaning protocol wa followed and patient adhered to their uual bathing routine. The operative area wa then prepared with the identified olution and allowed to dry for 3 minute to reduce fire rik and mopping-up of olution that could continue microbial kill during tranport. Aerobic and anaerobic wab were obtained before kin preparation (pre-preparation pecimen), 3 minute after kin preparation (pot-preparation pecimen) and at the peri-inciional area jut after kin cloure (pot-cloure pecimen). The aerobic ample were collected into Stuart tranport medium and immediately taken to the laboratory where it wa plated into blood, chocolate and McConkey agar. The culture plate were then incubated aerobically at 37 o C and examined every 24hour for two day. The anaerobic culture were inoculated into Roberton cooked-meat media at the theatre and taken immediately to the microbiology laboratory for proceing. All ample for anaerobe were cultured on Anaerobic, Chocolate and MacConkey agar and incubated in Anaerobic ga pack and examined daily for 6 day. The bacterial growth wa identified uing macrocopic and microcopic method, biochemical method and tandard atla. The total number of colonie were enumerated by macrocopic count and the two predominant organim recorded in the order of their denitie and rendered a bacteria/cm 2 in accordance with tandard laboratory identification method 18,19. The primary outcome meaure were the kin microbial load in number of bacteria/cm 2 and the proportion of poitive culture after the ue of each type of urgical kin preparation olution. Any advere reaction were noted a well. Potoperatively the patient were followed up for a minimum of 1 year or till death. Decriptive tatitic were calculated for all variable of interet. Continuou meaure were ummaried with the ue of mean and tandard deviation, wherea categorical data were ummaried with the ue of count and percentage. A two-tailed Student T-tet, Mann-Whitney U tet, Chi quared tet and Fiher exact tet were ued to compare variable a appropriate. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

82 82 82 ISSN Eat Cent. Afr. J. urg Statiticalignificance wa conidered at a level of p Becaue the actual colonial count were highly kewed, logarithm tranformation wa carried out for normalization. Reult A total of 100 patient were recruited.the mean age of the tudy patient wa year (range, year); there were 53 female (53%) and 47 male (47%). In 3 patient the planned procedure wa not carried out in order to give room for emergencie but prepreparation and pot-preparation pecimen were collected in two of thee patient. Mot of the urgery wa in the hip and thigh region (52%), while 16% were in the forearm and hand; 15% were each in the houlder and arm and in the ankle and foot region; 3% and 1% were in the leg and pine repectively. The type of urgery included open reduction and internal fixation or intramedullary nailing in 55 patient (55%), Arthrocopy or Hemiarthroplaty in 17 patient (17%), oft tiue releae or biopie in 11patient (11%), oteotomie/curettage/bone biopie in 11 patient (11%), percutaneou wire/pin fixation in 2 patient and a laminotomy in 1 patient. The mean duration of kin preparation wa 182 econd (range, econd), mean duration of urgery wa 125 minute (range, minute) and mean duration of preoperative admiion wa 4 day (range, 0-35 day). In the PI group 3 patient had diabete mellitu, none wa on corticoteroid while in the CHG-A group 3 patient had diabete mellitu while 2 were on corticoteroid. There wa no ignificant baeline difference between the two group. Skin flora Overall, a poitive bacterial growth wa obtained in 76 patient (76.8%) prior to kin preparation. Thirty-two patient (32.6%) had combined aerobic and anaerobic organim before kin preparation. Pre-preparation, aerobic culture wa poitive in 54 patient (54.5%) while anaerobic organim were grown in 53(53.1%) ubject. Double aerobic iolate were obtained in 6 patient while 2 patient had double anaerobic iolate. There wa no ignificant difference in pre-preparation culture reult for the PI and CHG group (80% veru 73.5%, chiquare analyi, p = 0.48). Fig. 1 A bar graph illutrating the number of poitive bacterial iolate on the kin of the patient before kin preparation. Staph= Staphylococcu COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

83 83 83 ISSN Eat Cent. Afr. J. urg The mot common organim iolated overall were Staphylococcu epidermidi (coagulaenegative Staphylococcu,42 iolate), followed by Propionibacterium pp (17 iolate), Nonhaemolytic treptococcu (11 iolate) and Bacillu pp (11 iolate). Their prevalence and that of the other major organim are a hown in Figure 1.The mot common organim iolated after kin preparation were Propionibacterium pp followed by Staphylococcu epidermidi. Figure 2a. Overall poitive culture rate. Figure 2b. Aerobic culture rate Figure 2c. Anaerobic culture rate. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

84 84 84 ISSN Eat Cent. Afr. J. urg Reduction in poitive culture There wa no ignificant difference in the overall poitive culture rate following kin preparation, dropping from 80% to 54% in the PI group and from 73.5% to 44.9% in the CHG-A group (p=0.365). There wa alo no ignificant difference in the overall pot-cloure culture ratefor the two group (p=0.462, Fig 2A).For aerobe, there wa a ignificant difference between the group in their pot-preparation culture rate,reducing from 60% to22%in the PI group compared to from 49% to 6.2% in CHG-A group(p=0.026). Their pot-cloure poitive culture rate were not ignificantly different (p=0.435, Fig 2B).There wa alo no ignificant difference in the anaerobic pot-preparation culture poitive rate (p=0.946) and pot-cloure culture rate (p=0.883) for the two group (Fig 2C). Figure 3a. Aerobe Log organim count Figure 3b. Anaerobe Log organim count COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

85 85 85 ISSN Eat Cent. Afr. J. urg Reduction in bacterial count There wa no difference in the pre-preparation aerobic count, with the mean log aerobic bacterial count 7.847/cm 2 for the PI group and 7.620/cm 2 for the CHG-A group (p=0.109).the mean log anaerobic pre-preparation count wa 8.06/cm 2 for the PI group and 7.863/cm 2 for the CHG-A group (p=0.58). For the aerobe, the mean pot-preparation count dropped to 7.498/cm 2 for the PI group and increaed to 7.651/cm 2 for the CHG-A group (Fig 3). The mean potpreparation anaerobic count reduced to 7.962/cm 2 for the PI group and to 7.843/cm 2 for the CHG-A group (Fig 3A).There wa no ignificant difference in the pot-preparation aerobic count (p=0.715) and the anaerobic pot-preparation count(p=0.335) for the two group. Compared to the pot-preparation count, there wa an increae in the aerobic pot-cloure count to 7.731/cm 2 for the PI group and to 8.00/cm 2 for the CHG-A group, while there wa a drop in the anaerobic count to 7.941/cm 2 for the PI group and to7.584/cm 2 for the CHG-A group(fig 3B).However, there wa no ignificant difference between PI and CHG-A group in the aerobic pot-cloure count(p=0.520) while there wa a ignificant difference in the anaerobic potcloure count (p=0.025). Secondary outcome There were no recorded advere effect in either group. The overall infection rate wa 3.2%, with two infection in the PI group (one uperficial and one deep inciional; no organim grown) and one infection in the CHG group (organ pace, Staphylococcu aureu and Echerichia coli) a at one year follow up. Dicuion Pot-operative orthopaedic infection are frutrating to treat and ha both financial and long term conequence 1. Though the rate of orthopaedic SSI are dropping in developed countrie, the number of procedure being performed i riing with concomitant increae in the number of patient with urgical ite infection 3,4. The rate of SSI in orthopaedic practice in le developed countrie are till on the high ide though wide variation exit 5-7.There are many factor aociated with potoperative urgical ite infection 4,7. Many trategieare being employed to reduce SSI rate in orthopaedic, including the ue of effective kin preparation olution 11,20. Many tudie have evaluated the efficacy of variou preoperative kin preparation olution but their concluion have been controverial The current tudy found no overall difference in the efficacy of Povidone Iodine and Chlorhexidine Alcohol in clearing the bacterial flora of the area of operation in orthopaedic patient. Both were able to reduce the poitive culture rate for all organim overall with no ignificant difference between the two after kin preparation: a reduction of 26% by PI and 28.6% by CHG-A (p=0.365). Alo, there wa no ignificant difference in the mean potpreparation aerobic count (p=0.715) and anaerobic count (p=0.335).the apparent increae in the mean pot-preparation aerobic count for CHG-A wa due to the fact that only three patient with high initial bacterial count till had culturable aerobe on their kin after preparation in the CHG-A group a compared to 11 patient for PI group. Thi finding correlate with the report of Savage et al 15 in lumbar pine urgery in which they found no difference between the efficacy of Chlora-prep and Dura-prep in eliminating kin microbe; a drop from 84% to 0% for Chlora-prep and from 80% to 6% for Dura-prep (p= 0.24). Alo,two tudie uing infection rate a a comparator found conflicting reult: Darouiche et al 16 found Chloraprep to be better than Betadine in preventing SSI in General urgery cae (9.5% veru 16.1%; p=0.004), while Swenon et al 17 found Dura-prep and Betadine-Iopropyl alcoholto be better than Chlora-prep in General urgery with the lowet infection rate in the Iodine group(3.9% and 6.4% veru 7.1%). COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

86 86 86 ISSN Eat Cent. Afr. J. urg In analying the differential effect of PI and CHG-A on aerobe and anaerobe, an intereting pattern emerge. CHG-A wa found to ignificantly reduce the pot-preparation aerobic culture poitive rate compared to PI (p=0.026). Alo, CHG-A wa able to peritently reduce anaerobic count during the period of urgery with a ignificantly lower pot-cloure anaerobic count (p=0.025). Thi better efficacy of CHG-A in clearing aerobic organim have been documented in everal tudie. Bibbo et al 12 in Foot and Ankle urgery compared CHG crub and iopropyl alcohol (IPA) paint to PI crub and paint and found a culture poitive rate of 79% in the PI group compared to 38% in the CHG-A group. Otrander et al 13 alo in the foot and Ankle found no difference in infection rate in all three group compared but found Chlora-prep to have ignificantly le bacterial colony count after kin preparation than Dura-prep and Technicare. A imilar finding wa reported by Saltzman et al 14 in houlder urgeryin which Chlora-prepwa ignificantly better at reducing the overall bacterial poitive rate a well a the CNS poitive rate compared to PI and Duraprep. The overall poitive culture rate were 31% in the Betadine group, 19% in the Duraprep group and 7% in the Chloraprep group. Similar to the reult of the current tudy, Saltzman et al 14 did not find any difference in the efficacy of the two agent on Propionibacterium acne, an anaerobe. Thi tudy alo found out that in general, the bacterial flora on the kin of general orthopaedic patient i imilarto that publihed for pecialty orthopaedic urgery. The Coagulae negative Staphylococcu (Staphylococcu epidermidi) wa the commonet bacterial found in thi tudy followed by the anaerobe Propionibacterium pp a finding conitent with the tudie of Savage et al 15, Saltzman et al 14 and Otrander et al 13. There are ome limitation to thi tudy. Firt, the current tudy wa not powered to detect difference in urgical ite infection between the two group. Second, the reult might have been different if we had compared an alcoholic preparation of PI againt CHG-Alcohol. Alo, no neutralizing agent were ued after collecting the ample to block further microbial kill during tranport and thi could have influenced the reult. Concluion Depite thee limitation, thi tudy found thatboth PI and CHG-A are effective at reducing bacterial coloniation of the kin of orthopaedic patient after kin preparation. However, CHG- A i better able to eradicate aerobe from the kin of orthopaedic patient and it eemto demontrate a more peritent action on anaerobe even to the pot-cloure period and upre the generally oberved increae in kin organim count that occur during urgery. Acknowledgement The author would like to thank the following for their upport: ProfeorTemitope Alonge, ProfeorSamuel Ogunlade, Dr Ambroe Rukewe, Dr AkinFatiregun, ProfeorAnthony Oni and Dr Yomi Oyenuga. Conflict of interet The author declare that there are no conflict of interet pertaining to thi article. Reference 1. Barne CL. Overview: the health care burden and financial cot of urgical ite infection. Am J Orthop (Belle Mead NJ) 2011;40: Bruce J, Ruell EM, Mollion J, Mollinon J, Krukoki ZK. The meaurement and monitoring of urgical advere event. Health Technol Ae 2001;5: Kapadia BH, Pivec R, Johnon AJ, Ia K, Naziri Q et al. Infection prevention methodologie for lower extremity total joint arthroplaty. Expert Rev Med Device 2013;10: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

87 87 87 ISSN Eat Cent. Afr. J. urg 4. Jain RK, Shukla R, Singh P, Kumar R. Epidemiology and rik factor for urgical ite infection in patient requiring orthopedic urgery. Eur J Orthop Surg Traumatol 2015;25: Enweani UO. Potoperative wound infection in clean orthoapedic cae: incidence and pattern: National Potgraduate Medical College of Nigeria, Madu KA, Enweani UN, Katchy AU, Madu AJ, Aguwa EN. Implant aociated urgical ite infection in orthopaedic: a regional hopital experience. Niger J Med 2011;20: Ikeanyi UO, Chukwuka CN, Chukwuanukwu TO. Rik factor for urgical ite infection following clean orthopaedic operation. Niger J Clin Pract 2013;16: Cronquit AB, Jakob K, Lai L, Della Latta P, Laron E. Relationhip between kin microbial count and urgical ite infection after neurourgery. Clin Infect Di 2001;33: Lawal OO, Adejuyigbe O, Oluwole SF. The predictive value of bacterial contamination at operation in pot-operative wound epi. Afr J Med Med Sci 1990;19: Ako-Nai AK, Adejuyigbe O, Adewumi TO, Lawal OO. Source of intra-operative bacterial colonization of clean urgical wound and ubequent pot-operative wound infection in a Nigerian hopital. Eat Afr Med J 1992;69: Boco JA, 3rd, Slover JD, Haa JP. Perioperative trategie for decreaing infection: a comprehenive evidence-baed approach. J Bone Joint Surg Am 2010;92: Bibbo C, Patel DV, Gehrmann RM, Lin SS. Chlorhexidine provide uperior kin decontamination in foot and ankle urgery: a propective randomized tudy. Clin Orthop Relat Re 2005;438: Otrander RV, Botte MJ, Brage ME. Efficacy of urgical preparation olution in foot and ankle urgery. J Bone Joint Surg Am 2005;87: Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS,Koh JL. Efficacy of urgical preparation olution in houlder urgery. J Bone Joint Surg Am 2009;91: Savage JW, Weatherford BM, Sugrue PA, Nolden MT,Liu JC,Song JK et al. Efficacy of urgical preparation olution in lumbar pine urgery. J Bone Joint Surg Am 2012;94: Darouiche RO, Wall MJ, Jr., Itani KM, Otteron MF, Webb AL, Carrick MM et al. Chlorhexidine-Alcohol veru Povidone-Iodine for Surgical-Site Antiepi. N Engl J Med 2010;362: Swenon BR, Hedrick TL, Metzger R, Bonatti H, Pruet TL, Sawyer RG. Effect of preoperative kin preparation on potoperative wound infection rate: a propective tudy of 3 kin preparation protocol. Infect Control Hop Epidemiol 2009;30: Koneman EW, Allen SD, Janda WM, Shreckenberger PC, Winn WC. Color Atla and Textbook of Dignotic Microbiology. 4th ed. Philadelphia: JB Lippincott, Hopital MMDUC. Standard Operating Procedure: Univerity College Hopital,Ibadan, Fletcher N, Sofiano D, Berke MB, Obremky WT. Prevention of perioperative infection. J Bone Joint Surg Am 2007;89: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

88 88 88 ISSN Eat Cent. Afr. J. urg Evaluation of the Outcome of Femoral Plate )teoynthei in a Teaching Hopital in a Developing Country. O.J. Ogundele 1, A.I. Ifeanya 1, A.A. Fakoya 2, T.O. Alonge 1. 1,Department of orthopaedic and Trauma, Univerity College Hopital, PMB 5116, Ibadan, Oyo tate, Nigeria. 2Department of urgery, Univerity College Hopital, PMB 5116, Ibadan, Oyo tate, Nigeria. Correpondence to: O.J. Ogundele, ogunjoh@yahoo.com or ogunjoh128@gmail.com. Background: Fracture of the femur are a common preentation of traumatic injurie and are uually aociated with other injurie. The need for urgical fixation i undiputed although operative option are varied, and often the choice i baed on fracture pattern, available facilitie and the urgeon' preference. Thi deciion hould be determined by the predicted functional outcome rather than by the type of implant to be ued. The objective of thi tudy wa to evaluate the reult of treatment of femoral haft fracture uing plate oteoynthei in our centre. Method: Thi wa a retropective tudy done by reviewing the medical record of patient preenting with femoral haft fracture between 2005 and Reult: A total of two hundred and four patient underwent plate oteoynthei of femoral haft fracture within the period under conideration. One hundred and eventy (83.3%) patient achieved clinical and radiological union after an average of 5month. There were 12 (5.9%) non-union, 10 (4.9%) infected implant and 4 (2%) broken implant. Concluion: Plate oteoynthei i vital in the management of femoral fracture epecially in developing countrie where the cot of care i entirely borne by the patient and relation. Careful patient election and meticulou pot-operative follow-up care are eential for a favourable outcome. Introduction The femur i the tronget, longet and heaviet bone in the body and i eential for ambulation. It i compoed of 3 part - the haft or diaphyi, proximal and dital metaphye. Several large mucle attach to the femur. Proximally, the gluteu mediu and minimu attach to the greater trochanter, reulting in abduction of the femur when there i a fracture. The iliopoa attache to the leer trochanter, reulting in internal rotation and external rotation following fracture. The linea apera (the rough line on the poterior urface of the femoral haft) reinforce the trength and erve a an attachment for the gluteu maximu, adductor magnu, adductor brevi, vatu mucle, and the hort head of the bicep femori. Ditally, the large adductor mucle ma attache medially, reulting in an apex- lateral deformity after femoral fracture. The medial and lateral head of the gatrocnemiu attach to the poterior femoral condyle, reulting in flexion deformity in dital-third fracture. 1 The blood upply enter the femur through metaphyeal arterie and branche of the profunda femori artery, penetrating the diaphyi and forming medullary arterie extending proximally and ditally. Healing of femoral fracture i enhanced by the urrounding oft tiue and local recruitment of blood upply around the fracture ite. 1, 2 The cope of femoral fracture i wide and generally high energy force are involved with multiytem trauma in majority of the cae. There i uually aociated ignificant oft tiue injury and evere communition. 3 Caue of femoral fracture include motor vehicular trauma uch a COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

