[Negative pressure therapy in austere environments: extremities]. / Thérapie par pression négative en situation précaire: les membres (2ème partie).

Negative pressure therapy (NPT) is widely used in developed countries where it a technique of choice in the management of wound healing on extremities. Because of the cost, the specific ressources necessary forNPT are scarce in austere environments. This report describes a simple, economical alternative technique using a "breathing bandage" that can be made from from widely used surgical products.

Tubulovillous adenoma of the appendix: a case report and review of the literature.

We report the case of a young woman hospitalized for a chronic appendicular syndrome. The histological examination of the resected specimen revealed a rare tumor: tubulovillous adenoma, discovered in 0.02% of all appendectomy procedures. Treatment is most often limited to appendectomy, but in the event of incomplete excision or associated adenocarcinoma, right hemicolectomy may be required. After surgery, a follow-up colonoscopy is recommended due to the higher risk of second gastrointestinal neoplasms in patients with appendicular tumors.

[Radical surgery in intrahepatic cholangiocarcinoma]. / Chirurgie radicale des cholangiocarcinomes périphériques.

The aim of this retrospective study was to evaluate the results of surgical treatment of intrahepatic cholangiocarcinoma treated by the same team. Between 1988 and 2005, 75 patients underwent surgery for intrahepatic cholangiocarcinoma. There were 53 resections including three additional interventions for recurrence. Twenty-seven exploratory laparotomies showed non resectable tumors and two were followed by a liver transplantation at the beginning of the study. Major hepatectomy was performed in 85% of resections while hepatectic resection was extended to an adjacent organ in 40%. A lymphadenectomy was performed in 32 cases. Mortality was 7.8% (two massive pulmonary embolisms, one mutiple organ failure after transplantation and one post-operative peritonitis). Global morbidity was 47%. Resectability was 66%. In case of surgical resection, the median survival rate was 18 months versus 4 months without resection (p<0.001). Actuarial survival rates at 1 year, 3 years and 5 years were 69, 31 and 27% respectively. Positive nodes decreased the survival rate (13 months versus 20 months, p=0.01). A positive margin (R1 or R2 resection) did not significantly decrease the survival rate (18 months versus 15 months). In conclusion, intrahepatic cholangiocarcinoma is a tumor that often requires a major or an extended hepatectomy. Complete resection is an acceptable and reasonable goal, whatever the patient's age. This radical surgical approach can prolong survival. Palliative surgery is not an option if incomplete resection is predicted.

[Negative pressure therapy in precarious situations. Part 1: abdomen and perineum]. / Therapie par pression négative en situation précaire. 1e partie: abdomen et périnée.

Negative pressure therapy (NPT) is a proven safe and effective technique to promote healing of complex adominoperineal wounds using either an open or closed approach. Specifically designed devices are available in industrialized countries but high cost is a limiting factor for their use in developing countries. The purpose of this report is to describe a simple, easy-to-use technique that is suitable for austere environments. In addition to low-cost, the main advantage of this technique is that it can be performed by anyone using resources readily available in any operating room.

[Current management of sigmoid volvulus in the tropics]. / Prise en charge actuelle du volvulus du sigmoïde en milieu tropical.

Sigmoid volvulus is a frequent medical emergency in Africa. Diagnosis is mostly based on clinical examination and plain abdominal films. Emergency surgical therapy is required for patients presenting severe clinical and radiographic signs. Sigmoidectomy can be performed in a single stage with immediate restoration of digestive continuity or in two stages with colostomy followed by reconstruction several months later. The choice of technique depends on the patient's general condition and intestinal viability, but should also take into account the morbidity, cost, and social consequences associated with colostomy. For patients without severe signs, the method of choice consists of initial detorsion using an endoscope, if available. This strategy allows elective single-stage sigmoidectomy, which is the preferred procedure. Ideally sigmoidectomy after detorsion should be carried out within a few days during the same period of hospitalization and, if possible, using the celioscopic approach.

[Acute liver failure and severe exertional heat stroke: uneasy management in Africa]. / Coup de chaleur d'exercice grave et insuffisance hépatique aiguë: difficultés de prise en charge outre-mer.

