Typhoid Intestinal Perforation Prognostic Score in Poor-Resource Settings.

Background: Mortality from peritonitis due to typhoid intestinal perforation (TIP) in sub-Saharan Africa is high. Objectives: This study aimed to determine the predictive factors of mortality, propose a prognostic score, and determine the appropriate surgical treatment for TIP in low-resource settings. Materials and Methods: This was a retrospective data collection of peritonitis due to TIP admitted at Zinder National Hospital from 2014 to 2021. To build a typhoid intestinal perforation prognostic score (TIPPS), patients were randomised into two groups: a score-building group and a validation group. Univariate and multivariate analyses were performed to identify risk factors of mortality. The value of P <0.05 was assigned significant for all analyses. Results: TIP accounted for 52.4% (n = 1132) of all cases of peritonitis (n = 2159). The median age was 12 years. Rural provenance represented 72.2% (n = 817). Deaths accounted for 10.5% (n = 119). The factors influencing mortality were respiratory rate ≥24/min (odds ratio [OR] = 2.6, P = 0.000), systolic blood pressure <90 mmHg (OR = 0.31, P = 0.002), serum creatinine >20 mg/L (OR = 2.6, P ≤ 0.009), haemoglobin (OR = 2.1, P = 0.000), comorbidity (OR = 3.5, P = 0.001), the American Society of Anesthesiologists score IV&V (OR = 3.3, P = 0.000), admission and management delay > 72 h (OR = 3.2, P = 0.001), and a number of perforations (OR = 2.4, P = 0.0001). These factors were used to build a "TIPPS" score, which ranged from 8 to 20. The risk of mortality was associated with increased TIPPS. The performance of this score was good in the two groups (area under receiver operating characteristic > 0.83). According to the severity and mortality risk of TIP, we classified TIPS into four grades: grade I (low risk: 8-10), grade II (moderate risk: 11-13), grade III (high risk: 14-16) and grade IV (very high risk: 17-20). Conclusion: The TIPPS is simple. It can describe the severity of the disease and can predict the risk of death. The study highlights the importance and impact of timely and adequate perioperative resuscitation in more complicated cases.

[Female inguinal herniain Niger : diagnostic, therapeutic and evolutionary aspects]. / La hernie inguinale de la fille au Niger : aspects diagnostique, therapeutique et evolutifs.

AIM: The aim of this study was to evaluate the diagnostic, therapeutic and evolutionary aspects of female inguinal hernia (ovarian hernia). PATIENTS AND METHODS: This was a prospective and descriptive study lasting 6 years (1st January 2014 to 31st December 2019). It included all girls aged 0 to 15 years old with ovarian hernia, received in the pediatric surgery department of the Hôpital National AmirouBoubacar Diallo in Niamey. The variables studied were the socio-demographic characteristics of the patients, personal and family history, and those related to diagnostic, therapeutic and evolutionary aspects. RESULTS: With 23 recorded cases, ovarian hernia had a hospital frequency of 8.7%. The average age of the patients was 5.6 years (range: 4 months and 11 years). The average duration of evolution before diagnosis was 8 months (range: 0 days and 36 months). The hernia was mainly located on the right side: 14 cases (60.85%). The hernial sac during the operation was most often empty: 11 cases (47.85%). It contained at least the ovary for 10 patients (43.5%). There were 2 cases of strangulated hernia (8.6%). All the patients benefited from a herniotomy. The average operating time was 26.7 days (range: 0 days and 146 days). No deaths and no postoperative complications were recorded after a 3-month follow-up. CONCLUSION: Ovarian hernia in this study is a rare condition often encountered in young girls. In spite of a late treatment, the therapeutic results were satisfactory.

BUT: Le but de cette étude était d'évaluer les aspects diagnostiques, thérapeutiques et évolutifs de la hernie inguinale de la fille (hernie de l'ovaire). PATIENTS ET MÉTHODES: Il s'agissait d'une étude prospective et descriptive portant sur une période de 6 ans (1er janvier 2014 au 31 décembre 2019). Elle incluait toutes les filles âgées de 0 à 15 ans présentant une hernie de l'ovaire reçus dans le service de chirurgie pédiatrique de l'Hôpital National Amirou Boubacar Diallo de Niamey. Les variables étudiées étaient les caractéristiques sociodémographiques des patientes, les antécédents personnels et familiaux et celles liées aux aspects diagnostiques, thérapeutiques et évolutifs. RÉSULTATS: Avec 23 cas recensés, la hernie de l'ovaire avait une fréquence hospitalière de 8,7%. Les patientes étaient en moyenne âgé de 5,6 ans (extrêmes : 4 mois et 11 ans). La durée moyenne d'évolution avant le diagnostic était de 8 mois (extrêmes : 0 jours et 36 mois). La hernie était principalement située à droite : 14 cas (60,85%). Le sac herniaire au cours de l'intervention était le plus souvent vide : 11 cas (47,85%). Il contenait au moins l'ovaire chez 10 patientes (43,5%). Il y avait 2 cas de hernie étranglée (8,6%). Toutes les patientes bénéficièrent d'une herniotomie. Le délai opératoire moyen était de 26,7 jours (extrêmes : 0 jours et 146 jours). Aucun décès et aucune complication postopératoire après un suivi de 3 mois n'avaient été enregistrés. CONCLUSION: La hernie de l'ovaire est dans cette étude une affection rare rencontrée souvent chez la petite fille. Malgré une prise en charge tardive les résultats thérapeutiques étaient satisfaisants.