89 89 89 ISSN Eat Cent. Afr. J. urg auto crahe, motorcycle crahe, pedetrian traffic injurie, run-off the road traffic injurie, gunhot and fall etc. Iolated femoral fracture alo occur in patient with metabolic bone dieae, primary and econdary bone tumour and repetitive tre. Injury mechanim and age ditribution i alo known to follow a bimodal ditribution. 4 High energy injurie caue fracture in young adult, uually road traffic crahe and gunhot. Low energy injurie are known to occur commonly in the elderly and are due to fall and uually have a local or general factor weakening the mechanical trength of the bone. 5 The femur i very vacular and fracture can reult in ignificant blood lo into the thigh. Up to 40% of iolated fracture may require tranfuion a up to 3 unit of blood may be lot. Thi i ignificant epecially in the elderly who have a reduced cardiovacular reerve. The rik of vacular injury i alo high and thi further increae the requirement for blood tranfuion. 6 About 420 open reduction and internal fixation are done annually at our centre, a 1000-bed teaching hopital in Nigeria. Patient and Method Thi i a retropective tudy to evaluate the reult and effectivene of plate oteoynthei of femoral fracture in our centre. Two hundred and four patient who had open reduction and internal fixation for femoral fracture in our hopital between 2005 and 2012 were recruited into thi tudy. Our operating theatre diarie were reviewed and all the cae of plate oteoynthei of the femoral haft carried out during the period under conideration were extracted. The cae record were then pulled out from the record department. Information about age, gender, fracture claification, ite of the fracture, energy tranfer, aociated injury, caue of fracture, time pent in hopital before urgery, outcome of treatment, complication and the number of unit of blood tranfued were extracted from their medical record. The data obtained wa tranferred to a computer preadheet and analyzed uing the Statitical Package for the Social Science (SPSS Inc.) verion Categorical data were compared uing the Chi quared tet, a p value of 0.05 wa regarded a ignificant. Continuou variable were expreed a mean ± SD (tandard deviation). Reult A total of two hundred and four patient who underwent plate oteoynthei of femoral haft fracture within the period under conideration were recruited into the tudy. There were one hundred and eventeen (57.4%) male and eighty-even (42.6%) female in a ratio of 1.4:1. The age of the patient ranged from 7 to eighty-five year (mean age = 34.1 ± 13.8 year). The age ditribution of the patient i hown in figure 1. One hundred and eighty-one (88.7%) patient had cloed fracture while twenty-three (11.3%) had open fracture. Detail are preented in figure 2. One hundred and ninety (93.1%) patient were involved in high energy injurie. Motor-vehicular crahe were reponible for one hundred and twenty-two (59.8%) cae and motorcycle crahe for ixty-one (29.9%). Other include gunhot (3.4%) and fall (6.9%). Thi i hown in figure 3. The mean number of day pent in the hopital before urgery wa approximately 4.0 ± 5.9 day. One hundred (40%) patient had blood tranfuion. Eight (3.9%) patient had three unit of blood while eighteen (8.8%) had two. Seventy-four (36.3%) patient had one unit of blood each. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

90 90 90 ISSN Eat Cent. Afr. J. urg The blood tranfuion were preoperative, intraoperative or pot operative depending on their haemoglobin concentration and packed cell volume. One hundred and twenty-eight (62.8%) patient had aociated injurie which include head injurie, facial fracture, foot gangrene, pelvic fracture, cervical and thoracic pine injurie, chet injury, humeral and tibia fracture and blunt abdominal injurie. Seventy-ix (37.3%) patient did not have aociated injurie. Detail are preented in Figure 4. One hundred and eighty-one (88.7%) of the fracture occurred at the mid-haft, 13 (6.4%) at the dital third, 7 (3.4%) at the proximal third while 3 (1.5%) were egmental. One hundred and fifty nine (78%) patient had open reduction and internal fixation (ORIF) with broad dynamic compreion plate (BDCP), 19 (9.3%) patient had angled blade plating while 7 (3.4%) had ORIF with narrow dynamic compreion plate (NDCP). Ten (4.9%) had internal fixation with condylar blade plate while 8 (3.9%) had condylar buttre plating. One patient (2.5%) had Jewett nail plating. Figure 1. Age ditribution of patient who had plate oteoynthei for femoral haft fracture Figure 2. Claification of femoral haft fracture operatively treated by plate oteoynthei according to the everity of the open injury COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

91 91 91 ISSN Eat Cent. Afr. J. urg Figure 3. Caue of injury in patient who had plate oteoynthei for femoral fracture Figure 4. Aociated injurie in patient who had plate oteoynthei for femoral haft fracture COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

92 92 92 ISSN Eat Cent. Afr. J. urg Table 1. Outcome of treatment of patient who had plate oteoynthei for femoral haft fracture Outcome of treatment Number of patient Clinical and radiological union 170 (83.3%) Non union 12 (5.9%) Infected implant 10 (4.9%) Broken implant 4 (2.0%) Dicharge againt medical advice 1 (0.5%) Referral to another hopital 1 (0.5%) Lot to follow-up before union 2 (1.0%) Joint tiffne 4(2.0%) Total 204(100.0%) One hundred and eventy (83.3%) patient had clinical and radiological union of their fracture while 12 (5.9%) had non-union. Ten (4.9%) had infected implant and 4 (2.0%) broken implant. The outcome of treatment could not be acertained in 4 patient. Two of thee patient were lot to follow-up, one wa referred to another hopital for proximity to relation while another dicharged againt medical advice. Detail are preented in table 1. Treatment modalitie for the aociated injurie include external fixation of open fracture, craniotomy, dynamic compreion plating with or without bone grafting for tibio-fibula fracture, exploratory laparotomy, below knee amputation for cruh injurie of the foot, cloed thoracotomy tube drainage and uturing of laceration. Dicuion The cope of femoral fracture i wide and generally high energy force are involved with multiytem trauma in majority of the cae. 3, 7 Femoral fracture followed a bi-modal age ditribution in thi tudy with peak age at 20-29year and above 60year which i imilar to the report by Taylor etal. 4, 8 The diagnoi of femoral haft fracture i made traight-forward by the preence of uch clinical ign a axial deviation, hortening, abnormal function and pain. An aement of oft-tiue damage i an integral part of every clinical examination. Open fracture are le common becaue of the dene oft-tiue cover around the femur. Only 11% were open fracture in thi tudy. Laceration of the mucle layer, however, can be preent and ubcutaneou de-gloving injurie hould not be overlooked depite an intact integument. Aement of neuro-vacular function i alo mandatory. 9 A number of tudie have upported early aggreive urgical management of the patient with multiple injurie and long bone fracture. A trong relationhip exit between early fixation of femoral fracture and reduction in the number of day in the intenive care unit, the number of day in hopital, and the incidence of adult repiratory ditre yndrome, pneumonia, infection and death. 10 In thi tudy, mot cae (62.8%) were operated within 2day of preentation in the hopital. Thoe who had longer pre-operative tay were delayed either becaue of lack of theatre lot or aociated life threatening injurie which had to be taken care of before plate oteoynthei. Studie in the 1960 and 1970 by Charnley, Guindy and Wilber, uggeted that fracture operated on early (within 0-6 day after fracture) when compared to thoe operated COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

93 93 93 ISSN Eat Cent. Afr. J. urg on late (after more than 6 day) had a higher incidence of non-union, delayed union and refracture. Modern day tudie have refuted thee claim and how no benefit from delaying urgery. 11 Standard x-ray examination conit of view in two plane. Adjacent joint mut be included o that ipilateral fracture of the femoral neck or tibia plateau are not mied. A femur fracture in a young individual i alway the conequence of a coniderable trauma and may involve other injurie. More extenive examination are required in the polytrauma patient or if concomitant injurie to the pelvi, pine or knee joint are upected, ince uch additional injurie will affect treatment. 9, 12 Known aociated injurie with femoral fracture are vacular injurie, nerve injurie, ipilateral femoral neck fracture, knee injurie and tibia fracture. 12 Head injury wa the commonet aociated injury in thi tudy occurring in 27(13.2%) patient. Thi i cloely followed by tibio-fibula fracture 25 (12.3%) and maxillofacial injurie which occurred in 16(7.8%) patient. Other include cervical and thoracic pine injurie with paraplegia, chet injurie, 2(1%) foot injurie with reultant gangrene etc. The current favoured treatment of femoral haft fracture i with tatically locked reamed intramedullary nailing. 13 Alternative include traction with or without cat bracing, plate oteoynthei and external fixation. The principle of anatomical reduction and table fixation of femoral haft fracture followed by early limb rehabilitation have gained widepread acceptance. Diatifaction with the reult of non-operative treatment of femoral haft fracture, becaue of prolonged hopitalization, high cot, fracture hortening, malunion, delayed union and joint tiffne ha led to the development of variou operative technique for the management of femoral haft fracture. Plate oteoynthei i an important technique which i advantageou in ituation where intramedullary nailing i not ideal and in reource poor etting like our where it i relatively cheaper and facilitie for intramedullary nailing are either not readily available or the functionality cannot be guaranteed a a reult of technical fault or inceant power outage. All implant are out- of- pocket expene by the patient and/ or the relation. Other reaon why plating may be favoured over intramedullary nailing include adult and paediatric polytrauma with concommitant head trauma or pulmonary compromie, ipilateral femoral neck and haft fracture, Open fracture with a vacular injury where exploration i mandatory, fracture location in the proximal or dital femoral haft and exceively narrow intramedullary canal. 14 The principle of accurate reduction and table internal fixation of femoral fracture with plate hould be followed. The commonly ued implant for plate oteoynthei in our center include broad dynamic compreion plate(bdcp), narrow dynamic compreion plate(ndcp), Jewett nail plate, angled blade plate, condylar blade and buttre plate. Thi tudy how the dwindling popularity of Jewett nail plate in our centre a in mot part of the world. Depite the improvement in anatomical reduction, earlier mobilization, decreaed pulmonary morbidity and earlier dicharge from hopital, plating i aociated with it an array of complication which range from non-union, infected and broken implant and joint tiffne. 15 The problem of knee movement ha not been completely addreed. Thi i a bit kewed in that plating i more likely to be ued in the dital third fracture where knee movement i more likely to be affected. 15,16 Malunion, infection, mechanical failure of fixation, delayed union, nonunion, re-fracture and re-operation are all poible complication following plate fixation of femoral fracture. Accurate open reduction and plate fixation require coniderable experience COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

94 94 94 ISSN Eat Cent. Afr. J. urg and operative expertie to enure atifactory reult. Recent evolution in plating technique ha lead to the concept of careful tiue diection, epiperioteal expoure of bone, and indirect reduction of fracture to minimize tripping and devacularization of bone fragment. Reduced oft tiue diection alo lead to le quadricep tethering and improved knee range of motion. Reduction of the fracture to achieve anatomic alignment of intra-articular fracture and optimal rather than maximal tability i the goal. 14,16 Routine bone grafting of the medial cortical defect a advocated in the 1980 by Loomer etal 16 i no longer advocated, however in ituation where there i extenive fracture communition with devacularization of fragment primary bone grafting i trongly advied. 14,17 Longer plate relative to the fracture length are thought to be particularly important, increaing the lever arm of the plate. Optimal ue of crew through the plate a oppoed to maximal ue of crew the length of the plate ha alo been uggeted. 14, 17 Loomer 16,17 alo reported on 45 patient who had plate oteoynthei who had their fracture healed at 7month, returned to work at 12month and reumed porting activitie at 15month. In thi tudy the average interval before patient returned to work wa 18month. The diparity in time taken to return to work i due to the fact that ome of the patient have evere aociated injurie which kept them in bed longer and ome elderly patient who took longer to commence ambulation. Concluion Plate oteoynthei i till a vital tool in the management of femoral fracture epecially in developing countrie where the cot of care i entirely borne by the patient and the relation. Our reult are comparable to thoe obtained from other centre around the world. Careful election of cae a well a meticulou pot-operative follow-up care are eential for a favourable outcome in the treatment of femoral haft fracture with plate oteoynthei. Reference 1. Selvadurai N. Femoral haft fracture. In: Gavin J, Franceca N, editor. Apley ytem of Orthopaedic and Fracture. London: Hodder Arnold, p Bucholz R, Brumback R. Fracture of the haft of the femur. In: Rockwood C, Green D, Bucholz R etal, editor. Rockwood and Green Fracture in Adult. Philadelphia: Lippincott-Raven, 1996.p Oetern H, Tcherne H. Pathophyiology and claification of oft tiue injurie aociated with fracture. In: Tcherne H, and Gotzen L, editor. Fracture with oft tiue injurie. Berlin: Springer Verlag, p Hedlund R, Lindgren U. Epidemiology of diaphyeal femoral fracture. Acta Scand orthop 1986 Oct; 57(5): Clement N, Aitken S, Duckworth A, McQueen M, Court-Brown C. Multiple fracture in the elderly. J Bone and Joint urgerybr Feb; 94(2): DiChritina D, Riemer B, Butterfield S etal. Femur fracture with femoral or poppliteal artery injurie in blunt trauma. J orthop trauma. 1994; 8: Whittle AP, Wood GW II. Fracture of the lower extremity. In: Campbell' Operative Orthopedic, 10th, Canale ST. (Ed), Moby, St. Loui p Taylor M, Banerjee B, Alpar E. The epidemiology of fractured femur and the effect of thee factor on outcome. Injury. 1994b; 25: COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

95 95 95 ISSN Eat Cent. Afr. J. urg 9. Dankward H. Femur: Shaft (including ubtrochanteric). In: Thoma R, William M, AO principle of fracture management. Chri L, Alberto F etal. Editor. Thieme Verlag p Charah WE, Fabian TC, Croce MA. Delayed urgical fixation of femur fracture i a rik factor for pulmonary failure independent of thoracic trauma. J Trauma. 1994; 37: Bone L, Johnon K, Weigelt J, Scheinberg R. Early veru delayed tabilization of femoral fracture. A propective randomized tudy. J Bone and Joint urg. 1989; 71A: Taylor M, Banerjee B, Alpar E. Injurie aociated with a fractured haft of the femur. Injury. 1994; 25: Brumback R, Reilly J, Poka A, Lakato R, Bathon G, and Burge A. Intramedullary nailing of femoral haft fracture. Part I: Deciion-making error with interlocking fixation. J Bone and Joint Surg. 1988; 70A: Rozbruch S, Muller U, Gautier E, Ganz R. The evolution of femoral haft plating technique. Clin Orthop Relat Re. 1998; 354: Geiler W, Powell T, Blickentaff K, Savoie F. Compreion plating of acute femoral haft fracture. Orthopedic 1995;18: Loomer RL, Meek R, DeSommer F. Plating of femoral haft fracture: the Vancouver experience. J Trauma. 1980; 20: Rüedi T, Lücher J. Reult after internal fixation of comminuted fracture of the femoral haft with DC plate. Clin Orthop Relat Re. 1979; 138:74-6. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

96 96 96 ISSN Eat Cent. Afr. J. urg Intranaal Endocopic Repair of Bilateral Choanal Atreia in a Male Newborn with Crouzon Syndrome A.D. Dunmade 1, I.O. Ajayi 1, B.S. Alabi 1, O.A. Mokuolu 2, B.O. Bolaji 3, O.I. Oyinloye 4 1Department of Otorhinolaryngology, Univerity of Ilorin Teaching Hopital, Ilorin, Nigeria. 2 Department of Paediatric, College of Health Science, Univerity of Ilorin, 3 Department of Anaetheia, College of Health Science, Univerity of Ilorin, Ilorin, Nigeria. 4 Department of Radiology, College of Health Science, Univerity of Ilorin, Ilorin, Nigeria. Correponding to: Ajayi IO, drlanreajayi@gmail.com Bilateral choanal atreia i a rare developmental problem in which there i narrowing of the poterior naal aperture. Commoner in female newborn, it i uually aociated with repiratory ditre and cyanoi. We preent a 30hr old male child with repiratory ditre and intermittent cyanoi at birth. On examination patency wa not demontrable in both naal cavitie on inertion of naal catheter. Low-doe CT can demontrated bilateral choanal atreia. Patient had intranaal endocopic repair of atreia and naal tenting. Child wa dicharged after 4week and wa followed up for 5month. Introduction Congenital bilateral choanal atreia, a rare neonatal emergency, i a developmental abnormality in which there i narrowing of poterior naal aperture occurring in 1 in 7000 to birth 1,2. Commoner in female newborn than their male counterpart, it i frequently unilateral and more often affect right ide than left ide 3. It can be bony or membranou or mixed. Frequently aociated anomaly i CHARGE Syndrome (Coloboma, Heart dieae, choanal Atreia, mental and growth Retardation, Genital hypoplaia, Ear deformitie). Other aociated anomalie include Treacher Collin Syndrome, Down yndrome and Crouzon yndrome among other 4. Patient often preent with repiratory ditre, cyanoi and difficulty with feeding. If emergency meaure i not taken urgently, it may reult in death 5. We preent a male neonate with bilateral choanal atreia, who had trannaal repair uing an endocope, powered microdebider and naal tenting within 72hr of life. Cae preentation Thi wa a 2.6 kg full term male neonate with Apgar core of 7/1 and 9/5 wa delivered by emergency caearean ection on account of eclampia in hi primiparou mother. He preented with repiratory difficulty and occaional cyanoi that improved with cry immediately after delivery. Attempt at uctioning mucou ecretion from the naal cavitie met with reitance that neceitated tranferring child to Neonatal Intenive Care Unit (NICU) with SPO2 of 84%. On examination, the child wa in repiratory ditre evidenced by tachypnoea (55 breath/min), intercotal and ternal receion, and occaional cyanoi. He had COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