Exertional heat stroke (EHS) is a medical emergency defined as tissue injury secondary to a prolonged period of extreme hyperthemia during strenuous physical activity. In the vast majority of cases, EHS is associated with minimal liver involvement with no clinical manifestations. However acute hepatic insufficiency has been reported including a few cases treated by liver transplantation but with poor results suggesting that conservative management is preferable. The purpose of this report is to describe a patient who developed EHS with acute liver insufficiency and multiple organ failure in Djibouti. Despite the remote location and limited medical resources available, full recovery was achieved with conservative therapy and intensive care.

Incarcerated obturator hernia: early diagnostic using helical computed tomography.

Obturator hernia is a rare event with poor clinical signs. Delayed diagnosis is a cause of increased mortality due to ruptured gangrenous bowel. We report a case of incarcerated obturator hernia which highlights the usefulness of computed tomography (CT) scanning in diagnosing this condition.

Fortuitous discovery of common bile duct stones: results of a conservative strategy.

OBJECTIVE: The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy. PATIENTS AND METHODS: Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken. RESULTS: Cholecystectomy was performed in 124 patients with symptomatic gallstones and no signs predictive of stones in the common bile duct. A stone was found fortuitously in the common bile duct in 12 patients. The control cholangiogram was normal in two of these patients on day two (16.7%) and in six others (50%) at the six-week control. All 12 patients remained free of symptoms suggesting the presence of a stone in the common duct. Presence of the drain had no impact on quality-of-life. Endoscopic extraction was finally performed for four patients (33.3%) to remove a stone from the common bile duct. CONCLUSION: Early surgical or endoscopic extraction of stones in the common bile duct should not be undertaken systematically in asymptomatic patients. Spontaneous asymptomatic clearance of the common bile duct is observed in about half of patients.

Isolated common femoral artery injury caused by blunt trauma.

The authors report an isolated common femoral artery injury caused by blunt trauma with dissection and secondary ischaemia. A 21-year-old man was admitted to hospital after being stabbed during acute alcoholic intoxication. He presented with a stab wound on the left leg and blunt trauma in the right groin. The surgical exploration of the left-sided wound did not disclose any vascular injury. After a 12-hour period of observation, the patient was discharged. Six hours later, he came back with severe ischaemia on the right leg caused by a femoral artery dissection. The patient underwent surgical revascularization, and fully recovered. Isolated artery blunt trauma is a rare event. In this observation, the absence of early symptoms resulted in delayed diagnosis.

[Recent injuries to the left diaphragm: value of laparoscopy in Africa and Europe]. / Lésions récentes du diaphragme gauche: intérêt de la laparoscopie, en Afrique comme en Europe.

Management of recent diaphragm injury is challenging. The purpose of this report is to describe two patients who presented injuries to the left diaphrgmatic cupola, i.e., rupture due to blunt trauma in Europe and a stab wound in Africa. The value of laparoscopy for diagnosis and treatment are discussed in these contrasting settings.

[Primary peritonitis in Sub-Saharian Africa: a 15 case series]. / Péritonites primitives en Afrique subsaharienne: à propos de 15 cas.

Primary peritonitis (PP) is an infection of the peritoneal cavity occurring in the absence of a documented intraabdominal source of contamination. It is one of the main infectious complications of cirrhosis but is rare in healthy subjects. The purpose of this retrospective study is to describe a series of 15 cases of PP treated over a 3-year period at the Principal Hospital in Dakar, Senegal. The patient population was young (all but 2 under age of 13 years) and predominantly female (87%) with no predisposing factors. Clinical presentation always involved typical peritonitis. Surgical exploration was performed in all cases by laparotomy (n=13) or laparoscopy (n=2). Intra-operative bacteriologic sampling was performed systematically. Probabilistic antimicrobial therapy was administered in all cases using a triple-drug combination including a cephalosporin or betalactamine, an aminoside and metronidazole. This unconventional combination was designed to allow low-cost wide-spectrum coverage. As in patients with cirrhosis, the most common microbial agents were gram-negative bacteria (47%). Streptococcus pneumoniae was identified in 40% of cases. Infectious ORL and pulmonary sites were suspected in some cases. Although no supporting bacteriologic evidence was obtained, the high frequency of pneumococcal involvement as well as the age and female predominance of the patient population is consistent with contamination via the female genital tract. The cases in this series present unusual epidemiological, clinical and bacteriologic features. In Europe surgical treatment can be avoided thanks to the availability of modern facilities to support further laboratory examinations. In Africa antimicrobial therapy and peritoneal lavage are the mainstay treatments. Use of laparoscopy should be expanded.

