Operative versus conservative treatment for giant omphalocele: Study of French and Ivorian management.

INTRODUCTION: The giant omphalocele is currently a surgical challenge. The morbidity and mortality associated with its care is non-negligible. Nowadays, different studies have revived the debate between conservative and surgical management for giant omphalocele. The purpose of this study is to compare the conservative and surgical management of the giant omphalocele in terms of morbidity and mortality. METHODS: Retrospective study including all giant omphaloceles comparing surgical management (French University hospital centers) and tanning (Ivory Coast University hospital center). Epidemiology was studied as well as medical and surgical managements both intra and post operative. RESULTS: One hundred and forty-seven patients included (98 patients in the "tanning" group and 49 in the "surgery" group). Hospital length of stay is significantly shorter in the "tanning" group as they do not spend time in intensive care unit. Morbidity is higher in "surgery" group. The average duration for oral empowerment was acquired at 179 days in the "surgery" group, whereas in the "tanning" group 90% was immediately and exclusively breastfed. No significant differences in terms of epithelialization time. CONCLUSION: The tanning treatment has its own place in the therapeutic arsenal in the management of the giant omphalocele no matter where it takes place. However, its realization in surgical environments prevents certain complications related to the technique or the pathology.

Trauma of the external genital in children: Emasculation, a paediatric case report.

An 8-year-old boy was brought to the paediatric surgery department having amputated his penis and both testicles during a road traffic accident. Examination of the perinea showed a complete amputation of penis, scrotum and testicles. We performed debridement and skin suture initially. The urethral orifice was catheterized by a 10 F Foley's catheter. I the herein case report, we discuss the incidence, management and complications of genital amputation in a young boy. Moreover, the existing literature in this subject is reviewed.

[Selective laser trabeculoplasty in African blacks]. / Trabéculoplastie sélective chez le mélanoderme africain.

INTRODUCTION: The treatment of primary open angle glaucoma (POAG) is preferably medical. However, when medical therapy fails, alternative or complementary treatments may be considered. In this regard, selective laser trabeculoplasty is a widely popular procedural treatment whose accepted benefits have been very little studied in African blacks. The objective of this study was to assess the efficacy of selective laser trabeculoplasty on the reduction of intraocular pressure (IOP) in African blacks with POAG. METHODS: We conducted a retrospective study of black patients treated with selective laser trabeculoplasty between March 2010 and March 2011. All patients had POAG with trabecular meshwork accessible over 360°. The treatment protocol consisted of a 360°treatment in two sessions (180°/session) 15 days apart. Success was defined as decrease from the initial IOP≥3mm Hg without additional medications. RESULTS: We included 44 patients, corresponding to 82 eyes. The mean age of the patients was 55.94±11.66 years with extremes of 19 years and 76 years. The mean intraocular pressure before laser treatment (initial IOP) was 18.43±4.81mm Hg. After laser treatment, the mean pressure reduction was (i) 3.81mm Hg (20.67%) at 15 days ; (ii) 4.08mm Hg (22.14%) at 1 month; (iii) 4.45mm Hg (24.14%) at 3 months; and (iv) 4.95mm Hg (26.86%) at 6 months. The success rate after laser treatment was 67.60% at 15 days, 83.78% at 1 month, 72.09% at 3 months and 80.43% at 6 months. CONCLUSION: Selective laser trabeculoplasty is effective in African blacks. Its efficacy is comparable to that of a carbonic anhydrase inhibitor or even a prostaglandin. It could be a complementary or substitutive alternative to POAG medications in African blacks.

[Vitiligo occurring on dermal melanocytosis (nevus of Ota) in a dark-skinned patient]. / Vitiligo dévéloppé sur une mélanocytose dermique (nævus de Ota) chez une patiente à peau foncée.