97 97 97 ISSN Eat Cent. Afr. J. urg microcephaly, hypertelorim, bilateral proptoi, low et microgloia and flat face. Body temperature wa 36.7 o Celiu. ear, micrognathia, Figure 1. Photograph of the baby howing orogatric tube in-itu to keep the oropharynx patent for airway Figure 2. CT can demontrating bilateral choanal atreia (hort arrowed) and left mixed type (long arrowed) COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

98 98 98 ISSN Eat Cent. Afr. J. urg Figure 3. Naoendocopic view of right and left poterior choanae atreia Figure 4. Photograph howing naal tent in-itu after repair Naal examination revealed flat naal bridge. No patency wa demontrable bilaterally. Uing naal catheter FR 6, patency tet revealed obtruction to paage at 2cm on the right and at 2.7cm on the left from the nare, thereby making upicion of bilateral choanal atreia (BCA) very high. Naal endocopic examination wa however deferred till the baby wa relaxed under general anaetheia. The heart ound were normal with no murmur and the heart rate wa 120/min. Other ytemic examination revealed hypoplatic peni but eentially normal abdominal finding. Immediate meaure taken at preentation wa inerting an oro-gatric tube to keep the child breathing through the mouth and for feeding (Figure 1). Supplemental oxygen via facemak, prophylactic antibiotic and intravenou fluid were alo given. At 48 hour into admiion the child had confirmatory low-doe radiation CT can of the noe and paranaal inue uing a low doe technique of 50ma, the child abdomen, genital and COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

99 99 99 ISSN Eat Cent. Afr. J. urg limb were alo wrapped in protective lead apron. The CT demontrated thickening of the bony vomer cauing complete obtruction of the right naal cavity and bony narrowing of the left naal cavity with membranou central portion (Figure 2). Echocardiography revealed normal tudy. Other ancillary invetigation were eentially normal. At 68 hour of admiion, patient wa cheduled for intranaal endocopic urgical correction of the bilateral choanal atreia under endotracheal general anaetheia. Intra-operative endocopic finding uing Hopkin rod (0 and 30 degree, 2.7mm by Karl Storz, GmbH, Germany) included complete bony right choanal atreia and mixed (bony and membranou) left choanal atreia (Figure 3). Uing powered microdebrider, a gentle trannaal puncture of the atretic plate wa performed. In addition to uing the angulated debrider tip, at each tep of puncturing the atretic plate, care wa taken to maintain urgical principle by keeping the ue of angled microdebrider tip to the naal floor plane in order not to accidentally enter the phenoid. The naopharynx wa contantly viualized with 30 degree telecope to enure afe puncture of the atretic plate at each tep. After puncturing the plate with debrider tip, Waton-William rap ize 2 wa then ued to widen and moothen the raw edge of the poterior choanae. A 3.0mm cut-to-ize endotracheal tube wa thereafter inerted bilaterally to tent the repaired choanae. The anterior end of the tent were utured to a tube brace and columela uing vicryl ize 3/0 uture (Figure 4). The patient wa continued on antibiotic and oro-gatric tube for feeding throughout the time the tent wa in itu. The intranaal tent wa removed after 4 week. The patient wa ubequently dicharged thereafter in table clinical condition without naal obtruction or mouth-breathing. No complication wa recorded in our patient. There wa no ymptomatic or clinical evidence of retenoi throughout the period child wa followed up at our out-patient clinic. Plan wa made to repeat naendocopy at 6 month pot-operative. He wa however lot to follow up after 5 month due to undicloed reaon from the parent when contacted on phone depite giving their informed conent to thi report. Differential diagnoi Congenital naal piriform aperture tenoi (CNPAS) may mimic BCA 6. But a the name implie, CNPAS i a problem with tenoi and not atreia. Ditinction i made on CT can finding. Other differential include congenital bilateral dacrocytocoele, deviated naal eptum, encephalocele, and naal dermoid 7. Dicuion Bilateral choanal atreia i a rare developmental problem in which there i failure of complete canalization of the naal cavitie due to peritent buconaal (or naobuccal) membrane of Hochtetter 8. During the fourth week of intra-uterine life, the naal placode deepen to lie between the medial and lateral naal procee. The medial procee alo fue to form the frontonaal proce which compreed to form the naal eptum a the lateral naal procee approach each other. The naal eptum then grow poteriorly to divide the two naal cavitie. Each naal cavity i cloed poteriorly COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

100 ISSN Eat Cent. Afr. J. urg by bucconaal membrane (a thinned out poterior wall of the naal ac). Thi i expected to break down ixth week in utero. It peritence i thought to be the caue of choanal atreia. Bilateral choanal atreia contitute 40-45% of congenital choanal atreia which i commoner in female with male to female ratio ranging from 1:2 to 1:5 9. Clinical ymptom are preent at birth and could be a caue undiagnoed neonatal death. Thoe with delayed diagnoi later in life have been reported in literature 10,11. BCA i claified into bony (90%), membranou (6%) or mixed (4%) type 4. Our patient wa a male with bilateral mixed type. Choanal atreia i often aociated with other anomalie like CHARGE, but our patient preented with upected Crouzon yndrome evidenced by cranioyntoi and hypoplatic face. No cardiac anomalie or muculoketal leion were however een in our patient. Choanal atreia preentation (epecially when bilateral) often include difficulty with breathing, cyclical cyanoi and difficulty with feeding which were the cardinal ymptom in thi reported cae 12. Becaue neonate are obligate naal breather, they tend to develop repiratory ditre that may reult in even death. High index of upicion i needed to make prompt diagnoi. In thi reported cae, diagnoi wa made within 30 minute of birth. An attempt to uction the patient noe at birth which met with reitance made the attending reident doctor to upect choanal atreia. If child had been delivered outide the hopital etting, higher chance are there to loe thi patient to neonatal death due to mied diagnoi. Miting of metallic patula and cotton wool wick can alo be ued to demontrate naal patency at birth. Computed tomographic can would differentiate the bony from the membranou type, etimate the thickne and identify other bony anomalie like congenital ethmoidal otoema 12. Our reported cae had low-doe radiation CT can to minimize expoure to ionizing irradiation. Low doe (50 ma) can of the paranaal inue in thin axial cut uing the multilice technique with recontruction in agittal plane demontrated the choanal atreia in thi reported cae. The low-doe technique doe not affect the meaurement accuracy of choanal atreia 13. Variou urgical technique have been ued to correct choanal atreia. Thee include the tran-palatal approach, the tran-eptal approach, the endocopic trannaal approach, advanced drill technology and ue of LASER. From review of literature, intranaal approach ha been adjudged the route of choice 9. We explored endocopic intranaal approach for the patient imilar to advanced drill technology reported by Vickery and Gro uing powered microdebrider 14. Direct viualization of the atretic plate add value to urgical technique and ultimately it outcome thereby minimizing complication and le bleeding. Variou factor have been identified a indice to ucceful repair and low retenoi incidence 9. The combination of drilling with curettage, ue of a rigid intead of a oft tent, and ue of antibiotic throughout the period tent wa in itu added to the ucce recorded in our reported cae. Concluion Bilateral congenital atreia in a male with crouzon yndrome i uncommon. A high index of upicion i needed to diagnoe thi neonatal emergency early in order to prevent death. Endocopic intranaal puncture of atretic plate with powered microdebrider and tenting within 72 hour of life offer a good urgical outcome with le complication. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

101 ISSN Eat Cent. Afr. J. urg Reference 1. Gujrathi CS, Daniel SJ, Jame AL, et al. Management of bilateral choanal atreia in the neonate: an intitutional review. Int J Pediatr Otorhinolaryngol 2004; 68(4): Theogaraj SD, Hoehn JG, Hagan KF. Practical management of congenital choanal atreia. Plat Recontr Surg 1983; 72: Samadi DS, Shah UK, Handler SD. Choanal atreia: a twenty-year review of medical comorbiditie and urgical outcome. Laryngocope 2003;113(2): Bergtrom L, Owen O. Poterior choanal atreia: a yndromal diorder. Laryngocope 1984; 94: Saleem AF, Ariff S, Alam N, et al. Congenital bilateral choanal atreia. J Pak Med Aoc 2010; 60(10): Saleem AF, Ariff S, Alam N, et al. Congenital bilateral choanal atreia. J Pak Med Aoc 2010; 60(10): John EN, Mbam TT, Nimkur LT, et al. Synchronou congenital naal piriform aperture tenoi and atreia: a rare accompaniment of mid-facial dytoi and caue of neonatal upper airway obtruction: a cae report. Jo Journal of Medicine 2012; 6(3): Brachlow A, Schwartz RH, Bahadori. Intranaal mucocele of the naolacrimal duct: an important caue of neonatal naal obtruction. Clinical Pediatric. 2004, 43: Moey PA, Little J, Munger RG, et al. Cleft lip and palate. Lancet 2009;374(9703): Singh B. Bilateral choanal atreia: key to ucce with the trannaal approach. J Laryngol Otol Jun;104(6): Imail A, Abdulkadir AY. Bilateral Choanal atreia in a 7-year-old boy: A Cae Study. Niger Potgrad Med J Dec; 20(4): Tatar EÇ, Ozdek A, Akcan F, Korkmaz H. Bilateral congenital choanal atreia encountered in late adulthood. J Laryngol Otol Sep; 126(9): Xue-zhong Li, Xiao-lan Cai, Lei Zhang, et al. Bilateral congenital choanal atreia and oteoma of ethmoid inu with upernumerary notril: a cae report and review of the literature. J Med Cae Report 2011; 5: Al-Noury K., Lotfy A. Role of Multilice Computed Tomography and Local Contrat in the Diagnoi and Characterization of Choanal Atreia. Int J Pediatr 2011; 2011: Vickery CL, Gro CW. Advanced drill technology in treatment of congenital choanal atreia. Otolaryngol Clin North Am. Jun 1997;30(3): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

102 ISSN Eat Cent. Afr. J. urg End Stage Achalaia Cardia Maked by Chet Trauma: A Cae of Diagnotic Mimicry J.I. Ahmad 1, M.M.Tettey 2 1Conultant Cardiothoracic Surgeon, Diviion of Cardiothoracic Surgery, Department of Surgery, Aminu Kano Teaching Hopital, PMB 3452, Kano, Nigeria 2Conultant Cardiothoracic Surgeon, National Cardiothoracic Centre, Korle-Bu Teaching Hopital, Accra, Ghana, Correpondence to: Dr. Jameel Imail Ahmad, iajameel@yahoo.com Background: Achalaia i the commonet primary eophageal motility diorder. Long tanding achalaia reache the end-tage form when the oeophagu become dilated and tortuou and often amenable only to eophagectomy. At thi tage the diagnoi may not be traight forward. Our objective i to emphaie the need for detailed evaluation of chet trauma patient who may have coincidental background chet dieae uch a end-tage Achalaia. Cae Report: We report a 52 year old lady with end-tage achalaia who preented elewhere with blunt chet trauma and the radiographic feature were midiagnoed a the equelae of the chet trauma or a chet tumour and then referred to u. Thorough evaluation led to the diagnoi of the end-tage Achalaia and he uccefully underwent tranhiatal eophagectomy. Concluion: There i need for detailed evaluation of chet trauma patient and high index of upicion for concomitant condition hould be demontrated to prevent complication and improve the patient outcome. Key word: End-tage Achalaia, Midiagnoi, Chet trauma Thi cae report wa preented at the 55 th conference of the Wet African College of Surgeon in Abidjan, Cote D ivoire on 3 rd March 2015 Introduction Achalaia cardia i a primary oeophageal motility diorder characterized by failure of relaxation of the lower oeophageal phincter (LES) during wallowing and aperitali of the oeophageal body. Achalaia ha an incidence of 1 in 100,000 individual and a prevalence of 10 in 100,000 with equal gender and racial preponderance 1. The peak incidence i in year age group 2. The aetiology i unknown but autoimmune, viral and neurodegenerative procee are thought to be reponible. Achalaia when left untreated can progre to an end-tage form and lead to complication which can make the diagnoi difficult. Concomitant other condition may alo mak the diagnoi. Thi can lead to inappropriate treatment and further complication. The gold tandard invetigation for the diagnoi of Achalaia i oeophageal manometry although it i rarely available in our etting. When the diagnoi i made early, modified Heller eophagocardiomyotomy i the treatment of choice and ha good outcome. Tranhiatal oeophagectomy with cervical oeophagogatrotomy i the treatment of choice when the oeophagu become markedly dilated and tortuou auming a igmoid hape. Cae Report We report a 57 year old woman referred to our centre with 2 month hitory of breathlene, eay fatigability and right ided chet pain. She wa involved in a road traffic accident 9 month earlier when he utained right clavicular fracture which wa managed conervatively. Chet COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

103 ISSN Eat Cent. Afr. J. urg radiograph howed opacity occupying mot of the right lung zone which perited on the follow up chet X-ray (Figure 1). She wa referred to u with differential diagnoe of right lung collape, fibrothorax from clotted Haemothorax and right lung tumour. Further review revealed a prolonged hitory of intermittent dyphagia for liquid and olid for the pat 20 year. She had an epiode of haematemei and paage of malaena 5 month prior to preentation. No odynophagia or ignificant weight lo. She i a known hypertenive on medication and had hyterectomy 10 year earlier. On examination, he wa not pale, afebrile and haemodynamically table. Repiratory rate wa 18cpm and there wa decreaed right chet movement with dullne and decreaed air entry over the right middle and lower chet zone. A Chet CT Scan requeted before obtaining the hitory of dyphagia uggeted a maive dilatation of the oeophagu. The anteropoterior diameter of the eophagu at the upper, middle and lower chet zone are 6.8cm, 7.4cm and 10.07cm repectively with an average diameter of 8.09cm(Figure 2). Barium wallow wa done which howed feature of achalaia cardia with groly dilated and tortuou oeophagu (igmoid oeophagu) and an upper gatrointetinal endocopy howed a dilated and roomy oeophagu, tenoed gatroeophageal junction and mall uperficial gatric ulcer. Other baeline haematological invetigation were normal The patient wa couneled and prepared for oeophagectomy. Tranhiatal oeophagectomy with cervical oeophagogatrotomy wa done. The potoperative recovery wa table and he wa commenced on graded oral ip 7 day potoperatively. The chet tube wa removed 2 day later and he wa dicharged on 12 th day potoperatively. When een 2 week at the out-patient department clinic he wa table. She wa noticed to develop keloid on the car 6 month later but he ha remained table and atified 18 month after the oeophagectomy. Figure 1. Chet X-ray for end-tage Achalaia howing right chet opacity due to the dilated eophagu COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

104 ISSN Eat Cent. Afr. J. urg Dicuion Figure 2. CT-Scan of the chet with dilated eophagu with the diameter at different level Achalaia cardia i a primary oeophageal motility diorder characterized by failure of relaxation of the lower eophageal phincter (LES) during wallowing and aperitali of the oeophageal body. It feature were firt decribed by Sir Thoma William in 1674 who alo uggeted the ue of fih whalebone for dilatation but the term achalaia wa firt introduced by Arthur Hurt in The aetiology i unknown but autoimmune, viral and neurodegenerative procee are thought to be reponible with reultant damage to the myenteric plexu, paucity of inhibitory neuron and elective timulation at the plexu. Thi lead to unoppoed cholinergic timulation and contraction of the lower oeophageal phincter and conequent hypertenion at the LES. The normal diameter of the Eophagu i 2.5-3cm. The clinical feature of achalaia include preence of prolonged intermittent dyphagia to liquid and olid, odynophagia and regurgitation. Weight lo may be a feature epecially in prolonged cae. Oeophageal manometry i the gold tandard for diagnoi in achalaia 1 but it i not widely available in our etting and plain chet X-ray, barium wallow and upper gatrointetinal endocopy are the mot commonly ued diagnotic modalitie which our patient did. Achalaia i claified into four baed on the everity and oeophageal dilatation. 4 In minimal achalaia there i retention of food but no dilatation while mild achalaia i aociated with vigorou diorganized motor activity and a dilated diameter of le than 4cm. Moderate Achalaia ha a uniform dilatation of 4-6cm and evere achalaia ha an eophageal diameter of more than 6cm. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

105 ISSN Eat Cent. Afr. J. urg End-tage Achalaia i the advanced form of achalaia where the oeophagu i dilated (diameter >6cm), tortuou and aume a igmoid configuration. The oeophagu i termed megaeophagu. Thi i imilar to the finding in our patient who had a dilated oeophagu with average diameter of 8.09cm. The dependent part within the chet allow for retention and tai of food. The aociated regurgitation reult in recurrent chet infection and lung abcee while the prolonged inflammation can lead to oeophageal quamou cell cancer. 5 The diagnoi may be difficult becaue of thee aociation. Few midiagnoe were reported in the literature. Kapadia et al 4 reported a cae of end-tage achalaia clinically midiagnoed a pulmonary Tuberculoi which wa reolved on chet x-ray evaluation. Khan et al 6 alo reported a patient who preented with acute airway obtruction with unclear diagnoi which wa alo reolved with chet x-ray evaluation and immediate improvement noted with rapid oeophageal decompreion. Our literature earch did not yield a prior report of end-tage Achalaia maked by chet trauma leading to it midiagnoi imilar to our patient but the diagnoi of the end-tage achalaia wa reolved by the radiological evaluation done a in the previou report although chet CT-can gave the firt hint intead of chet x-ray a in earlier reported midiagnoe. The Chet X-ray feature of our patient were thought to be the equelae of the chet trauma. Thi could be interpreted a a pneumothorax with ome lung collape and inerting a chet tube would have lead to oeophageal perforation and mediatiniti with the attendant worened morbidity and mortality. The midiagnoi of a right chet tumour wa alo entertained ubequently and the requeted CT-Scan wa the modality that gave the firt hint to an oeophageal dieae. Thu it i pertinent for phyician to thoroughly evaluate patient with chet trauma and have an index of upicion for other concomitant condition. Thi will prevent complication and offer the appropriate treatment to the patient. The treatment for end-tage achalaia i urgical. Laparocopic Heller cardiomyotomy with antireflux procedure ha been propoed by ome urgeon a the initial treatment option with good outcome reerving oeophagectomy for failed cardiomyotomy 7. Feccani and co-worker 8 decribed a laparocopic Heller cardiomyotomy, Dor fundoplication and a pull down procedure where 1-2 intramucular U-titche are applied on the right ide of the lower oeophagu to retore the verticality of the oeophagu (Figure 3 a-d). Figure 3. Heller cardiomyotomy, Dor fundoplication and a pull down procedure. Adapted from Feccani and co-worker COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

