Adult groin hernia surgery in sub-Saharan Africa: a 20-year systematic review and meta-analysis.

PURPOSE: To realize a systematic review to evaluate groin hernia surgery for adults in sub-Saharan Africa. METHODS: We conducted a systematic review and meta-analysis, the primary objective of which was to determine the surgical techniques used for unilateral groin hernia surgery in sub-Saharan Africa. Studies published in the last 20 years were considered. A meta-analysis estimated the pooled prevalence with 95% confidence interval (CI) of mortality, chronic pain and recurrence. A subgroup analysis compared the rate of complications between complicated or uncomplicated hernia. RESULTS: We included 113 articles. The most used technique was Bassini in 40.1%, followed by Lichtenstein in 29.9% and Shouldice in 12.6%. The overall mortality rate was 0.6% (95% CI 0.4-0.9). The pooled recurrence rate was 1.4% (95% CI 1.05-1.9). The pooled rate of chronic pain was 2.7% (95% CI 1.9-3.7). We found that mortality rate for complicated hernias (6.4%) was higher compared to uncomplicated hernias (0.2%). This difference was statistically significant [p ≤ 0.001; OR = 47.7; 95 CI (27.2-83.47)]. CONCLUSION: This review showed that pure tissue repairs are the most used techniques with Bassini and Shouldice as leading procedures. The post-operative rates of recurrence and chronic pain are low. However, there is a high heterogeneity between studies than can underestimate these pooled prevalences. The consultation at complication stage remains frequent and associated with a higher mortality. Futures studies should focus on improving the quality of studies in terms of design and follow-up to increase the degree of evidence.

Irreducible posterolateral elbow dislocation: A case report.

Elbow dislocations are very common, particularly in the posterolateral variety. Closed reduction is usually easy. However, an irreducible elbow dislocation without associated fracture is rare. We report the case of a 21-year-old patient who presented with an isolated posterolateral irreducible elbow dislocation. Open reduction revealed the buttonhole radial head in the capsule and the complex ligaments. A significant protrusion of the radial head associated with a closed reduction failure is highly suspicious of an irreducible dislocation.

Short bowel syndrome: difficulties of management in rural areas.

INTRODUCTION: The causes of short bowel syndrome are multiple, but most often in sub-Saharan Africa they result from extensive surgical resection that leaves less than 200 cm. Intestinal failure appears rapidly with a major hydroelectrolytic deficiency and malabsorption. Management requires parenteral nutrition that can be life-long. OBSERVATION: A 53 year-old patient underwent surgery in 1986 for peptic ulcer disease and recovered successfully. He was admitted in July 2015 for acute bowel obstruction of more than 8 hours duration. Intraoperative exploration showed irreversible ischemia in the small bowel, related to tight adhesions. An extensive resection leaving 110 cm of bowel was carried out. Postoperatively, nutritional monitoring and oral supplementation were prescribed and associated with proton pump inhibitors and antidiarrhea drugs. Parenteral feeding was not available. The postoperative period was characterized by temporary stability followed by a significant weight loss, then by two hospitalizations for severe malnutrition and intercurrent infection. Death occurred 7 months after the operation. CONCLUSION: Parenteral nutrition is essential in short bowel syndrome. Availability, especially for a long-term use, is a major problem in our context, and alternatives are rare.

Complications inattendues de la chirurgie: deux cas de brûlure par plaque de bistouri électrique.

There is a real risk of electrical accidents in the operating theatre, with the growing number of electrical, electronic and flammable liquids used. Electrocautery remains the most commonly used device for its electrosurgical effect of coagulation or tissue section. When it is defective or misplaced on a small area of the skin, it can cause a typically deep, slow healing skin burn. It adds an unexpected iatrogenic morbidity to the initial condition, with devastating consequences for the patient, the surgeon and sometimes the hospital. We report two cases of cutaneous burn by the neutral plate that occurred intraoperatively when using electrocautery in monopolar mode, and discuss etiology, clinical and prevention aspects.

[Interest of ambulatory simplified acute physiology score (ASAPS) applied to patients admitted in an intensive care unit of an infectious diseases unit in Dakar]. / Intérêt de l'indice de gravité simplifié ambulatoire (IGSA) appliqué à des patients admis dans l'unité de soins intensifs (USI) d'un service de pathologie infectieuse à Dakar.

The evaluation of patients by a scale of gravity allows a better categorization of patients admitted in intensive care unit (ICU). Our study had for objective to estimate interest of Ambulatory Simplified Acute Physiologic Score (ASAPS) applied to patients admitted in ICU of infectious diseases department of FANN hospital. It was about a descriptive and analytical retrospective study, made from the data found in patients' files admitted into the USI infectious diseases department of FANN hospital in Dakar, from January 1(st), 2009 till December 31st, 2009.The data of 354 patients' files were analyzed. The sex-ratio was 1.77 with an average age of 37.6 years ± 19.4 years old [5-94 years]. The majority of the patients were unemployed paid (39.6%). The most frequent failures were the following ones: neurological (80.5%), cardio-respiratory (16.7%). The average duration of stay was 6.2 days ± 8.2 days going of less than 24 hours to more than 10 weeks. The deaths arose much more at night (53.1%) than in the daytime (46.9%) and the strongest rate of death was recorded in January (61.5%), most low in October (26.7%). The global mortality was 48.3%. The rate of lethality according to the highest main diagnosis was allocated to the AIDS (80.5%). The average ambulatory simplified acute physiology score was 5.3 ± 3.6 with extremes of 0 and 18. The deaths in our series increased with this index (p = 0.000005). The female patients had a rate of lethality higher than that of the men people, 55.5% against 44.2% (p = 0.03). In spite of a predictive score of a high survival (ASAPS < 8), certain number of patients died (n = 105) that is 61.4% of the deaths. The metabolic disturbances, hyperleukocytosis or leukopenia when realised, the presence of a chronic disease, seemed also to influence this lethality. ASAPS only, although interesting, would not good estimate the gravity of patients, where from the necessity thus of a minimum biological balance sheet. It seems better adapted for patients with a high value (ASAPS≥8). This score when it is low, is not correlated, in our study, at a high survival rate as waited in this population.

