Background: The incidence of multiple primary cancers is reported to be between 0.734% and 11.7%. The occurrence of another malignancy of different organ in patients with known malignant tumor is known as double malignancy and is categorized into synchronous; in which the cancer occurs at the same time or within 6 months and metachronous; in which cancer follows in sequence more than 6 months apart. We review the presentation and management of synchronous malignancies in two different organs. Patients and Methods: All the patients who underwent surgery for malignancy between July 2009 and July 2013 were reviewed and the patients who had synchronous malignancies were identified. Their clinical presentation, treatment and outcome were evaluated. Results: Out of a total of 286 patients with malignancies treated in our institute, four had synchronous primary malignancies (1.39%). Three of them underwent surgery simultaneously for both the malignancies and were given adjuvant chemotherapy. One patient presented with colonic obstruction due to sigmoid carcinoma which was operated in an emergency setting and was later in the postoperative period found to have a synchronous periampullary carcinoma. Two of the patients who were managed with surgery followed by chemotherapy are doing well. Whereas the other two patients have died. Conclusion: Treatment strategies in cases of double malignancy depend on treating the malignancy that is more advanced first, or sometimes both malignancies could be treated simultaneously. If both are amenable to surgical resection as in two of our cases both the malignancies may be dealt with at the same time. The prognosis of the patients with dual malignancies depends on the aggressiveness and the stage of presentation of the more advanced tumor.

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Pyomyoma (suppurative leiomyoma) is a rare disease that can result in very serious complications. Though most cases have occurred in pregnant or postmenopausal women with a predisposing factor, we present a case that apparently presented spontaneously. A young nulligravid woman presented with a history of abdominal pain and swelling of 2 weeks duration which became worse despite use of potent broad-spectrum antibiotics. She had no fever or predisposing factors, but had history of leiomyoma. Ultrasonographic scan showed an enlarged uterus with a solitary large mass. Internal heterogeneous echogenicity was noted within the mass in the anterior wall of the body of the uterus. With a clinical impression of degenerated leiomyoma, she underwent abdominal myomectomy. However, intraoperative findings showed a leiomyoma with abscess formation. The postoperative course was uneventful. Pyomyoma is rare and may be difficult to diagnose clinically, especially in women with a nonspecific clinical presentation. A strong clinical suspicion and prompt surgical intervention with the use of broad-spectrum antibiotics can be lifesaving.

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Malignant phyllodes tumor may occur with heterelogous differentiation. Sarcomatous stromal elements that may be seen in these tumors include angiosarcoma, chondrosarcoma, leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and liposarcoma. However, liposarcomatous stromal differentiation in malignant phyllodes tumor is very rare. We report a case of an 18-year-old lady who presented with a 4-months history of recurrent huge rapidly growing ulcerated left breast mass. A clinical impression of ulcerated malignant phyllodes tumor was made. Simple mastectomy was necessary due to the recurrent nature of the lesion, presentation, and available facilities. Histological findings revealed a lesion exhibiting leaf-like pattern and composed of a highly cellular stroma demonstrating myxoid changes, liposarcomatous differentiation including lipoblasts and bizarre tumor giant cells. A histologic diagnosis of malignant phyllodes tumor with liposarcomatous differentiation was made. She had an un-eventful post-operative period and was discharged to follow up.

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Small bowel obstruction due to internal herniation of jejunum through a congenital defect in the falciform ligament is a rare occurrence. Literature search shows not more than 14 cases of internal herniation of the small bowel through a congenital defect of the falciform ligament; and there are no reports of challenges faced in the diagnosis of herniation in pregnant patients. Here, we describe a rare case of internal hernia which posed significant diagnostic dilemma as the patient was 20 weeks primigravida. With restriction on the use of imaging tools, diagnosis of small bowel obstruction due to internal herniation through the falciform ligament was done by combining clinical findings with magnetic resonance imaging (MRI) and laparoscopy. The intestinal obstruction was resolved laparoscopically. The recovery was uneventful and the patient was discharged on postoperative day 4. The diagnosis of internal hernia as a cause of intestinal obstruction is usually difficult especially in the pregnant patient. However, careful examination and appropriate investigations will suggest the diagnosis which if promptly treated would be attended by a satisfactory outcome.