106 ISSN Eat Cent. Afr. J. urg Oeophagectomy i the commonet treatment for end-tage achalaia and Tranhiatal eophagectomy with cervical oeophagogatrotomy i the preferred option. Devaney et al 9 reported good outcome of patient who underwent oeophagectomy for end-tage Achalaia with 94% done through the Tranhiatal approach. They tated their patient election criteria for thoe to undergo eophagectomy. Cardiomyotomy i choen for thoe with oeophageal diameter of >6cm when the oeophageal axi i traight. On the other hand, Oeophagectomy i done once the oeophagu become tortuou and igmoid which render it functionle. Colon interpoitioning i another option epecially if the tomach i not uitable a a graft 10. The index patient underwent ucceful tranhiatal oeophagectomy and cervical oeophagogatrotomy with good outcome. Concluion End-tage achalaia occur in neglected prolonged achalaia and it diagnoi may be hrouded by it complication or other clinical condition uch a chet trauma and the midiagnoi may lead to wrong treatment with fatal outcome. Thu Phyician hould conider the poibility of concomitant clinical condition uch a end-tage achalaia in evaluating chet trauma patient. Reference 1. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline:diagnoi and management of Achalaia. Am J Gatroenterol. 23 July 2013; /ajg Wolf AS, Wright CD. Eophageal motility diorder. In: Shield TW et al. General thoracic urgery.7 th edition Lippincott William and Wilkin. 3. Paul D, Tutuian R. Achalaia: An overview of Diagnoi and treatment. J Gatrointetin Liver Di. September 2007; 16 (3): Kapadia KB, atokar PR, Mody AE, Prabhudeai PP. Difficultie in diagnoi and treatment of Megaoeophagu (a cae report). J Potgrad Med 1989;35: Bhavar MS, Vora HB, Rathi UU, Venugopal HG. Eophageal carcinoma econdary to Achalaia Cardia: A cae report with literature review. J Dig Endoc 2012;3(3) Khan AA, Shah WH, Alam A, Butt AK, Shafqat F, Malik K et al. Achalaia eophagu; preenting a acute airway obtruction. J Pak Med Aoc Aug;57(8): Panthanacheewaran K, Purhad R, Rohila J, Saraya A, Makharia GK, Sharma R. Laparocopic Heller Cardiomyotomy: A viable treatment option for igmoid eophagu. Interactive cardiovacular and Thoracic urgery 0(2012) 1-6. doi; /ictv/iv Feccani E, Mattioli S, Lugarei ML, Di Simone MP, Bartalena T, Polotti V. Improving the urgery for Sigmoid Achalaia; Long term reult of a technical detail. European Journal of Cardiothoracic Surgery 2007; 32: Devaney E, Lannettoni M, Orringer MB, Marhall B. Eophagectomy for Achalaia: Patient election and clinical experience. Ann Thorac Surg 2001 Sep;72(3): Peter JH, Kauer WK, Crooke PF, Ireland AP, Brennar CG, Demeeter TR. Eophageal reection with colon interpoition for end-tage Achalaia. Arch Surg 1995 Jun;30(6):332-6 COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

107 ISSN Eat Cent. Afr. J. urg A cae of evere epi following tranrectal protate biopy O.Y. Oluyemi 1, C.J. Elikwu 2. 1Department of Surgery, Ben Caron School of Medicine, Babcock Univerity/Babcock Univerity Teaching Hopital,Ilian, Ogun State, Nigeria 2Department of Medical Microbiology & Paraitology, Ben Caron School of Medicine, Babcock Univerity/Babcock Univerity Teaching Hopital,Ilian, Ogun State, Nigeria Correpondence to:o.y Oluyemi, oluyemioy@gmail.com Introduction Protate biopy preent a ignificant percentage of complication. Infection complicate more than 5% of patient ubjected to protate biopy 1 and i the mot common reaon for hopitalization following protate biopy 2,3. The factor predicting a higher uceptibility to infection have been largely unknown but ome literature have highlighted in the aetiopathogenei the importance of augmented prevalence of ciprofloxacin reitant bacterial train (E. coli) in the rectum flora. Cae report We report a cae of an elderly man, who had no urinary ymptom. A 74year old man preented in our general outpatient clinic with no urinary ymptom but had elevated total erum Protate Specific Antigen (PSA) during hi annual medical check-up. The PSA wa 19.01ng/ml, which prompted the attending phyician to refer him to our Urology Clinic. We found him to be a healthy-looking elderly man. The finding on general examination were eentially normal. On digital rectal examination, the phincteric tone wa normal; the rectal mucoa wa mooth; the protate gland wa enlarged, grade III, mooth, firm, nontender, median groove and lateral ulci were preerved. We made a clinical diagnoi of chronic protatiti. A repeat erum PSA tet wa 17.90ng/ml. The ultraonography revealed a 79.7gm homogenou protate gland. He wa commenced on oral ciprofloxacine 500mg twice daily for ix week, baed on the preumptive diagnoi of chronic protatiti. Thereafter the erum PSA wa 24.60ng/ml. He wa conequently cheduled for a tranrectal protate biopy. Pre-biopy, IV pentazocine 15mg, IV acetaminophen 600mg and IV Gentamycin 160mg were given. He had caudal block anaetheia with 200mg plain lidocaine and an extended (10 core) biopy wa performed. After the biopy, he wa commenced on oral ciprofloxacine 500mg twice daily for five day and acetaminophen 1000mg three time daily for three day. Four day after the protate biopy, he developed evere weakne, fever (37.2 o C) and haematuria, uggetive of epticaemia. Urine culture did not yield any organim. He wa treated with intravenou ceftriazone and Gentamycin, there wa reolution of hi ymptom and he wa dicharged after eight day of admiion. However he re-preented four day later with evere weakne and fever (38.3 o C). The urine culture yielded no growth of organim. Preliminary blood culture yielded Streptococcu pecie. He wa treated with intravenou levofloxacine. At thi point, the hitology report wa available, howing fibromucular hypertrophy with glandular hyperplaia and chronic inflammation. He developed hypotenion( BP 80/50mmHg); packed cell volume = 19%; white cell count = 44.3 x 10 9 /L. On peripheral blood film, red cell how hypochromia, aniopoikilocytoi, target cell, fragmented cell and tear drop cell; white cell how leucocytoi predominantly COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

108 ISSN Eat Cent. Afr. J. urg granulocyte, left hift of neutrophil with toxic granulation. The glycaemic profile wa within normal limit. HIV creening wa non-reactive. Catheter wab culture yielded Echerichia coli reitant to all teted antibiotic. Urethral wab culture yielded Peudomona aeruginoa reitant to all teted antibiotic. Sputum culture yielded Staphylococcu aureu reitant to all teted antibiotic. He wa reucitated and tranferred into the Intenive care Unit. He wa tranfued with four pint of O negative packed red blood cell, hi blood group being O negative. The evere weakne and fever perited, hence the antibiotic wa changed from levofloxacine to vancomycin, but there wa no improvement. Subequently the antibiotic wa changed to meropenem. He then began to make gradual teady improvement and utained clinical tability. He wa on admiion for thirteen day in the Intenive Care Unit before he wa dicharged. Dicuion The mot common complication following protate biopy include infection, bleeding, and urinary retention 1,2. Infection-related complication following protate biopy include aymptomatic bacteriuria, urinary tract infection, febrile urinary tract infection, and epi 3. Our patient alo did not manifet urinary ymptom except for being febrile. It i highly worriome the finding from recent report of an increaing number of men requiring hopitalization a a reult of ignificant infectiou complication following protate biopy 4. Although the caue of thee recently reported trend may be multifactorial, the emerging pattern of fluoroquinolone-reitant bacteria 5-7 and the lack of an evidence-baed, tandardized regimen for peri-procedural antimicrobial prophylaxi for protate biopy appear to be the mot important etiologic factor reponible for thee trend 8. Although, our patient had pre-biopy prophylaxi with a tarting doe of IV Gentamycin, he wa immediately placed on oral fluoroquinolone, ciprofloxacin pot biopy becaue of the extended biopy experienced. With good tiue penetration and randomized trial upporting it benefit, mot literature ha upported ciprofloxacin i the choice of prophylactic agent for tranrectal protate biopy 9,10. Alternative attempt to cover the common organim E. coli, K. pneumoniae, P. aeruginoa and Enterococcu include another fluoroquinolone, a econd or third generation cephaloporin or Gentamycin 11,12. There i no good evidence upporting the ue of metronidazole 12. However, the different bacterial iolate in our patient, with their multidrug reitance feature highly ugget the high antibiotic conumption rate either by the patient or the local community of the hopital where patient preented. Thi i largely due to the non exitence of antibiotic policy and guideline in our local environment 13. Alo, a multi organim epi i the likely caue of evere epi in thi patient. Mot protate biopie are performed tranrectally, and introducing rectal bacteria into the urinary tract i a ignificant concern. Concluion Thi report remind u that eriou complication can occur a a reult of tranrectal protate biopy. Further reearch need to be done to evaluate the prevalence of drug reitance and to elect an optimal prophylaxi regimen. There i alo an urgent need for antibiotic audit and the development of antibiotic policy and guideline in the local intitution. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

109 ISSN Eat Cent. Afr. J. urg Reference 1. Berger AP, Gozzi C, Steiner H, et al. Complication rate of tranrectal ultraound guided protate biopy: a comparion among 3 protocol with 6, 10 and 15 core. J Urol 2004;171: Akduman B, Akduman D, Tokgöz H, et al. Long-term fluoroquinolone ue before the protate biopy may increae the rik of epi caued by reitant microorganim Urology 2011;78: Zani EL, Clark OA, Rodrigue Netto N Jr. Antibiotic prophylaxi for tranrectal protate biopy. Cochrane Databae Syt Rev 2011; 5:CD Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complication after protate biopy: data from SEER-Medicare. J Urol Nov;186(5): Batura D, Rao GG, Nielen PB. Prevalence of antimicrobial reitance in intetinal flora of patient undergoing protatic biopy: implication for prophylaxi and treatment of infection after biopy. BJU Int 2010;106: Horcajada JP, Buto M, Grau S, et al. High prevalence of extended-pectrum betalactamae-producing enterobacteriaceae in bacteremia after tranrectal ultraoundguided protate biopy: a need for changing preventive protocol. Urology 2009;74: Steenel D, Slabbaert K, De Wever L, Vermeerch P, Van Poppel H, Verhaegen J. Fluoroquinolone-reitant E. coli in intetinal flora of patient undergoing tranrectal ultraound-guided protate biopy-hould we reae our practice for antibiotic prophylaxi? ClinMicrobiol Infect 2011 Jul Shandera KC, Thibault GP, Dehon GE. Variability in patient preparation for protate biopy among American urologit. Urology. 1998;52: Roach MB, Figueroa TE, McBride D, et al. Ciprofloxacin veru gentamicin in prophylaxi againt bacteremiain tranrectal protate needle biopy. Urology 1991;38: Aron M, Rajeev TP, Gupta NP. Antibiotic prophylaxi for tranrectal needle biopy of the protate: a randomizedcontrolled tudy. BJU Int 2000;85: Young JL, Li MA, Szabo RJ. Sepi Due to Fluoroquinolone-reitant Echerichia coli After TranrectalUltraound-guided Protate Needle Biopy. Urology 2009;74: Burden HP, Ranainghe W, Perad R. Antibiotic for tranrectal ultraonography-guided protate biopy:are we practiing evidence-baed medicine? BJU Int 2008;101: World Health Organiation, promoting rational ue of medicine: core component. WHO Policy on Medicine 2002: No 5. Geneva COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

110 ISSN Eat Cent. Afr. J. urg Hepatic haemangioma: a Cae Report and Review of Literature S. A. Salati, A. Al Kadi Department of Surgery, Unaizah College of Medicine, Qaim Univerity Qaim, Kingdom of Saudi Arabia Correpondence to: Dr. Sajad Ahmad Salati, docajad@yahoo.co.in, docajad@gmail.com Hepatic haemangioma account for about quarter of all benign tumour of the liver. In lat few decade, lot of advance have been made in the field of diagnoi and management of thee leion. Thi article preent a cae of hepatic haemangioma that i under follow-up of the author. Furthermore the ubject i reviewed in the light of recent literature Introduction Hepatic haemangioma and i the econd mot common tumour een in the liver after metatae and account for 73% of all benign liver tumour with a frequency of % at autopy 1. They are compoed of mae of blood veel with atypical or irregular in arrangement and ize. They are alo referred to a cavernou haemangioma due to the cavernou vacular pace een in hitological tudie. Thee benign tumour are uually mall, olitary or multiple, and aymptomatic 2. Cae preentation A 32 year old female, married with two children, reported with vague pain in upper abdomen of everity of 3/10 on Viual analogue cale. There wa no ignificant pat medical, urgical, drug-intake or family hitory. On examination, the vital ign were table and the abdominal examination revealed no poitive finding. Ultraonogram of the Abdomen revealed the liver to be of average ize (12 cm) with a homogenou parenchymal echo-pattern and normal calibre of portal vein and biliary tree. There wa a well-defined hyperechoic leion een in the left liver lobe meauring about 3.5 X 2.5 x 2.8 cm and the feature were uggetive of haemangioma (Fig 1 ). Figure 1. Ultraonogram Depicting Hyperechoic Haemangioma in the Left Lobe of Liver CT can of the abdomen and pelvi with IV and oral contrat revealed a 2.7 cm low-attenuation ma in Segment 5 of the liver (in right lobe) howing peripheral puddling of contrat in the portal venou phae characteritic of a haemangioma (Figure 2). There were no other hepatic leion or intra or extra hepatic biliary ductal dilatation.the gallbladder, pleen, pancrea and COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

111 ISSN Eat Cent. Afr. J. urg both kidney/ adrenal had normal feature. There wa no acite or retroperitoneal lymphadenopathy. Figure 2. Contrat enhance CT Scan depicting hepatic haemangioma (hown with red arrow) in (A) Tranvere plane (B) Sagital plane (C) Coronal plane. The firt degree family member (parent, two ibling and two children) were creened by abdominal ultraonography and were found to have no leion. The patient wa counelled under follow up, without any active intervention. USG tudie repeated at follow up of one year revealed that the leion had remained tatic in dimenion. Pathophyiology The aetiopathogenei of hepatic haemangioma i not undertood completely. They are potulated to be vacular malformation or hamartoma of congenital origin that undergo enlargement by ectaia rather than by hypertrophy or hyperplaia. No definite familial or genetic mode of inheritance ha been decribed though a few cae erie have been reported in literature, indicating ome role for familial link. Moer et al 2 preented a report of a large family of Italian origin where three female patient in three ucceive generation uffered from large ymptomatic hepatic haemangioma. In addition, two other female relative exhibited aymptomatic haemangioma on ultraonography. The author potulated that retriction of the dieae to the female could be explained by ex-dependent difference in penetrance or expreivity of a preumable "liverhaemangioma" gene or the production of proliferative factor, uch a female ex hormone. The author alo oberved an unexplained increaed incidence of thyroid adenoma among member with or without hepatic haemangioma of the reported family. Diez Redondo P et al 3 decribed a family in which ix member from three ucceive generation preented hepatic haemangioma. One of the cae wa taking oral contraceptive and had a painful giant haemangioma with biochemical abnormalitie while the remaining cae were aymptomatic. Li P et al 4 reported two ibling (a male and a female) with Dubin-Johnon yndrome with multiple hepatic haemangioma. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

112 ISSN Eat Cent. Afr. J. urg Several pharmacologic agent have been potulated to promote the growth or induce ymptom in haemangioma. Thee include female ex (endogenou /exogenou) hormone 5,6 and teroid. Spitzer D et al 7 reported aymptomatic increae in hepatic haemangioma in pregnant women following ovarian timulation therapy with clomiphene citrate and human chorionic gonadotropin. Graham E et al 8 reported a cae of ymptomatic hepatic haemangioma with haemorrhage during pregnancy and mentioned etrogen to be the poible caue the growth of haemangioma. Epidemiology Frequency The reported incidence rate varie widely and i approximately 2%. The prevalence rate at autopy i a high a 2-7.3% 1,8. The widepread ue of non-invaive abdominal imaging modalitie ha led to increaed detection of aymptomatic leion in recent time. Sex Women, epecially with a hitory of multiparity, are affected more often than men. The femaleto-male ratio reported in literature 9 varie from 3-6:1. Age Hepatic haemangioma can occur at all age though 60 to 80 percent of cae are diagnoed in individual aged year. Female often preent at a younger age and with larger leion. Further the leion reponible for ymptom are more likely in female 6. Hepatic haemangioma may be een in infancy and have alo been detected prenatally in a growing fetu. Iaac 10 tudied 194 foetue and neonate with hepatic tumour diagnoed prenatally (n = 56) and in the neonatal period (n = 138) and found haemangioma to contitute 60.3% (n=117) of cae. Pathology Hepatic haemangioma vary in ize from a few millimetre to many centimetre though uually are 2-4 cm % are olitary and the larger leion may be pedunculated On gro examination, the leion appear a dark-purple cytic mae, which collape when ectioned due to oozing out of blood. They can be found in either of the lobe of the liver, though are predominantly found in the right lobe. Leion tend to be well circumcribed and often urrounded by a thin capule /interface 13. The cut urface exhibit a red-brown appearance with a pongy conitency that may how haemorrhage, carring, phlebolith or calcification. Microcopically, the tumour i compoed of large (cavernou) vacular pace of varying ize, lined by a ingle layer flat tumour endothelial cell (which appear very imilar to normal cell). The vacular compartment are eparated by thin fibrou eptae and may contain thrombi. Large haemangioma may how feature of collagenou car or fibrou nodule a thromboi occur and very rarely, there may be focal tromal calcification and oification. Clinical preentation Haemangioma are generally mall, aymptomatic and dicovered incidentally when the liver i imaged for unrelated condition 14 or when the liver i examined at laparotomy or autopy. Goodman 15 in 1987 found that the ymptom are experienced by 40% of cae with greater than 4-cm haemangioma and by 90% of cae with 10-cm haemangioma. Upper abdominal pain /dicomfort or fullne i the mot common complaint, when the leion become ymptomatic. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