Waiting time for short-stay surgery in a paediatric surgery department.

AIM: The aim of this study was to assess the waiting time (WT) for a short-stay surgery and determine its possible determinant factors. PATIENTS AND METHODS: This was a retrospective study conducted in the Department of Paediatric Surgery at the National Hospital of Lamordé of Niamey, Niger. It included patients aged 0-15 years who benefitted from a short-stay surgery (24-48 h of hospitalisation) during a period of 19 months (1st January 2017 - 31st July 2018). Patient, diagnosis and surgical treatment data were gathered. WT was the time elapsed between the indication of a surgical operation and its realisation. The Kruskal-Wallis test was used with a threshold statistical significance of < 0.05. RESULTS: Short-stay surgery constituted 25.4% of all operating activities (n = 271). Inguinal or inguinoscrotal hernia was the most frequent pathology at 31.38% (n = 85). The mean WT was of 116.6 days (range: 4-491 days) and the median was 114 days. WT was greater than or equal to 3 months for 63.9% of the patients (n = 173). Based on pathology, the mean WT varied between 57.5 days (ovarian hernia) and 163.6 days (5.8 months) for epigastric hernia. A significantly longer WT was observed with the presence of a comorbidity (P = 0.0352) but was not associated with patient residence (P = 0.0951). CONCLUSION: A long WT for a short-stay surgery should be improved upon by different interventions with respect to the supply and demand of care and the setting of priorities.

Perioperative management of gastrointestinal surgery in a resource-limited hospital in Niger: Cross-sectional study.

BACKGROUND: Perioperative management in digestive surgery is a challenge in sub-Saharan Africa. Objective: To describe the process and outcomes of perioperative management in gastrointestinal surgery. MATERIALS AND METHODS: This was a single center cross-sectional study over a 4-month period from June 1 to September 30, 2017, in a Nigerien hospital (West Africa). This study included caregivers and patients operated on gastrointestinal surgery. RESULTS: We collected data for 56 caregivers and 253 patients underwent gastrointestinal surgery. The average age of caregivers was 38.6 ± 8.7. The median length of professional practice was 9 years. Almost 52% of caregivers (n = 29) did not know the standards of perioperative care. The median age of patients was 24 years, and male gender constituted 70% of cases (n = 177) with a sex ratio of 2.32. Patients came from rural areas in 78.2% (n = 198). Emergency surgery accounted for 60% (n = 152). The most surgical procedure was digestive ostomies performed in 28.9% (n = 73), followed by hernia repair and appendectomy in 24.5% (n = 62) and 13.9% (n = 35) respectively. The postoperative course was complicated in 28.1% (n = 71) among which 13 deaths. In the group of caregivers, the poor practice of perioperative management was associated with poor professional qualification, insufficient equipment, insufficient motivation (p < 0.05). The ASA3&ASA4 score, undernutrition, emergency surgery, poor postoperative monitoring, and poor psychological preparation were associated with complicated postoperative outcomes (p < 0.05). CONCLUSION: The inadequacy of the technical platform and the lack of continuous training for healthcare staff represented the main dysfunctions of our hospital. The risk factors for complications found in this study need appropriate perioperative management to improve prognosis in gastrointestinal surgery.

Diagnosis and surgical approach of adult Hirschsprung's disease: About two observations and review of the literature. Case series.

