Factors affecting apparent demand for the VRTB in the pilot programme

This is a 12-month prospective study. Patients of both sexes of 19 years and above admitted with MIO in Abia State University Teaching Hospital, Maranatha Specialist Hospital, Nnenna Hospital Limited and Ebony Hospital Limited all in Aba from May 2004 to April 2005 were included in the study. The diagnoses were made clinically and radiologically and confirmed at surgical exploration in some difficult cases.

* STUDY AREA

The study was carried out in Aba, the commercial nerve centre of Abia State in South Eastern Nigeria. Owing to the location of the city, patients come from Imo, Rivers, Bayelsa, Cross River and of course Abia State for treatment. Abia State University Teaching Hospital, Maranatha Specialist Hospital, Nnenna Hospital Limited, and Ebony Hospital Limited were used for the study.

The Teaching Hospital is located at the centre of Aba, while the three private hospitals are located at the three main areas of the town viz: Osisioma (Maranatha Specialist Hospital), Aba North (Nnenna Hospital Ltd) and Aba South (Ebony Hospital Ltd ). These private hospitals are busy, adequately staffed with surgeons as the Medical Directors. These are hospitals in Aba where standard surgical procedures are performed.

When there are disruptions of services at the Teaching Hospital, most patients go to these private Hospitals for surgical treatment.

* METHODOLOGY

The written permission of the Ethical Committee of Abia State University Teaching Hospital was obtained. The permissions of the Medical Directors of the three

private hospitals and request for their supervision were gotten (Appendix IIA, IIB, IIC).

The consent of the patients or relations were sought and obtained (Appendix III). The author was called whenever there was a patient (19 years and above) suspected to have MIO in the centres used for this study.

Having established the diagnosis following history and physical examination, the patient’s/relation’s consent to be included in the study was gotten.(Appendix 111).

Relevant information about the patient was entered in a proforma (Appendix 1) administered by the author. The patient was admitted. The proforma was completed before the patient was discharged or after death.

Each patient was managed by ensuring adequate resuscitation. Baseline PCV, WBC, serum electrolytes, blood urea and serum creatinine were performed. Grouping and cross-matching of blood when indicated was also done. Plain posterior-anterior (P-A) chest, and abdominal radiographs in supine and erect positions were done except in the obvious conditions such as obstructed external hernia.

In a bid to ascertaining the diagnosis, and ensuring that a standard protocol was followed, the author examined all the patients with MIO. He performed, assisted or observed the operations in 85% of 94 surgical operations performed in this study.

The author saw all the patients in this study and was involved in the management of all the patients until they were discharged or died. He also saw all the patients at ABSUTH and 85% of the patients from the private hospitals that came for post-operative visits.

Conservative management in the form of “drip and suck” was offered to 10(9.6%) of the patients. Eight (8) out of the 10 patients were suspected to have adhesive intestinal obstruction while 2 had faecal impaction. Nasogastric tube aspiration was done in

conjunction with intravenous fluid rehydration to correct electrolyte and fluid derangement detected clinically and biochemically. This was followed by regular vital signs monitoring and serial abdominal examination to assess improvement or otherwise of the conservative management. Failure of 3 of the patients with suspected adhesive bands to respond positively within 48 hours of conservative management led to surgical intervention. Passage of flatus and/or faeces, reduction in the volume of nasogastric tube aspirate, reduced abdominal distension and return of normal bowel sounds were taken as evidence of improvement in patients’ clinical condition. Patients were then gradually re-introduced to enteral feeding.

* PRE-OPERATIVE PREPARATION OF THE PATIENTS

Once a diagnosis of MIO was made, oral intake was stopped and the patient was commenced on intravenous fluids (usually crystalloids). Subsequent resuscitative measures then depended on deficiencies detected on clinical assessment and biochemical results of serum electrolytes, urea and creatinine. When absolutely necessary to monitor the hourly urine output, patients were catheterized. Thirty to fifty mls/hour of urine was regarded as adequate.

Nasogastric tube decompression was introduced when patient had vomited persistently or had abdominal distension. Most of the obstructed external hernias did not require nasogastric tube decompression when they presented early. Intravenous antibiotics usually cephalosporin and metronidazole were administered and continued post-operatively when necessary. After the decision to operate had been taken or conservative management had been instituted in suspected adhesive intestinal obstruction, parenteral pentazocine was administered in adequate doses. Written informed consents were

obtained from the patients or relations (Appendix IV). The anaesthetists were duly informed and the patients properly booked in the theatre.

* INTRA-OPERATIVE PROTOCOL

After resuscitation and informed consent, exploratory laparotomies were done under general anaesthesia with, cuffed endotracheal tube or regional anaethesia especially for obstructed external hernias. An adequate incision was made depending on the suspected primary cause of the intestinal obstruction. Operative findings were recorded as follows:

* Macroscopic nature of peritoneal fluid

* Definitive cause of obstruction

* Part of bowel affected and the site of obstruction

* Viability or otherwise of the bowel

* Length of the gangrenous bowel resected was determined using sterile suture materials measured by metre rule.

Indications for bowel resection were gangrene, incomplete reduction of intussusception, obstructive neoplastic lesions and bowel redundancy in sigmoid volvulus.

Bowel continuity after resection was restored by end-to-end anastomosis except in 2 cases of rectal malignancy where Hartman’s procedures were performed. All specimens of excised bowel were sent for histopathological examination.

* POST-OPERATIVE PROTOCOL

Patients were placed on intravenous fluid with nothing allowed by mouth until the return of bowel activity. Nasogastric tube with regular aspiration was continued where indicated. Analgesics and antibiotics were also continued. Vital signs and strict input/output were recorded If the incision wounds became infected, a wound swab was

taken for microscopy, culture and sensitivity. Stitches were removed between 7 and 10 days post-operatively depending on the condition of the wound.

Post-operative complications if they occurred were documented and the patient managed accordingly until they were fit for discharge or death occurs. Discharged patients were seen in the clinic in 2 weeks and then 6 weeks post-operatively. After the second post-operative visit they were discharged from the out-patient clinic in the absence of any obvious post-operative complication. Patients with complications were seen more frequently and managed adequately.

* DATA ANALYSIS AND PRESENTATION

The data collected in the Proforma were transferred into electronic data format on micro-computer using the EPI-INFO (Version 6) Software. X² (chi-square) test was used to test association with categorical variables. P-value of less than or equal to 0.05 was taken as significant so that the null hypothesis was rejected. P-value of more than 0.05 was regarded as non-significant and the null hypothesis upheld. The data was presented in tables, bar charts, pie charts and venn diagrams as necessary.