113 ISSN Eat Cent. Afr. J. urg Le common complaint include nauea, anorexia, dypepia and early atiety, which are een when large haemangioma compreion the adjacent organ 16. The pain i uually mild but can become evere due to thromboi or bleeding within the leion and aociated tretching and inflammation of Glion' capule. Pain from an acute thromboi can lat up to three week and be aociated with pyrexia and derangement of liver function 17. Phyical examination i generally normal and the only finding of ignificance, een infrequently, are an enlarged liver or the preence of an arterial bruit over the right upper quadrant. The atypical preentation of hepatic haemangioma include: 1. High output cardiac failure from maive arteriovenou hunting, particularly in the children 18, jaundice from compreion of the bile duct 20, 3. hypothyroidim refractory to hormone replacement therapy, due to the preence of high level of 3-iodothyronine de-iodinae activity in the hemangioma, that catalyze the converion of thyroxine and triiodothyronine to biologically inactive hormone, revere triiodothyronine, and 3,3'-diiodothyronine Gatrointetinal bleeding from haemobilia 21, 22, and 5. Pyrexia of unknown origin 23, polymyalgia rheumatica, reitant to teroid Kaabach-Merritt yndrome (KMS) i a rare and evere coagulation diorder characterized by profound thrombocytopenia, microangiopathic hemolytic anemia, and conumption coagulopathy In children, cutaneou haemangioma may erve a marker for hepatic haemangioma. Huge JA et al 30 found that aymptomatic hepatic haemangioma occurred in nearly 25% of infant preenting overall with ix or more mall or a ingle large cutaneou haemangioma. Differential Diagnoe Hepatic haemangioma have to be differentiated from other benign and malignant paceoccupying liver leion. Benign leion include cyt, adenoma, regenerating nodule, focal nodular hyperplaia, and abcee and the malignant leion include hepatocellular carcinoma, hepatic angioarcoma and hepatic metatae. In hitopathology, the pecimen need to be differentiated from: i. Hereditary hemorrhagic telangiectaia: the leion ha aberrant portal veel with dilated vacular channel within portal tract, ii. Infantile hemangioendothelioma: the leion ha cellular atypia. iii. Pelioi hepati: the leion ha no fibrou epta Diagnoi Hepatic haemangioma have certain characteritic that point toward the diagnoi on ultraonography, computed tomography (CT), or magnetic reonance imaging (MRI) A minority of leion are however atypical and may require multiple imaging tet or conventional arteriography or even urgical intervention to achieve a confident diagnoi 33. Plain radiograph Plain abdominal radiograph may be normal or may how evidence of calcification within the leion. However thi calcification lack pecificity in haemangioma. Ultraound Ultraound typically reveal a well-demarcated, hyperechoic, homogeneou, ma. Colour Doppler Sonography (CDS) can depict intratumoural flow and peritumoural hepato-fugal portal flow in patient with hepatic haemangioma accompanied by arterioportal hunt 34. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

114 ISSN Eat Cent. Afr. J. urg Lim 35 preented a erie of 45 patient with hepatic haemangioma and found the tumour depth to be a ignificant variable that affect the capability of CDS to depict uch finding. The frequencie of intratumoural flow and peritumoural hepatofugal portal flow were a high a 88% and 80% for hallow ( 30 mm) leion, and they were 40% and 35% for deep (>30 mm) leion (p=0.0012; p=0.0051). Contrat-enhanced ultraound (CEUS) Ultraound contrat agent conit of ga-filled echogenic microbubble that enhance the ultraound ignal produced by flowing blood. Thi variant of ultraonography demontrate typical haemangioma imaging characteritic, in form of peripheral nodular contrat enhancement and iri-diaphragm ign in a high percentage of patient with undetermined leion thereby improving the noninvaive functional characterization and differentiation of haemangioma 36. Sirli R et al 37 preented a erie which proved that CEUS diagnoed correctly 90% of hemangioma, all with typical enhancement pattern and diagnoed additional 40% of hemangioma that could not be diagnoed on the tandard ultraound.ryu SW et al 38 found that the enitivity, pecificity, and accuracy for CEUS were 94.6% that i comparable to CT and MRI and hence CEUS can be highly reliable if appropriate acoutic window i available. Computed tomography A non-contrat-enhanced CT can of a haemangioma uually demontrate a well-demarcated hypo-dene ma. Calcification may be een in approximately 10 % of leion. The leion may appear a hyperdene relative to the urrounding parenchyma in patient with fatty liver. The adminitration of contrat medium reult in peripheral nodular or globular enhancement in the early phae (in up to percent of hemangioma >4 cm in ize), followed by a centripetal pattern or "filling in" during the late phae 39. After a delay of three or more minute, the leion claically opacify and remain iodene or hyperdene on delayed can. Enhancement may however be abent in hemangioma with large cytic area or car tiue. Recently a retrieval-baed computer-aided diagnoi (CADx) ytem for the characterization of liver leion in computed tomography (CT) can ha been introduced and in a tudy by Dankeri P et al 40, the tand-alone predictive performance of the CADx ytem wa aeed and compared to that of three qualified radiologit who were provided with the ame amount of image information to which the CADx ytem had the acce and CADx ytem wa found to be highly reliable. Magnetic reonance imaging MRI ha emerged in recent year a a highly accurate, noninvaive technique for diagnoing haemangioma becaue of it high contrat reolution, lack of ionizing radiation, and the poibility of performing functional imaging equence 41. With advance in hardware and coil ytem, thi modality ha a enitivity and enitivity of more than 94 percent. Typically, the leion have low ignal intenity on T1-weighted image and are hyperintene on T2-weighted image. When gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA) i ued a a contrat agent, the leion enhance in a fahion imilar to that een on dynamic CT diplaying early peripheral dicontinuou nodular or globular enhancement on arterial phae can with progreive centripetal enhancement or "filling in" on delayed can. Typically, haemangioma follow the ignal intenity of blood and the preence of intraleional fibroi reult in area of low intenity on T2-weighted image. On High-b-value diffuionweighted, DW-MR Image, the leion often how finding that ugget retricted diffuion 42. Duran R et al (43) in 2015 preented the reult of a retropective tudy of 89 patient with 231 hepatic haemangioma and found that the MR imaging characteritic of haemangioma were imilar in patient with normal compared to fibrotic and cirrhotic liver. Le T2 hine-through effect wa een in haemangioma developed on cirrhoi, the latter being an important finding to highlight in thee patient at rik of developing hepatocellular carcinoma. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

115 ISSN Eat Cent. Afr. J. urg Nuclear medicine tudie Technetium-99m pertechnetate-labeled red blood cell pool tudie (99mTc-RBC pool tudie) i a highly pecific imaging technique for haemangioma a it hypervacular nature may create equivocal reult on CT or MRI 44. The tudy how an initial hypoperfuion during arterial flow, which i followed by gradual increae of tracer peaking 30 to 50 minute after the injection. Delayed image diplay retention of the iotope within the leion. The enitivity of the method ha been found to be about 76%, pecificity 98%, poitive predictive value 98% and negative predictive value 79%. With SPECT (ingle photon emiion computerized tomography), enitivity of the method increae to 95%, pecificity 98%, poitive predictive value 98% and negative predictive value 94% 45. RBC SPECT/CT imaging uing thi hybrid SPECT/CT ytem i feaible and ueful in the identification or excluion of upected hepatic haemangioma located near region with high blood activity like the inferior vena cava, the heart or hepatic veel 46. Management Hepatic haemangioma are motly mall and aymptomatic at the time of diagnoi, and they do generally tend to remain o or grow very lowly for the ret of the life. In addition, malignant tranformation of thee leion ha not been reported in literature. Hence mot hepatic haemangioma may be left afely alone. However, there are rare cae in literature where the growth of thee leion ha been rapid and conitent. Yohida et al 47 reported an 11-fold growth in hepatic haemangioma over a period of 11 year, when the volume of the leion had grown from 123 cc to 1343 cc. Radiologic tudy follow-up Once the diagnoi of hepatic haemangioma i confirmed by radiologic tudie, opinion varie whether follow-up radiologic tudie are warranted to reae the ize of the leion. Yeh et al 48 followed up 180 hepatic haemangioma in 130 adult patient, for more than 5 year with at leat twice ultraound examination and found that the diameter of 14 (7.7%) haemangioma in 13 patient increaed and the leion volume doubling time of ranged from 17.3 to month. Kobayahi et al 49 evaluated conecutive ultraonogram of 27 haemangioma in 23 patient over a follow-up period ranging from 12 to 114 month (average 44) and found that ix (22.2%) haemangioma changed in ize, which included three leion with increae in ize, one leion with decreae in ize and two leion with pontaneou regreion. Haan et al 50 in 2014 reported the reult of a retropective cohort tudy undertaken at an academic hopital tertiary referral centre to evaluate the growth rate of hepatic haemangioma on cro-ectional imaging tudie during a 10-year period ( ). A total of 163 haemangioma were identified in 123 patient and the mean (SD) initial ize wa 3.2 (cm. During follow-up, 39.3% of haemangioma grew 5% or more in mean linear dimenion and the mean (SD) annual linear growth rate wa found out to be 0.03 (0.21) cm for all leion and 0.19 (0.23) cm for thoe that grew 5% or more. By volume, 44.7% of leion grew 5% or more and the mean (SD) annual volumetric growth rate wa 2.8% (21.0%) for all leion and 17.7% (22.8%) in thoe that grew 5% or more. The author concluded that the overall rate of growth i low but treed the need for further reearch to determine the treatment modalitie of the patient with more rapidly growing haemangioma. Ng et al 51 tudied the giant hepatic haemangioma with the median maximal diameter of the leion wa 5.5 cm (range, cm ) in 42 female and 22 male patient with a median age of 49 (range, 27-84) year. The median duration of follow-up wa 34 month. Mot (54%) of the COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

116 ISSN Eat Cent. Afr. J. urg patient were aymptomatic, but in 17% the haemangioma enlarged to exceed it original ize by more than 20%. There were no haemangioma-aociated complication. The author concluded that if the diagnoi i uncertain, elective further invetigation may be neceary but the leion with a confirmed diagnoi tend to remain tatic in ize and hence performing regular can for aymptomatic giant liver haemangioma may not be neceary Medical treatment Since 1990, ome cae were reported to how hrinkage of hepatic haemangioma after interferon therapy 52. In recent year, cae have been publihed which how reduction of haemangioma by inhibition of growth factor and kinae. Mahajan D et al (53) in 2008 reported an incidental reduction in the ize of liver haemangioma following ue of vacular endothelial growth factor (VEGF) inhibitor bevacizumab. Yamahita et al 54 reported the ucceful ue of Sorafenib, multikinae inhibitor in the management of a 76-year-old man with a giant cavernou haemangioma meauring more than 20 cm in diameter. Tumour volume reduced from 1492 ml at baeline to 665 ml after 78 day of treatment with orafenib 600 mg/day. Report have been publihed in recent literature that point toward the efficacy of low doe propranolol, a non-elective beta-blocker, in the management of infantile hepatic haemangioma Surgical Treatment The major indication for elective urgical management of hepatic haemangioma include abdominal pain, extrinic compreion of adjacent tructure, cardiac failure, coagulopathy etc., diagnotic uncertainty and rapid enlargement wherea bleeding after rupture (60) or needle biopy mandate emergent urgical intervention. There are three procedure for urgical management of hepatic haemangioma including: 1. Liver reection 2. Enucleation 3. Liver tranplantation The procedure are conducted by open approach or by minimally invaive (laparocopic/robotic) approach 1. The choice of the urgical procedure to be carried out depend upon the location and the morphology of the leion 59. Martinez- Gonzalez et al 59 reported urgical management in 24 patient with ymptomatic liver haemangioma, 16 patient underwent liver reection (66.6%), and 8 leion were enucleated (33.3%). Four patient (16.6%) preented operative complication including potoperative bleeding in two (8.3%), fever in one (4.1%) and abdominal haematoma in one (4.1%). There wa no operative mortality. 22 patient (91%) achieved complete ymptomatic relief. Demircan et al 58 operated upon 15 patient and 11 patient underwent enucleation of the leion while the other 4 patient underwent reection procedure. Complication occurred in 2 (13.4%) patient and 1 patient with the larget tumour (30cm) died of bleeding and coagulopathy. One patient wa lot to follow up and 12 out of the remaining 13 operated patient (92.3%) reported complete relief of ymptom. In the erie of Kayaoglu et al 57, enucleation wa found to be afe and effective operation in 18 haemangioma ranging in ize from 2-30cm (mean 12.7cm). Ozden et al 61 and Popecu et al 62 alo found enucleation to be rapid and afe and hence preferable over reection. But Guiliante et al 63 found reection and enucleation to be equally effective and afe and conidered the ize of the leion to be reponible for complication rather than the choice of the procedure. Fu XH et al 64 preented the outcome in 172 patient who underwent enucleation of hepatic haemangioma. The leion were centrally located in 76 patient (44.2%) and peripherally located in 96 patient (55.8%). The author concluded that enucleation to be a afe urgery for haemangioma in any COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

117 ISSN Eat Cent. Afr. J. urg part of the liver, although it i technically more demanding for centrally than peripherally located haemangioma. Baer et al 13 advocate routinely performing complete extra-hepatic ligation of the main arterial upply before attempting enucleation of a haemangioma to reduce blood lo and define the interface with the normal liver tiue. Farge et al 65 had 50% of the operated patient with peritent ymptom during follow up and hence treed on proper preoperative election and work-up to rule out other caue of abdominal ymptom. Liver tranplantation ha alo been ued uccefully to treat elected ymptomatic patient with unreectable giant or diffue haemangioma and haemangioma aociated with Kaabach- Merritt yndrome Surgical ligation of feeding veel a a urgical technique i alo mentioned in literature for the management of hunting liver haemangioma that otherwie would rapidly lead to intractable cardiac failure. Rokitanky wt al 69 in 1998 preented a ucceful uage of tranhepatic compreion uture uing polytetrafluoroethylene (PTFE) pledget and elective ligation of large feeding veel from right hepatic artery. Arterial embolization Surgical reection may not be technically afe or poible in certain cae due to the maive or diffue nature of the leion, proximity to vacular tructure, acute bleeding after pontaneou rupture or due the patient' general ill-health. In uch ituation, arterial embolization ha been reported a an option in the literature to control acute bleeding, manage ymptom, and to hrink hemangioma prior to urgical reection Branche of the hepatic artery are embolized with ubtance like fat, gel foam, bleomycin or polyvinyl alcohol Bozkaya H et al 72 in 2014 decribed ucceful embolization with bleomycin mixed with lipiodol of 32 ymptomatic giant haemangioma in 26 patient [21 female, five male; age year (mean ± 1.53)] who were otherwie unfit for urgical intervention. Angioembolization reult in hrinkage of the leion, thereby minimizing the rik of complication. The recognized complication of thi procedure include pain, fever, abce formation and non-granulomatou arteriti with eoinophilic infiltration.the long-term ucce rate of embolization (without ubequent urgical reection) i however not well tudied a yet. Radiotherapy Hepatic irradiation with a doe of Gy in fraction over everal week ha been ued to treat ymptomatic haemangioma.report are publihed in literature ince 1960 and the technique of delivery have ignificantly improved over lat decade.thi modality i however generally reerved for unreectable leion a it required month to deliver the required fraction of therapy. Tumour regreion and ymptom relief i noted in mot patient, with minimal morbidity Radiofrequency ablation In recent year, radiofrequency ablation (RFA) ha emerged a a afe, feaible, and effective technique for treatment of giant ymptomatic hepatic cavernou haemangioma. Mode of delivery i through percutaneou, open urgical and laparocopic route. Van Tilborg et al 77 reported ucceful management of 4 patient with a large-volume, ymptomatic hepatic cavernou haemangioma of >10 cm were treated with bipolar RFA during laparotomy with ultraound guidance. Peri-procedural hrinkage of the leion wa remarkable and intermediate-term volume reduction ranged from 58-92% after 6 month. Symptom relief after 6 month wa complete in two patient (50%) and coniderable in the other two (50%). COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