BACKGROUND: Nevus of Ota is a rare disease most frequently found in Asians. It presents clinically as a bluish gray hyperpigmentation of one side of the face. Transformation into melanoma and glaucoma are the main risks. The appearance of vitiligo lesions with poliosis within a nevus of Ota is exceptional. PATIENTS AND METHODS: A 22-year-old female patient with a nevus of Ota consulted for depigmentation of the eyelashes. Physical examination revealed hyperpigmentation in the right orbitofrontal part of her face, achromic macules and eyelash poliosis. A diagnosis was made of vitiligo developing on a nevus of Ota. Ophthalmologic examination showed hyperpigmentation of the sclera. Regular dermatologic and ophthalmologic follow-up was instituted. DISCUSSION: Vitiligo is a condition characterized by the development of depigmented lesions secondary to chronic degradation of the melanocytes of the epidermis and the follicles. Its occurrence on congenital nevus and melanoma has already been reported. However, its appearance in dermal melanocytosis is very rare. Since the first observation of this association in 1979, only 4 other cases have been reported. The pathogenic mechanisms of this association are still poorly understood. Histopathological examination generally shows a loss of epidermal melanocytes, especially in the basal layer, while dermal melanocytes remain unaffected. In this context, vitiligo developed on dermal melanosis appears to result from the difference between the properties of normal (epidermal) melanocytes and ectopic (dermal) melanocytes. CONCLUSION: Association of vitiligo with nevus of Ota is rare. Herein, we report a new case in a dark-skinned subject.

Surgical treatment of femoral diaphyseal fractures in children using elastic stable intramedullary nailing by open reduction at Yopougon Teaching Hospital.

INTRODUCTION: Elastic stable intramedullary nailing (ESIN) has transformed children's femoral shaft fracture treatment, but this technique requires an image intensifier. Without it, open reduction is used to check fracture reduction and pin passage. The aim of this study was to describe our techniques and to evaluate our results at the middle term. HYPOTHESIS: The open reduction and ESIN technique provides satisfactory results with few major complications. PATIENTS AND METHODS: This was a retrospective study that focused on femoral diaphyseal fractures treated in the pediatric surgery unit at Yopougon Teaching Hospital (Abidjan, Côte d'Ivoire) between January 2007 and December 2013. Twenty children older than 6 years of age who underwent open reduction and ESIN without image intensifier assistance were included. Functional outcomes were assessed using Flynn's criteria. Postoperative complications and sequelae were recorded. RESULTS: At the 16-month follow-up, the results were excellent in 11 (55%) cases, good in eight (40%), and poor in one (5%) case. The mean duration of surgery was 71min (range, 57-103 min). The mean time for bone healing was 11.6 weeks (range, 7-15 weeks) and the average time to nail removal was 6 months. Complications included wood infection (n=3), skin irritation (n=3), knee stiffness (n=2), malunion (n=3), scar (n=5), and leg length discrepancy (n=3). DISCUSSION: Open reduction and ESIN yielded satisfactory results with few major complications. This method could be an alternative in low-income countries where the image intensifier is often unavailable. LEVEL OF EVIDENCE: Level IV retrospective study.

Outcomes of conservative treatment of giant omphaloceles with dissodic 2% aqueous eosin: 15 years' experience.

BACKGROUND: The surgical management of giant omphalocele is a surgical challenge with high mortality and morbidity in our country due to the absence of neonatal resuscitation. This study evaluates conservative management of giant omphalocele with dissodic 2% aqueous eosin. MATERIALS AND METHODS: In the period from January 1997 to December 2012, giant omphaloceles were treated with dissodic 2% aqueous eosin. The procedure consisted of twice a day application of dissodic 2% aqueous eosin (sterile solution for topical application) on the omphalocele sac. The procedure was taught to the mother to continue at home with an outpatient follow-up to assess epithelialization. We studied the duration of the hospital stay, the learning curve of the procedure by the mother, the complications, the duration and the percentage of complete epithelialization and the mortality. RESULTS: A total of 173 giant omphaloceles had a conservative treatment with dissodic 2% aqueous eosin. The average hospital stay was 21 ± 6 days. The learning curve by the mother of the procedure was 10 ± 3 days. Complications of treatment were intestinal functional occlusion 22% and omphalocele sac infection 18%. The complete epithelialization of the omphaloceles sac after application of dissodic 2% aqueous eosin was 68.5%. Mortality was observed in 25.5%. CONCLUSION: Conservative treatment of giant omphaloceles by dissodic 2% aqueous eosin is a simple, efficient and a good alternative to surgery. The mother can easily learn its procedure which reduces the duration of hospital stay.

Delayed treatment of supracondylar elbow fractures in children.

