Download That Patients May Not Die After Successful Surgery

UNIVERSITY OF LAGOS
Inaugural Lecture 2013 Series
“THAT PATIENTS MAY NOT DIE AFTER
SUCCESSFUL SURGERY”
By
Oluwole Ayoola ATOYEBI
MB, BS. Honours (Lagos), FMCS, FWACS, FICS
Professor of Surgery
College of Medicine of the University of Lagos
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PROTOCOL
The Vice-Chancellor, Professor Rahamon Adisa BELLO,
Deputy Vice-Chancellor (Academic & Research), Professor Babajide ALO,
Deputy Vice-Chancellor (Management Services), Professor Duro ONI,
Registrar and Secretary to Senate & Governing Council, Oluwarotimi SODIMU Esq.
My Provost, Professor Folashade Tolulope OGUNSOLA
Dean, Faculty of Clinical Sciences, Professor Foluso Ebun Afolabi LESI,
Deans of Other Faculties
Members of Senate of the University of Lagos
My Lords, Spritual and Temporal
Distinguished Ladies and Gentlemen.
INTRODUCTION
I wish to commence this Lecture by appreciating our Vice-Chancellor for approving my choice of
date for this Inaugural Lecture despite the short notice. I felt I should, as soon as possible, discharge
my obligation of delivering my Inaugural Lecture immediately after completing my tenure as the 12th
Provost of the College of Medicine of the University of Lagos because the lecture had become almost
8 years overdue. I apologize for this delay which was largely due to my other services to the
community. I was the National President of the Nigerian Medical Association when I was appointed
a Professor in the Department of Surgery of the University of Lagos, the University of First Choice
and the Nation’s pride. Over the last 4 years, I also served as the Provost of the College of Medicine
of the University of Lagos. All through these periods, I was also engaged in some clinical duties and
was thus unable to deliver the lecture before now..
Mr. Vice-Chancellor Sir, my Inaugural Lecture is the 14th by an Academic Surgeon from my
Department and I must pay homage to others before me. These Professors were Late H. O. Thomas,
Late Akin O. Adesola, E. Ade Elebute, Late Paul Omodare, Erete O. Amaku, Late M. O. A. Jaja, G.
O. A. Sowemimo, B. Akande, J. T. da Rocha-Afodu, D. N. Osegbe, P. A. Okeowo, H. O. AdeyemiDoro and lastly in 2005, Professor Ajesola A. Majekodunmi before the department of Opthalmology
was excised from the Department of Surgery. Incidentally, I am the 4th Provost of the College
produced by my department, and the three great men before me delivered their inaugural lectures
either just before or during their tenure as Provost and I believe I am following the trend by
delivering my own soon after leaving office.
I have been considering the topic for my Inaugural Lecture since I was first shortlisted for a fullProfessorial appointment in 2001 but the appointment did not come until several years thereafter. It
is noteworthy that after I have considered other options like “The Evolution of a Breast Surgeon”,
“Surgical Outcome: Beyond Surgical Precision”, “The Travails of an Academic Surgeon” and some
others, I have finally settled for the original idea of over eleven years ago. The title of my lecture,
“That Patients May Not Die After Successful Surgery”, is borne out of a shocking experience I had
when I was admitted to this University over four decades ago which influenced my choice of surgery
as a Specialty, the direction of my research endeavours as an Academic Surgeon and indeed my
involvement in what we refer to as “MEDICAL POLITICS”.
It is interesting to note that when I completed the Secondary School education in 1969, my plan was
to become an Engineer as I thought I should do well in it having obtained A1 in Physics and
Additional Mathematics among others at the West African School Certificate Examination. In
addition, I hoped to be in a profession that would enable me to use my hands as well as my brain.
However, when I arrived in Lagos to submit my application form for admission to University of
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Lagos, I stayed overnight with my Uncle, Mr. Kunle Adetunji, because I arrived late in the evening.
During the night, he insisted that I should change my choice of course to Medicine instead of
Mechanical Engineering and I bulged. I spent my first year, referred to as Preliminary Medicine, at
this Main Campus at Akoka and lived in the boy’s quarters of one of the Lecturers in the then College
of Education. The shocking experience was that a distinguished Professor in the College of
Education was announced to have died at the Lagos University Teaching Hospital after a “successful
surgical operation” which involved removal of a swelling at the front of the neck due to an enlarged
Thyroid gland (referred to as a Goitre). I could not imagine how an operation could have been
described as successful and the patient moved to the ward only to die thereafter. I was sad and
challenged; I felt surgery should be the area that I should pay attention to in my career as a doctor.
According to Wikipedia, the free online encyclopedia, “Surgery, (from Latin: Chirurgiae meaning
“hand work”) is an ancient medical specialty that uses operative manual and instrumental techniques
on a patient to investigate and or treat a pathological condition such as disease or injury or to keep
bodily function or appearance. An act of performing surgery may be called surgical procedure or
operation”. It is now well known that Medicine as a profession is as much of an “Art” as well as
“Science”. One can therefore accept, without fear of contradiction, the definition that “Surgery is a
technology consisting of a physical intervention on tissues to treat diseases, injuries and anomalies”.
According to Atul Gawande of Havard’s School of Public Health, “Surgery is a profession defined by
its authority to cure by means of bodily invasion. The brutality and risks of opening a living person’s
body have long been apparent, the benefits only slowly and haltingly worked out. Nonetheless, over
the past two centuries, surgery has become radically more effective, and its violence substantially
reduced — changes that have proved central to the development of mankind’s abilities to heal the
sick1”.
Ancient Surgery dates back to pre-historic times and one of the earliest archeological evidence is
trepanned skulls from the Stone Age. Some adults had holes cut in their skulls. There are different
postulates for the purpose of the procedure, but it may as well be performed on people with head
injuries to release pressure on the brain as is done today by neurosurgeons. There were also
substantial evidence in pre-historic times of highly skilled Indians who were pioneers of plastic
surgery as they reconstructed damaged noses (rhinoplasty) as people were often punished by having
the nose cut off. Surgery in the Middle Ages was developed to a higher degree in the Islamic world
by Abulcasis, an Andalusian-Arab physician and scientist who helped to shape the European Surgical
practice where a new type of craftsmen emerged, the barber-surgeons, who not only cut hair, they
also pulled teeth and performed simple operations such as amputations and setting of broken bones.
Between the 16th century and 19th century, surgery became slightly more advanced with emergence
of great surgeons like Andreas Vesalius (1514-1564), Ambroise Pare (1510-1590, father of military
surgery) and John Hunter (1728-1793) who invented the life-saving procedure of tracheostomy and is
often referred to as the Father of Modern Surgery. Surgery increasingly became more of “Science”
than “Craftmanship” as it was based on knowledge of Anatomy.
Mr. Vice-Chancellor Sir, before the middle of the 19th century, when Joseph Lister introduced
“Antiseptic Surgery”, infection following apparently successful surgical operations contributed to
half of the deaths and this led to a common report by surgeons that the “Operation was a success
but the patient died”, a term that has now gone to common usage to describe failed interventions
and projects which may have nothing to do with medicine. Joseph Lister published his work in the
foremost international medical journal, The Lancet (March 1867) under the title “Antiseptic Principle
of the Practice of Surgery”2. Antisepsis is the removal of transient microorganisms from the skin and
instruments by the use of chemical solutions. This progressed to Aseptic techniques which are aimed
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at further minimizing infection by the use of sterilized instruments and gloves and also employing the
no-touch technique.
Modern Surgery has however developed rapidly in the 20th century with new approaches to the
control of not only INFECTIONS but also BLEEDING which was responsible for most of the other
half of post-operative deaths. Subsequently, the discovery of Blood Transfusion allowed major
surgeries to be carried out without the fear that the patient would die of shock from excessive
bleeding. Control of PAIN by modern anaesthetic techniques also allowed a more expansive area for
surgical adventures. The result of this is that situations where surgery would have been thought to be
impossible are now regularly explored thereby posing new challenges. Surgery is now carried out on
persons of all ages from the unborn child to the very elderly. In this regard, Academic Surgeons must
not only continually research into new methods to treat diseases and injuries but also into appropriate
measures that will not only make surgery safe for the patient but similarly ensure that the patients are
safe for surgery. This means that the whole arena of surgical care must be covered, meaning that preoperative, intra-operative and post-operative care must all be continually improved to ensure an
excellent surgical outcome.
Mr. Vice-Chancellor Sir, it has been stated that the most striking story of surgery in recent decades is
how firmly it has become established as an essential tool for helping people live long and healthy
lives. Virtually no one who lives long enough escapes having a condition for which effective
treatment requires surgery — a serious orthopedic injury, a cataract, a tumor, obstructed labor, joint
failure, severe cardiac disease etc. Today, surgeons have in their arsenal more than 2500 different
procedures. Thus, the focus of recent advances in the field has been less on adding to the arsenal than
on ensuring the successes of the treatments we have already1.
By far the most exciting recent development in surgery is the minimization of the invasiveness of
surgical procedures with the advent of laparoscopic or thoracoscopic surgery (called keyhole
surgery). The debilitating extensive abdominal incisions (which in some instances might have been
more than 25cm long, the type nicknamed “from Cairo to Cape Coast”) have been reduced by
minimally invasive procedures to just half a centimeter! The subsequent introduction of endoscopic
and percutaneous techniques has turned incisions into mere puncture wounds!!
What Is A Successful Surgery?
Mr. Vice-chancellor Sir, we have earlier defined Surgery as the use of operative manual and
instrumental techniques on a patient to investigate and/or treat disease or injury, or to keep bodily
function or appearance. It therefore means that a SUCCESSFUL SURGERY is one that accomplishes
what it sets out to do and the patient leaves the operating theatre alive. The task successfully
accomplished may be removal of a diseased organ or foreign material or repair/reconstruction of
injured or abnormal part of the body. But is that all? What happens if complications set in and the
patient dies subsequently? Has the operation succeeded indeed?
Death after surgical operation is termed operative mortality. Traditionally, operative mortality has
been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the
hospital, and even after 30 days if the patient had remained in hospital after the operation. Most perioperative mortality, that is death soon after the surgery, is attributable to complications from the
operation (such as bleeding, sepsis and/or failure of vital organs) or co morbidities (pre-existing
medical conditions). It is therefore mandatory that measures must be put in place to reduce the
incidence of complications and to provide facilities to tackle any unavoidable complication. This is
the thrust of my lecture, “That Patients May Not Die after Successful Surgery”.
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Surgical Infections
Despite a number of advances that have been made in infection control practices, including improved
operating room ventilation, sterilization methods, barriers, surgical technique, and availability of
antimicrobial prophylaxis, infections remain a substantial cause of morbidity and mortality in
surgical patients2. This is because technological advances and increasing safety of anaesthesia have
led to the performance of more complicated operation, longer hours of surgery, more geriatric
patients operated, foreign materials often implanted into the body during surgery, organ
transplantations often carried out requiring suppression of immunity to infection and increased use of
invasive diagnostic modalities.
Surgical infection is an infection arising from the site of surgical trauma or one in which there is
anatomic or mechanical problem that must be resolved by operation or another invasive procedure to
cure the infection. It follows therefore that antibiotic treatment will not resolve the infection without
solving the mechanical problem. There are some special characteristics of surgical infections which
are much unlike medical infections. There are impaired damaged host defences, especially the natural
skin barrier, immunological defects are global after trauma and there is often nutritional deficiency.
The invading organisms are polymicrobial, consisting of both aerobic and anaerobic organisms. The
microorganisms are often from endogenous flora (which have become opportunistic pathogens by
being in the wrong places) but can also be from exogenous contamination.