118 ISSN Eat Cent. Afr. J. urg Fan et al 78 preented a tudy of a total of 68 patient, 18 male and 50 female, age 43.1 (30-64), with 104 hepatic haemangioma, cm in diameter ( mean ize = 5.6 cm), who were treated by ultraound-guided RFA, via percutaneou (n = 19), laparocopic (n = 29), or open urgical (n = 20) approach. In 7 patient with hepatic leion larger than 7 cm in diameter, Pringle manoeuvre wa ued to occlude the hepatic blood flow during the laparocopic and open RFA therapy. The author concluded that RFA therapy to be a afe, feaible and effective treatment option and that hepatic inflow occluion by Pringle manoeuvre can reduce the blood lo and increae the therapeutic efficacy ignificantly. Fan et al 79 preented the reult of another erie of 30 patient treated by RFA therapy after uture and ligation urgery (SL group, n = 15, with 18 liver leion) or RFA therapy without uture and ligation urgery (non-sl group, n = 15, with 17 liver leion) and concluded that RFA therapy combined with uture and ligation urgery i a afe, feaible, and effective treatment modality for giant hepatic haemangioma and that it can reduce blood lo, horten RFA therapy time, and increae therapeutic efficacy of RFA. Role of Biopy Due to the advance and wide availability of a range of diagnotic imaging modalitie and the complication of biopy including rupture, the imaging-guided biopy of haemangioma i uually not reorted to, except in extremely atypical cae 1. Hepatic haemangioma in pregnancy Inpite of growth promoting influence of etrogen on hepatic haemangioma 8, the leion generally behave indolently during pregnancy and can be oberved 80. However, there are rare report in literature, where intervention wa required on emergent bai due to complication like rupture and coagulopathy 81. Summary Hepatic haemangioma are the commonet benign tumour of liver. They are uually diagnoed incidentally. Imaging modalitie have made the diagnoi pecific in recent year.they generally remain aymptomatic and do not require any active intervention or prolonged followup. For ymptomatic, undefined or complicated leion, urgical management i the main tay of therapy though other newer, le invaive modalitie have come up in lat few decade. Reference 1. Toro A, Mahfouz AE, Ardiri A, Malaguarnera M, Malaguarnera G, Loria F, Bertino G, Di Carlo I. What i changing in indication and treatment of hepatic hemangioma. A review. Ann Hepatol. 2014; 13(4): Moer C, Hany A, Spiegel R. Familial giant hemangioma of the liver. Study of a family and review of the literature. Praxi (Bern 1994). 1998; 87(14): Diez Redondo P, Velicia Llame R, Caro-Paton A. Familial hepatic hemangioma. Gatroenterol Hepatol. 2004; 27(5): Li P, Wang Y, Zhang J, Geng M, Li Z. Dubin-Johnon yndrome with multiple liver cavernou hemangioma: report of a familial cae. Int J Clin Exp Pathol. 2013; 6(11): Glinkova V; Shevah O; Boaz M; Levine A; Shirin H. Hepatic haemangioma: poible aociation with female ex hormone. Gut. 2004; 53(9): van Malentein H, Maleux G, Monbaliu D, Verlype C, Komuta M, Rokam T, Laleman W, Caiman D, Fevery J, Aert R, Pirenne J, Neven F. Giant liver hemangioma: the role of female ex hormone and treatment. Eur J Gatroenterol Hepatol. 2011; 23(5): Spitzer D; Krainz R; Graf AH; Menzel C; Staudach A. Pregnancy after ovarian timulation and intrauterine inemination in a woman with cavernou macrohemangioma of the liver. A cae report. J Reprod Med. 1997; 42(12): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

119 ISSN Eat Cent. Afr. J. urg 8. Graham E, Cohen AW, Soulen M, Faye R. Symptomatic liver hemangioma with intra-tumor hemorrhage treated by angiography and embolization during pregnancy. Obtet Gynecol. 1993; 81(5 ( Pt 2)): Taeva A, Taev V, Bonev S, Dimitrova V. Liver hemangioma-urgical point of view. Khirurgiia (Sofiia) ;( 2): Iaac H Jr. Fetal and neonatal hepatic tumor. J Pediatr Surg. 2007; 42(11): Moon HK, Kim HS, Heo GM, Shin WG, Kim KH, Jang MK, Lee JH, Kim HY, Kim DJ, Cho SJ. A cae of pedunculated hepatic hemangioma mimicking ubmucoal tumor of the tomach. Korean J Hepatol. 2011; 17(1): Kudara N, Chiba T, Andoh T, Tukahara M, Oana S, Terui T, Endoh M, Inomata M, Orii S, Suzuki K, Ueugi N, Sugai T, Nakamura S, Yohida T. A cae of hepatic hemangioma with pedunculated extrahepatic growth imulating ubmucoal tumor of the tomach. Nihon Shokakibyo Gakkai Zahi. 2004; 101(3): Baer HU, Dennion AR, Mouton W, Stain SC, Zimmermann A, Blumgart LH. Enucleation of giant hemangioma of the liver. Technical and pathologic apect of a neglected procedure. Ann Surg. 1992;216(6): Bahirwani R, Reddy KR. Review article: the evaluation of olitary liver mae. Aliment Pharmacol Ther. 2008; 28(8): Goodman Z. Benign tumor of the liver. In: Okuda K, Ihak KG. Neoplam of the liver. Tokyo: Springer-Verlag; 1987: Pudil J, Martinek J, Belan T, Ryka M. Atypically localied hepatic haemangioma a a caue of dypeptic yndrome. Rozhl Chir. 2006; 85(7): Pateron D, Babany G, Belghiti J, Hadengue A, Menu Y, Flejou JF, Erlinger S, Benhamou JP. Giant hemangioma of the liver with pain, fever, and abnormal liver tet. Report of two cae. Dig Di Sci. 1991; 36(4): Kucherov IuI, Zhirkova IuV, Getman AN, Ivleva SA, Rekhviahvili MG. Clinical cae of treatment of hepatic haemangioma by propranolol in the newborn. Vetn Ro Akad Med Nauk ; (5-6): Bruce S, Downe L, Devonald K, Ellwood D. Noninvaive invetigation of infantile hepatic hemangioma: a cae tudy. Pediatric. 1995; 95(4): Ito K, Taira K, Arii S. Intrahepatic bile duct dilatation with a liver cyt and hemangioma: report of a cae. Surg Today. 2009; 39(3): Mikami T, Hirata K, Oikawa I, Kimura M, Kimura H. Hemobilia caued by a giant benign hemangioma of the liver: report of a cae. Surg Today. 1998; 28(9): Birth M, Ortlepp J, Bontikou S, Amthor M, Weier HF, Bruch HP. Intermittent activity-induced hemobilia caued by liver hemangioma. Dig Surg. 2000; 17(3): Lee CW, Chung YH, Lee GC, Kim JY, Lee JS. A cae of giant hemangioma of the liver preenting with fever of unknown origin. J Korean Med Sci. 1994; 9(2): van Gorcum M, van Buuren HR, Huain SM, Zondervan PE, IJzerman JN, de Man RA. Fever a a ign of inflammatory yndrome in a female patient with hepatic haemangioma. Ned Tijdchr Geneekd. 2005; 149(22): Beho K, Etani Y, Ichimori H, Miyohi Y, Namba N, Yoneda A, Ooue T, Chihara T, Morii E, Aoki T, Murakami M, Muhiake S, Ozono K. Increaed type 3 iodothyronine deiodinae activity in a regrown hepatic hemangioma with conumptive hypothyroidim. Eur J Pediatr. 2010; 169(2): Kadry Z, Mentha G, Cereda JM. Polymyalgia rheumatica a a manifetation of a large hepatic cavernou hemangioma. J Hepatol. 2000; 32(2): Watzke HH, Linkech W, Hay U. Giant hemangioma of the liver (Kaabach-Merritt yndrome): ucceful uppreion of intravacular coagulation permitting urgical removal. J Clin Gatroenterol. 1989; 11(3): Wakabayahi S, Yamaguchi K, Kugimiya T, Inada E. Succeful anethetic management for reection of a giant hepatic hemangioma with Kaabach-Merritt yndrome uing FloTrac ytem. Maui. 2011; 60(11): Vogel T, Lammer B, von Herbay A, Kunz BM, Donner AJ, Furt G, Goretzki PE. Kaabach-Merritt yndrome in giant hemangioma of the liver. A cae report. Chirurg. 2002; 73(7): Hughe JA, Hill V, Patel K, Syed S, Harper J, De Bruyn R. Cutaneou haemangioma: prevalence and onographic characteritic of aociated hepatic haemangioma. Clin Radiol. 2004; 59(3):273. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

120 ISSN Eat Cent. Afr. J. urg 31. O'Neill EK, Cogley JR, Miller FH. The in and out of liver imaging. Clin Liver Di. 2015; 19(1): Klotz T, Montoriol PF, Da Ine D, Petitcolin V, Joubert-Zakeyh J, Garcier JM.Hepatic haemangioma: common and uncommon imaging feature. Diagn Interv Imaging. 2013; 94(9): Cha EY, Kim KW, Choi YJ, Song JS, Cho KJ, Lee MG. Multicytic cavernou haemangioma of the liver: ultraonography, CT, MR appearance and pathological correlation. Br J Radiol. 2008; 81(962):e Choi SH, Kim KW, Hong GS, Lee SJ, Kim SY, Lee JS, Kim HJ. Sonography of hepatic hemangioma accompanied by arterioportal hunt. Clin Mol Hepatol. 2014; 20(1): Lim KJ, Kim KW, Jeong WK, Kim SY, Jang YJ, Yang S, Lee JJ. Colour Doppler onography of hepatic haemangioma with arterioportal hunt. Br J Radiol. 2012; 85(1010): Dietrich CF, Merten JC, Braden B, Schueler G, Ott M, Ignee A. Contrat-enhanced ultraound of hitologically proven liver hemangioma. Hepatology. 2007; 45(5): Sirli R, Sporea I, Popecu A, Danila M, Martie A, Bota S, Jurchi A, Sendroiu M. Contrat enhanced ultraound for the diagnoi of liver hemangioma in clinical practice. Med Ultraon. 2011; 13(2): Ryu SW, Bok GH, Jang JY, Jeong SW, Ham NS, Kim JH, Park EJ, Kim JN, Lee WC, Shim KY, Lee SH, Kim SG, Cha SW, Kim YS, Cho YD, Kim HS, Kim BS. Clinically ueful diagnotic tool of contrat enhanced ultraonography for focal liver mae: comparion to computed tomography and magnetic reonance imaging. Gut Liver. 2014; 8(3): Bilello M, Gokturk SB, Deer T, Napel S, Jeffrey RB Jr, Beaulieu CF. Automatic detection and claification of hypodene hepatic leion on contrat-enhanced venou-phae CT. Med Phy. 2004; 31(9): Dankerl P, Cavallaro A, Tymbal A, Cota MJ, Suehling M, Janka R, Uder M, Hammon M. A retrievalbaed computer-aided diagnoi ytem for the characterization of liver leion in CT can. Acad Radiol. 2013; 20(12): Taouli B, Koh DM. Diffuion-weighted MR imaging of the liver. Radiology. 2010; 254(1): Agnello F, Ronot M, Valla DC, Sinku R, Van Beer BE, Vilgrain V. High-b-value diffuion-weighted MR imaging of benign hepatocellular leion: quantitative and qualitative analyi. Radiology. 2012; 262(2): Duran R, Ronot M, Di Renzo S, Gregoli B, Van Beer BE, Vilgrain V. I magnetic reonance imaging of hepatic hemangioma any different in liver fibroi and cirrhoi compared to normal liver? Eur J Radiol. 2015; 84(5): Bore R, Mahapatra GN, Meht R, Plumber S, Dhuri S, Ali S. Scintigraphic finding of a ilent hepatic haemangioma. J Aoc Phyician India. 2010; 58: Artiko MV, Sobic-Saranovic PD, Periic-Savic SM, Stojkovic VM, Radoman BI, Knezevic SJ, Petrovic SN, Obradovic BV, Milovic V. 99mTc-red blood cell SPECT and planar cintigraphy in the diagnoi of hepatic hemangioma. Acta Chir Iugol. 2008; 55(4): Schillaci O, Danieli R, Manni C, Capoccetti F, Simonetti G. Technetium-99m-labelled red blood cell imaging in the diagnoi of hepatic haemangioma: the role of SPECT/CT with a hybrid camera. Eur J Nucl Med Mol Imaging. 2004; 31(7): Yohida J, Yamaaki S, Yamamoto J, Kouge T, Takayama T, Haegawa H, Takayau K, Muramatu Y, Moriyama N, Hirohahi S. Growing cavernou haemangioma of the liver: 11-fold increae in volume in a decade. J Gatroenterol Hepatol. 1991; 6(4): Yeh WC, Yang PM, Huang GT, Sheu JC, Chen DS. Long-term follow-up of hepatic hemangioma by ultraonography: with emphai on the growth rate of the tumor. Hepatogatroenterology. 2007; 54(74): Kobayahi T, Kawano M, Tomita Y, Tamano T, Saegua S, Horinaka M, Monma T, Oguma M, Yanagiawa N, Ohe T. Follow-up tudy of hepatic hemangioma. Nihon Shokakibyo Gakkai Zahi. 1995; 92(1): Haan HY, Hinhaw JL, Borman EJ, Gegio A, Leveron G, Winlow ER. Aeing normal growth of hepatic hemangioma during long-term follow-up. JAMA Surg. 2014; 149(12): Ng WW, Cheung YS, Lee KF, Wong J, Yu SC, Lee PS, Lai PB. I regular follow-up can for giant liver haemangioma neceary? Hong Kong Med J. 2007; 13(5): Yanai S, Tutumi H, Hotubo T, Takahahi A, Miyao N, Satoh M, Chiba S. Development of a teticular haemangioma after interferon therapy for hepatic haemangioma: a cae report. Eur J Pediatr. 1997; 156(10): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

121 ISSN Eat Cent. Afr. J. urg 53. Mahajan D, Miller C, Hiroe K, McCullough A, Yerian L. Incidental reduction in the ize of liver hemangioma following ue of VEGF inhibitor bevacizumab. J Hepatol. 2008; 49(5): Yamahita S, Okita K, Harada K, Hirano A, Kimura T, Kato A, Okita K. Giant cavernou hepatic hemangioma hrunk by ue of orafenib. Clin J Gatroenterol. 2013; 6(1): Kucherov IuI, Zhirkova IuV, Getman AN, Ivleva SA, Rekhviahvili MG. Clinical cae of treatment of hepatic haemangioma by propranolol in the newborn. Vetn Ro Akad Med Nauk. 2014;(5-6): Muthamilelvan S, Vinoth PN, Vilvanathan V, Ninan B, Amboiram P, Sai V, Anand V, Scott JX. Hepatic haemangioma of infancy: role of propranolol. Ann Trop Paediatr. 2010; 30(4): Kayaoglu HA, Hazinedaroglu S, Ozkan N, Yerdel MA. Surgical treatment of ymptomatic cavernou hemangioma of the liver. Acta Chir Belg. 2004; 104(2): Demircan O, Demiryurek H, Yagmur O. Surgical approach to ymptomatic giant cavernou hemangioma of the liver. Hepatogatroenterology. 2005; 52(61): Martinez-Gonzalez MN, Mondragon-Sanchez R, Mondragon-Sanchez A, Gomez-Gomez E, Garduno- Lopez AL, Bernal-Maldonado R, Onate-Ocana LF, Ruiz-Molina JM. Cavernou hemangioma of the liver and hepatic hemangiomatoi. Indication and reult of the urgical reection. Rev Gatroenterol Mex. 2003; 68(4): De Beul P, Roel P, Heirwegh G, Janen A, Claiken B. Spontaneou rupture: a rare complication of hepatic hemangioma. JBR-BTR. 2014; 97(5): Ozden I, Emre A, Alper A, Tunaci M, Acarli K, Bilge O, Tekant Y, Ariogul O. Long-term reult of urgery for liver hemangioma. Arch Surg. 2000; 135(8): Popecu I, Ciurea S, Braoveanu V, Hrehoret D, Boeti P, Georgecu S, Tulbure D. Liver hemangioma reviited: current urgical indication, technical apect, reult. Hepatogatroenterology. 2001; 48(39): Giuliante F, Ardito F, Vellone M, Giordano M, Ranucci G, Piccoli M, Giovannini I, Chiarla C, Nuzzo G. Reappraial of urgical indication and approach for liver hemangioma: ingle-center experience on 74 patient. Am J Surg ; 201(6): Fu XH; Lai EC; Yao XP; Chu KJ; Cheng SQ; Shen F; Wu MC; Lau WY. Enucleation of liver hemangioma: i there a difference in urgical outcome for centrally or peripherally located leion? Am J Surg. 2009; 198(2): Farge O; Daradkeh S; Bimuth H. Cavernou hemangioma of the liver: are there any indication for reection? World J Surg. 1995; 19(1): Vagefi PA, Klein I, Gelb B, Hameed B, Moff SL, Simko JP, Fix OK, Eiler H, Feiner JR, Acher NL, Freie CE, Ba NM. Emergent orthotopic liver tranplantation for hemorrhage from a giant cavernou hepatic hemangioma: cae report and review. J Gatrointet Surg. 2011; 15(1): Meguro M, Soejima Y, Taketomi A, Ikegami T, Yamahita Y, Harada N, Itoh S, Hirata K, Maehara Y. Living donor liver tranplantation in a patient with giant hepatic hemangioma complicated by Kaabach-Merritt yndrome: report of a cae. Surg Today. 2008; 38(5): Kumahiro Y, Kaahara M, Nomoto K, Kawai M, Saaki K, Kiuchi T, Tanaka K. Living donor liver tranplantation for giant hepatic hemangioma with Kaabach-Merritt yndrome with a poterior egment graft. Liver Tranpl. 2002; 8(8): Rokitanky AM, Jakl RJ, Gopfrich H, Voitl P, Anzbock W, Waipaul M, Sacher M, Hruby W. Special compreion uture: a new urgical technique to achieve a quick decreae in hunt volume caued by diffue hemangiomatoi of the liver. Pediatr Surg Int. 1998; 14(1-2): Jain V, Ramachandran V, Garg R, Pal S, Gamanagatti SR, Srivatava DN. Spontaneou rupture of a giant hepatic hemangioma - equential management with trancatheter arterial embolization and reection. Saudi J Gatroenterol. 2010; 16(2): Lupinacci RM, Szejnfeld D, Farah JF. Spontaneou rupture of a giant hepatic hemangioma. Sequential treatment with preoperative trancatheter arterial embolization and conervative hepatectomy. G Chir. 2011; 32(11-12): Bozkaya H, Cinar C, Beir FH, Parıldar M, Oran I. Minimally invaive treatment of giant haemangioma of the liver: emboliation with bleomycin. Cardiovac Intervent Radiol. 2014; 37(1): Ia P. Cavernou haemangioma of the liver: the role of radiotherapy. Br J Radiol. 1968; 41(481): Okazaki N, Yohino M, Yohida T, Ohno T, Kitagawa T. Radiotherapy of hemangioma cavernoum of the liver. Gatroenterology. 1977; 73(2): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