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Acute inversion is a rare but serious obstetric emergency. Women can rapidly develop profound shock which can prove fatal if not treated appropriately. A young multiparous woman was rushed to the obstetric unit of the hospital with a history of delivery at home under the supervision of her husband a few hours before presenting with a mass protruding from the vagina and associated severe vaginal bleeding. On examination, she was noticed to have complete uterine inversion of the uterus. She was promptly resuscitated with intravenous fluids and the uterus was manually replaced immediately. She was further managed with analgesics, uterotonic agents, antibiotics and three pints of blood was transfused. She made uneventful recovery and she was discharged from the hospital after 3 days. Uterine inversion is rare, therefore a strong clinical suspicion and prompt intervention in the form of immediate replacement of the uterus, blood transfusion, intravenous fluids with the use of broad spectrum antibiotics can be life-saving. The management of acute uterine inversion should be incorporated into skills and drills training.

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Background: Sickle cell anemia (SCA) is characterized by a constant state of hemolysis which leads to hyperbilirubinemia. Hyperbilirubinemia may predispose to development of pigment gallstones in these patients. Gallstones in SCA patients increase morbidity and mortality and poses diagnostic dilemma as most patients are asymptomatic. The objective of this study was to evaluate the gallbladder using ultrasonography, biochemical, and hematological parameters among adult SCA patients in steady state at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. Patients and Method: We conducted a case-control cross-sectional study of adult SCA patients attending the hematology clinic of ABUTH, Zaria, Nigeria and HbAA controls. Sixty-seven consenting adult SCA patients in steady state and twenty HbAA controls had abdominal ultrasonography, biochemical, and hematological tests on blood samples. Information obtained was entered and analyzed using Statistical Package for the Social Sciences (SPSS) 17.0. Statistical evaluation consisted of descriptive analysis and comparison of means using student's t-test. Level of significance was set at P < 0.05. Results: Of the 67 SCA patients, 19 (28.4%) had gallstones, and the prevalence increased with increasing age of the patients. There were significant differences in all laboratory parameters between SCA patients and the HbAA controls except alkaline phosphatase levels. While there were no significant differences in these parameters between SCA patients with gallstone and those without gallstone except the gallbladder volume. All the SCA patients with gallbladder stones were asymptomatic. Conclusion: There is a high prevalence of gallbladder stone in SCA patients, especially after the age of 20 years. Thus, abdominal ultrasonography should be part of the routine care of SCA patients, especially after the second decade of life.

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Background: The gold standard for the treatment of posterior urethral valves (PUV) in children is endoscopic ablation of the valves under direct vision. This study reports the use of Foley's catheter balloon in the ablation of posterior urethral valves in children in a developing center in Nigeria. Patients and Methods: Thirteen patients with PUV seen at the Obafemi Awolowo University Teaching Hospital in Ile Ife between January 2004 and March 2008 were included. The patients' age ranged from 7 days to 3 years. Results: The obstruction was completely relieved in 12 out of the 13 patients(88.9%). There were no cases of significant hemorrhage, perineal hematoma, or urinary extravasations. All mothers reported good urinary stream and absence of straining at micturition. Six patients had bilateral hydronephrosis on pre-avulsion USS while 4 had vesico-ureteric reflux on micturating cystourethrogram. All patients had resolution of the hydronephrosis on follow up USS and the electrolytes and urea status has remained normal during the follow-up period ranging from 3 months to 1 year. Conclusion: Foley catheter ablation of PUV in children is a simple and cost-effective technique and may offer an alternative in resources limited environment.