I have therefore directed a considerable part of my research efforts into the study of surgical
infections so that we may continually evaluate how they come in, where they come from and devise
how to tackle the situation so “That patients do not die after successful surgery”
Burn Sepsis
Mr. Vice-chancellor Sir, I want to assure you that I am happy to be Professor in the General Surgery
Unit with mandate to teach research and provide services in Gastro-enterology. Endocrinology and
Breast Surgery. I must however confess that my first love was NOT General Surgery but Burns and
Plastic Surgery. At the time I obtained my Fellowship in Surgery, my mentors, Professor J. T. da
Rocha-Afodu (now Emeritus Professor) was Head of our department while Professor B. Akande was
the Chairman of Medical Advisory Committee (CMAC) of the Lagos University teaching Hospital
(LUTH). The two of them were in the General Surgery Unit and needed more hands and they
therefore encouraged me (I dare not say tricked me) to settle in the General Surgery Unit with the
assurance that I could still practise Plastic Surgery as part of General Surgery. I was thereby moved
away from my initial guardian in the Burns and Plastic Unit, Professor G. O. A. Sowemimo, who was
busy at that time as the Provost of the College of Medicine of the University of Lagos.
Prior to this, my interest in Burn Sepsis had been stimulated in 1985 during my 5-month Clinical
attachment to the West Lothian Burns and Plastic Service at the Bangour General Hospital, near
Edinburgh, Scotland, United Kingdom. I discovered that patients with severe burns were managed in
specialized burns centre with facilities for critical care and so these patients survived the early threats
usually posed by excessive fluid losses and also inhalational injury from inhaled smoke.
Unfortunately, a number of them still died from invasive burn sepsis despite adequate care of the
burn wounds which included Tangential Excision of deep dermal burns, Escharectomy of Full
thickness burns and early skin grafting.
As part of the requirements for the Fellowship of the National Postgraduate College in Surgery
(FMCS), I conducted a research project titled “A Study of Sepsis in Burn Injuries in Lagos”. The
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justification was the fact that bacterial infection had continued to be a major problem in the
management of the burned patient despite recent advances in treatment. Since the natural defence of
the human epidermis is lost in burns, infection of the burn wounds with the danger of bloodstream
invasion remains a threat until all wounds are healed. Since 1982, MacMillan of the Shriners Burns
Unit in Cincinati, Ohio, USA had aptly stated that ‘nowhere in Medicine and Surgery has the
changing parade of pathogens been more evident than in burns’3. This categorical statement was
from the knowledge that Streptococcus pyogenes was the most frequently recognized cause of burn
wound sepsis in the early part of the 20th century but over the years, Pseudomonas aeruginosa and
Staphylococcus aureus have become the most frequently isolated organisms in most burn units. Since
there is abundant evidence that the spectrum of infective agents varies from time to time and from
place to place, it has thus become mandatory to carry out periodic reviews of the bacterial flora of
burn wounds in all centres so that preventive strategies could be modified as necessary. Previous
reports on burn sepsis in Nigeria were all retrospective in nature and no sequential analysis had been
reported to determine the period of emergence of the different microorganisms4.
I therefore prospectively studied all patients with fresh burns who were admitted to the Lagos
University Teaching Hospital (LUTH) between December 1988 and June 1989. The patients were all
managed, according to our standard protocol, in the general surgical and paediatric wards, as there
was no specialized burn unit in LUTH at that time and there is still none till today.
Wound swabs were taken from the burn wounds on admission and at weekly intervals during change
of dressings for 5 weeks or until all burn wounds were healed. Each wound swab was immediately
placed in 10ml of Stuart’s transport medium (Oxoid) and promptly sent to the laboratory for
processing. The samples were processed by conventional methods for isolation of aerobic and
anaerobic organisms and sensitivity tests to antibiotics were done by the disc diffusion methods in the
Research Laboratory of Professor Tolu Odugbemi. Organisms difficult to identify were further
characterized and confirmed using the Analytical Profile Index (API) method.
FIGURE 1
Fresh Full Thickness Burns with Eschars – usually Sterile on admission
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Analysis of the results showed that almost all (96.7 per cent) of the wound swabs were reported
sterile on admission but by the end of the first week, 60.0 percent of the wound swabs had
microorganisms isolated from the wounds and in subsequent weeks the surface contamination rate
decreased progressively as the wounds healed (Table I).
Table I: Result of Bacteriological cultures
Time of sampling (weeks)
st
Result
Admission
1
2nd
3rd
Sterile
30(96.7)
6(19.4) 9(34.6)
9 (40.9)
Single
1(3.3)
16(51.6) 8(30.8)
10(45.5)
Isolate
Multiple
0
9(29)
9(34.6)
3(13.6)
Isolates
Total
31 (100)
31 (100) 26(100)
22(100)
4th
13(65)
6(30)
5th
10(76.9)
2(15.4)
1(5)
1(7.7)
20(100)
13(100)
Table II shows the isolates from the burn wounds at weekly intervals post-burn. The predominant
organism was Staphylococcus species which formed 41.2% of all isolates at the end of the first week
after admission. Pseudomonas aeruginosa formed 25.8 percent, Coliforms form 8.8% of all isolates,
while diptheroids, Citrobacter, Proteus species and some unidentified non-lactose fermenters formed
5.9% each. β –haemolytic streptococcus was not isolated at all but there was one isolate (2.9%) of an
α-haemolytic Streptococcus. However, by the end of the second week, Pseud. aeruginosa had
become more predominant (40.7 per cent), while Staphylococci formed only 18.5 per cent of all
Table II: Number of organisms isolated from wound cultures
Time of sampling (weeks)
Total
Admission 1st 2nd 3rd 4th 5th No.
Staph.aureus
13 4
1
18
Staph.epidermidis
1
1
2
α-haemolytic streptococcus
1
3
2
6
β-haemolytic streptococcus
Pseud.aeruginosa
1
8
11 5
4
1
30
Klebsiella aerogenes
4
2
2
2
10
Proteus spp.
2
4
7
3
2
18
Coliforms
3
3
Unidentified
non-lactose 2
2
fermenters
Dipthheroids
2
2
Citrobacter
2
2
Anaerobes
0
Total
1
34 27 17
9
5
93
%
19.4
2,1
6.4
32.3
10.7
19.4
3.2
2.2
2.2
2.2
0
100
isolates. The Gram-negative organisms, as a group, predominated by the end of the second week
(70.3 per cent) with the appearance of Klebsiella aerogenes and Proteus spp. surpassing Pseud.
aeruginosa in frequency in weeks 3 and 5 postburn. Altogether, the Gram-negative organisms were
the most frequently isolated organisms from the burn wound, with Pseud. aeruginosa forming 32.3
per cent of all isolates. Staphylococci followed with 21.5 per cent preponderance and this was
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closely followed by Proteus species (19.4 percent) and Klebsiella aerogenes (10.8 percent),
Anaerobic microorganisms were conspicuously absent. The study showed that Pseudomonas
aeruginosa and Staphlococcus aureus were the commonest organisms involved in Burn sepsis and
thus, antimicrobial topical agents used in the first week to prevent infection must take care of
Staphlococcus aureus while for subsequent weeks, the agents must be able to prevent colonization by
Pseudomonas aeruginosa and other gram-negative organisms. We therefore advocated the use of
topical silver sulphadiazine in the first week postburn period while discouraging the use of Mafenide
acetate which is inaffective against Staphylococci. The sequential analysis of the bacteriology of
burn wounds was the first in our sub-region and the results were published in the 1992 edition of
BURNS, the official Journal of the International Society for Burn Injuries (ISBI) and has been
severally cited. Indeed, I was excited when the Library of the United States Army Institute for
Surgical Research, Fort Sam, Houston, Texas, USA requested for a copy of the reprints which I
quickly forwarded. It is interesting that the Resarch Centre reciprocated by sending me reprints of
articles from the centre for several years.
I proceeded to study the relationship of bacteraemia (invasion of the blood by bacteria) to mortality in
burn patients5. This is because screening for evidence of bacteraemia is an objective assessment of
invasive infection in burn patients and has often been chosen for study. It is well known that not all
burn patients with lethal infections are bacteraemic, and positive blood cultures are not exclusively
confined to septic patients3. However, bacteraemia following burn injury generally correlates well
with serious infection and McManus et al6, had demonstrated that bacteraemia was associated with a
21% increase of mortality above that predicted by logistic regression analysis of injury severity and
age. They also showed that mortality in a group of patients with gram-negative bacteraemia was
about 52% greater than that predicted for patients without bacteraemia.
We assessed anaerobic and aerobic venous blood cultures at weekly intervals and whenever there was
clinical evidence of septicaemia in all patients with major burns seen over a six-month period. There
were thirty-one (31) consecutive patients with fresh major burns during this period. Although 14 of
the patients had positive blood cultures, only 55.6% of these developed clinical evidence of
septicaemia. Pseudomonas aeruginosa was the most frequent isolate (30%) in patients with
bacteraemia and in those with clinical evidence of septicaemia. This organism was cultured in 50%
of the fatal cases. Twenty percent (20%) of the positive blood cultures grew Staphylococcus
epidermidis but the patients showed no clinical evidence of septicaemia and all survived. Anaerobes
were not cultured from any of the burns cases.
Table III: Organisms Isolated from Blood Cultures (Aerobic and Anaerobic)
Adm 1st
2nd 3rd
4th
5th
WK WK WK WK WK
1.
Staphylococcus aureus
1
1
2.
Staphylococcus epidermidis
2
1
1
3.
Pseudomonas aeruginosa
4
1
1
4.
Klebsiella aerogenes
2
5.
Escherichia coli
2
1
6.
Undentified non-lactose fermenters 1
1
7.
Candida albicans
1
8.
Anaerobes
TOTAL
1
8
4
2
2
3
Total (%)
2(10%)
4(20%)
6(30%)
2(20%)
3(15%)
2(10%)
1(5%)
0(0%)
20(100%)
All septicaemic patients that survived had prolonged periods of hospitalization and all the fatalities
were due to septicaemia with demonstrable gram-negative bacteraemia. It was also found that
septicaemic patients who were below 10 years of age had greater mortality (71.48%) than older ones.
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Nonetheless, the difference between the mean percentage TBSA (Total Body Surface Area) burned in
patients with septicaemia and those without septicaemia was statistically significant. This showed
that the development of blood stream invasion by organisms infecting the wound is directly related to
the percentage TBSA burned.
Table IV: Characteristics of Patients with Clinical Evidence of Septicaemia
Case Age
Sex Burns Depth
of Wound
Blood
No.
Years
Burns
1
35
M
45
2nd and 3rd 1. Staph. Aureus
Candida
degrees
2. Klebsiella aerogenes albicans
3. Proteus mirabilis
2.
3
F
42
2nd degree
1. Klebsiella aerogenes Klebsiella
2. Pseudomonas
Aeruginosa
rd
3
17
M
34
3 degree
1. Staph.aureus
Pseudomonas
2. Pseudomonas spp.
aeruginosa
rd
4
5
M
36
3 degree
1. Streptococcus spp.
No growth
2. Pseudomonas
aeruginosa
5
9
F
31
2nd & 3rd 1. Staph.aureus
Klebsiella
degrees
2. Klebs aerogenes
Aerogenes
3. Pseudomonas spp.
6
44
M
60
2nd degree
1. Pseudomonas
No growth
aerogenes
2. Klebs aerogenes
7
10
F
36
2nd & 3rd Pseudomonas
Pseudomonas
degrees
Aeruginosa
Aeruginosa
8
25
M
38
2nd & 3rd Staph.aureus
No growth
degrees
9
11/12 M
30
2nd & 3rd 1. N. L. F.
N. L. F.
degrees
2. Staph.aureus
10
14
F
27
2nd degree
Staph.aureus
E.Coli
11.
36
F
16
12
1
M
33
13
30
M
49
14
10
M
35
1st and 2nd
degrees
2nd and 3rd
Degrees
1st and 2nd
degrees
1st and 2nd
degrees
Proteus spp.
1. N.L.F.
2. Staph.aureus
1. Staph.aureus
2. Streptococcus
Pseudomonas spp.
Outcome
Survived
(160 Days)
Died
(14th Day)
Died
(42 Days)
Survived
(175 Days)
Survived
(240 Days)
Survived
(47 Days)
Died
(5th Day)
Survived
(67 Days)
Died
(9th Day)
Survived
(50 Days)
No growth
Survived
(44 Days)
N.L.F.
