Background: The fundamentals in the treatment of acute peritonitis include resuscitation, treatment of septicemia, control of the contaminating source and peritoneal toilet. Numerous studies have shown the roles of different solutions such as normal saline, antibiotics and betadine as intraperitoneal lavage, in reducing morbidity and mortality of peritonitis. The objective of this study was to present our findings on the role of intraperitoneal lavage with normal saline and normal saline followed by super-oxidized solution in patients with acute peritonitis. Materials and Methods: The patients were randomly allotted by slip method into two groups of 50 each. In the control group, after the definitive surgery for the pathology of peritonitis, the peritoneal cavity was lavaged with normal saline and closed after putting drains. In the study group, after the definitive surgery the peritoneal cavity was lavaged with saline followed by 100 ml of super-oxidized solution and drains were closed for 1 h after abdominal closure. The patients were followed-up for morbidity and mortality. Results: Surgical site infection (SSI) was present in 27 out of 100 cases in both groups. In the study group, out of 7 infected cases, intraperitoneal fluid cultures were positive in 6 cases, but only 3 had positive swab cultures. In the control group, out of 20 infected cases, swab culture was positive in 16 cases (p = 0.0399). Among the study group, bowel sounds return in 4.10 ± 1.20 days compared to 5.9 ± 1.17 in the control group. In the study group, fever >100°F developed in 14 (28%) patients in the post-operative period whereas in the control group it was 29 (58%) (p < 0.0024). SSI rates in the two groups were (7/50) 14% and (20/50) 40% respectively (p = 0.0034). Conclusion: This study suggests that super-oxidized solution is effective and safe in reducing post-operative complications including SSI, burst abdomen and episodes of post-operative fever.

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Symptomatic clavicular non-union is a rare clinical condition which causes pain and functional disability, if not managed on time. We report the long-term consequences in a 25 year old young male patient with established atrophic and aseptic non-union of the middle third of the clavicle. Patient was treated by open reduction and internal fixation with Arbeitsgemeinschaft für Osteosynthesefragen (AO) Dynamic Compression Plate and autologous cancellous bone grafting harvested from the iliac crest. There was no operative or post-operative complications and the patient returned to the previous level of activities. We conclude that plate fixation with bone grafting is a reliable and safe method for the management of symptomatic non-united fractures of the middle third of the clavicle.

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Background: A surgical fire is a rare but life-threatening event. They are always unexpected and commonly occur in head and neck surgeries resulting in severe burns, disfigurement, and in some cases death. Injuries are not limited to patients alone as they may also involve health-care personnel in the operating theater. There is a resurgence in the awareness of this intra-operative challenge as well as an understanding of the need for a team approach to prevention. Materials and Methods: The surgical fire triangle is a useful paradigm that describes the three elements necessary for initiation of a surgical fire i.e., ignition source, fuel, and an oxidizer. This review will identify operating theatre contents capable of acting as ignition/oxidizer/fuel sources and highlight the management and prevention of surgical fires. Results: Surgical fires can be prevented by education across all professional boundaries in the operating theater. This will entail information on how the elements of the fire triangle interact, recognizing how standard operating room equipment can initiate a fire, and vigilance for the circumstances that increase the likelihood of a surgical fire. Conclusion: Promoting a culture of fire safety in the theater is not optional. Education on the prevention of surgical fires should be included in the curriculum of undergraduate medical students. There is an urgent need to stimulate debate within National burn associations in this context, leading to the formation of proposals to be incorporated into existing National burn prevention plans.

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Background: Proximal hypospadias with chordee is the most challenging variant of hypospadias to reconstruct. Significant variability exists for preferred approaches of repair. Often combinations of procedures are required in staged manner. Here, we have combined steps of pelvic fracture urethral distraction defects (PFUDD) repair with tubularized incised plate procedure in a single stage. Materials and Methods: A total of 8 patients consisting of 5 adults (mean age 20 years) and 3 children less than 3 years old that presented with proximal hyposphadias were included. All patients underwent degloving and progressive perineal approach as described by Webster for repair of PFUDD including mobilization of the entire bulbar urethra from the neomeatus to the membranous urethra with division of lateral attachments, division of attachment from perineal body and corporal separation. Mobilization of the urethral plate from the corpora cavernosa to the glans was carried out. The urethral plate was tubularized with a dorsal incision. Results: The neomeatus was advanced by a distance of 2.5-3.8 cm in all eight patients. Dartos fascia was used in 5 adults and 1 child for cover. Two patients required a tunica vaginalis flap as dartos was tethered during the harvesting. Catheter drainage was 18 days on an average (14-21 days). Fistula (pinpoint) occurred in one adult, which healed with further catheter drainage. All the patients were voiding normally and satisfied in terms of cosmetic appearance. None of the patients had wound infection or total disruption, residual chordee, meatal stenosis or any erectile difficulties. Conclusion: The steps of progressive perineal approach for repair of posterior urethral distraction defects if followed aids in achieving the goals of proximal hypospadias surgery in a single stage.