INTRODUCTION: Hirschsprung's disease (HD) is uncommon in adulthood. In this study, we describe the management of two cases of adult Hirschsprung's disease treated with transanal colonic pull-through procedure followed by a delayed coloanal anastomosis. PATIENTS AND METHODS: This was a retrospective (December 2016 to Jun 2019) study included two cases of adult HD with confirmed Hirschsprung disease who underwent surgery at Zinder National hospital, Niger. The registration number is researchregistry 5174. RESULTS: These were two patients aged 21 years (male) and 22 years (female) admitted to the emergency department with an acute bowel obstruction. The history finds a delayed passage of meconium at birth with a history of long-standing recurrent constipation since early childhood for the 2 patients. A lateral colostomy was performed urgently in both patients and the barium enema revealed a disparity of the sigmoid colon with corn shaped transition zone. Histologic examination of the biopsy specimen confirmed the diagnosis of HD. Surgery was done according to transanal endorectal pull-through procedure followed by delayed coloanal anastomosis. Patients were regularly followed over a period of 16 months. Constipation was gone, no continence problem was reported and quality of life was rated satisfactory. CONCLUSION: The discovery of Hirschsprung's disease is rare in adulthood. Transanal endorectal pull-through procedure followed by delayed coloanal anastomosis with conventional surgery is a suitable option for the treatment of HD and gives a good result.

Surgical management of pyelo-ureteral junction syndrome in a resource-limited setting: case of Zinder National Hospital, Niger.

BACKGROUND: Pyelo-ureteral junction syndrome (PUJS) is a frequent congenital malformation. We report the surgical management of PUJS by pyeloplasty according to Anderson-Hyne-Kuss's procedure at the Zinder National Hospital.. METHODS: This was a retrospective study from January 2013 to December 2016 (4 years), including patients who have undergone surgery for PUJS. RESULTS: Twelve (12) cases of PUJS had a surgery among which 66.7% were men with an average age of 32.5 ± 7.6 years. The clinical symptomatology was lumbar pain or renal colic in 92.3% of cases. This pain had evolved for more than 2 years for 58.3% of the cases. Ultrasound coupled with intravenous urography or CT-scan was performed to confirm the diagnosis of PUJS in 58.3 and 41.7% of cases. The average serum creatinine level at admission was 181.25 ± 67.3 µmol/L [Lab reference range: 53-97 µmol/L]. The Anderson-Hynes non dismembered pyeloplasty is used for all the patients. The release of a crossing lower pole vessel was performed in 25%, pyelolithotomy in 16.7%. The average surgery time was 118.3 ± 20.7 min. The average hospital length of stay was 10.8 ± 3 days. Immediate postoperative complications were recorded in 33.3% (n = 4). Postoperative outcomes were considered good by disappearance of clinical, biological and radiological signs. CONCLUSION: The Anderson-Hynes non dismembered pyeloplasty gives good results and provides a successful alternative in an environment where laparoscopy and robotic surgery are not developed.

[Peculiarities of anesthesia for the surgical treatment of pheochromocytoma: about a case]. / Particularité de l'anesthésie pour cure chirurgicale du phéochromocytome: à propos d'un cas.

This study decribes the treatment of a 37-year old female patient, with a history of poorly treated arterial hypertension (AH), referred to surgical consultation with right lower back pain, vertigo, headache, sweating and palpitations. During hospitalization, blood pressure (BP) ranged between 130/80 mm Hg and 190/120 mm Hg. The remainder of the clinical examination was normal. Thoracoabdominal scanner showed adrenal mass measuring 55x45x65 mm compressing the inferior vena cava and the right renal vein. The assay of urinary vanilmandelic acid (VMA) was 11.8mg/24hours. The assay of catecholamines in the blood was not performed. The diagnosis of pheochromocytoma was retained and surgical indication was determined. During pre-anaesthesia consultation, clinical examination showed good general condition, blood pressure (BP) to190/120 mmHg, normal cardiopulmonary auscultation and prediction criterion of easy intubation (Mallampati II). The patient underwent preoperative treatment with alpha-blockers and beta-blockers, and calcium channel blocker. Adrenalectomy was performed using midline laparotomy. The patient didn?t have hemodynamic instability during mobilization and tumor resection. The postoperative course was uneventful. She was discharged home on postoperative day 7. At 3 months? follow-up, the patient had no clinical signs and blood pressure was normal. Anesthesia for the surgical treatment of pheochromocytoma is feasible even in resource-limited settings. An adequate preoperative preparation of the patient helps prevent complications.

Isolated Right-Sided Posttraumatic Diaphragmatic Hernia.

Diaphragm is a compliant musculoaponeurotic barrier located between thoracic and abdominal cavities. Traumatic diaphragmatic rupture is a rare clinicopathological entity. We report a case of right-sided posttraumatic hernia in a child following blunt trauma to highlight diagnostic difficulties and therapeutic specific aspects. A 10-year-old boy was admitted to the emergency surgical department with thoracic trauma following pedestrian accident. At admission a haemothorax was suspected and treated by pleural drainage. The diagnosis of a right-sided diaphragmatic rupture was made after computed tomographic scan forty-eight hours later. At surgery, a reduction of herniated abdominal content and a suture of diaphragmatic defect were performed. The postoperative recoveries were uneventful and the patient was followed up for 12 months without symptoms. The possibility of a diaphragmatic rupture should be kept in mind and sought after any trauma of the thoracoabdominal junction as the diagnosis can be challenging in emergency department.