Died
(10th Day)
Staphyloccus Survived
aureus
(60 Days)
Pseudomonas Died
aeruginosa
(16th Day)
The pattern of antibiotic sensitivities of the organism isolated from blood culture shows that most of
the organisms were resistant to the antibiotics usually prescribed in our environment viz ampiclox,
gentamycin and metronidazole. The study showed that while gentamycin may have some effect, the
ampicillin/cloxacillin combination is of no value and should be discontinued. Also, since anaerobes
were not isolated, the metronidazole component may be unnecessary and thus a waste of scarce
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resources. The bacterial pathogens were however all sensitive to ceftazidime, a third generation
cephalosporin antibiotic that is well known for its anti-pseudomonal effectiveness. The findings of
this study, which had since been published5, were presented at the 10th Congress of the International
Society for Burn Injuries (ISBI) in Paris, France in June 1994, having won the Pfizer Travel
Fellowship Award. The findings of this study of invasive burn wound infection led to a trial of
Ceftazidime (Fortum®) as Monotherapy in the treatment of septicaemic burn patients7. This is
because chemotherapy of established burn wound infection is so notoriously unreliable that it is often
desirable to treat several burned patients, whose clinical condition is deteriorating, with antibiotics
capable of preventing invasion by the bacteria already colonizing the burns, whether or not evidence
of such invasion is present. Diagnosis of invasive infection and septicaemia must be made on clinical
grounds and initial treatment must of necessity be blind, using broad-spectrum antibiotics.
We therefore carried out a drug trial on patients with major burns showing clinical evidence of
septicaemia (blood stream infection). The clinical evidence of septicaemia consisted of unrelenting
pyrexia, tachypnoea, altered sensorium and ileus. A combination of antibiotics, (ampicillin,
cloxacillin, gentamicin and metronidazole) was initially used for all patients with evidence of
septicaemia and only those who were unresponsive, were placed on ceftazidime monotherapy.
FIGURE 2
Severely ill lady with septic major burns. (Greenish discharge indicative of Pseudomonas
aeruginosa infection).
At the commencement of ceftazidime therapy, all other antibiotics were stopped and wound swabs
and venous blood specimens were taken for microscopy, culture and sensitivity tests. Ceftazidime
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was then administered intravenously at a dosage range of 1 – 2g 12 hourly depending on the weight
of the patients and severity of their clinical condition. The clinical progress of each patient was
closely monitored for any possible side effects. Further microbiological specimens were taken at the
end of the one week’s course of Ceftazidime therapy.
Table V: Clinical characteristics of study subjects
No.
Sex
Age
Burning Agent
Depth of
Burns
2o
2o
3o
2o
2o & 3o
3o
2o & 3o
3o
2o
2o
3o
1
M
35 yr. Explosion/Flames
2
F
19 yr. Hot Oil
3
M
17 yr. Chemical
4
M
44 yr. Explosion/flame
5
F
9 yr.
Flame
6
M
5 yr.
Hot water
7
F
36 yr. Flame
8
M
26 yr. Electrical
9
F
14 yr. Flame
10
M
30 yr. Flame
11
M
28 yr. Hot water
*= Died during a second septicaemic episode
% Burns
Outcome
45%
43%
34%
60%
31%
36%
16%
15%
45%
45%
24%
Survived
Survived
Survived
Survived*
Survived
Survived
Survived
Survived
Survived
Survived
Survived
It was notable that ten out of the eleven patients with clinical evidence of septicaemia following burn
injuries survived utilizing ceftazidime as monotherapy. The eleventh patient died during a second
septicaemic episode following recovery from an earlier episode treated with ceftazidime. It was
therefore concluded that though the trial was small, ceftazidime monotherapy appears to be effective
in the management of invasive burn sepsis while awaiting isolation of the offending micro-organism
in patients who are unresponsive to the commonly used antibiotics.
Worried about the unsatisfactory situation in which Burn patients are still managed in open
surgical/medical wards, along with a variety of other patients and the high risk of transmission of
infection from patients, attending staff and fomites, workers in developing countries have adopted the
practice of administering systemic antibiotic prophylaxis based on the local burn wound bacterial
isolates so as to reduce the alarming rate of infection. Systemic antibiotic prophylaxis in the
management of burns may be defined as the administration of systemic antibiotics started
immediately after injury with the aim of preventing burn wound infection. The goal is to effectively
saturate the oedema fluid at a time when the humoral defences are low and treatment is continued
until the formation of healthy granulation tissue which is able to withstand invasive infection. Our
sequential analysis of burn wound swabs in 1989 had revealed that the common organisms were
sensitive to co-trimoxazole, erythromycin, genticin and colistin4. One of our Senior Registrars, Dr.
Andrew Omotayo Ugburo (now a Senior Lecturer with his eyes on becoming an Associate Professor
very soon), was therefore encouraged in December 1995 to design a study to find out if the use of
some of the antibiotics will be effective in preventing or delaying the onset of wound colonization
and wound infection. As part of the requirements for the Fellowship of the National Medical College
in Surgery (FMCS), we supervised his prospective study of 61 patients to evaluate the role of
systemic antibiotic prophylaxis in the control of burn wound infection using the antibiotics identified
in our earlier studies4,5. The patients were randomized into three groups: group 1 (n = 21) received
ampicillin and cloxacillin; group 2 (n = 20) received erythromycin and genticin and a control group
(n = 20) received no systemic chemo prophylaxis. The burn wounds were similarly managed. Wound
colonization was determined from surface wound swab cultures while invasive burn infections were
determined by wound biopsy.
11
The study showed no significant difference between wound infection time of control and group 1 nor
was there such difference between the control and group 2 (P > 0.05). The commonest organism
infecting burn wounds in all the groups was Pseudomonas aeruginosa followed by Staphylococcus
aureus. There was however a significant difference between the treatment groups and the control (P <
0.05) with regard to the percentage of infected wounds that grew P. aeruginosa, compared to those
that grew Staphylococcus aureus. It was concluded that systemic antibiotic prophylaxis is of no value
in controlling burn wound sepsis, and might even favour the growth of P. aeruginosa in the burn
wounds7. So what is next? That will be for Dr. Ugburo to pursue further as I have moved fully to the
General Surgery specialty. Nonetheless, it is obvious that if we are to make progress, LUTH should
urgently establish a dedicated BURNS UNIT where patients with major burns are isolated and treated
appropriately. This is a major step to take so “THAT OUR PATIENTS MAY NOT DIE AFTER
SUCCESSFUL SURGERY” which usually involves regular wound dressings and several theatre
sessions of skin grafting.
THE GENERAL SURGERY SPECIALTY
Surgery as a discipline covers a huge area, and modern surgery has developed to such an extent that
the body of knowledge and technical skills required have necessitated that surgeons specialize in one
type of surgery or the other. As stated by Atul Gawande, the renowned American Surgeon and
Journalist, “Expertise is the mantra of modern medicine. The medical profession's answer has been to
go from specialization to super-specialization. There is perhaps no field that has taken specialization
further than Surgeons. Surgeons are so absurdly ultraspecialized that when we joke about right ear
surgeons and left ear surgeons, we have to check to be sure they don't exist” In actual fact, there are
at least seven main specialties in Surgery and some of these are further divided into sub-specialties.
The main specialties are Cardiothoracic Surgery (operating on heart and lung problems),
Neurosurgery (operating on the brain, the central nervous system and the spinal cord),
Otorhinolaryngology, (also referred to as “ENT”, concentrate on Ear, Nose and Throat surgery),
Paediatric Surgery (involves working on children’s wide ranging surgical problems), Plastic Surgery
(work with burns and trauma victims and includes cosmetic surgery), Orthopaedic Surgery
(managing conditions of bones and joints), Urology (treating conditions in the genito-urinary system)
and of course, General Surgery.
General surgeons are trained to possess a wide range of knowledge and skills to deal with all kinds of
surgical emergencies, with emphasis on acute abdominal problems and also carry out elective
operations on the gastro-intestinal tract (surgical gastroenterology), endocrine glands and the breast.
A number of sub-specialties have emerged within General Surgery and these include Breast Surgery,
Colorectal surgery (surgery of the large intestine, rectum and the anus), Endocrine surgery (for
diseases of the thyroid and other endocrine glands), Upper Gastrointestinal and Hepato-biliary
Surgery (including obesity surgery), Transplant Surgery and Vascular surgery (operating on the main
blood vessels of the neck, trunk and limbs). It is noteworthy that General surgery is in the vanguard
for the introduction of minimally invasive procedures and Laparoscopic (or “keyhole”) surgery is
therefore an integral and crucial skill that has developed across the whole spectrum of general
surgery.
ACUTE ABDOMEN
One of the major areas of operations for a General Surgeon is the Abdomen which is notorious for its
propensity for Surgical Infections. The Acute Abdomen is a condition in which there is abdominal
pain of sudden onset that necessitates urgent treatment and which may require surgical intervention to
prevent fatality. The natural history of abdominal pain depends on the exact pathologic process which
may resolve spontaneously or may progress to widespread inflammation of the inner lining of the
12
abdomen (generalized peritonitis) with a high probability of death. There are numerous causes of
Acute Abdomen and these include Inflammatory lesions (Appendicitis, perforated peptic ulcers,
Typhoid perforations, etc), obstructive lesions (obstructed hernias, adhesive bowel obstructions,
volvulus, etc), lesions causing haemoperitoneum (blood in the abdominal cavity from ruptured blood
vessels or other organs following trauma), Gynaecologic problems and a number of non-surgical
causes that require only medical treatments.
The accurate diagnosis of the cause of acute abdominal pain is one of the most challenging
undertakings in emergency medicine. It is well known that clinical features are overlapping and
physical findings are often non-specific. Since plain abdominal radiography (X-Ray) is one
investigation that can be obtained readily and within a short period of time to help the physician
arrive at a correct diagnosis, the study of the relevance of plain abdominal radiography in an Acute
Abdomen was therefore evaluated in the management of abdominal emergencies seen in our unit9.
All patients had supine and erect abdominal x-ray before any therapeutic intervention was
undertaken. The diagnostic features of the plain films were compared with final diagnosis to
determine the usefulness of the plain X-rays. The 100 consecutively presenting patients were
eventually found to have Intestinal obstruction (24%), perforated typhoid enteritis (20%), gunshot
injuries (13%), generalized peritonitis (13%), blunt abdominal trauma (12%), acute appendicitis (8%)
and perforated peptic ulcer (10%).
FIGURE 3: Chest Radiograph Showing Free Intra-abdominal Air Under The Right
Hemidiaphragm Indicative of Perforated Viscus
13
FIGURE 4: Erect Plain Abdominal Radiograph Showing Multiple Air-Fluid Levels Indicative
of Intestinal Obstruction
Our findings revealed that plain abdominal radiographs showed high sensitivity in patients with
intestinal obstruction (100%) and perforated peptic ulcer (90%). We therefore recommended that
Plain Abdominal radiography should be an integral part of management of patients presenting with
an Acute Abdomen especially with the clinical suspicion of bowel obstruction and gastrointestinal
perforation.
Appendicitis
Acute appendicitis is one of the commonest indications for emergency abdominal surgery in our
teaching hospital and in most centres world-wide10,11. Appendicitis is the inflammation of the
vestigial wormlike structure attached to the caecum which is the beginning of the large intestine.
Typically, surgical intervention is in the form of appendicectomy (removal of the Appendix) through
a limited incision, if uncomplicated, or formal laparotomy (opening of the whole abdomen) if the
appendix is perforated. Mortality in uncomplicated cases is less than 1% rising up to 12%, if there is
perforation, especially in children and the elderly. In acute appendicitis, most textbooks categorically
state that moderate leucocytosis (increase in the number of white blood cells), ranging from 10,000 to
18,000/cmm which is accompanied by a moderate neutrophilia, is the rule in acute uncomplicated
appendicitis. Many reports have also validated the Alvarado score which is a clinical scoring system
used in the diagnosis of appendicitis11. The score has 6 clinical items and 2 laboratory measurements
with total score being 10 points out of which 2 points are for leucocytosis and one point is for
neutrophilia.