122 ISSN Eat Cent. Afr. J. urg 75. McKay MJ, Carr PJ, Langland AO. Treatment of hepatic cavernou haemangioma with radiation therapy: cae report and literature review. Aut N Z J Surg. 1989; 59(12): Lee HL, Chung TS, Chen SW, Lao WT. CT and MRI finding correlate with the time-coure of unreectable cavernou haemangioma of the liver after fractionated radiotherapy. Br J Radiol. 2012; 85(1011):e van Tilborg AA, Nielen K, Scheffer HJ, van den Tol P, van Waeberghe JH, Siete C, Meijerink MR. Bipolar radiofrequency ablation for ymptomatic giant (>10 cm) hepatic cavernou haemangioma: initial clinical experience. Clin Radiol. 2013; 68(1):e9-e Fan RF, Chai FL, He GX, Li RZ, Wan WX, Bai MD, Zhu WK, Cao ML, Li HM, Yan SZ. Clinical evaluation of radiofrequency ablation therapy in patient with hepatic cavernou hemangioma. Zhonghua Yi Xue Za Zhi ;85(23): Fan RF, Chai FL, He GX, Wan WX, Bai MD, Cao ML, Li HM, Yan SZ. Radiofrequency ablation therapy combined with uture and ligation urgery for patient with giant cavernou hemangioma of the liver. Zhonghua Yi Xue Za Zhi. 2006; 86(30): Cobey FC, Salem RR. A review of liver mae in pregnancy and a propoed algorithm for their diagnoi and management. Am J Surg. 2004; 187(2): Ebina Y, Hazama R, Nihimoto M, Tanimura K, Miyahara Y, Morizane M, Nakabayahi K, Fukumoto T, Ku Y, Yamada H. Reection of giant liver hemangioma in a pregnant woman with coagulopathy: Cae report and literature review. J Prenat Med. 2011; 5(4):93-6. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

123 ISSN Eat Cent. Afr. J. urg Omental Eviceration Following Bicycle Handlebar Injury N.A. Lone 1, S.A. Salati 2 1Conultant Surgery, Khyber Hopital, Srinagar, India 2Aitant Profeor, College of Medicine, Qaim Univerity, Saudi Arabia. Correpondence to: Dr. Sajad Ahmad Salati, docajad@gmail.com Introduction Direct impact bicycle handlebar-related injurie poe a eriou health rik to children and reult in ubtantial health care cot 1. The trauma i generally blunt in nature and abdominal wall rupture leading to eviceration i rarely reported in literature 2. Cae Report A 10 year boy wa brought to the emergency department after having fallen onto hi bicycle handle bar from the front. The abdominal examination revealed an obviou protruion of omentum through a defect in the right lower quadrant about 4 cm infero-lateral to the umbilicu (Figure 1 A). The abdomen wa explored under general anetheia and due to effect of mucle relaxant, the omentum got reduced revealing the true extent of the abdominal wall defect (Figure 1B). Other injurie were ruled out and the defect wa cloed in layer. There were no complication in the potoperative period. The patient wa dicharged on the econd potoperative day and the operation ite wa healthy (Figure1 C). Figure 1. (A) Eviceration of omentum (B) Abdominal wall defect after reduction of evicerated omentum (C) Surgical ite on econd pot-operative day Dicuion A child falling from a bicycle i a common cenario and can be regarded a a non-ignificant mechanim of injury with lateral fall a a low level of energy get being ditributed to a large area of the body or to an extremity. However, in the forward fall from a bicycle (a in our reported cae the body get truck in the toro againt the bicycle handlebar (often bare or lacking protective equipment). The reultant focued impact over a mall cro-ectional area, in combination with increaed abdominal preure a a reult of the initial impact of the bicycle COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

124 ISSN Eat Cent. Afr. J. urg create a ignificant probability of injury to the abdominal wall and anterior vicera, including the liver, pleen, tomach, bladder, colon and mall bowel 3. Nadler et al 4 compared the outcome in children flipping from the bicycle over the handlebar (n = 160) with thoe utaining direct impact from the handlebar (n = 61) and concluded that the children who uffered from handlebar injurie were more likely to require operative intervention (19/61 veru 28/160, p = 0.04) and had a tatitically ignificantly longer length of hopital tay (3 day veru 1 day, p < 0.001). Cherniawky et al 5 in their retropective analyi of 462 children admitted with bicycle related trauma, found the abdominal handlebar injurie in 9% of cae contributing to 19% of all internal organ injurie, and 45.4% of olid, 87.5% of hollow, 66.6% of vacular or lymphatic, and 100% of pancreatic injurie. They further potulated that the handlebar injurie were 10 time more likely to caue evere injury. The injurie at time can manifet only with ubtle clinical feature and hence lead to delay in diagnoi and management, thereby increaing the morbidity and mortality 5,6 In the erie by Cherniawky et al, 50% of patient with handle bar injurie were midiagnoed at their initial preentation. Winton et al 7 tudied the economic apect of handlebar injurie in children and found that the etimated national cot in the United State aociated with handlebar-related abdominal and pelvic organ injurie were $9.6 million in total hopital charge, $10.0 million in lifetime medical cot, $11.5 million in lifetime productivity loe, and $503.9 million in lifetime monetized quality-adjuted life-year. Hence, it i treed that the children reporting with an imprint or bruie made by the handlebar edge on the abdominal wall, or who preent a clear hitory of injurie by a bicycle handlebar hould be treated with utmot care 3-6 and deemed a eriou, until proven otherwie by proper evaluation, frequently repeated clinical examination and timely imaging. Prohibiting the ue of bicycle with unpadded handlebar and requirement for afer handlebar deign with innovative oft padding like rubber handlebar helmet to avoid harp cutting end, may provide an avenue to prevent bicycle handlebar injurie primarily 8 jut a trategie and legilation for helmet utilization by bicyclit have proven to reduce the number of eriou head injurie 4. Reference 1. Winton FK, Wei HB, Nance ML, Vivarelli-O'Neill C, Strotmeyer S, Lawrence BA, Miller TR. Etimate of the incidence and cot aociated with handlebar-related injurie in children. Arch Pediatr Adolec Med. 2002; 156(9): Minh Hung Nguyen, Adam Waton, Ed Wong. A 6-year-old boy preenting with traumatic eviceration following a bicycle handle bar injury: a cae report. Cae J. 2009; 2: Karaman I, Karaman A, Alan MK, Erdogan D, Cavuoglu YH, Tutun O. A hidden danger of childhood trauma: bicycle handlebar injurie. Surg Today. 2009; 39(7): Nadler EP, Potoka DA, Shultz BL, Morrion KE, Ford HR, Gaine BA. The high morbidity aociated with handlebar injurie in children. J Trauma. 2005; 58(6): Cherniawky H, Bratu I, Rankin T, Sevcik WB. Seriou impact of handlebar injurie. Clin Pediatr (Phila). 2014; 53(7): Lam JP, Eunon GJ, Munro FD, Orr JD. Delayed preentation of handlebar injurie in children. BMJ. 2001; 322(7297): Winton FK, Wei HB, Nance ML, Vivarelli-O'Neill C, Strotmeyer S, Lawrence BA, Miller TR. Etimate of the incidence and cot aociated with handlebar-related injurie in children. Arch Pediatr Adolec Med. 2002; 156(9): Clarnette TD, Bealey SW. Handlebar injurie in children: pattern and prevention. Aut N Z J Surg. 1997; 67(6): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

125 ISSN Eat Cent. Afr. J. urg Unuual Preentation of Invaive Baidiobolu mycoi a a Pelvic Ma in a 3-year-old Child: a Cae Report J. Trudea 1, G. Mwango 1, J. Mathaiya 2, I. Githinji 1, C. Onyambu 1, E. Walong 2. 1Department of Diagnotic Imaging and Radiation, Univerity of Nairobi 2Anatomic Pathology Unit, Department of Human Pathology, Univerity of Nairobi Correpondence to: Dr. Mwango Glady, gmwango@yahoo.com Background: Invaive fungal infection by agent of ubcutaneou mycoi in immunocompetent patient i rare and therefore poe a diagnotic challenge. Zygomycoi i endemic in Africa, Aia and Latin America; but i rarely conidered a a differential diagnoi in paediatric pelvic mae due to it non-pecific clinical preentation and abence of etablihed predipoing factor. Thi cae report aim at increaing the clinical upicion of thi condition which lead to timely patient management. Cae Report: We preent a cae of a 3 ½ year-old boy who wa referred to a tertiary teaching hopital in Kenya with what wa thought to be a peri-anal abce not reponding to antibiotic treatment. Imaging tudie revealed an infiltrating pelvic ma whoe imaging feature mimicked pelvic paediatric malignancie. The eventual diagnoi on hitopathology wa invaive zygomycoi caued by Baidiobolu pecie. The patient uccumbed to the illne and autopy confirmed the diagnoi. Concluion: Diagnoi of invaive zygomycoi require a high index of upicion. Clinical, radiological and pathological correlation i required for timely diagnoi and management. There are no reliable radiological feature that ditinguih thee leion from other paediatric malignancie. Introduction There are le than 1000 proven cae of invaive zygomycoi worldwide 1. Mot of thee cae have been reported within the lat two decade, indicating it ignificance a an emerging dieae 2,3. Since the microorganim i acquired through inhalation; paranaal inue and lung are affected in a majority of cae (39% and 24% repectively) 2. Other ytem affected are the kin (19%) and the gatrointetinal tract (7%) 2. Wherea there are few cae report of oteomyeliti and endocarditi; there ha been no report of pelvic zygomycoi 1. Zygomycoi i a group of filamentou fungi which conit of two order, the Mucorale and the Entomophthorale 2. Mucorale are characteried by an acute angioinvaive infection in immunocompromied patient 2. Entomophthorale, which include Conidiobolu and the more common Baidiobolu pecie, i characteried by a chronic non-angioinvaive, ubcutaneou infection of the thigh, buttock or trunk in immunocompetent individual 1. In Eat Africa, a review of 80 cae of zygomycoi (then referred to a phycomycoi) wa performed in Uganda in 1976, which howed that 76% to 88% of the patient were le than 10 year of age 4. In the review, the peculiar ditribution of the dieae wa attributed to the ue of toilet leave following defecation 4,5. Baidiobolu ranarum i found in decaying plant material, leave of deciduou tree and oil within tropical and ubtropical area 1,4. We report a unique COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

126 ISSN Eat Cent. Afr. J. urg cae of pelvic baidiobolomycoi which mimicked a pelvic embryonal tumour in a Kenyan infant and preented a clinical and radiological diagnotic dilemma. Cae Report A 3 ½ year-old boy wa referred to a tertiary teaching hopital from a county hopital in Kenya with a peri-anal abce of one-month hitory not reponive to antibiotic treatment. There wa no hitory of fever, trauma, bowel or urinary ymptom. On phyical examination, he wa found to be normal in height and weight for age and afebrile. He had a oft, non-ditended abdomen with no palpable ma. There wa a warm, tender, perianal welling which wa dicharging pu and inguinal lymphadenopathy. The child wa immunocompetent. Surgical inciion and drainage of the peri-anal abce had been performed and intravenou metronidazole and ceftriaxone adminitered with no clinical improvement. Figure 1. Lateral plain pelvic radiograph howing a oft tiue ma antero-inferior to the acro-coccygeal bone. Viualized pelvic bone and femur are intact. (Radio-opaque marker on anal orifice) Figure 2A. Ultraound image howing an ioechoeic pelvic ma infiltrating the bladder and cauing bladder wall thickening. Ballooned Foley catheter i een in itu.. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

127 ISSN Eat Cent. Afr. J. urg Figure 2B. Ultraound image of the kidney howing bilateral hydronephroi more prominent on the left. m c A B b C m D Figure 3. Axial contrat enhanced CT can image of the abdomen and pelvi. A) Bilateral hydronephroi left more than right. B) Large heterogeneouly enhancing ma (m) in the pelvi diplacing adjacent igmoid colon (c). C) Ma urrounding the urinary bladder (b) and involving it wall. The ma (m) urround and involve the rectum. D) The ma i een to extend to the left inguinal region and left gluteal region (arrow) with aociated bilateral inguinal lymphadenopathy. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

128 ISSN Eat Cent. Afr. J. urg A B b m r C D Figure 4: Axial contrat enhanced CT can image of the abdomen and pelvi in the delayed phae. A) Bilateral hydronephroi with excretion from the right kidney, a evidenced by contrat media in the dilated right renal pelvi. No contrat excretion noted from the left kidney. B) The large, ill-defined pelvic ma i een urrounding the dilated ureter. The colotomy ite noted, on the left anterior abdominal wall (arrow). C) The ma i een to urround and involve the urinary bladder (b) and rectum(r). D) The ma (m) extend into the left adductor compartment. There i bilateral inguinal lymphadenopathy Figure 5: Gro photograph of the pelvic organ and large intetine howing an infiltrating ma engulfing the urinary bladder with relative paring of the colon. The ma involve the COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

129 ISSN Eat Cent. Afr. J. urg rectal and bladder eroa. There i no evidence of intetinal obtruction or vacular involvement Figure 6. Photomicrograph of hitological ection of the pelvic ma: Image 1 (Haematoxylin and Eoin) how chronic granulomatou inflammation with multinucleated giant cell and fungal hyphae. The arrow how the Splendore-Hoeppli phenomenon. Image 2 (Grocott Methenamine Silver) how fungal hyphae with characteritic dark taining of the fungal cell wall. Image 3 (Immunohitochemitry, polyclonal anti Baidiobolu immunohitochemitry) confirm the genu of the fungal hyphae. Laboratory finding at the tertiary hopital revealed haemoglobin level of 9.78g/dl, peripheral blood leucocytoi of 32.2 x 10 9 /L, neutrophilia (74.1% on differential count) and thrombocytoi (744 x 10 9 /L).There wa no evidence of peripheral blood eoinophilia. Chet radiograph wa unremarkable and a pelvic AP and lateral radiograph howed an ill-defined ofttiue denity ma overlying the acrum. A ubequent ultraound examination howed a large ill-defined oft tiue ma filling the rectoveical pouch and encloing the urinary bladder. There wa thickening of the bladder wall, bilateral hydronephroi and hydroureter. The liver, gall bladder, pancrea and pleen were normal. There wa no para-aortic adenopathy. An infiltrating pelvic malignancy wa upected, rhabdomyoarcoma being the mot likely diagnoi. Surgical drainage of the peri-anal abce and an inciional biopy wa re-attempted and an indurated cutaneou leion wa found, there wa no pu. Inciion biopie of the cutaneou leion a well a an exciion biopy of the inguinal lymph node were ubmitted to the laboratory for hitopathology. A few day later however, the child developed intetinal obtruction. Thi required urgical management, a igmoid colotomy wa fahioned. Abdominopelvic CT can uing water for oral contrat and iodinated non-ionic water-oluble intravacular contrat wa performed. There wa a large ill-defined, infiltrating oft tiue ma with heterogeneou contrat enhancement, occupying the entire pelvic cavity and engulfing the urinary bladder and rectum. The bladder wall wa markedly thickened. The adjacent pelvic wall were infiltrated and the leion extended into the left ichio-rectal foa, gluteal and adductor compartment. There wa aociated inguinal lymphadenopathy, bilateral COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

130 ISSN Eat Cent. Afr. J. urg hydroureter and hydronephroi; more evere on the left than the right. No acite or intraabdominal adenopathy wa een. The liver, gall-bladder, pleen, adrenal and pancrea were normal. There wa no keletal involvement. During the pot-operative period, the child developed high-grade fever. Repeat peripheral blood count howed worening anaemia (7.95g/dl), leucocytoi (25.3 x 10 9 /L with a neutrophilia of 72.6%) and thrombocytoi (501 x 10 9 /L). Urinalyi wa poitive for nitrite-poitive Klebiella which wa enitive to meropenem. He received antibiotic therapy but unfortunately uccumbed due to epi. Hitopathology of the perianal ma biopy wa reported a a pilonidal inu with no evidence of ubcutaneou mycoi. Section of the lymph node biopy tained with haematoxylin and eoin, and Grocott Methenamine Silver howed a non-necrotizing chronic granulomatou inflammatory leion with foreign body type multinucleated giant cell and filamentou fungal hyphae. At autopy, a oft-tiue infiltrating abdominal-pelvic ma wa found ariing from the pelvic floor, acra-coccygeal and pubic region, and extending to the abdominal aortic bifurcation. The ma engulfed the rectum and igmoid, the iliac vacular channel, the perioteum of the ileum and the pelvic facia. Kidney ection demontrated hydronephroi and hydroureter. Further hitopathological analyi of the ma confirmed the preence of the filamentou fungal hyphae. Polyclonal immunohitochemitry (IHC) and polymerae chain reaction (PCR) confirmed infection by Baidiobolu pp. Dicuion In thi cae report, the young male patient preented with perianal ubcutaneou mycoi and a pelvic ma, which extended to involve the pelvic floor, pelvic wall, rectum and urinary bladder. The clinical ymptom and ign were nonpecific, leading to initial conideration of perianal abce. On imaging, the ma mimicked an embryonal rhabdomyoarcoma. However thi wa revealed on hitopathology a a chronic infection by Baidiobolu pp. Thi i the firt report of baidiobolomycoi in a child whoe preentation i a pelvic ma. Baidiobolomycoi preent a painle erythematou firm ubcutaneou plaque 5. There may be kin ulceration, lymphadenopathy and non-pitting oedema of the involved limb 4. Viceral involvement i rare and ha been reported in the gatrointetinal tract where it preent with tran-mural thickening, intimal nodule and ulceration reembling Crohn dieae or gatrointetinal malignancie 3,6. In the cae preented, there wa involvement of the kin, ubcutaneou tiue and peri-pelvic facia with encaing of the pelvic vicera. According to the majority of cae report, ubcutaneou and invaive baidiobolomycoi i aociated with anemia, eoinophilia, elevated IgE, elevated ESR and thrombocytoi 6,7. In thi cae, there wa no evidence of peripheral blood eoinophilia, which contributed to the diagnotic dilemma. Untreated zycomycoi infection i aociated with 100% mortality rate 3. Zygomycoi i diagnoed by identifying it characteritic morphology on tiue biopy where it induce a non-necrotizing granulomatou chronic active inflammation 5. Surrounding the hyphae i a dene eoinophilic infiltrate and the Splendore-Hoeppli reaction 5,7. Molecular technique are ued in combination with morphology becaue, unlike culture, they are rapid, precie and accurate 7. Applying Polymerae Chain Reaction (PCR) in addition to morphology uing routine, pecial and immunohitochemical tain, we can confirm that the fungu i Baidiobolu p. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