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Background: Both open and laparoscopic appendectomies are commonly performed procedures. The aim of this study was to investigate the differences between open and laparoscopic appendectomy (LA) in the management of acute appendicitis. Patients and Methods: This study was conducted at Bahrain Defence Force Hospital in the Kingdom of Bahrain. A total of 106 patients who underwent appendectomies in the year 2009 were included in the study. A total of 71 patients had laparoscopic appendectomies, while the remaining 35 underwent open procedures. Clinical outcome measures were compared between the two groups with respect to six variables. Results: The study included 106 patients: 71 underwent LA while the remaining 35 underwent open appendectomy (OA). The operating time was shorter for the OA patients than for the LA patients (LA, 73.5 +/- 35 min vs. OA, 59.5 +/- 23 min; p value 0.033), which is statistically significant. The difference in hospital stay of 1.55 +/- 1.0 days for the LA group and 1.77 +/- 1.3 days for the OA group with P-value 0.323 was not statistically significant. Return to oral diet was the same in both groups with no statistical difference (LA, 14.4 +/- 7.6 h vs. OA, 15 +/- 7.9 h; p = 0.720), return to work (LA, 11 +/- 4.8 days vs. OA, 11+/- 4.1 days; p = 0.964). Although the rate for overall complications was lower in the LA group (2.8% vs. 5.7% in OA), it was not statistically significant (p value = 0.452). Conclusions: The overall results showed no significant difference between the laparoscopic and open appendectomies, except for the operating time that was significantly shorter in the OAs.

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Introduction : The incidence of AIDS-associated Kaposi's sarcoma (AAKS) is increasing in the West African sub-region. The objective of this study was to describe the epidemiologic and clinical features of AAKS. Materials and Methods : This study was carried out in a tertiary health center with a federal government supported AIDS treatment program in Zaria, Nigeria. The subjects comprised 137 consecutive patients evaluated for AAKS from 2006 to 2011. Following evaluation appropriate specimens were taken for histologic, virologic, and immunologic assessment. Result : There were 137 patients representing 1.4% of HIV infected patients seen during the study period. The male to female ratio was 1.3:1. Their ages ranged from 2 to 58 years, mean of 32 ± 6 and females were younger than males. Mean duration of symptoms was 4.2 ± 1.5 months. Kaposi's sarcoma was the AIDS-defining disease in 95 (69.3%) patients while in 42 (30.7%) it was diagnosed between 1 and 15 months after the diagnosis of HIV infection. The lower limbs were the most frequent sites of lesions. Females had more disseminated lesions involving an increased number of lesions at multiple anatomical sites compared with more localized lesions in the males (OR 2.7, 95% CI 1.5-7.0). The CD4 count ranged from 19 to 798 cells/mm ³ , median 132; interquatile range 102-317 cells/mm ³ while the median HIV RNA copies/ml of plasma was 51,723 (ranged 250-917, 254). Conclusion : The prevalence of AAKS is increasing in our institution. Female patients were younger and had more disseminated disease that progressed faster than in males. Timely identification of HIV-infected patients is essential to avoid the consequences of immunological deterioration associated with delayed anti-retroviral therapy.

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Background: Frequently, a general surgeon is called upon to consider the diagnosis of appendicitis in a girl or woman who is pregnant or has recently delivered. The burden of clinical decision-making and execution of treatment would rest on the general surgeon, with other specialists playing peripheral, but important supportive roles. This condition is relatively rare in pregnancy. A delay in operative intervention is often incurred in view of the risk of general anesthesia and operation on the fate of the pregnancy. Promptly diagnosed in a patient who sought medical assistance early in the evolution of the disease, acute appendicitis in pregnancy (AAP) should not pose an operative challenge to the contemporary surgeon or risk to the woman and her unborn child. It is the aim of this review to appraise AAP in the light of contemporary evidence based medicine and to demystify it with a view to encouraging general surgeons to boldly confront a potentially lethal disease and not to add to the patient's suffering by hiding behind unnecessary laboratory and imaging investigations. Materials and Methods: Many search engines are used such as MedLine, PubMed and Google scholar to search out discussions related to AAP. All the acquired information was processed to arrive at the conclusions drawn here in this essay. Results: AAP can be promptly diagnosed and treated with high index of suspicion. Awareness of this condition in pregnant patients must be high. The condition if diagnosed early and treated promptly can have a good outcome. Conclusion: Acute appendicitis is a relatively rare condition in pregnancy; surgeons must have a high index of suspicion as early diagnosis and treatment are important factors in a safe outcome of this condition.