14
We12 therefore decided to study the Leucocyte counts in patients with appendicitis in view of the
documented findings that black populations uniformly have lower leucocyte counts than the normal
values quoted for Caucasians. All patients diagnosed clinically as cases of acute appendicitis at the
Lagos University Teaching Hospital over a period of 12 months were prospectively studied. Preoperatively, 5mls specimen of venous blood was taken from the patient as soon as the diagnosis was
made and sent for the estimation of haemoglobin level, total and differential white cell count. Postoperatively at discharge from the hospital, another 5mls specimen of venous blood was taken from
the patient and sent for the estimation of haemoglobin level, total and differential white cell count.
The haematological studies were compared with two controls. Firstly the patients served as their own
control. The half life of neutrophils is about 8 hours and the level of leucocyte count rapidly returns
to normal as soon as the stimulus responsible for the increase had been removed. At the time of
discharge, it was expected that the white cell count was normal and can then serve as control. The
second control was with data accepted as standard for this environment.
Table VI: Comparable White Blood Cell Count in black and white population
LAGOS
IBADAN
LUSAKA
PHILADELPHIA
Mean WBC x
109/L
5.42
6.44
5.15
7.0
Mean
Neutrophil%
36.0
39.5
37.0
53.0
Range
+
250x109/L
2.7-8.6
3.2-10.8
1.9-8.4
4.3-10.0
Table VII: Pre-operative leucocyte count and neutrophil % in inflamed vs normal healthy
population values from Lagos.
Normal Lagos Values Inflamed T
p
95%
Cases
Confidence
Interval
No of Patients
175
63
Mean WBC x 109/L 5.42+1.7
5.8+1.8
1.07
>0.05
-0.074-0.834
Mean neutrophil%
36.0+11.5
54.8+14.7 6.91
<0.05
14.76-22.84
As in the Table above, we found that the pre-operative mean leucocyte count in patients with simple
inflamed appendices was not statistically different from the mean for normal healthy population, but
the mean neutrophil’s percentage was significantly higher in cases with inflamed appendices. Also, as
shown below, the pre-operative values of leucocyte count and neutrophil percentage from patients
with inflamed appendices showed no significant difference from those with non-inflamed appendices,
Table VIII: Pre-operative leucocyte count and neutrophil % in non-inflamed vs inflamed nonperforated appendices.
No of Patients
Mean WBC x109/L
Mean neutrophil%
Non
Inflamed
24
5.6+2.0
52.4+15.8
Inflamed
T
P
95% Confidence
Interval
63
5.8+1.8
54.8+14.7
0.32
0.473
>0.05
>0.05
-0.73-1.13
-5.0-9.8
15
Patients with perforated appendices have significantly higher pre-operative values of mean leucocyte
count and mean neutrophil percentage than patients with inflamed non-perforated appendices; P <
0..05 (Table IX).
Table IX: Pre-operative leucocyte count and neutrophil % in Perforated Appendices vs
Inlamed Appendices.
No. of Patients
Mean WBC x109/L
Mean neutrophil %
Perforated
Cases
Inflamed
Cases
16
10.5+5.4
71.7+20.1
63
5.8+1.8
54.8+14.7
T
P
95%
Confidence
Interval
2.780
2.458
<0.05
<0.05
1.97-7.43
6.25-27.55
Our research endeavour demonstrated that there was no significant increase in leucocyte counts in
patients with acute appendicitis as the values from patients with normal appendices were not
statistically different from those with inflamed appendices. Leucocytosis with neutrophilia were only
Table X: Organisms Isolated from Patients with Appendicitis
Organisms
NonInflamed
Perforated
Inflamed
Escherichia coli
2
41
12
Total
Percentage
55
35.9
Enterococcus faecalis
2
27
6
35
22.9
Bacteroides spp
-
17
5
22
14.4
Enterococcus spp
-
9
1
10
6.5
Anaerobic Streptococcus
-
5
1
6
3.9
Staphylococcus aureus
-
4
2
6
3.9
Pseudomonas species
-
3
2
5
3.3
Shigella species
-
2
1
3
2.0
Klebsiella spp
-
3
-
3
2.0
Yersinia enterocolitica
-
3
1
4
2.6
Proteus mirabilis
-
2
-
2
1.3
Salmonella species
-
1
1
2
1.3
Total
4
153
100
16
found in patients with perforated appendices particularly those associated with significant peritoneal
soiling. Since delay will be dangerous, we advocated that a high index of suspicion is mandatory to
commence treatment in our environment without waiting for the result of the white cell counts which
if found to be elevated would indicate that it was already complicated. It is much safer to remove a
normal appendix than to risk the development of generalized peritonitis. This was published in the
Nigerian Journal of Surgery in 1995 (Atoyebi, Enenmoh and Akande12).
The knowledge of the bacterial agents associated with acute appendicitis is important so as to
determine the appropriate antibiotic to use as prophylaxis during appendicectomy especially if
surgery is postponed for any reason whatsoever. We therefore carried out a prospective study of the
bacteriology of acute appendicitis in 134 patients treated at the Lagos University Teaching Hospital
over twelve calendar
months. Swabs of peritoneal exudates on the inflamed appendix and its surroundings were taken
during appendicectomy and sent in Stuart’s transport medium for anaerobic and aerobic cultures.
Bacteriological results were obtained in 92 cases which showed that common intestinal
microorganisms such as Escherichia coli, Enterococcus faecalis and Bacteroides, were involved in
that order. About 53.3% of the swabs grew more than one organism. The most frequent bacterial
combinations were Escherichia coli with Enterococcus faecalis and Escherichia coli with
Bacteroides. Yersinia enterocolitica which was reputed to be common was not frequently isolated,
and constituted only 2.6% of all isolates.
The pathogens found in this study12 and the antibiotic sensitivity pattern have shown that a
combination of Ampiclox, Gentamicin and Metronidazole is appropriate for use in patients with acute
appendicitis, rather than insist on the more expensive 3rd generation cephalosporins.
Generalised Peritonitis
Generalized peritonitis is intra-abdominal sepsis involving more than one quadrant of the abdominal
cavity. It is a deadly form of intra-abdominal infection with very high mortality rates of about 3050% despite aggressive surgical techniques designed to combat it13. Generalized peritonitis is a
more severe form of intra-abdominal infection than the usually localized peritonitis found in acute
appendicitis. It constitutes the final fatal pathway for any unresolved intra-abdominal infection by
leading to blood invasion of microorganisms (bactereamia) and septicaemia.
I supervised Dr. Chinedu Nwigwe in carrying out a study of the prognostic factors in generalized
peritonitis with a view to documenting the current pattern of peritonitis and to determine the
parameters affecting morbidity and mortality in all cases of peritonitis in LUTH. Sixty-seven
consecutive patients with generalized peritonitis presenting over a period of one year were studied.
The biodata, clinical data, and intra-operative findings were collated and subsequently analyzed.
Typhoid ileal perforation and ruptured appendicitis were the commonest causes accounting for 17.9%
each.
A high mortality rate of 38.8% was recorded and this falls in line with previous reports on peritonitis.
The study showed that while Gender and Level of the Surgeons (Consultant Vs Senior Registrar) did
not influence mortality, Age, malignancy, colonic involvement, pre-operative duration of illness,
character of exudates and organ failure were the main prognostic factors in our study14.
17
FIGURE 5
Purulent fluid in the abdominal cavity in Generalized peritonitis
Table XI
Frequency of Causes of Peritonitis and Age Range and Mean Age
Perf. Pud = Perforated Peptic ulcer disease.
Typhoid Intestinal Perforation
Typhoid fever is still prevalent in many developing countries due to the unsanitary conditions in most
of these places especially due to lack of potable water. The infection is caused by Salmonella typhi
and is transmitted through the faeco-oral route.
Perforation of the ileum (small intestine) remains one of the commonest and the most dramatic
complication of Typhoid fever where the infection is still prevalent.
18
A prospective study of patients with typhoid perforation seen at the Lagos University Teaching
Hospital was carried out over a 6-year period. There were 78 consecutive patients, the majority
(80.7%) of whom were within the age range of 11 and 30 years (mean 20.9 + SD 11.2 years) and
were mostly (65.4%) students.
Table XII: Age Distribution of Patients Studied
Age Group
No. of Males
No. of Females
(years)
0-10
2
11-20
35
7
21-30
20
1
31-40
7
1
41-50
2
1
51-60
1
61-70
1
TOTAL
68
10
Total no. of
patients
2
42
21
8
3
1
1
78
Percentage
2.6
53.8
26.9
10.2
3.9
1.3
1.3
100%
All patients were managed using the standard procedure of prompt surgical intervention after
adequate resuscitation. The mean of the period of resuscitation was 20.10 + SD 9.3 hours. After
adequate resuscitation with intravenous fluids until the patients are making adequate urine, the
abdomen is usually opened to evacuate the infected intra-abdominal collection and close the
perforation(s) using standard techniques. The abdominal cavity is usually lavaged thoroughly with
normal saline before closing up the abdomen. Despite all these meticulous measures, the case fatality
rate was 12.8% and the mean period of hospitalization for survivors was 21.1 + 11.7 days. There was
a statistically significant difference (p=0.001) between the proportion of survivors and non survivors
who had jaundice (serum bilirubin>35µmol/L) before surgery.
Table XIII: Some Patients’ Parameters in Relation to Prognosis
Parameters
Age (in years)
Admission Temp oC
Admission Pulse Rate
Packed Cell Volume (PCV%)
K+ mmol/L
Na+ (mmol/L)
HCO3 (mmol/L
Urea (mmol/L
Amount of peritoneal fluid (mls)
Interval between perforation and
presentation (days)
Surgical Intervention Time (Hours)
Survivors
n=68 (mean+SD)
20.52 + 10.17
38.28 + 0.70
114.17 + 15.33
35.80 + 6.39
4.05+ 0.61
132.81 + 7.52
21.81+ 5.61
9.95 + 5.73
1001.92 + 308.46
Non-Survivors
n=10 (mean+SD)
23.9 + 10.50
38.43 + 0.69
112.2 + 10.77
37.63 + 1.92
4.043 + 0.40
133.33 +7.45
17.29 + 4.23
15.61 + 9.53
1666.67 + 683.13
P Value
4.06 + 2.84
3.86 + 2.19
0.83
24.05 + 16.27
16.00 + 11.69
Statistical significance = p < 0.05
0.33
0.63
0.89
0.18
0.85
0.82
0.043*
0.041*
0.019*
0.14
The study showed that high serum urea levels, acidosis, presence of jaundice and very large amount
of peritoneal fluid (above 1 litre) were associated with poor prognosis. However, there was no
statistically significant difference (P > 0.05) between survivors and non-survivors as regards the age,
19
sex, temperature at presentation, pulse rate, serum Na+, serum K+ and both the site and number of
ileal perforations.
It is concluded that patients with typhoid perforation need to present early because despite
appropriate intervention, most of those who are jaundiced, ureamic or acidotic carry poor prognosis.
We therefore advocated that such patients should be transferred to an intensive care setting and
managed accordingly, so “THAT THE PATIENT WILL NOT DIE AFTER SUCCESSFUL
SURGERY”. These findings were presented at the 38th World Congress of Surgery (International
Surgical Week) which was held in August 1999 at Vienna, Austria and the paper stimulated a lot of
interest. The World Journal of Surgery, the official publication of the International Surgical Society
requested for the full length article after the presentation but because of the message I needed to pass
to the Nigerian medical community, I chose to publish it in our own journal, the Nigerian Quarterly
Journal of Hospital Medicine15 which is now indexed by PUBMED.