131 ISSN Eat Cent. Afr. J. urg Concluion Thi i the firt report of pelvic baidiobolomycoi. It mimicked malignant dieae and lacked peripheral blood eoinophilia. Delayed diagnoi wa due to a low index of upicion and nonpecific radiological feature. Clinical, radiological and pathological correlation i required for timely diagnoi and management of thi dieae. Acknowledgment Prof Emily Rogena, Department of Pathology, Univerity of Nairobi), Dr Sherif Zaki (Diviion of High Conequence Pathogen, CDC), Dr Fazzal (Pediatric Surgery Reident Univerity of Nairobi) Reference 1. Roden M, Zaouti T, Buchanan W, et al. Epidemiology and outcome of Zygomycoi: A review of 929 reported cae. Clinical Infectiou Dieae. 2005; 41: Bittar D, Van-Cauteren D, Lauternier F, et al. Increaing Incidence of Zygomycoi (Mucormycoi) in France, Emerging Infectiou Dieae Geramizadeh B, Foroughi R, Kehtkar-Jahromi M, et al. Gatrointetinal Baidiobolomycoi, an emerging infection in the immunocompetent hot, a report of 14 patient. Journal of Medical Microbiology. 2012; 61 (12): Mugerwa J. Subcutaneou phaehyphomycoi in Uganda. Britih Journal of Dermatology. 1976; 94: R, Kontoyianni D and Lewi. Agent of Mucormycoi and Entomophothoramycoi. [book auth.] Bennet J and Dolin R Mandel G. [ed.] 7th. Principle and practice of Infectiou Dieae. Philadelphia : Churchil Livingtone, 2010, pp Huein M, Mahmoud R. Mucocutaneou Splendore-Hoeppli phenomenon. Journal of Cutaneou Pathology. 2008; 35: Zabolinejad N, Naeri A, Davoudi Y et al. Colonic Baidiomycoi in a child: Report of a culture proven cae. International Journal of Infectiou Dieae. 2014; 22: Vikram H, Smillac J, Leighton J, et al. Emergence of Gatrointetinal Baidiolomycoi in the United State, with a review of worldwide cae. Clinical Infectiou Dieae. 2012; 54 (12): COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

132 ISSN Eat Cent. Afr. J. urg Management of Cholangiocarcinoma in Developing Countrie. : Report of Seven Cae and Review of Literature. EBFK Odimba 1, M. Nthele 2, P. Phiri 3, C. Saleh 4 1Department of Surgery, Univerity teaching Hopital, Luaka, 2 Conultant urgeon, Livingtone General Hopital, Livingtone, 3 Conultant Surgeon, Mana General Hopital, Mana, 4Lubumbahi Univerity Clinic. Correpondence to: Prof E.B.F.K. Odimba, etienne.odimba@yahoo.com Background: Cholangiocarcinoma are primary malignant tumour developing from the epithelia of the biliary duct from the liver to the end of the bile duct in the duodenum. The objective of thi review wa to hare our experience of even well documented with thi condition out of eleven obervation treated at the Luaka Univerity Teaching Hopital (UTH) and point out the impact of palliative urgery played to provide comfortable quality urvival. Method: Thi wa a ten-year retropective tudy all patient operated on at the Luaka Univerity Teaching Hopital with confirmed diagnotic of cholangiocarcinoma. Seven well documented cae out of eleven treated were conidered for thi tudy. Reult: Of the even patient diagnoed with cholangiocarcinoma, four were male and three were female with age ranging from 57 to 68 year and mean age of 64 year. At the time of admiion, painle obtructive jaundice, with lo of appetite and lo of weight were recorded in 5 of the 7 patient followed by chronic right upper quadrant pain (28.56%). Abdomen Ultraound and CT Scan were performed only in two patient (28.56%) and the per tran hepatic cholangiogram in one patient(14.48%). Not any hitological diagnoi wa made pre or intra operatively. The finding and management outcome are decribed. Concluion: Depite the mall number of thee tumour (very rare worldwide) but by reviewing literature data, author noted the everity of the condition related to long tanding jaundice and co-morbiditie, confirmed the challenge in diagnoi and therapeutic deciion making. They encourage reaonable tumour reection and bile diverion a able to procure atifactory urvival a they had many twelve-month urvival after palliative urgery without free margin a expected in world literature. However they continue appealing for more modern medical imaging and hitological diagnotic tool in their urgical facilitie. Key word: Cholangiocarcinoma, Bile duct, Gall bladder, Bile obtruction, biliary convergence, Surgery. Introduction Cholangiocarcinoma are malignant tumour of mutated epithelial cell of the biliary duct from the liver to the duodenum 1. Thee cancer of the bile duct are rare: 1-2 cae/ inhabitant in the Wetern world but eem increaing in ome circumtance a tated by Landi et al 2, prevailing in people of 50 to 70 year old 3. They alway preent eriou diagnotic and treatment challenge ince they uually grow lowly and pread gradually and are diagnoed in advanced tage 2, 4 making the prognoi poor worldwide with a 5-year relative urvival etimated for intrahepatic bile duct cancer: 15% (localized), 6% (regional), 2% (ditant) and for extrahepatic bile duct cancer: 50% (localized), 24% (regional), 2% (ditant) a tated by American cancer ociety 5. The uual chronic hortage of required management tool in developing countrie enhance thi challenge in our etting. The objective of the tudy wa to analyze a ten-year experience on bile duct cancer at the Luaka with regard to the management of thee tumour and a 12-month potoperative follow-up. COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

133 ISSN Eat Cent. Afr. J. urg Patient and Method Thi wa a ten-year retropective tudy from 1/1/2001 to 1/11/2010 at the Luaka Univerity Teaching Hopital (UTH) including all patient undergoing urgery for cholangiocarcinoma. Author erved alo a participant oberver. The Luaka UTH i the urgical catchment of Zambia and the tertiary referral of the country for all major in general and biliary tree cancer in particular. A total of eleven bile duct cancer were retrieved during the tudy period but only even with well documented record with regard to targeted variable were conidered with thi tudy taking in account a twelve-month potoperative follow-up. The tudy ued a tructured quetionnaire including age, ex, ABO group, co-morbiditie, rik factor, main complaint at the time of admiion, clinical examination finding, performed invetigation and finding, urgical technique a well a problem encountered in deciion making, hitological diagnoi and the twelve month-follow up with regard to complication and mortality. Depite the mall number of patient, after data collection, variable were categorized among independent and dependent, compiled and preented on table and diagram. Cae Report The finding in the even cae are ummarized in the table below. Table 1. Cae 1. Feature / complaint MB...NG.; F/62Y; DOA: 15/02/01; ABO group: A+ Symptom Right upper quadrant pain; Lo appetite; Athenia; Weight lo Co-morbiditie High Blood preure; Diabete milletu/2; ASA:2 Rik factor Cholecytiti; Galltone Sign Right upper quadrant tenderne; Murphy tet +; liver enlargement, High blood preure Laboratory tet Hb/10,5g/dL; Bilrubin: 20µmol/L; ALP:40iu/L; Fat BS: 18mmol/L; HBSAg: negative Medical Imaging Plain Xray: Right lung baal infiltration, Raied rightt diaphragm; Enlarged liver Per operative finding and treatment 27/2/01: Right Gall bladder tumour evading liver, Perihepatic lymph node: Extended cholecytectomy to 5 th, 6 th liver egmentectomy+ Outcome clearance+ intraoperative cholangiographie through T tube Clavien 2 complication. Dicharge on 11/3/01; lat review 12month later; WHO core 2 KEY: Hb: Hemoglobin, BS: Blood ugar, ALP: Alkaline phophatie, HBSAg: Hepatiti B erum Antigen. Ultra ound. PUD: Peptic ulcer dieae. BP: Blood preure Table 2. Cae 2 Particular and complaint LUK.DAN ; M/57Y ; DOA 05/09/02. ABO group: B+ Symptom Painle jaundice; Lo appetite; Athenia; Weight lo Co-morbiditie Drinker 20 year; Smoker 15 year; ASA: 3 Rik factor Hepatiti B; Liver cirrhoi Sign Deep jaundice; Enlarged liver; Right hypochodrium ma; Murphy tet+ Laboratory tet Hb/9,5g/dL. Bilrubin: 600µmol/L ALP:70iu/L; HBSAg: poitive Medical Imaging done Plain Xray/ non pecific infiltration of lung, US: enlarged liver, dilated common bile duct Per operative finding and treatment 19/10/02: Exploratory laparatomy; Cholecytectomy+ clearance+ Ttube + Intra-operative cholangiogram; Intrahepatic peripheral and peri hepaticpedicle biopy: cholangiocarcinoma Outcome Clavien 2 Complication; Dicharged on 11th November 2002; Lat new 2 nd month after dicharge; WHO core 3; Death 3/12 potoperatively COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

134 ISSN Eat Cent. Afr. J. urg Table 3. Cae 3. Particular and complaint CHI...PAT; F/64Y; DOA 17/07/04. ABO group: A+ Symptom Puriti before Painle jaundice; Athenia; Lo of appetite; Weight lo Co-morbiditie Diabete mellitu type 2; HBP ; Atenolol Alcohol (occaionally.); ASA: 3 Rik factor Gall bladder tone (previou cholecytectomy) Sign Deep jaundice; Enlarged liver; Murphy tet negative; BP: 160/90+ Laboratory tet Hb/10,5g/dL; Bilrubin: 80µmol/L; ALP:90iu/L; FatBS 12mmol/L; Medical Imaging done US: Very dilated intra hepatic duct. Tranhepaticcholangio+++: dilatation of left and right intra hepatic duct, not viualization beyond Per operative finding and treatment 17/08/04: Thoracolaparotomy: Klatkin tumour; Hepaticojejunotomy (Y-loop end to ide + biopie) Outcome Clavien 2 Com-plication: bile leak+epi. Dicharged on8 th//9/04 Lat new 12 month after dicharge: WHO core 3 ; Alive 12 th month potoperatively. Table 4.Cae 4. Particular and complaint NK..CHA ; M/66Y ; DOA 11/06/05. ABO group: B+ Symptom Painle jaundice; Puriti before; Lo of appetite; Athenia; Weight lo Co-morbiditie High blood preure 15 year; Alcohol occaionally; ASA2 Rik factor PUD on triple therapy for 6 year Sign Deep jaundice; Enlarged liver; Ditended gall bladder, Murphy tet poitive; BP: 150/95+ Pule rate 110 Laboratory tet Hb/11g/dL. Bilrubin: 95µmol/L ALP:92iu/L; Blood culture: Kebiella; AgHBS: negative Imaging done US: enlarged liver, acalculou gall bladder., Dilated bile duct from uprapancreatic area egment: Tranhepatic cholangiogram informative+++: Per operative finding and treatment 17/07/05: Exploratory laparotomy; Tumour exciion +Choledocojejunotomy (Y loop end to ide + biopie); 4 unit blood; Abdominal drain Outcome Clavien 1 Complication: Dicharged on 3/8/05 Lat new 12 month after dicharge: WHO core 2 ; Table 5. Cae 5. Particular and complaint Symptom Co-morbiditie Rik factor Sign Laboratory tet Medical Imaging done Per operative finding and treatment SE MUN ; M/65Y; DOA 27/07/07. ABO group: B+ Painle jaundice; Puriti before; Athenia; Lo of appetite; Weight lo HBP for 8 year Alcohol (occaionally.) ASA3 Ulcerative coliti 6 year Deep jaundice; Enlarged liver; Ditended gall bladder, Murphy tet poitive; BP: 140/95+ Hb/10g/dL. Bilrubin: 90µmol/;L ALP:96iu/L; AgHBS: negative; US: enlarged, hetergenou liver, acalculou gall bladder; dilated uprapancreatic and intrahepatic duct. CT Scan.informative+++ 15/8/2007: Exploratory laparotomy; finding: retropanceratic bile duct ma; Cholecyto-jejunotomy (Y loop end to ide + biopie); 4 unit blood; Abdominal drain; biopy Outcome Clavien 1 Complication: Dicharged on 25 TH Augut 2007 Lat new 12 month after dicharge:who core 3 COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

135 ISSN Eat Cent. Afr. J. urg Table 6. Cae 6. Particular and ND..SHI ; F/65Y ; DOA 25/11/09 ; ABO group: A+ complaint Symptom Right hypochondrium pain; Athenia; Lo of appetite Co-morbiditie High Blood Preure; Duodenal PUD; ASA: 2 Rik factor Right hypochondrium chronic pain: cholecytiti, galltone Sign Right hypo-chondrium tenderne, Murphy tet poitive; Right upper quadrant ma, Raied blood preure Laboratory tet Hb/10,5g/dL. Bilrubin: N ALP N Fat BS: 8mmol/L; Imaging done Chet Xray + plain abdomen Normal Per operative finding and treatment 27/2/01:: Exploratory laparotomy: Tumoral gall bladder with tone. Cholecytectomy. Intraoperative cholangiogram. Hitology: Adenocarcinoma of Gall Bladder Outcome Clavien 1 complication.; Dicharge after 1 week; Lat review WHO core 1 Table 7. Cae 7. Particular and complaint Symptom Co-morbiditie Rik factor Sign Laboratory tet Imaging done Per operative finding and treatment Outcome BA. FU; M/68Y; DOA: 22/4/10 /04/10. ABO group: O+ Painle Jaundice 2/12;Puriti before; Athenia Lo of appetite; Weight lo HBP, Alcohol ASA3 Ulcerative coliti 6 year Deep jaundice; Enlarged liver; Ditended gall bladder, Murphy tet poitive Hb/9g/ dl. Bilrubin: 100µmol/L ; ALP:98iu/L; AgHBS: negative. US: enlarged hetergenou liver, acalculou gall bladder; dilated upra pancreatic and intrahepatic duct. Abdomen CT Scan.informative TH May 2010: Exploratory lap; finding; Retro pancreatic bile duct ma; Cholecyto-jejunotomy (Y loop end to ide + biopie); 4 unit blood; Abdominal drain; biopy Clavien 1 Complication: Dicharged after 10 day. Lat new 3 month after dicharge:who core 3. Death 5 month pot dicharge There were even patient: four male (57.1%) and three female (42.9) with age ranging from 57 to 68 year and mean age of year. Male to Female ratio wa of 4/3: The patient ABO group ranged a follow: 3 A+ (42.9%), 3 B+ (42.9%) and 1 O+ (14.3%). At the time of the admiion the prominent ymptom were: painle obtructive jaundice, with lo of appetite with or without pruriti in five patient (71.4%), followed by chronic right upper quadrant pain (28.6%). All even patient have co-morbiditie (100%) with ASA claified at ASA3 for four patient (57.1%), ASA2 for three patient (42.9%); high blood preure in ix patient (85.71%); alcohol abue in three patient (42.9%); diabete mellitu in two (28.6%) and tobacco abue in one (14.3%) At leat one rik factor of developing a cholangiocarcinoma wa found in each patient (100%); hitory of gall tone or cholecytiti or cholecytectomy in three patient (42.86%); peptic ulcer dieae in two (28.86%); liver cirrhoi in one (14.28%), hepatiti B in one (14.28%) and ulcerative coliti in one (14.3%) The main phyical ign were included deep jaundice (71.4%), enlarged liver (85.71%), right upper quadrant tenderne (42.9%), right upper quadrant ma (42.9%), high blood preure at COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

136 ISSN Eat Cent. Afr. J. urg the time of admiion (85.7%). Liver function tet confirmed the obtructive (71.4%) with raied conjugated bilirubin and alkaline phohatae. Six patient (85.7%) had an haemoglobin rate lower than the normal. Only in three cae (42.9%) out of even the real location of the tumour had been etimated by pre-operative medical imaging: tranhepatic cholangiogram (third obervation), Ultraonography and CT Scan (fifth and 7 th obervation). Almot for all the even cae (100%) the precie location wa made during the operation with or without intraoperative cholangiogram that erved alo in checking the quality of the repair. Figure 1. Tranhepatic cholangiogram: hilar tumour without extenion Figure 2. Tranhepatic cholangigram: infra hilar obtruction Figure 3. Intra-operative cholangiogram: Slightly dilated bile duct. Abence of bile leak Figure 4. US: Low denity liver metatae Figure 5. CTcan Tumour Head of Pancrea COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)

137 ISSN Eat Cent. Afr. J. urg Figure 6. Well differentiated Cholangiocarcinoma (gall bladder) Obervation 1 Figure 7. Poorly differentiated cholangiocarcinoma Intrahepatic duct bile. Obervation 2 Figure 8. Cholangiocarcinoma: papillar type Figure 9. Bile duct carcinoma, mucine type The intraoperative finding, procedure of treatment and outcome are ummarized in Table 8 Apart from one from the gall bladder tumour dicovered on the piece of cholecytecomy done for cholecytiti, the ix other cae were conidered a advanced tumour with macrocopically ditant depoit and performed urgery wa aumed palliative. Palliative urgery and 12- month follow-up for the variou tumour tood a follow: four patient were till alive on the 12 th month review (longer urvival than that from literature): one after an extended cholecytectomy for gall bladder cancer, a econd after pot cholecytectomy for gallbladder tone and tumour, a third after convergence tumour exciion and hepaticojenotomy, a fourth after partial upra pancreatic bile tumour exciion and choledoco-jejunotomy for an infra hilar and pre pancreatic biliary tumour and the fift after a cholecyto jejunotomy for retropancreatic bile duct tumour. The death occurred in two other cae: three month after an exploratory laparotomy with biopy of bilateral intrahepatic cholangiocarcinoma and the lat after cholecyto-jejunotomy for retropancretic bile duct malignant tumour COSECSA/ASEA Publication -Eat and Central African Journal of Surgery. July/Augut 2015 Volume 20 (2)