BACKGROUND: Supracondylar fractures are the most common elbow fractures in children and are usually treated on an emergency basis, using percutaneous pinning. However, the treatment is often delayed in areas where healthcare resources are scarce. HYPOTHESIS: Delaying treatment does not influence the perioperative complication rate. MATERIALS AND METHOD: We retrospectively reviewed the medical charts of 89 children aged 2 to 15 years in whom surgery for extension-type supracondylar elbow fractures was delayed by more than 48 hours. The 53 boys and 36 girls with a mean age of 6 years 9 months had severe fracture displacement (28 stage III and 61 stage IV according to Lagrange and Rigault classification scheme). Mean time to treatment was 4.5 days (range: 2-17 days). Open reduction and crossed K-wire fixation via the posterior approach were performed in all 89 patients. Postoperative complications and sequelae were collected. Functional outcomes were evaluated using Flynn's criteria. RESULTS: Outcomes were satisfactory in 74 (83.2%) of patients. Postoperative complications occurred in 13 (14.6%) patients and consisted of surgical site infection (n=7, 7.8%), iatrogenic nerve injury (n=3, 3.4%), and reoperation (n=3, 3.4%). At last follow-up after a mean of 5 months, three (3.4%) patients had cubitus varus and one had a recurrent fracture due to massaging. Elbow motion was limited in 11 (12.4%) patients. No case of compartment syndrome was recorded. DISCUSSION: Despite an average time to surgery of 4.5 days, the outcome was satisfactory in 83% of cases. Delayed treatment was not associated with an increased rate of perioperative complications. LEVEL OF EVIDENCE: Level IV, retrospective study.

Elastic stable intramedullary nailing in paediatric traumatology at Yopougon Teaching Hospital (Abidjan).

CONTEXT: Elastic stable intramedullary nailing has revolutionised the treatment of fractures in children. AIM: To report our experience with this current technique of management of fractures in children. METHODS AND MATERIALS: A retrospective study of all children with fractures treated by this method from November 2003 to June 2006 at the Paediatric Surgery Department of Yopougon Teaching Hospital, Abidjan, Côte d'Ivoire. Data were recorded from their medical charts regarding demographics, fracture patterns, associated injuries, morbidity, and outcome. RESULTS: A total of 38 children (14 boys; mean age, 11.7 years; range, 9-15 years) with 41 fractures, sited at femur (n=15), humerus (n=8), tibia and fibula (n=6), forearm (n=7), and radial neck (n=5), associated with other injuries in 7 cases, were enrolled in the study. The mean interval for surgery was 6.8 days. Open reduction was required 5 times (12.1%). The hospital stay was in the range 5-12 days. Minor adverse events were 1 (2.4%) early tibial loss of reduction, 3 (7.3%) skin irritations and 2 (4.8%) transient knee limitations. Complications (17.3%) included 2 axial (4.8%) and 1 rotational (2.4%) femoral malunions below 15°; 3 elbow (7.3%) and 1 knee stiffness (2.4%) in openly reduced cases. Solid consolidation was achieved in all cases, with no disturbance in standard union times. At a mean follow-up period of 16 months (range, 9-28 months), all but 3 patients with opened joints recovered full range of motion, and none showed either limp and gait anomalies or re-fracture after removal of wires. CONCLUSION: Elastic stable intramedullary nailing in children fractures is easy to perform and has little complications if a proper technique is used.

The paediatric surgeon and his working conditions in Francophone sub-Saharan Africa.

BACKGROUND: This study described the current conditions of work of paediatric surgeons in Francophone sub-Saharan Africa (FSSA) and set the debate at the level of the humanist thinking in medicine. PATIENTS AND METHODS: This was a multicentre study from 1 st May to 30 th October 2008. The African Society of paediatric surgeons' directory was used to identify paediatric surgeons in the Francophone's countries in Sub Saharan Africa. The parameters studied were number of surgeons per country, means of training, working conditions, remunerations, needs for continuous training and the research. RESULTS: A total of 41 paediatric surgeons (68.33%) responded. The average number of paediatric surgeons per country was 5. The means of training included government scholarships among 7 paediatric surgeons (17.07%), scholarship from a non-governmental organisations in 14 (34.15%) and self-sponsorships in 20 (48.78%). The average salary was 450 Euros (€) (range: 120-1 400 Euros). Most of the paediatric surgeons (68.29%) had internet services for continuous update courses and research. Thirty six paediatric surgeons (87.80%) had no subscription to specialised scientific journals. CONCLUSION: The paediatric surgeon in FSSA faces many problems related to his working and living conditions that may have a negative impact on their competences.