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Fibrous proliferation of testicular tunica also known as fibrous pseudotumor of the testis are are uncommon lesions. These lesions are usually difficult to clinically differentiate from testicular tumors. We describe two cases of pseudotumors of the paratesticular region. The tumors in both cases simulated the appearance of a neoplastic process on gross examination. The first patient presented with a testicular mass while the second presented with acute scrotal abscess. A fibromatous pseudotumor completely encased the testes in both patients. In addition to fibrosis, ossification of the tunica led to "eggshell calcification" on imaging in the first case. Both tumors were successfully resected with an uneventful recovery. Histological examination revealed hypocellular dense collagen bundles with areas of coagulative necrosis with mononuclear inflammatory infiltrate. No evidence of cellular atypia or increased mitosis was seen. There was no tumor recurrence at 15 months follow-up. Fibrous pseudotumors should be considered in the clinical differential diagnosis of testicular and paratesticular masses.

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Abcess within a brain tumor is very rare and is usually seen in a pituitary tumor. We present a patient with glioblatoma that was found to contain abcess at operation. A 50-year-old man presented with a rare case of glioblastoma associated with intra-tumoral abscess formation manifesting as seizures, headache and vomiting after fever, cough, and chest infection. Computed tomography and magnetic resonance imaging demonstrated a ring-enhanced lesion mimicking malignant glioma. Craniotomy and tumor removal were performed. Abscess formation within the intra-axial tumor was found intra-operatively. Histological examination revealed glioblastoma with abscess and the etiological agent was anaerobic gram-negative bacilli. The post-operative recovery of the patient was satisfactory. Abcess in a gliobastoma is uncommon. The suspected route of microbial migration and colonization in this tumor was probably bacteremia from chronic lung infection. Careful evaluation and appropriate treatment would lead to a good outcome.

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Background: Glaucoma is a common cause of blindness in developing nations. The objective of this study is to determine the severity of primary open angle glaucoma and audit health records of glaucoma patients in our center. Materials and Methods: A retrospective case note search of glaucoma patients from out-patient clinic was carried out between January 2001 and December 2010. Data analysis included descriptive statistics and exact binomial 95% confidence interval (CI) calculated for the mean estimates. Results: Seventy-six patients (152 eyes), comprising 49 (64.5%) males and 27 (35.5%) females were included in the study. The age ranged from 15 to 88 years (mean: 54.2 ± 14.5). Forty-five (59.7%) presented with normal vision and 10 (13.2%) had visual acuity <3/60 in at least one eye. Cup-Disc-Ratio (CDR) on the right eyes were ≤0.6 = 12 (15.8%), >0.6 < 0.9 = 27 (35.5%), >0.9 = 35 (46.1%) and left eyes were 15 (19.7%), 29 (38.2%), 28 (36.8%), respectively. Mean intraocular pressure (right eyes) at presentation was 20.3 mmHg (95% CI, 17.4-23.3) and reduced to 13.4 mmHg (95% CI, 10.7-16.0) at the last readings while left eyes from a mean of 20.3 mmHg (95% CI, 16.9-23.8) reduced to 12.1 mmHg (95% CI, 10.0-14.3). The mean presenting CDR were 0.79 (95% CI, 0.74-0.83) and 0.73 (95% CI, 0.68-0.79) in right and left eyes, respectively. CDR showed statistical significance with age (p < 0.001, yate-corrected X ² -test) but not with sex (p = 0.807). Conclusion: Late presentation of glaucoma cases is a major problem in Calabar. We recommend public enlightenment, case detection, and early treatment to reduce ocular morbidity.

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Background: Teratomas generally arise in the gonads, although several cases are reported in the extra gonadal sites. This study described the histopathological features of cases seen in a tertiary institution in Nigeria. Materials and Methods : This is a retrospective study of surgical biopsy specimens seen over 10-year period; data were analyzed with respect to age, sex, site, and histopathological characteristics and grading. The H and E, stained slides were retrieved in each case and reviewed microscopically by the authors. Results : Teratomas were observed in two adult and 37 infants and children. The age range was 5 days-38 years. Site of origin was Sacrococcygeal in 43.6%, retroperitoneal in10.3%, cervical in 12.8% and 20.5% in others. Mature teratomas account for 82.0% while 18.0% were immature teratoma. Three of the immature teratoma were grade III while the remaining four where grade II. There were more benign than malignant teratomas. Conclusion : Extragonadal teratomas are common in our environment with benign preponderance.