Study of Surgical Site infection
A Surgical site infection (SSI) is an infection that occurs in the part of the body where surgery was
performed and is the most common nosocomial (hospital-acquired) infection. It continues to be a
burden on systems that deliver healthcare and on patients with considerable morbidity and mortality
consequent to this complication of surgery. The situation is not different even in the advanced
economies. A study from the USA showed that patients who develop SSI had on average, five extra
hospital days, and were five times more likely to be re-admitted to hospital and re-operated on than
those without infection. Patients with hospital acquired infection were also reported to be twice as
likely to die during the postoperative period16.
Surgical site infection (SSI) is divided into Incisional SSI and Organ/space SSI. Incisional SSI is
further classified into superficial incisional SSI (those involving only the skin and subcutaneous
FIGURE 6: Diagramatic representation of Levels of Surgical Site Infections
http://dx.doi.org/10.1016/j.arth.2007.03.014
tissue) and deep incisional SSI (those involving deep soft tissues of the incision e.g. fascial and
muscle layers). The Organ/space SSI involves any part of the deeper anatomy (e.g. abdominal cavity,
organs or spaces),
20
Since Surgery involves making incisions whereby the normal skin protective barrier is breached,
there is always the risk of the incision getting infected. However, the risk is dependent on the type of
wound at the end of the procedure. Traditionally, surgical wounds are classified into four: Clean,
Clean-contaminated, Contaminated and Dirty/infected wounds with increasing risk of SSI. Although
endogenous risk factors, such as immune suppression, obesity or advanced age are known to be the
major predisposition to SSI, the role of external risk factors in the pathogenesis is now clearly
established. There are currently four preventive measures considered to have a high level of evidence
of success in the prevention of SSI: surgical hand preparation, appropriate antibiotic prophylaxis and
postponing an elective operation in the case of active remote infection17.
Mr. Vice-Chancellor Sir, I must through you register my appreciation to the University for granting
our group a Research Grant to study the “Sources of Nosocomial Bacterial Pathogens in Surgical
Infections” (CRC Grant no:………..). I was the principal Investigator.
We carried out a prospective study18 to evaluate the effectiveness of a standard surgical hand scrub at
the Lagos University Teaching Hosptial. Each participant during 200 consecutive surgical operative
procedures had swabs taken from the hands after surgical hand scrub. Samples were also taken from
the chlorhexidine (the antiseptic soap and lotion) and the water kept in basins for the surgical scrub as
there was often no running water from the taps in the Theatre.
Bacteriological cultures and antibiotic sensitivity tests were carried out on all specimens.
There were 620 participants and organisms were cultured from the hands of 16.1%. Organisms
isolated from hand swabs, water and disinfectants included coagulase negative Staphylococcus,
Acinetobacter spp, Pseudomonas spp. Proteus mirabilis and Eikenella corrodens. Antibiograms of
the organisms cultured were similar, suggesting a common source of contamination.
Table XIV: Surgical units and frequency of isolation of bacterial pathogens after surgical hand
scrub.
Surgical Units
No. of Swabs Taken
180
No. of times
Organism were
isolated
40
Percentate (%)
frequency of
occurrence
22%
General Surgery
Urology
100
20
20%
Orthopaedic
80
15
18.75%
Cardio-thoracic
40
5
12.5%
Gynaecology
100
10
10%
Paediatrics
120
620
10
100
8.3%
16.1%
It was concluded that bacterial pathogens are often still present on the hands after the surgical scrub.
The source of contamination is most likely the water used and we suggested for improvements by
provision of well treated running water from the taps and avoiding breaks in the aseptic technique for
even the clean elective cases.
21
Table XV: Micro-organisms and the number of Surgeon from which they were isolated
No.
Micro-organisms isolated
Number of Personnel from
whom organisms were isolated
1
Proteus mirabilis
2
No. of Colonies
observed per
plate
TNTC
2.
Coagulase negative Staphylococcus
19
TNTC
3
Serratia marcescens
4
3–7
4
Acinetobacter spp.
2
5–7
5
Klebsiella pneumonia
2
4
6
Streptococcus faecium
3
5
7
Enterobacter cloacae
2
5
8
Pseudomonas aeruginosa
7
6–9
9
Ps. Putida
7
TNTC
10
Ps. Mendocina
5
8 – 10
11
Pseudomonas stutzeri
4
8 – 15
12
Burkholderia cepacia
1
5
13
Eik. corrodens
7
20 - 25
No growth
TNTC= Too numerous to count
We also focused on Nosocomial intrinsic infections19 to determine the bacterial pathogens in the
aforementioned two hundred (200) patients undergoing surgery of various kinds at the Modular
theatre of the Lagos University Teaching Hospital (LUTH). The operative procedures included
colonic resection, exploratory laparotomy, appendicectomy, orchidectomy, urological procedures
including prostatectomy, orthopaedic surgeries, thoracic surgeries, Caesarean sections,
myomectomies and other gynaecological procedures. Three main types of specimens were collected.
The first was the excised/resected specimen and pus (if present) and secondly the incision wounds
were swabbed in the theatre before closing and samples were also subsequently collected from the
wound after 3-4 days that patients have been moved to the ward. The Third specimen was catheter
specimen of urine (CSU) which was collected immediately after operation and a follow-up urine
specimen was also collected 3-4 days in the ward postoperatively.
Specimens were transported in Stuart’s transport medium while urine samples were collected in
sterile bottles and transported to the research laboratory immediately. Standard laboratory methods
were used to identify and characterize isolates. Urine cultures which yielded at least 20 (5 x 104)
22
colonies forming unit (CFU) were classified as significant bacteriuria. While I supervised the
collection of surgical specimens, Mrs M. T. Niemogha (now Dr. Niemogha and currently an
Associate Professor in Medical Laboratory Science) took responsibility for the Laboratory work
under the supervision of Professors Tolu Odugbemi and Sade Ogunsola.
We analyzed the relationship between Bacterial Pathogens found in the Theatre and on the Ward and
found that the different organisms isolated on the ward were significantly higher than those isolated
in the theatre (Table XVI). Pseudomonas aeruginosa was the commonest pathogen from patients on
the ward and theatre with 66 and 27 isolates respectively, followed by Staphylococcus aureus with 64
(9.3%) and 20(8.4%) respectively. Kingella kingae was the least frequently isolated pathogen from
patients on the ward with only 2(0.2%) isolates. The difference in the rates of isolation from the
theatre and the ones from the ward were statistically significant (P<0.05%).
We also found that there was a direct link of isolates from catheter urine specimens from the theatre
with those isolated on the ward. For general surgery patients with duration of catheter at least 5 days,
Proteus sp and Pseudomonas sp were isolated within the range of 30-70% each from theatre and
ward. Isolates which included yeast, Morganella morganii, E. coli, and Pseudomonas sp were within
40%-60% from urology patients from theatre and ward, which was significant for endogenous source
Table XVI: Nosocomial Bacterial Isolates Found in the Theatre and on the Ward
23
Table XVII: Comparison of Isolates from Catheter Specimen of Urine (CSU) in the Theatre
and Patients in the Ward
of pathogens (P<0.05). The 60% and 83% of catheter associated urinary infection from urology and
paediatric patients respectively were also significant, p<0.05. Some procedures had higher rates of
bacteria implicating the catheter as an associated cause of urinary tract infection. Genitourinary
manipulation had 77.3% (17/22) significant bacteriuria, whereas paediatric patient had 69.2%
(18/26). Those who had appendicectomy done were least with 16.7% (1/6), (p<0.05). In general,
significant catheter - associated bacteriuria was 216 (64.7%) while non-significant bacteriuria was
118 (35.3%).
Mr. Vice-chancellor Sir, we subsequently carried out a prospective cross sectional study to determine
the baseline surgical site infection rate following abdominal surgeries, determine the influence of
various factors on infection rates, and evaluate the predictive value of the ASA (American Society of
Anaesthesiologists), SENIC (Study of Efficacy of Nosocomial Infection Control), NNIS (National
Nosocomial Infection Surveillance) indices on infection rates20. One hundred and forty four (144)
consecutive patients who had abdominal surgeries at the Lagos University, Teaching Hospital over a
one year period were studied by one of our Resident Doctors, Dr. Mofikoya (now a Consultant
Surgeon and Senior Lecturer), under our supervision. Demographic, clinical and relevant other
parameters were documented. Those who developed surgical site infection (SSI) had swabs taken for
aerobic and anaerobic cultures and also antimicrobial sensitivity tests. Swabs taken from wounds
were immediately placed into Robertson cooked meat broth (for anaerobic cultures) while swabs for
aerobic cultures were inoculated into blood and MacConkey agar and incubated at 37oC.
We found out that the wound infection rate was 17.4%. Surgeries involving the small and large
intestines made up 75% of all infected cases. The predictive factors for infection were prolonged
operating time, surgical procedures classified as contaminated or dirty, high ASA (American Society
of Anaesthesilogists) scores, SENIC (Study of Efficacy of Nosocomial Infection Control), NNIS
(National Nosocomial Infection Surveillance Index) scores20. We concluded that the predictive scores
24
can be utilized to identify high risk surgeries and institute appropriate measures to reduce surgical site
infections.
We have also carried out further analysis on the aetiological bacteria pathogens21. From the 25
infected wounds, 8 aerobic and 6 anaerobic organisms were cultured. All the aerobic organisms were
gram negative. The most frequent aerobe was Pseudomonas aeruginosa (7/25 patients) followed by
Enterobacter spp, Providencia spp and Candida albicans.
Bacteroides species were isolated from 14 patients, 9 of which were B Fragilis, B assacharolyticus
in 3 and B. ovis in 2 cultures. Other organisms isolated include Eubacterium spp, Actinomyces spp,
Fusobacterium spp, Peptostreptococcus spp and Propionobacterium spp. Antibiotic sensitivity
pattern of the organisms is shown in the table below.
Table XIV: Organisms and culture sensitivity
Organism
No
%
Bacteroides spp
14
28
Eubacterium spp
2
16
Actinomycesspp
2
16
Fusobacteriumspp
2
16
Propionobacterium spp 1
4
Peptostreptococcuss spp 2
8
No growth
3
12
caz
37.5
Pseudomonas spp
7
28
60
Enterobacter spp
5
20
25
Proteus spp
4
16
R
Klebsiella
3
12
50
Escherichia Coli
1
4
R
Citrobacter spp
1
4
50
Providencia spp
1
4
No growth
1
4
% sensitivity
cro
12.5
12
75
33.3
50
50
50
Cxm
12.5
R
R
33.3
R
R
R
gen
37.5
R
R
33.3
R
50
R
nit
R
12
R
R
R
R
R
cro–ceftriaxone, cxm–ceftaxime, caz–ceftaxidine gen–gentamycin nit–nitrofurantoin R–resistance
We have shown that Pseudomonas spp, Enterobacter spp. and Bacteroides are the predominant
organisms causing SSI in patients having abdominal surgeries. Majority of the aerobic agents appear
to be resistant to most of the tested antimicrobials. We have therefore advocated that antibiotic
prophylaxis for abdominal surgeries should be based on the sensitivity pattern of the common
pathogens that are incriminated in abdominal infections. It should however be noted that systemic
prophylactic antibiotics are only useful as adjuvants and not substitute for adequate surgery. It should
not be abused to prevent development of resistant strains. Administration should begin at induction
of anaesthesia and be continued throughout the operation and for drugs with short half-lives, multiple
doses should be given during long procedures.
Helicobacter pylori and Peptic Ulcer Disease
Mr. Vice-Chancellor Sir, surgical infection is an area of special interest to me but before I am
accused of posing as a Microbiologist, I will shortly move from speaking about bacteria to other areas
of my research endeavours. I will however wish to highlight a little about some of the studies that we
25
carried out with regards to peptic ulcer disease, one of the causes of acute and/or chronic abdominal
pain, in which a bacterium has been implicated.