[Accidents of circumcision in children in Abidjan, Côte d'Ivoire]. / Accidents de circoncision chez l'enfant à Abidjan, Côte d'Ivoire.

Circumcision is the most common surgical procedure carried out in boys in our countries. It is performed by medical members but also by traditional practitioners. Circumcision is considered as a benign operation but its complications are common, sometimes severe and the treatment delicate. Authors reported 35 cases of circumcision's complications in boys, aged of 2 days to 14 years old who were circumcised by traditional practitioners and by medical members. The most frequent complications were urinary meatus stenosis (17 cases), haemorrhage (5), total glans section (3), urethral fistula (3), and incomplete circumcision (3). These complications were caused by traditional practitioners in 19 cases, paramedical members in 11 cases, and 5 cases by physicians. Among these complications, fistula and amputation had required delicate surgical procedure. All the stenosis were treated by meatal plasty and fistula were sutured with one recurrence. Partial glans section underwent Mathieu's procedure and the total sections were referred to the plastic surgeon. Authors recommend surgical procedure for circumcision which must be performed in medical center or by well trained practitioners.

Operative treatment of proximal humeral fractures in children: indications and results.

BACKGROUND: In most children proximal humeral fractures are treated non-operatively with generally good results. This review discusses the indications of operative treatment and assesses the treatment results. MATERIALS AND METHODS: The charts of 20 patients (14 girls; mean age: 12.3+/- 2.8 years; range: 7-16 years) with proximal humeral fractures who were operated on at our institution were reviewed from 1992 to 2002. RESULTS: There were five metaphyseal fractures and 15 physeal injuries which were angulated according to Neer-Horowitz score as grade III in four cases and grade IV in 16 cases with a mean angulation of 47.8+/-39.1 degrees (range: 6-148 degrees). Associated lesions comprised open fracture and head trauma in two cases each. Patients with associated injuries were operated on primarily and the 16 others by secondary intention. All but one were reduced via an anterior approach with internal fixation. They were assessed for clinical and radiological healing at a mean follow up of 3.6 years ranging from 1.2 to 7.8 years. CONCLUSION: Based on our study, surgical option is indicated for severely displaced and unstable fractures in older children and adolescents.

[Results of treatment of forearm fractures in the child]. / Resultats du traitement des fractures des deux os de l'avant bras de l'enfant.

OBJECTIVE: To describe epidemiology and to bring back the results of the treatment of the fractures of the forearm fracture. POPULATION AND METHOD: During 3 years and 3 months, we studied the forearm fractures of the children from 0 to 15 years. For each one of them, we studied, the age, the sex, the aetiology and the characteristics of the fracture, the treatment carried out and their evolution. RESULTS: Sixty-nine forearm fractures were listed, the frequency was 23 fractures per years. The sex ratio was 2,63 and the average age was 8 years and 2 months with 13 month and 15 years as extremes. The accidents of play accounted for 93% of the aetiologies. The cutaneous injuries were associated to the fracture in 30 cases (43%). The fractures with displacement was observed in 25 cases (36%), green steak fracture in 21 case (30%), fracture without displacement in 13 case (19%) and other displacements 10 cases (15%). The treatment was orthopaedic (reduction and immobilisation) in 97% of the cases. We observed 3 cases (4%) of secondary displacements under plaster and 6 cases (9%) of the vicious cal. CONCLUSION: The orthopaedic treatment is usually indicated for the Key words: fractures with anatomical restitution. The failures of the orthopaedic treatment need to be treated surgically.

[Experimental study of the influence of the segmental transverse colic reversion on the intestinal transit time]. / Etude experimentale de l'impact de l'inversion d'un segment colique transverse sur le transit intestinal.