Acute intestinal obstruction due to extrinsic compression by previa myoma and ectopic pregnancy: a case report.

BACKGROUND: Acute intestinal obstruction during pregnancy is a rare digestive surgical emergency with significant maternal and fetal mortality. Diagnosis is difficult, often delaying the management. Here, we report an exceptional association of mechanical acute intestinal obstruction due to compression by previa uterine leiomyoma, and a ruptured ectopic pregnancy. CASE PRESENTATION: This is the case report of a 43-year-old primiparous black woman from a rural area, who was admitted to the surgical emergency department for acute intestinal obstruction. At examination on admittance, our patient had a bad general condition with clinical anemia. She had an occlusive syndrome that had been evolving for 3 days. A physical examination of her abdomen showed a widespread distension with an irregular and polylobed solid mass occupying the whole of the lower-umbilical and hypogastric area. A rectal examination found an empty rectum, and the mass was perceptible in Douglas's pouch. At the vaginal examination, we found the same mass and a finger holster was clean. The diagnosis of intestinal occlusion by a tumor was retained. The laparotomy revealed a distended intestine, a ruptured right tubal ectopic pregnancy and a polymyomatous uterus. The most massive previa leiomyoma was adhering and compressing the rectal and sigmoidal hinge. A total hysterectomy was performed and histopathological examination of specimens confirmed myoma and ectopic pregnancy. The surgical follow-up was uneventful, and our patient was discharged on postoperative day 12. CONCLUSIONS: The etiological diagnosis of acute intestinal obstruction during pregnancy is not easy, especially in the context of a low-income country where the means of biological and radiological diagnosis are lacking. A laparotomy is required before diagnosis of acute surgical abdomen and its management will depend on the intraoperative findings and the condition of the patient.

Pattern of Lower Intestinal Ostomies in a Low-Income Country: Case of Southeast of Niger Republic.

BACKGROUND: Intestinal ostomies are common surgical procedures performed in visceral surgery as part of management for several gastrointestinal diseases. This study aims to report the socio-demographic characteristics, indications and prognosis of intestinal ostomies in low-income country. METHODS: This was a 4-year retrospective study (January 2013 to December 2016) at Zinder National Hospital (Niger). All patients with a digestive ostomy on an ileum or colic segment were included in the study. RESULTS: During the study period, 2437 patients underwent digestive surgery, including 328 gastrointestinal stomas (13.5%). Patients classified ASA3 were 60.7% (n = 199). The median age was 12 years (IQ: 7-25). Children represent 64% (n = 210) of patients with ostomy. The sex ratio was 2.60. The stoma was performed in emergency in 96.3% (n = 316) of cases. Acute peritonitis was the main indication of the stoma in 70.73% (n = 232). The ileostomies accounted for 75.61% (n = 248). Ostomy was intended as temporary in 97.3% of cases (n = 319). Complications were observed in 188 patients (57.3%). Mortality was 14.02% (n = 46). The indigent status (OR: 4.15 [2.20-7.83], P = 000), ASA score 4 (OR: 2.53 [1.54-4.15], P = 0.0003), Altemeier class IV (OR: 4.03 [2.10-7.73], P = 0.0000) and ileostomy (OR: 2.7853 [1.47-5.29], P = 0.0018) were statistically associated with the occurrence of major complications. The mean time for stoma closure was 59.3 ± 14.5 days. CONCLUSION: Acute peritonitis was the main indication of digestive ostomy. The occurrence of major complications was associated with bad socioeconomic status, ASA4 score, Altemeier class IV and ileostomy.

Acute mechanical intestinal obstruction in children at zinder national hospital, Niger: Aetiologies and prognosis.