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Hydatid disease of the liver is a common problem in developing countries. We present a case of huge hydatid cyst in the superior-posterior segments of liver, which was managed through combined abdominothoracic approach. Surgical intervention was done first through subcostal incision followed by anterolateral thoracotomy through sixth intercostal space with circumferential incision in the diaphragm as exposure through the abdominal approach was inadequate. The cyst was drained and the cavity filled with omentum to obliterate the residual space. Patient recovered well and was discharged after 1 week. This approach is useful when access is inadequate to hydatid cysts in the superior and posterior parts of the liver.

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Mixed goblet cell carcinoid-adenocarcinoma in the gastrointestinal tract is a rare disease. The incidence of such tumors have been reported to range from 0.3-4.3%. A 70-year-old female presented with acute intestinal obstruction. Explorative laparotomy revealed tumor in the tip of appendix, stricture of distal ileum around 30 cm proximal to ileo-cecal junction due to circumferential serosal deposits of metastatic tumor leading to acute intestinal obstruction. Widespread metastasis was present with ascitis. Histopathological examination revealed mixed goblet cell carcinoid-adenocarcinoma of appendix with metastasis of mixed features in ileum and omentum. Appendicectomy and resection of the stricture with end to end anastomosis was performed.

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Male breast abscess is a rare occurrence. Few cases have been reported earlier in association with human immunodeficiency virus infection, salmonella infection, and breast cancer. However, male breast abscess resulting as a complication of epidermoid cyst has not been reported yet. The diagnosis of male breast abscess is clinical. The typical inflammatory skin changes can be noteworthy clue to the diagnosis. Ultrasonography and fine needle aspiration cytology are useful adjuncts in making diagnosis and finding the probable etiology of the abscess. The treatment of simple male breast abscess is incision and drainage along with daily dressings. In the presence of infected epidermoid cyst as the underlying pathology, the cyst wall should be completely excised to prevent recurrence. We describe an interesting case of male breast abscess occurring due to infected epidemoid cyst which was treated adequately with incision and drainage along with cyst wall excision and post-operative regular wound dressings.

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Background: Gynecological malignancies are very common in Northern Nigeria. Although cervical cancer has been classified as HIV-related malignancy, little information is available on the pattern of presentation of gynecological malignancies in HIV patients. The objective of this study was to analyze the age distribution, site of origin, stage, and HIV status of cases of gynecological malignancies seen at a radiotherapy facility in Northern Nigeria. Patients and Methods: Between January 2006 and December 2011, consecutive patients with histologically confirmed gynecological malignancies were studied retrospectively and evaluated with respect to age, site of tumor, histological type, stage of disease, and retroviral status. Patients' folders were reviewed using a standardized structured proforma. Results were analyzed using Epi Info software 3.4.1, 2007 edition. Results: A total of 350 gynecological malignant cases were reviewed. The age range was 21-86 years, with a mean age of 49 years, a modal age group of 41-50 years, and a median age of 50 years. The commonest gynecological malignancy observed was cervical cancer (81.7%), followed by ovarian epithelial cancer (6%), endometrial cancer (4%), ovarian germ cell tumor (3.14%), vaginal cancer (2.3%), vulvar cancer (2.3%), and myometrial sarcoma (0.6%). In all, 85.1% patients had locally advanced disease, 9.4% had metastatic disease, and 5.4% had early stage disease at presentation. HIV seropositivity was 10.3%; however, 94.4% of those with HIV had cancer of the cervix. Conclusion: In this review, the peak modal age group for gynecological malignancies is the fifth decade of life. Cervical cancer is the commonest gynecological malignancy seen with preponderance of late stages of the disease at presentation. HIV seropositivity is highest among women with cervical cancer than among women with other cancers, as seen in the facility.