The ground-breaking discovery of Marshall and Warren in 1984, which earned them nobel laurels,
has demonstrated that Helicobacter pylori, a microerophilic, spiral, gram-negative bacillus is a major
causative agent of peptic ulcer disease and chronic antral gastritis. Numerous clinical studies have
confirmed this association and we have also confirmed the association in various studies carried out
in our unit22, 23. Eradication of gastric H. pylori infections is known to be associated with reduction in
duodenal ulcer relapse. Several studies have shown that eradication of H. pylori results in regression
of concomitant antral gastritis and a dramatic reduction in duodenal ulcer recurrence rates. It is
however interesting to note that while H. pylori is suppressed by quite a number of antimicrobials,
antibiotics and anti ulcer agents, eradication rates have been suboptimal, and most monotherapies
have rarely exceeded 20% eradication rate.
We therefore carried out a study24 to determine the safety and efficacy of Ranitidine Bismuth Citrate
(RBC) in the treatment of patients with H. pylori associated duodenal ulcer given in co-prescription
with some antibiotics. Ranitidine Bismuth Citrate (RBC) combines the anti-secretory properties of
Ranitidine (a Histamine2 receptor blocker) and the mucosal protective properties of Bismuth to
provide a conducive environment for ulcers to heal in the absence of excessive acidity. The Study
was an open multi-centre study wherein we recruited adult patients with duodenal ulcer who are
proven to have H. pylori infection detected by a positive CLOTM test on an antral and/or fundic
biopsy taken during endoscopy. The main study centres were the Lagos University Teaching
Hospital. Aminu Kano Teaching Hospital, Kano and Obafemi Awolowo University Teaching
Hospital, Ile-Ife. Patients received RBC for 4 weeks in co-prescription with either clarithromycin for
14 days or amoxicillin plus metronidazole for 7 days. Patients returned for repeat endoscopic
assessment at least 28 days after the end of treatment.
Altogether fifty-eight (58) patients (33 males and 25 female), who completed the study, were
evaluated. The mean age was 39.99 + SD 9.40 years. At the end of treatment, the ulcers had healed
in 96.5% of the cases. Eradication of H. pylori was confirmed with a negative CLOTM test in 96.67%
of the patients who had RBC and clarithromycin and in 71.67% of those who had RBC and
amoxicillin combined with metronidazole. There was no report of any significant adverse event in
any of the patients. I must acknowledge the fact that the drugs used for the trial and the CLOtestTM
kits were provided by GlaxoWellcome Nigeria Limited, courtesy of my friend, Mr. Bunmi Olaopa,
FPSN, who was the Managing Director of the company at the time.
We therefore concluded that in the treatment of patients with H. pylori associated duodenal ulcer,
Ranitidine Bismuth Citrate is a safe drug that is efficacious in the healing of duodenal ulcer and
eradication of H. pylori when used in co-prescription with either clarithromycin alone or amoxicillin
plus metronidazole. However monotherapy using clarithromycin displayed slight superiority. This
finding has enhanced our current treatment protocol because with the availability of the Proton pump
inhibitors (PPI) which are more effective than RBC, we get very good results treating duodenal ulcers
with PPI combined with clarithromycin and amoxicillin. This is the reason why we hardly receive
many cases of perforated duodenal ulcers these days unlike we used to have before the discovery of
the association of H. pylori with duodenal ulcers and development of drugs that eradicate the
organism and allow the ulcers to heal. I am however saddened by the fact that the discovery came 25
years after my father, Pa Joseph Ajide Atoyebi, had died after supposedly an apparently successful
operation at the Wesley Guild Hospital at Ilesha for perforated duodenal ulcer! What a pity!!
26
Improvised Surgical Suction Drain
Mr Vice-Chancellor Sir, permit me to briefly describe a little improvised suction drain that I invented
so “THAT PATIENTS MAY NOT DIE AFTER SUCCESSFUL OPERATION”. You may recall that
I highlighted the sad occurrence in this University over 40 years ago when a Professor was reported
to have died after an apparently successful surgical operation to remove an enlarged thyroid gland
(Goiter). I do not know the cause of death in that particular instance but a well known possible cause
is that if blood collection under the operation site (haematoma) is not able to drain out, it may
compress the airway and cause death due to asphyxia. This is why closed suction drains have been
designed to prevent post-operative haematoma especially when skin flaps have been raised as is done
in operations for Goitres.
Since 1952, when Raffl25 developed a method of continuous suction drain employing an external
source of vacuum connected to the drainage tube, various refinements have taken place and these
days, suction drains are now supplied as complete kits (Redivac®, Portovac® etc). Unfortunately,
financial constraints limit the availability of these elegant kits in developing countries and as such,
various forms of improvisation had been designed to overcome this problem. I have therefore
designed a cheap and effective way of providing closed suction drainage using the ordinary plastic
infusion bottle and giving-set.
The materials for the drain consist of the ordinary plastic infusion bottle and the intravenous infusion
giving-set commonly used at the Lagos University Teaching Hospital. The contents of the infusion
bottle is emptied either by administering the fluid into the patient, if desired, or by discarding it. The
opening through which the bottle is emptied should however not be bigger than the size of the
pointed end (bottle end) of the infusion giving-set.
FIGURE 7: Materials for Improvised Suction drain beside ready-made Kit
27
Figure 7 shows the emptied and collapsed infusion bottle with its giving set (red-arrow) shown beside
the popular ready-made kit (Redivac®).
The needle and threaded rubber end of the giving set are removed leaving only the plastic tubing.
Side holes are made on the plastic tubing using scissors to cut the holes after making an almost 180o
bend of the tube (Figure 6). The holes made are each about 0.2cm in diameter and these are made
1cm apart, asymmetrically over a length of tubing, between 10 - 25cm, depending on the size of
wound to be drained.
FIGURE 8: Showing how the holes for drainage being made on the giving set tube.
Using size 11 blade (or the tip of any surgical blade), a stab wound, slightly less in diameter than the
diameter of the tubing, is made outside the main incision line. Through this stab wound, the tubing is
brought into the wound with an artery forceps.
The emptied plastic infusion bottle is then systematically squeezed from the bottom end so as to
collapse it completely as shown in Figure 7. With the infusion giving set closed with the wheel
clamp, the pointed end of the infusion giving-set is then inserted into the squeezed plastic bottle
through the puncture site used for emptying the bottle. The wound is closed and the plastic tubing is
secured with a stitch before the wheel clamp is opened. Suction commences as soon as the wheel
clamp is opened, and blood or other fluid collection can be seen running into the tubing and gradually
into the plastic infusion bottle (Figure 9).
28
FIGURE 9: Showing the IMPROVISED plastic bottle suctioning Blood
The collapsed plastic bottle is placed at a level below the level of the patient’s bed as the suction is
further helped by gravity. The air chamber may be pumped periodically as this helps to dislodge
clots. This innovative use of the plastic infusion bottle obviates the need to possess a suction machine
to be applied to the system as was described when using glass infusion bottle for obtaining suction
drainage. It can therefore be used in a rural setting where there is no form of suction machine. We
have used this improvised device successfully in several operations that my Resident Doctors have
named it “ATOvac”. The use of this improvised device was presented to the 32nd meeting of the
Nigerian Surgical Research Society (NSRS) in December 1996. This earned me the admission to the
society as an intending member must present a paper adjudged to be an original work at a scientific
meeting of the NSRS before he could be admitted. A detailed description was subsequently
published26.
Breast Cancer
Mr. Vice-Chancellor Sir, out of the six well-defined subspecialties in General Surgery, I have chosen
the subspecialty of Breast Surgery and I now enjoy being addressed as a Breast Surgeon. As
documented in my profile, I hold the membership of the Nigerian Senologic Society, the American
Society for Breast Diseases and also Breast Surgery International. In actual fact, I currently direct the
major part of my surgical practice to treating diseases of the Breast.
Cancer is a term for a number of diseases caused by abnormal growth of cells. Normally, the cells
that make up the body divide and reproduce in an orderly manner so that they can grow, replace
worn-out tissue and repair injuries. Sometimes, cells grow out of control, divide more than they
should and form masses known as tumours. Some tumours do not spread to other parts of the body,
but may interfere with body functions and require removal. These are known as benign tumours.
However, Cancers are malignant, tumors that not only invade or destroy normal tissue, but cells
29
break away from the original tumor and migrate to other parts of the body. There they may form
additional malignant tumors. This process is known as metastasis.
Breast cancer is the most common type of cancers in Nigerian women and it has overtaken cancer of
the cervix which has been pushed to the second position. It has been established that every woman
has a lifetime risk of developing invasive breast cancer of about one in eight, or 13%. The incidence
appears to be rising but the only consolation is that death rates from breast cancer have been
gradually declining in the developed world due both to increased awareness and screening and also
improved treatment methods. Unfortunately, patients in Nigeria present at advanced stages when
little can be done and so the outcome is usually poor28. Breast cancer is a female disease and less
than 1% of this occurs in men. The incidence increases with age and it is only occasionally seen in
late teens as majority of patients are over 40years of age. Persons with family history have an
increased risk (both maternal and paternal relatives are important especially first-degree relatives)
and there is a direct genetic factor in 5%, who have the genes (BRCA 1 & BRCA 2). Other lesser risk
factors include nulliparity, having first delivery after 40 years, prolonged use of oral contraceptives,
use of hormone replacement therapy, early menarche and late menopause and also obesity.
We carried out an appraisal of one hundred patients with breast cancer seen at the Lagos University
Teaching Hospital (Atoyebi et al, 1997)29 and found that the commonest presenting feature was a
lump in the breast (81%), most of which were painless. The right breast was affected in 51%, the left
in 45% and 4% had both breasts involved. The whole breast was involved in 30 cases and it was not
possible to localize the quadrant of onset in such cases. In the remaining, there were 37, 15, 10 and 8
cases with tumour in the upper outer, upper inner, lower inner and lower outer quadrants respectively
making the upper outer quadrant the commonest location of onset (Figure 8).
Table XV:
Clinical Features of Breast Cancer Patients
____________________________________________________________________
Presenting Features
No. of Patients (%)
__________________________________________________________________
Breast Lump
81%
Breast Swelling
18%
Breast Pain
23%
Nipple Discharge
23%
Breast Skin Changes
5%
Breast Ulcer
20%
Jaundice and Hepatomegaly
14%
Lymphoedema of the Upper Arm
2%
Cough and Haemoptysis
19%
Pathological Fracture
7%
Paraplegia
3%
_________________________________________________________________
30
FIGURE 8
Distribution of the Cancerous Lesions in the Quadrants of the Breast
Table XVI: Duration of symptoms before Presentation
____________________________________________________________________
Duration of Symptoms
No. of Patients
% Total
before Presentation
_____________________________________________________________________
0 - 6 Months
36
36%
6 Months – 1 Year
22
22%
1 – 2 Years
30
30%
2 – 3 Years
3
3%
Over 3 Years
9
9%
_____________________________________________________________________
Total
100
100%
31
FIGURE 9
Advanced Breast Cancer Fungating at the Outer Upper Quadrant
Table V: Survival Analysis at Time of Appraisal
_____________________________________________________________________
Stage of
No. of
No.
No.
No. Lost to
Disease
Patients
Alive
Dead
Follow-up
____________________________________________________________________
I
6
5
1
0
II
17
9
3
5
III
25
16
3
6
IV
52
4
25
23
_____________________________________________________________________
Total
100
34
32
34
_____________________________________________________________________________
Most patients presented rather late as only 36% presented within 6 months of noticing a lump and the
earliest was at 2 weeks in a patient who was a trained nurse. At presentation most were at the late
stages of the disease (Figure 9). The Manchester’s method of staging of breast cancer was used in all
cases. Seventy-seven patients (77%) had advanced cancers (Manchester stages III or IV) and only
5% had clinically Stage I disease. Despite the expected high level of awareness about breast cancer
in an urban centre like Lagos, majority (54%) of our patients presented after 6 months of the first
symptom. Late presentation has unfortunately been reported30 to be the hallmark of most of Nigerian
32
breast cancer patients and various reasons have been attributed to this. Such reasons include social
and cultural inhibitions to describing female body parts, fear of surgery to remove the breast
(mastectomy) and various other ridiculous reasons not influenced by the patient’s educational status.