OBJECTIVE: to study the feasibility of the transverse segment colic reversion and to evaluate its impact on the intestinal transit time in the rat Wistar. METHOD: On a test group of the rats Wistar males anaesthetized, we isolated a segment from the transverse colon vascularized by a feeder pedicle. This segment colic was reversed and anastomosed into antiperistaltic out of termino-terminal on its site with polyglactine 6/0. Into post-operative, we studied, the weight, the volume of the ingestats, the intestinal transit time, the survival and the histological lesions of the reversed segment colic. On the group controls, we carried out the anastomosis of a segment of the transverse colon isolated and anastomosed into isoperisaltic. RESULTS: Thirty rats males of 231.5 +/- 8.3g had been operated, 15 for the test group and 15 for the control group. The average weight of the ingestats of the rats of the test group was of 21.87 +/- 3g and of 21.75 +/- 4.8g in the control group without significant difference. The intestinal transit occured at 3 +/- 1 post-operatives days in the test group and at 2 postoperative days in the control group. A mechanical obstruction of the bowels before the 15th post-operative day involved a mortality of 87% in the test group. Thirteen percent of the rats of the test group survived, with a regular catch of weight. The histological analysis showed inflammatory lesions on the proximal portion of the reversed segment and a normal wall without ischaemic injury on its distal portion. No death was observed in the group controls. CONCLUSION: The antiperistaltic anastomosis of a transverse segment colic within the colic in the rat Wistar, causes a stop of the intestinal transit time by mechanical occlusion without ischaemic lesion of the segment colic reversed.

[Therapeutic approaches for omphalocele in developing countries: experience of Central University Hospital of Yopougon, Abidjan, Côte d'Ivoire]. / Approches thérapeutiques des omphalocèles dans les pays en développement: l'expérience du CHU de Yopougon, Abidjan, Côte d'Ivoire.

A retrospective study about 80 cases of exomphalos treated in the digestive unit of the paediatric surgery department in Abidjan teaching hospital--Côte d'Ivoire had been performed to analyse the result of this malformation treatment during 8 years. Prenatal diagnosis was made in two cases on six antenatal ultrasounds. Prematurity involved 7% of newborn and their birth weight ranged from 2500 to 4000 grams in 70% of cases. Treatment began in 64% at birth, conservative treatment with merbromine tannage was systematic on the non disrupted exomphalos. Surgery was indicated in the disrupted exomphalos and in the complicated cases of conservative treatment. Intestinal occlusion was the main fatal complication observed in both treatments but most of the time it occurred with surgical closure. Total lethality reached 30%, influenced by exomphalos super infection and by neonatal resuscitation insufficient means. Authors think exomphalos lethality reduction implies antenatal ultrasonographic for early diagnosis which could indicate a possible caesarian section in case of the voluminous exomphalos in order to prevent disruption and neonatal resuscitation operation.

[Ten years experience in Mali community health centers]. / Dix ans d'expérience des centres de santé communautaire au Mali.

At the end of 10 years' existence, the community health centres of Mali show a way of organisation which meets the public health requirements and demands of financial viability of any health establishment. Their originality lays in several factors: their legal personality, their private status, their financial support of the medical staff, their management by a users association and the public utilities agreement they have signed with the department. In spite of their success which makes their numbers reach 350, they suffer from great deficiencies, which are resulted by the lack of democratic traditions within the associations, a inappropriate transparency of their accounts and an inefficient supervision from the part of the department. The main questions posed by this new experience concern the limits of the concept of community, the importance of citizenship in the development dynamics, the participation of private institutions in the accomplishment of public utilities, the jacobin and authoritarian attitude of the department representatives, the contradictions between multiplication of centres to improve geographic access and the requirements of financial viability.

[Diagnostic, therapeutic and prognostic aspects of intestinal typhoid perforations in children of Abidjan, Côte d'Ivoire]. / Aspects diagnostiques, thérapeutiques et pronostiques des perforations typhiques du grêle de l'enfant à Abidjan, Côte d'Ivoire.

We conducted a retrospective study on 48 children (with a sex ratio of 22 males to 26 females) who had been operated over the preceding 10 years for typhoid perforation on the viscera ward within the paediatric surgery department of Yopougon teaching hospital in Abidjan, Côte d'Ivoire. The mean age was 9 years 3 months ranging from 3 to 16 years. Typhoid peritonitis was diagnosed on the basis of symptoms, intestinal injuries and only rarely by way of biological examinations. Medical treatment associated three antibiotics: aminosid, metronidazol and the third generation of cephalosporin. Hydroelectrolytical and haematological resuscitation was performed 3 to 6 hours before laparotomy. Excision-suture was made in 81% of cases. Exclusive parenteral nutrition began 48 hours after the laparotomy. Mortality occurred in 6% of patients and morbidity in 46%. Complications were parietal suppurations, digestive fistula, parietal hernia, early occlusive syndromes and necrosed cholecystisis. Rectorragy and leucocytosis were considered as pejorative signs when associated to the classic typhoid peritonitis.