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Soft-tissue sarcoma of the hand is a rare entity. Hand sarcomas are more challenging to manage than those in other sites, due to a variety of factors including highly specialized, intricate anatomy, and absence of redundant soft-tissue. Hand-sparing surgery is now the most common option for sarcomas of the hand. We present our experience of hand sparring surgery in a patient with sarcoma of a thumb. We present a rare case of clear cell sarcoma of the thenar region of the right hand, managed by hand preserving wide excision of the primary tumor and amputation of the thumb at the metacarpal level. The wide defect created after excision of the tumor was effectively covered by a "fillet flap." Limb sparing, function preserving surgeries are the standard of care wherever possible. An effective technique, the fillet flap, which was pragmatic in providing a working hand for our patient can be valuable in a select group of patients in a low resource setting.

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Laparoscopic cholecystectomy (LC) has become the standard treatment for symptomatic cholelithiasis. Bile duct injury remains worrisome complication. We report a case of post-LC biloma causing empyema, respiratory distress and sepsis that was managed successfully. A 44-year-old male had bile leak post-LC. Endoscopic retrograde cholangiopancreatography showed common bile duct (CBD) injury. CBD stenting was done. 2 days later he developed severe sepsis due to Klebsiella pneumoniae biloma and empyema. Both were drained by computerized tomographic scan guided pigtail catheter. Empyema required further video-assisted thoracoscopic surgery. Bile leak following LC may progress to biloma and K. pneumoniae empyema with sepsis. Minimal invasive surgical procedure is a helpful and effective treatment.

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Feeding jejunostomy is a procedure of tremendous importance in our day-to-day practice of gastrointestinal surgery. Like any other surgical procedure, it is also associated with some common complications such as pain, infection, intra peritoneal leakage, dislodgment, strangulation, and small bowel necrosis. Small bowel intussusception is a complication of feeding jejunostomy, which is very rare and unique. We report the case of a 30-year-old female who presented with small bowel intussusceptions following feeding jejunostomy.

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Bezoars are usually present as a mass in the stomach. It is formed due to eating non-food items like hair (trichobezoar), vegetable matter (phytobezoar), and sand bezoar. There are many such cases reported in literature of bezoars but there very few cases of bezoar formed by plastic material. We report an unusual case of plastobezoar that was extending from the stomach to distal ileum, and the patient presented with features of intestinal obstruction. An 8-year-old female child was admitted with history of abdominal pain and constipation for 3 days. Her mother gave a history of ingestion of plastic fibers from mattress filled with plastic fibers by the patient. Abdominal examination revealed moderate distention and tenderness but with no features of peritonitis. Mental health assessment was performed by the psychiatrist and it did not reveal any gross abnormality. Following clinical examination, laboratory test and radiological imaging background, a diagnosis of intestinal obstruction due to bezoar was made. After proper resuscitation, laparotomy was performed and plastobezoar was removed from stomach and intestine through a gastrostomy and enterostomy respectively. Both stomach and intestine were primarily closed. Other abdominal viscera were normal. Abdominal cavity was closed in layers. Post operative period was uneventful. Patient was discharged in satisfactory condition. Early diagnosis of bezoar should be made by detailed history and psychiatric evaluation so that they can be treated endoscopically to avoid laparotomy and operative mortality.

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Background: Medical practitioners including some specialists who do not have vesicovaginal fistulae (VVF) management experience are in the habit of operating VVF patients and this result to a little success or even to more surgical trauma. Therefore it is imperative to have a simple, feasible and acceptable initial care of VVF patients by all medical practitioners. The objective of this study was to demonstrate the role of indwelling urethral catheter in initial management of obstetric fistulae. Materials and Methods: In a period of 1 year (July 2009-June 2010) seven patients with obstetric fistula were evaluated prospectively and divided into two groups. Group 1 (GP1) includes five patients (71.0%) who had indwelling urethral catheter as a mainstay for their management. Group 2 consists of two patients (29.0%) who had VVF repair via vaginal approach. Demographic information, types of VVF, healing success, associated obstetric injuries, and complications were analyzed. Results: The patients' age ranged from 14 years to 18 years with average of 16.30 years. Four patients out of the seven were booked at antenatal clinic; only two out of the former had delivered at a hospital. All babies were delivered at term with male to female ratio of 2.5:1. Four patients (57.10%) had eclampsia. Five patients (71.40%) had assisted deliveries while 2 (28.60%) had cesarean section because of prolong labor. Patients started leaking urine at average 10.40 (8-14) days after delivery. Urethral catheterization was enough to heal the fistula in 5 (71.40%) patients. Conclusion: Urethral catheterization is feasible and acceptable as an initial stage for obstetric VVF management, especially in poor resource communities.