[Abbreviated laparotomy for treatment of severe abdominal trauma: use in austere settings]. / Laparotomie écourtée pour traitement des traumatismes abdominaux sévères: application en milieu précaire.

Abbreviated laparotomy is a recent technique for management of patients with severe abdominal trauma. It is based on a unified approach taking into account the overall extent of injury and the victim's physiologic potential to respond to hemorrhage. It is the first step in a multi-modal strategy. The second step is the critical care phase. The third step consists of "second-look" laparotomy that should ideally be performed on an elective basis within 48 hours and is aimed at definitive treatment of lesions. The goal of abbreviated laparotomy is damage control using temporary quick-fix procedures limited to conspicuous lesions and rapid hemostasis and/or viscerostasis procedures so that the patient can survive the acute critical period. Tension-free closure of the abdominal wall, if necessary using laparostomy, is essential to avoid abdominal compartment syndrome. With reported survival rates of about 50% in Europe and the United States, this simple life-saving technique that requires limited resources should be introduced in Africa where severe abdominal trauma often involves young patients.

[Current management of stab wounds to the colon]. / Prise en charge actuelle des plaies coliques par arme blanche: applications en milieu tropical.

Stab wounds to the colon are a frequent surgical emergency. Local wound exploration under local anaesthesia is not required systematically. We recommend surveillance based on clinical observation and laboratory testing to detect peritoneal signs. If progression of symptoms is suspected, diagnostic peritoneal lavage (DPL) should be performed. Immediate surgical exploration is indicated in two cases, i.e., generalized peritonitis and haemodynamic instability due to internal bleeding. The preferred repair technique is direct suture or resection followed by a handsewn or mechanical anastomosis. The morbidity, cost and social consequences of colostomy must be taken into account. It should be considered as a salvage procedure for patients in critical condition or extensive colonic injury.

[Mesenteric trauma: management in austere environments]. / Traumatismes entéro-mésentériques en situation précaire.

Mesenteric trauma, i.e., injuries located in the bowel or organs supplied by the superior mesenteric artery, can be life-threatening. The incidence of these lesions is low. Most occur as result of blunt and penetrating abdominal trauma due mainly to gunshot wounds or road accidents. Management of these serious injuries can be challenging in the military field hospitals. The major problem in austere environment is the unavailabiity of computerized axial and other tools gene rally used for diagnosis. As an alternative to tomography diagnostic peritoneal lavage can be used with a high sensitivity for the detection of mesenteric trauma. The second difficulty is technical. General surgeons without vasular training or supplies must prepared to suspect and reonstuct lesions of the superior mesenteric available resources.

[Sarcoidosis presenting as a splenic pseudotumour]. / Rate pseudotumorale révélatrice de sarcoïdose.

INTRODUCTION: Multinodular splenomegaly is a rare form of extrathoracic sarcoidosis. It may be the presenting feature of the disease. It poses problems of differential diagnosis, in particular with lymphoma, tuberculosis and other granulomatous diseases. In the absence of typical associated lesions, particularly thoracic, histological roof is essential. CASE REPORT: We report the case of a 55-year-old caucasian woman with multinodular pseudotumoural splenomegaly, associated with some small mediastinal lymph nodes and some non-specific parenchymatous pulmonary nodules. The diagnosis of sarcoidosis was made on the basis of splenectomy after eliminating other causes of granulomatosis. CONCLUSION: This case report describes a rare presentation of sarcoidosis and discusses the differential diagnosis of multinodular splenomegaly. It underlines the necessity of an exhaustive aetiological investigation of splenic granulomatosis as the diagnosis of sarcoidosis remains one of elimination.