BACKGROUND: To describe the aetiological and prognostic aspects of acute mechanical intestinal obstruction (AMIO) in children at Zinder National Hospital (Niger). MATERIALS AND METHODS: This was a cross-sectional study on a period to January 2013-June 2015. The database included all children under 15 years of age with a surgical diagnosis of mechanical intestinal obstruction. P < 0.05 was considered statistically significant for analysis. RESULTS: AMIOs represent 21.78% (n = 78) of child digestive surgical emergencies (n = 358). Median age was 12 months (range: 1 day-15 years). Fifteen (19.23%) were neonates and sixty children (76.92%) had ≤60 months. The sex ratio (male/female) was 2.8. The mean time from onset to presentation was 39.96 ± 36.22 h. Intussusception and strangulated hernias were the main causes of AMIO with, respectively, 43.59% (n = 34) and 29.48% (n = 23). Anorectal malformations represent 17.95% (n = 14) of cases of AMIO. Intestinal resection was made in 22.08% and colostomy in 19.23% of patients. The average length of hospital stay was 6.44 ± 4.30 days. The post-operative complications were recorded in 26 patients (33.33%), mostly surgical site infections. Overall mortality of AMIO was 15.38% (n = 12). It was higher in the neonates (33.33%) (P = 0.032). Deaths were associated with delay of admission (P = 0.0005) and waiting time for surgery (P = 0.019). CONCLUSION: Intussusception and strangulated hernia are the most common cause of AMIO in children. Diagnostic and therapeutic delays, lack of paediatric intensive care and post-operative complications are prognostic factors.

[Etiology and prognosis of acute mechanical intestinal obstructions at the National Hospital of Zinder: Cross-sectional study of 171 patients]. / Etiologies et pronostic des occlusions intestinales aigues mécaniques à l'Hôpital National de Zinder: étude transversale sur 171 patients.

Acute mechanical intestinal obstruction (AIO) is one of the most frequent pathologies in emergency digestive surgery. The objective of this study was to describe the etiologic and prognostic features of acute mechanical intestinal obstruction at the National Hospital of Zinder (HNZ), Niger. We conducted a cross-sectional study including all the patients operated for AIO over a period of 24 months (January 2013 - December 2014) Mechanical intestinal obstructions represent 24.50% (n=171) of digestive surgical emergencies (n=622). The median age was 25 years (range: 1 day-95 years). The sex ratio was 3.5 in favour of men. Children accounted for 38.60% (n=66). The seat of the obstacle was at the level of the small bowel in 60.82% (n=104), colonic in 21.63% (n=37) and mixed in 17.54% (n=30). The mechanism of strangulation accounted for 88,89% (n=152), among these strangulated hernias were detected in 49,70% (n=85) of patients and acute intestinal invaginations in 19,88% (n=34) of patients. Anorectal malformations and tumors were the main cause of obstruction in 7.02% (n=12) and 3.51% (n=6) of cases respectively. Intestinal resection was performed in 52 cases (30.41%). Septic complications prevailed (n=39/53); among these parietal suppuration (n=23). The average length of stay in hospital was 7.82 days. The overall mortality rate was 11.70% (n=20). This was statistically correlated to intestinal necrosis (p=0.01) and to delayed hospital admission (p=0.04). There are many causes of AIO which are dominated by strangulated hernia. The high morbidity and mortality rate from AIO might be prevented by early treatment performed before intestinal necrosis occurs.

[Acute intestinal obstruction revealing enteropathy associated t-cell lymphoma, about a case]. / Occlusion intestinale aigue révélant un lymphome T digestif associé à la maladie cœliaque, à propos d'un cas.

Enteropathy associated T-cell lymphoma (EATL) is a rare complication of celiac disease (CD). We report a case of EATL associated with CD revealed by acute intestinal obstruction. A North African woman of 38 years old with a history of infertility and chronic abdominal pain was admitted in emergency with acute intestinal obstruction. During the surgery, we found a tumor on the small intestine with mesenteric lymphadenopathy. Histology and immunohistochemistry of the specimen objectified a digestive T lymphoma CD3+ and immunological assessment of celiac disease was positive. The diagnosis of EATL was thus retained. Chemotherapy (CHOEP protocol) was established as well as gluten-free diet with a complete response to treatment. The EATL is a rare complication of CD that can be revealed by intestinal obstruction. The prognosis can be improved by early treatment involving surgery and chemotherapy. Its prevention requires early diagnosis of celiac and gluten-free diets.

["Handlebar" hernia: a rare type of traumatic parietal hernia]. / Hernie « guidon ¼: un type rare de hernie pariétale traumatique.

We report the case of a 20-year old patient with a personal history of fall over his motorcycle handlebar occurring 28 days earlier. He was admitted in emergency surgery with abdominal pain. Clinical examination showed a circular impact area at the level of the left hypochondrium associated with painful swelling, irreducible and with no impulse on coughing The diagnosis of traumatic parietal strangulated hernia was established. The patient underwent surgical treatment using midline laparotomy revealing parietal breach associated with incarceration of a portion of the omentum which was necrotic. The necrotic omentum was resected and the breach was sutured. The postoperative course was simple and the patient was discharged on d5.