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Background: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model, its Portsmouth (P-POSSUM) modification are two surgical risk scoring systems used extensively to predict post-operative morbidity and mortality in general surgery. The aim was to undertake the study of validity of these models in Indian patients undergoing exploratory laparotomy for perforation peritonitis. Patients and Methods: A prospective study was performed, in which a total of 103 patients undergoing exploratory laparotomy for perforation peritonitis were included during the period of November 2011 to October 2013. The morbidity and mortality risks were calculated using the POSSUM and P-POSSUM. Results: Around 44/103 patients developed complications (total morbidity rate of 42.72%) in post-operative period; this was compared with POSSUM predicted morbidity. There was no statistical difference between observed and predicted morbidity (χ² = 45.607; df = 1; observed/expected ratio (O:E) = 0.82; P value = 0.000). Ten patients died (total mortality rate of 9.7%). The P-POSSUM expected mortality rate was compared. There was no statistical difference between the observed and P-POSSUM predicted mortality rates (χ² = 17.444, df = 1; P value = 0.000). However, P-POSSUM overpredicts mortality in our study (O:E = 0.25; P value = 0.000). Conclusion: POSSUM and P-POSSUM appear to be good and valid indices for use in risk prediction of morbidity and mortality, respectively (surgical outcome in perforation peritonitis) in the Indian population. We found that POSSUM accurately predicts morbidity but P-POSSUM is not able to predict mortality accurately.

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Background: Anal fissure is a common disease and has a myriad of treatment options. The aim of this study was to re-evaluate lateral subcutaneous sphincterotomy in the treatment of anal fissure. Patients and Methods: We retrospectively studied143 patients with chronic anal fissure at King Abdulaziz University Hospital between March 1995 and April 2011, to determine the outcome of lateral subcutaneous sphincterotomy. These patients were studied using file data, operative notes, post operative course, OPD follow up. Variables studied were age, sex, nationality, History of previous surgery, recurrence, open or closed sphincterotomy, healing of wound, duration of healing [weeks], post op pain, post op bleeding, incontinence of flatus, liquid or solid stool, length of incontinence, duration of surgery, and weather admitted or treated as a day case. Results: In our study the youngest patient was 18 years old and the oldest 67 years old with mean age 42.5 years. Majority were females 65% and males 35%. Saudis were 52.4% and non Saudis were 47.5%. 55.4% of patients had previous surgery. Recurrence occurred in 5.4% of patients. 42.3% underwent closed surgery and 57.7% open surgery. Duration of operation was minimum 4 minutes and maximum 25 minutes with mean duration of 14.5 minutes. 11.9% of patients needed admission while 88.1% were treated as day case. Healing occurred in 72.8% while 27.2% did not have healing of wounds. Majority of wound healed in one week-57.6% and 18.4 had healing in two weeks while longest healing occurred in 52 weeks. Longest follow up was 180 weeks. Post op pain occurred in 50% of cases and no pain in 50% of cases. Post op bleeding occurred in 23.9% of patients. There was no incontinence in 80.4% of cases while 14.1 % of patients had incontinence of flatus, 4.3% of liquid stools 1% incontinence of solid stool. Length of incontinence was one to sixteen weeks. In 16.3% cases incontinence was resolved and in 3.2% cases it did not resolve. 73.9% of patients expressed satisfaction of treatment while 17.3% were partially satisfied and 8.6% patients were not satisfied with the treatment. Conclusion: Lateral sphincterotomy is a safe, effective treatment of anal fissure and evolving as a gold standard treatment for chronic anal fissure.

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Cancer is a genetic disease and genetic mutation is in the heart of carcinogenesis. We attribute the defects to gene, but in fact it is their genetic protein products that regulate all cell activities, like cell division, deoxyribonucleic acid (DNA) repair, apoptosis, cell differentiation, etc. When they (gene and genetic protein) get mutated, a step ahead is taken towards carcinogenesis. The mutation leads to some basic attributes which ultimately is responsible for carcinogenesis. These are self-sufficiency in growth signals, insensitivity to growth inhibitory signals, evasion of apoptosis, unlimited replicative potential, sustained angiogenesis, invasive and metastasizing capabilities, and genomic instability due to defects in DNA repair. It is not necessary that all the attributes are essentially playing part at a given time, but some may be playing more important role than other. An endeavor is made in this article to address these attributes and their influence in carcinogenesis.

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