Another factor is the increased patronage of spiritual healers and traditional herbal homes who claim
they cure all diseases. The stage of the disease at presentation is therefore usually late and 77% of
our patients were at advanced stages (Stages III and IV). Management consisted of a combination of
treatment modalities like surgery, radiotherapy and chemo-endocrine adjuvant or neoadjuvant
therapy. Only supportive terminal care could be offered 11% of these patients. 32% of the patients
died within two years of presentation despite appropriate treatment. A lot of efforts are therefore still
needed to increase awareness to ensure early disease detection and treatment.
It is saddening to note that 19% of the patients claimed they did not notice any lump until the whole
breast became swollen or there was ulceration. This finding re-emphasizes the fact that breast selfexamination needs to be taught to all females above the age of 18 years. Screening Mammography
(X-rays of the Breast) would have detected most of the lesions before they became evident and all
women above the age of 40 years should have this done every year while younger women at high risk
should
FIGURE 9
MAMMOGRAM- Soft tissue X-ray of the Breast showing a lump behind Nipple
have annual ultrasound scan of the breast. This is because breast cancer detected during routine
screening is eminently curable by appropriate surgery that may not necessitate removal of the whole
breast. Early detection is therefore the only way to ensure “THAT PATIENTS DO NOT DIE AFTER
SUCCESSFUL SURGERY” for breast cancer.
33
A good number of original research work have been carried out on Breast cancer in the General
surgery Unit (GSU) and some of these were carried out by our Resident Doctors as part of the
requirements for the Fellowship in Surgery. Some of these are:
1. Dr. Linga Panchalinga – An Evaluation of Fine Needle Aspiration Biopsy in the Management
of Breast lumps. May 1999.
2. Dr. D. Egbikuadje – Evaluation of Blood loss and Transfusion Requirements in patients
undergoing mastectomy for carcinoma of the Breast. May 2000
3. Dr. O. Osinowo. The Role of Mammography in the management of Breast lesions at the
Lagos University Teaching Hospital. May 2005.
4. DR. C. B. Obioha: Intraoperative Lymphatic Mapping And Sentinel Lymph Node Dissection
In Carcinoma Of The Breast, May 2007
Another Resident Doctor, Dr. A. O. Ajiboye has just recently completed the study on “The Status Of
Oestrogen, Progesterone and HER-2 Receptors In Breast Cancer and the Disease Correlation in
Patients seen at LUTH”.
The major aim of these studies is not just for the sake of Academia but to guide our strategies both
for the prevention and treatment of this ravaging disease that is steadily increasing in its prevalence.
A recent study30 in which I was involved showed a 4.7% prevalence rate of breast lumps among fresh
female undergraduates of the University of Lagos. The knowledge of breast diseases, especially
breast cancer, was found to be low among female undergraduates of the University of Lagos as only
30% of the respondents had good knowledge of breast diseases especially breast cancer. We have
constituted the Lagos University Multi-disciplinary Breast Study group to carry out various studies to
improve the current dismal outcome of breast cancer management. Our team consists of Surgeons,
Histopathologists, Radiologists, Radiotherapist and Medical Oncologists, Psychologists and other
interested persons. We are approaching the University for a Robust Research Grant and I hope the
Vice-chancellor will assist us.
CONCLUSION
Mr. Vice-Chancellor Sir, I have highlighted a few of my research endeavours to discuss my topic for
today as an Academic Surgeon. A surgeon has been described as “an operating physician who has
the heart of a lion, the eyes of an eagle and the hands of a lady”. Rajarshi Mukherjee has stated that
“Academic surgery is not an oxymoron but that it is the perfect balance between practical and
cerebral”31. Any good surgeon must be intelligent, conscientious, creative, courageous, and
demonstrate perseverance on behalf of the patients. His actions must be deliberate, precise and
carried out with finesse. The programme of the day for a surgeon is hardly predictable and he must
accept the volatile environment as an enjoyable challenge. A good surgeon must be comfortable with
making quick decisions, assuming leadership readily, and discussing errors in a public forum. I can
assure you that I am fully at ease discussing our handicaps in front of this audience. After all, we only
provide the care; it is only God that can heal as enshrined in the Motto of the Lagos University
Teaching Hospital.
Mr. Vice-Chancellor Sir, I have in the one hour allocated to me tried to give an insight into the
travails of the General Surgeon who although known to be bold (“with the heart of a lion”) but does
not have the temerity to discountenance the infinitesimal micro-organisms causing surgical infections
because technology has failed to conquer these germs as of today. I have highlighted why the
Academic surgeon cannot work in isolation but must continually collaborate with microbiologists and
other Scientists to research into causes of morbidity and mortality following apparently successful
34
surgical procedures. From the foregoing, the necessity of multiple authorship for any good article in a
reputable journal is therefore not debatable in the life sciences. In the words of Bradley Aust in his
paper Odyssey of an Academic Surgeon31, he stated: “Academic surgeons have, by necessity,
committed themselves to the concept of the team approach to education, training, research, and
patient care. It is not a democratic process since there is usually a captain of the team. He serves as
the mentor and chooses his teams, sets their goals, supports their personal development, then sends
them out to practice or remain in academia, where they in turn assume the mantle of mentorship for
those who follow. As I mentioned earlier, it is extremely rare today to find a single-author paper.” I
have followed this pathway in the studies that I have alluded to in this inaugural lecture as many of
my mentees have through our collaborative studies obtained their Fellowships in Surgery and one
person actually used the platform of my research grant to complete her work for her Doctorate in
Microbiology, and they have all moved on in life.
Mr. Vice-Chancellor Sir, I have also shown that Breast cancer, which is now more prevalent, is an
area to which we have directed our attention and more efforts are needed to ensure early detection so
as to allow curative surgery. The appropriate surgery in such an instance may not necessitate the
mutilating operation of total removal of the breast (mastectomy) and as such, not only will the
operation be successful, we can be assured that the patient is unlikely to die from the disease.
RECOMMENDATIONS
Mr. Vice-Chancellor Sir, kindly permit me to seize this unique opportunity of Academic freedom to
make some recommendations:
Government
1. The Governments at all levels in this Country should stop playing politics with the health of
the citizens and ensure that health is given the priority it deserves. It is indeed regrettable that
in the 1999 Nigerian Constitution in current usage, health is neither in the concurrent nor the
exclusive list. Without putting it on any list, it was just mentioned in passing that every
Nigerian deserves to be in a good state of health. It is therefore not surprising that budgetary
allocation to Health is always inadequate. We budget billions of Naira for mundane issues like
building a new Banquet Hall at the Presidential Villa while the citizens wallow in poverty
with considerable disease burden. Healthcare services are not readily available, accessible and
affordable to most of our rural population and the urban poor citizens. I hereby plead with our
leaders to re-work the National Health Insurance Scheme so as to cover the most vulnerable
groups. Right now, it covers less than 5 per cent of the population and those covered are not
among the most vulnerable groups.
2. Government should take necessary steps to stop the charlatans who buy air-time on Television
and Radio stations to deceive the public that they can cure all ailments from Leprosy to HIV
and even to all forms of cancers. The National Broadcasting Corporation (NBC) should be
alive to its duties as regards the control of these unbridled advertisements which are clearly
against the extant Laws of the Federation that forbid advertisement of cure of some diseases
in the media. I took up this issue with the Director-General of NBC in 2005 when I was
National President of the Nigerian Medical Association but they have not performed till date.
The faith healers, trado-medical and other unorthodox healers are the ones that deceive our
patients for too long only to present to us late when the diseases are incurable; and thereby
give our institution the stigma of “Died in LUTH after a brief Illness”.
3. The finding that 19% of our patients claimed that they did not notice any lump until cancer
had involved the whole breast shows that Self Breast-Examination (SBE) needs to be taught
to all women as from the age of 18 years. This important Health Education issue should be
sponsored by Government and should be done in both the print and electronic media.
35
4. State Governments should ensure that facilities for Breast Ultrasound and mammography are
available at each Local Government Area and made affordable, if not completely free.
5. It is ludicrous to expect a Teaching Hospital to operate without running tap water AT ALL
TIMES. Since the Lagos State Government has been unable to provide potable tap water for
the teeming population of the Mega-City of Lagos, the Federal Government should specially
fund LUTH to ensure that water runs in all the taps at all times. Infection control is hardly
possible in the absence of running water.
Lagos University Teaching Hospital (LUTH)
1. After 50 years of existence, it is unacceptable for our Teaching Hospital to continue to treat
patients with major Burns in open wards along with other patients with variety of possible
infections. When I returned to the services of LUTH in 1988, I made a proposal for the
creation of a SPECIALIZED BURN UNIT so as to improve the treatment outcome of
severely burned patients. This was based on my experience at the West Lothian Burns
Services in Scotland, United Kingdom. I understand that after I left the Burns & Plastic
Unit, those who came after me also made similar proposals. I recommend that the current
LUTH Management should do something about this in line with the strides that are being
made in Renal Transplantation and allied matters.
University Of Lagos
1. The Vice-Chancellor is hereby encouraged to strengthen what he has started by expanding the
provision that has been made for Annual Medical Check-up at the Medical Centre. I
recommend that we should go a step further by making the submission of a Medical Report a
requirement before consideration of the Annual Performance Evaluation Report (APER)
forms. An enlightened Society like ours should not allow our members to die needlessly of
preventable diseases.
2. The reported finding that only 30% female undergraduates in the University of Lagos had
good knowledge of breast diseases especially breast cancer makes it mandatory that we
include this in the GST courses. We made a proposal in March 2011 for a new GST course on
Reproductive Health which is envisioned to equip students with knowledge and skill to
protect themselves against Sexually Transmitted Infections (STIs) including HIV infection, as
well as prepare them to serve as agent of change in their present and future communities as
regards Health matters. The proposal was deemed to be late and as such Professor Odeigah’s
committee could not accommodate it. I recommend that the proposal be revisited especially
for Students who are not in the Health Sciences.
The Nigerian populace through the Media
All Nigerians should be made aware of the CANCER’S SEVEN WARNING SIGNALS: 1. Change
in bowel or bladder habits, 2. A sore that does not heal, 3. Unusual bleeding or discharge, 4.
Thickening/lump in breast or elsewhere, 5. Indigestion or difficulty in swallowing, 6. Obvious
change in wart or mole and 7. Nagging cough or hoarseness
Mr. Vice-Chancellor Sir, the few recommendations I have made are based on my belief that we are
all stakeholders in health matters and we must all play our parts. As for those of us who are surgeons,
we should continually remind ourselves of the “Medical Litany” attributed to Sir Robert Hutchison
(1871 – 1960) and quoted by Hamilton Bailey and McNeill Love:
36
‘From inability to leave well alone;
From too much zeal for what is new and contempt for what is old;
From putting knowledge before wisdom, science before art, cleverness before common sense;
From treating patients as cases; and
From making the cure of a disease more grievous than its endurance,
Good Lord, deliver us’.
As Surgeons, in whatever we plan and do, we must work assiduously to ensure “THAT PATIENTS
DO NOT DIE AFTER SUCCESSFUL SURGERY”.
ACKNOWLEDGEMENTS
Mr. Vice-Chancellor Sir, kindly permit me to thank the creator of the Universe who has graciously
allowed us to witness this occasion. I thank the almighty God for creating me, preserving me and
providing for me from my very humble beginning to what I have been, what I am and what I will be
in future. To Him be all glory, praises, honour and adoration forever and ever more.
Mr. Vice-Chancellor Sir, I am very grateful to you for magnanimously allowing me to deliver this
Lecture to this distinguished audience today. May God continue to bless you. I have been lucky to
know the last 3 Vice-chancellors before you very closely and they have all contributed to my
progress in one way or the other. While wishing Professors Oye Ibidapo-Obe and Tolu Odugbemi
long life and continued good health, I pray for the repose of the soul of the amiable Late Professor A.