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Background: Immunotherapy for the treatment of malignancies is based on the concept that cancer cell might be specifically antigenic or that immune response is diminished in patients with cancer. Levamisole is a synthetic phenylimidazolthiazole that has been used in adjuvant chemoimmunotherapy in colon, rectal, stomach, and breast cancer. Only limited studies have been conducted regarding the use of immunomodulators in breast cancer. The aim of this study was to evaluate the effect of the addition of Levamisole to neo-adjuvant chemotherapy on local immune response in invasive breast cancer. Materials and Methods: A total of 27 consecutive patients with biopsy-proven breast cancer scheduled for neo-adjuvant chemotherapy were included in the study. Levamisole 50 mg thrice daily for 3 days, repeated at 2 weekly intervals, was given along with three cycles of neo-adjuvant cyclophosphamide 500 mg/m ² , adriamycin 50 mg/m ² , 5-FU 500 mg/m ² (CAF) given at 3-weekly intervals. Assessment of lymphocytic infiltration of tumor stroma was done before and after completing neo-adjuvant chemoimmunotherapy. Results: There was an increase in tumor infiltrating lymphocytes in 81.48% of patients after administration of Levamisole-based neo-adjuvant chemoimmunotherapy. In 75% of patients with clinical response to neo-adjuvant chemoimmunotherapy, there was an increase in tumor-infiltrating lymphocytes. In addition, in 68.2% of patients with an increase in tumor infiltrating lymphocytes, there was a clinical response to therapy. Conclusions: Our study suggests an immunostimulatory effect of Levamisole in breast cancer when given along with neo-adjuvant chemotherapy. However, a larger series is required to determine the clinical significance of these findings and whether neo-adjuvant chemoimmunotherapy should be recommended for routine use in breast cancer.

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Even though Meckel's diverticulum is the most common anomaly of the gastrointestinal tract, it is asymptomatic in the majority of cases. With life time complication rate of 4%, it is an uncommon cause of intestinal obstruction in adult. We report a case of Meckel's diverticulum attached to undescended testis presenting as acute abdomen in an adult with intestinal obstruction. The patient a 36-year-old man presented with acute abdominal pain, vomiting and distension. On examination, there was distension of the abdomen with tenderness and guarding rigidity and absence of testis in right scrotum. Erect X-ray of abdomen showed multiple air fluid levels suggestive of intestinal obstruction. A diagnosis of acute intestinal obstruction was made and the patient was resuscitated and taken to the operation theater after adequate hydration and antibiotic cover. On exploration, it was found that Meckel's diverticulum attached to undescended testis with diverticular band forming an entangled mass, which caused complete obstruction of the bowel. It was treated successfully with resection of diverticulum and the band followed by a bowel anastomoses and orchidectomy. We conclude that it is indeed rare for two different congenital anomalies coexisting together to cause intestinal obstruction in an adult patient. High clinical suspicion is required to diagnose such rare congenital abnormality which if followed promptly by surgical intervention would lead to a satisfactory outcome.

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Pancreatic endocrine tumors are uncommon and represent 1-2% of all pancreatic neoplasms. Nonfunctioning pancreatic endocrine tumors constitute 30-40% of pancreatic endocrine tumors. They can occur at any age, but are rare in childhood. About 65-80% of nonfunctioning pancreatic endocrine tumors are associated with clear-cut evidence of malignant behavior. A 14-year-old girl presented with abdominal pain of 2 weeks duration with occasional vomiting. Abdominal examination did not reveal any abnormality. Ultrasound and computed tomography (CT) scan of the abdomen showed solid mass lesion located in the head of pancreas. The patient underwent Whipple's pancreaticodudenectomy. Microscopically, the mass was circumscribed, containing oval to polygonal cells. There was no pleomorphism, significant mitotic activity or evidence of capsular or vascular invasion, and a diagnosis of benign pancreatic islet cell tumor was made. Although benign nonfunctioning pancreatic islet cell tumor is rare in children, such diagnosis should be considered when there is an isolated mass in the pancreas. Appropriate resection of such mass is attended with good outcome.

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