title: The challenges of cardiothoracic surgery practice in Nigeria: a 12 years institutional experience.
abstract: BACKGROUND
  Although the specialty of cardiothoracic surgery has been practiced in Nigeria for many years, open heart surgery (OHS) has only in the last decade become relatively more frequent, mainly through visiting foreign cardiac surgical teams. At this early phase of development it is faced with multiple challenges, especially financing and local skilled manpower for which solutions have to be identified in order to ensure sustainability and future growth. This study is aimed at highlighting these obstacles to growth of cardiothoracic surgery based on our own institutional experience at Lagos State University Teaching Hospital (LASUTH) and the current status of OHS activity in other cardiothoracic centers in Nigeria.
  
  
  METHODS
  Prospectively acquired data from our center from March 2004 to December 2015 was reviewed. A telephone survey was also conducted with all other institutions in Nigeria performing cardiac surgery.
  
  
  RESULTS
  During the study period 1,520 patients underwent various procedures with a mean age of 37±22.4 years and 813 (53.5%) were males. There were 450 major procedures (29.6%), 889 minor procedures (58.5%) and 181 endoscopic procedures (11.9%). The top ten clinical diagnoses were empyema thoracis (17.5%), malignant pleural effusion (14.7%), chest trauma (12%), hemodialysis access (6.1%), bradyarrhythmia (5.3%), aerodigestive foreign bodies (4.1%), vascular injury (3.9%), pericardial disease (3.8%), lung cancer (3.6%) and congenital heart disease (3.4%). The range of procedures was chest tube insertion (41.6%), endoscopy (11.9%), lung procedures (7%), arterio-venous fistula (6.1%), pacemaker implantation (5.3%), vascular repair (4.4%), OHS (3.4%), esophageal procedures (2.6%), chest wall surgery (2%), video assisted thoracic surgery (2%), closed heart surgery (1.6%), diaphragmatic procedures (1.6%) and thymectomy (1%). Survey of 15 centers in Nigeria with cardiac surgery activity showed a total of 496 OHS cases between 1974 and 2016, with 330 cases (66.5%) done between 2012 and 2016.
  
  
  CONCLUSIONS
  Infections, malignancy and trauma currently account for the bulk of cardiothoracic surgery practice in Nigeria, with surgical activity showing a predominance of minor procedures and comparatively minimal OHS activities. Identified challenges to increasing cardiothoracic surgical activity were limitations in manpower development, infrastructure, laboratory support, local availability of consumables, cost of surgery, funding mechanisms for surgery, multiple models for development of cardiac surgery, decentralization of efforts and lack of outcome data. Data collection and reporting of results must be started to enable development of more evidence-based practice.
authors.affiliation: Cardiothoracic Division, Department of Surgery, Lagos State University College of Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria; ; Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, Northern Ireland.
authors.forename: Bode
authors.initials: B
authors.lastname: Falase
authors.affiliation: Tristate Cardiovascular Services, Babcock University, Ilishan, Nigeria.
authors.forename: Michael
authors.initials: M
authors.lastname: Sanusi
authors.affiliation: Paediatric Cardiology Division, Department of Pediatrics, Lagos State University College of Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.
authors.forename: Adeola
authors.initials: A
authors.lastname: Animasahun
authors.affiliation: Cardiothoracic Division, Department of Surgery, Lagos State University College of Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.
authors.forename: Ogadinma
authors.initials: O
authors.lastname: Mgbajah
authors.affiliation: Department of Anesthesia, Lagos State University College of Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.
authors.forename: Adetinuwe
authors.initials: A
authors.lastname: Majekodunmi
authors.affiliation: Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, Northern Ireland.
authors.forename: Onyekwelu
authors.initials: O
authors.lastname: Nzewi
authors.affiliation: Department of Cardiothoracic Surgery, Atlanta Medical Centre, Atlanta, Georgia, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Nwiloh
authors.affiliation: Department of Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.
authors.forename: David
authors.initials: D
authors.lastname: Oke
keywords: Cardiothoracic surgery practice; Nigeria; institutional experience; open heart surgery (OHS); survey