B. Sofoluwe. His demise is still like a dream. May God bless the family he left behind.
Mr. Vice-Chancellor Sir, my father, Joseph Ajide Atoyebi, died the month after my 6th Birthday and
thus, I hardly knew him. The worst aspect of it was that he died in the morning of the day that we
were to have our promotion examination from Primary One to Primary Two. Everyone was crying
and there was pandemonium in the house. When I heard the School Bell indicating that the School
Opening Assembly would commence in half an hour, I insisted in getting dressed to get to school. A
family friend, Late Mr. Owolabi, assisted me and gave me Six pence to buy all the writing materials
that I needed and also to feed during the school hours. I would have missed the examination if not for
his intervention. My Late mother, Chief Abigail Onaolapo Atoyebi, took up the responsibility of
training all of her four children. I was the last child who had the opportunity of being trained to the
University level. By the time I was in the University, my eldest sister, Late Chief (Mrs) Janet
Modupe Akano was already a trained midwife working with the Western Region Government. She
and her husband were thus in a position to support my mother to foot the bill for my University
education. I am greatly indebted to them all.
Chief Solomon Adedayo, the loving and caring cousin of my father, has been the father that I have
ever known and he has been steadfast in giving me all the support that I have ever needed. I am very
grateful to him. He is 98 years old now and still very lucid. Even though he lost his sight to untreated
Glaucoma, he still recognizes everyone by their voice. It was too late before it was diagnosed.
I owe a debt of gratitude to my Uncle, Mr. Kunle Adetunji, who was the most junior among the
siblings of my mother but when I was young, I thought he was actually my elder brother and the first
born of my mother. He was the one who insisted in 1965 that I should move from Ila Grammar
School to Oyan Grammar School so that I could read Science subjects. According to him, “without
offering science subjects in today’s world, you will later regret as you would be limited to just a few
choices”. I reluctantly adhered to his advice. I was reluctant because I was a local champion who was
afraid of losing the pride of always taking the first position in my class. He was also the one who
changed my choice of course from Engineering to Medicine in 1971 when I came to Lagos to submit
37
my application form for admission to the University of Lagos. I have not regretted any of his
decisions that he has forced on me till date. I thank God for his life and for his influence on my life.
Between 1965 when I commenced my Secondary School Education and 1990 when I obtained the
Fellowship in Surgery, I have had so many teachers that it will require writing a whole book if I am
to mention all those who have taught me by name over the 25-year period. I however wish to register
my appreciation for all that my various teachers impacted on me. May God bless them all. My being
an Academic Surgeon today would not have been possible if I did not move to Oyan Grammar
School to study the Sciences. I am grateful to Late Chief J. K. Fadeyi, who was then the Principal of
the school and to the school herself for the solid foundation she gave me. When I came from Oyan
Grammar School to University of Lagos to meet others in Preliminary Medicine who were from the
renowned Lagos schools, I was scared. However, I dusted them all till our final year when I passed
WITH HONOURS which is the equivalent of First Class in Medicine; MB,BS being an unclassified
degree. I also bagged the prize for the overall best medical student in general. I remain eternally
grateful to Oyan Grammar School that prepared me and to the University of Lagos that made me a
medical doctor. Great Akokites!
I must acknowledge with thanks the tutelage that I received from all the retired Professors and
Consultants in the Department of Surgery of the Lagos University Teaching Hospital during my
rotations over the years. As of today, I am the most senior academic member of staff in full time
employment in the department of Surgery as those before me have retired. My surgical training
commenced in 1980 but was not completed until 1990 because there was a break between March
1985 and June 1988. The break was necessitated by the high-handedness of the Buhari/Idi-Agbon
Military Government that proscribed the National Association of Resident Doctors (NARD) and the
Nigerian Medical Association (NMA) with the arrest of the Associations’ officers that they could
find while I, the National President of NARD and some of the other officers escaped into exile
abroad. It was only after the regime had been overthrown and reprieve granted to all us that we
returned to the service. Interestingly, the doctors’ strike that we led was NOT to demand for a welfare
package for doctors. Our demand at that time was for the Military government to fulfill its promise
by equipping the hospitals and providing drugs. This is because the group justified their overthrow of
the Civilian Government of Alhaji Shehu Shagari by highlighting the fact that “hospitals have
become mere consulting clinics”. It is not surprising the regime did not last long!
This is why I must register, in a special way, my gratitude to Professor G. O. A. Sowemimo, who
along with Professor S. A. Ademiluyi and Mr. Jubril Oyeneyin, taught me the basic tenets of Plastic
Surgery. He however did not stop there. While I was in exile in Britain in 1985, it was Professor
Sowemimo that got me the Clinical attachment to the West Lothian Burns & Plastic Unit at Banguor
Hospital in Scotland, UK under Miss Anne B. Sutherland. Miss Sutherland was the first female
Plastic Surgeon in Britain and she died recently at the age of 88 years. On Professor Sowemimo’s
recommendations, I had free accommodation in the hospital premises and I had a wonderful exposure
to the modern methods of managing burns and to high-Tech Plastic & Reconstructive Surgery. I am
greatly indebted to Professor Sowemimo because he also supervised my Fellowship research project
on Burn Sepsis in conjunction with Professor Tolu Odugbemi, the world acclaimed bacteriologist and
our former Vice-Chancellor. Incidentally, Professor Tolu Odugbemi, OON, NNOM, FAS, had been
my brother-in-law for 10years before this project but we were not close at all because he had little
time for people who were not in Academics. Brother Tolu’s supervision of my project brought us
very close till today and at moment, if I have not spoken to him on phone for 2 weeks, I will be very
uncomfortable. He has contributed a lot to my research efforts and I owe it to him that I have cut a
niche for myself in this country as regards surgical infections.
38
Picture taken with my supervisors, Professors Odugbemi and Sowemimo, at one of the
Convocation Ceremonies of the National Postgraduate Medical College of Nigeria.
Emeritus Professor J. T. da Rocha-Afodu and Professor B. Akande brought me to the General
Surgery Unit and nurtured me until I started nurturing others. They treated me like one of their
relations from the beginning and encouraged me in my academic pursuits. They are great mentors
and I can never forget them. I pray that the Almighty God will bless them and grant them more useful
years in good health. I worked under various heads of department of surgery that I have not
mentioned and they all contributed to my growth despite the fact they all showed amazement that my
deep involvement in “Medical Politics” did not affect my clinical duties and academic programmes. I
am grateful to them all; these include Professor P. O. Okeowo, Late Professor N. A. Ojikutu and
Professors A. Majekodunmi, H. O. Adeyemi-Doro and S. O. Arigbabu.
I am also grateful to all those who I have worked with over the years without whom my work would
have been impossible. These are the Anaesthetists, the Nursing Staff, the Radiotherapists, the
Pathologists, the Medical Laboratory Scientists and all administrative staff in both the College of
Medicine and the Lagos University Teaching Hospital who are too numerous to name individually. I
thank everyone without exception.
I must specially recognize my colleagues in the General Surgery Unit. There was a time, following
the exit of Professors Folabi Olumide and Bashir Akande, when we were only four in number for
several years and all of us were in senior academic positions. We were then desperately looking for
young ones to recruit to the busiest Unit in the Teaching Hospital. We were then named the 4As Unit
– Adesanya, Atoyebi. Atimomo and Afodu. Although we usually quarrel every Monday morning
during the weekly Seminar and Research Meeting before Professor Da Rocha Afodu would mediate,
we enjoyed working with each other and our unit recorded more research publications than other
units in the department.
39
4As UNIT: O. A. ATOYEBI, JT da Rocha AFODU, C. E. ATIMOMO (Late), A. A. ADESANYA
I thank God that the unit now has some younger ones carrying on the banner. I have no doubt that O.
A. Osinowo, T. A. Olajide, A. O. Lawal and M. A. Afolayan, who are now Lecturer I, will carry on
the good work that will make us proud to the extent that even Late Emeritus Professor Akin Adesola,
who founded the Unit, would smile in his grave.
I must also thank all the previous Provosts of the College of Medicine who were in office since I was
employed in the College. These are Professors Soga Sofola, Tolu Odugbemi, Lekan Abudu and Steve
Elesha who at different times saw me rise through the ranks, from Lecturer I position to the Full
Chair that I now occupy. I am grateful to all of them. I will now specially thank the first female
Provost and my successor in Office, Professor Folashade Tolulope Ogunsola for serving me in
various capacities when I was Provost. She had previously collaborated with me in a number of
research endeavours and we have at least 5 joint publications. Madam Provost, thank you so much
and I wish you a successful tenure.
Mr. Vice-Chancellor Sir, It gives me great joy that the transformation of Schools in the College to
become full-fledged faculties of the University took place during my tenure as Provost. I sincerely
thank the current and all former Deans of the three new faculties, especially my home Faculty of
Clinical Sciences. I wish to specially single out Professor Adebukunola Adefule-Ositelu, my big
sister, who had worked with me in the Department of Surgery before she moved to Department of
Ophthalmology and thereafter the office of the Dean. She has been always supportive and I am
grateful for her love and prayers. I had a good number of new acquaintances in the University as the
Provost from 2009 to 2012. The Principal Officers at both the Main Campus and the College of
Medicine became very close friends. The Staff and Students, including their Unions, gave me
tremendous support. I am grateful to all.
Mr. Vice-Chancellor Sir, I wish to finally thank my friends and family who have supported me in my
journey in life to this present day. I have benefitted from the friendship of too many people, many of
whom are older than me, and as such it is impossible to list all of them. I appreciate my dear friends
in the Ultimate Circle of Nigeria, Ila Charity Club, Oyan Grammar School Old Students’ Association,
40
Yoruba Tennis Club, Medical Centre Staff Club and the University of Lagos Senior Staff Club. They
have given me great opportunities to enjoy the little time I have for leisure! I just want to thank them
all, especially BROS-B (Mr Adebayo Ajayi), who took time to proof-read the manuscript of this
Lecture. I am also grateful to the Clergy and the Laity of my Church, the Chapel of the Healing
Cross, Idi-Araba, especially members of the Fellowship of Hope and Anchor. I thank them for their
prayers and in helping my spiritual development.
My Brother and Sister, Mr. Kunle & Mrs. Yinka Adedayo deserve special mention as they housed my
wife and children during my travails when I had to go into exile in 1985. They accepted them readily
with joy. I will remain eternally grateful. God will continue to bless them and all theirs.
My nuclear and extended families in the ATOYEBI CLAN have continued to give me joy and I
therefore thank all my uncles, aunties, nephews, nieces and cousins for their continued support.
Members of my other family from the ODUGBEMI CLAN have also been so supportive and I must
appreciate them all especially Sister Titi, Brother Temitayo, Sister Simi, Olanlesi and Nimbus, the
Senator.
Mr. Vice-Chancellor Sir, my darling wife, Dr Oluwatoyin Olayide Atoyebi, has been a friend indeed
and my pillar of support at all times. She has remained loving and devoted from when we started
dating in 1974 as medical students in this University till today that we are grandparents. We have
bonded so much that we have accepted each other’s idiosyncracies! I thank her for being so caring
and affectionate. Our adorable children have also brought us joy and have even increased our
closeness. Our first child, Dolapo, who is now a Resident doctor specializing in Psychiatry, is married
to Mr. Ron Oseji and they have given us the ever smiling Nathan as a grandson. Our Second
daughter, Onaolapo Dagunduro, who read Accountancy is in Canada with her husband, Femi and our
grand-daughter, Oluwakuishe. The BABYGIRL of our house, Omolola, who obtained her B. Sc in
Pure Physics, got married recently to Mr. Adeola Akinsanya and we are waiting for another grand
child from them. Our last child, Oladipupo Atoyebi is the only one left in the house and is currently
an undergraduate in Architecture. What else would one ask from God? It has been a life of fulfillment
through the grace of God. It is the Lord’s doing and it is marvelous in our eyes!
Mr. Vice-Chancellor Sir, Distinguished ladies and Gentlemen. I thank you for your attention.
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