[Management of sigmoid volvulus in the tropical area of Thies (Senegal)]. / Prise en charge du volvulus du côlon sigmoïde en milieu tropical à Thiès (Sénégal).

The aim of this study is to report our experience in the management of sigmoid volvulus in a tropical environment. This retrospective study covers the period from June 1, 2010, to December 31, 2013, in the department of emergency surgery at the regional hospital of Thiés: 40 patients were admitted with sigmoid volvulus: 36 men and 4 women, with a mean age of 45 years (20-89 years). Twelve had chronic constipation. All four signs of occlusion were present in 72.5% of cases. Abdominal radiography confirmed the diagnosis in all cases. The volvulus resolved spontaneously in one patient, while the other 39 required laparotomy: 25 had a one-stage colectomy, and 11 patients a sigmoidectomy with a temporary colostomy. Two patients underwent a sigmoidopexy, one with a simple closure of a perforated duodenal ulcer. The morbidity rate was 7.5%, due mainly to complications of infection. The mortality rate was 10%. After a mean follow-up of 2.77 months (range: 15 days-12 months), no recurrences were observed. Sigmoid volvulus is a common condition in Africa especially in younger patients. The diagnosis is easy, based on clinical and abdominal radiography findings. Several procedures have been described but the one-stage colectomy remains the method of choice, especially in tropical areas where socioeconomic conditions are difficult.

[Tuberculoid leprosy revealed by active ulcerative colitis: a case report]. / Une rectocolite hémorragique révélant une lèpre tuberculoïde.

Leprosy is endemic in Senegal. In 2011, there were 73 new cases reported in Dakar. The circumstances of discovery are often dermatologic or neurologic. Few case reports describe an association with chronic inflammatory colitis, probably fortuitous. We report the case of a 30-year-old woman who had a tuberculoid leprosy revealed by active ulcerative colitis. Treatment according to the WHO protocol of leprosy, combined with corticosteroids and then methotrexate, resulted in healing of the leprosy and remission of the colitis.

[Evaluation of tolerance of zidovudine-lamivudine-nevirapine combination in HIV 1 patients in Fann Teaching Hospital in Dakar]. / Évaluation de la tolérance de l'association zidovudine-lamivudine-névirapine chez les patients VIH-1 au Centre hospitalier de Fann à Dakar.

We conducted a study to evaluate the tolerance of the zidovudine (AZT), lamivudine (3TC) and nevirapine (NVP) combination regimen in HIV-1 patients by a descriptive analytical retrospective study of all HIV-1 patients receiving AZT-3TC-NVP combination between 2008 and 2011. Seventy patients were included. Two thirds of the patients presented at least one side effect (44 cases). The digestive disorders (15 cases) and neuropsychiatric (14 cases) were the most frequent. Epigastralgia (20%), headaches (20%) and arthralgias (13%) were main side effects. A maculo-papular exanthema was noted in three cases. During the follow-up, five patients presented with anemia. No patient presented hepatic cytolysis due to NVP. All the patients followed for more than six months presented a side effect against 29.7% when the duration of treatment was equal to or less than 6 months (p=10(-5)). Most of the side effects due to the association AZT/3TC/NVP are minor. The evaluation of the clinical and biological tolerance must be maintained during all the follow-up.

[Current profile of cerebral toxoplasmosis in a hospital setting in Dakar]. / Profil actuel de la toxoplasmose cérébrale en milieu hospitalier à Dakar.

OBJECTIVE: To describe the current epidemiologic, clinical, diagnostic, and prognostic characteristics of cerebral toxoplasmosis in a hospital setting in Dakar. METHODS: This descriptive and analytic study examined the records of all HIV-positive patients with cerebral toxoplasmosis hospitalized at the infectious disease department at Fann (teaching) Hospital from January 2007 through December 2010. The diagnosis was based on clinical and computed tomography criteria completed by a therapeutic test with Cotrimoxazole. RESULTS: There were 26 cases of cerebral toxoplasmosis during the study period. The sex ratio (F/M) was 1.4. The mean age was 41.5 ± 11.2 years. The clinical signs were predominantly fever (88.5%), headache (77.5%), focal signs (64.5%), and disorders of consciousness (61.5%). Brain lesions were most often multiple (64.3%), with mass effects (54.1%) and peripheral edema (77.8%). Seven of the 26 patients died (lethality rate: 29.1%). Impaired consciousness (p = 0.023), high CD8 T-cell counts (p = 0.009), and anemia (p = 0.003) were significantly associated with a higher mortality rate. CONCLUSION: Cerebral toxoplasmosis remains a complication of AIDS in Dakar. Anemia, impaired consciousness, and high CD8(+) T cell counts were factors indicative of poor prognosis.

[Elimination of maternal and neonatal tetanus in Senegal: evolution of survey indicators of 2003-2009]. / Élimination du tétanos maternel et néonatal au Sénégal : évolution des indicateurs de surveillance de 2003 à 2009.

OBJECTIVES: This study aimed to estimate the evolution of the maternal and neonatal tetanus in Senegal from the tetanus vaccination coverage among pregnant women, the proportion of deliveries attended by trained medical personnel and the number of cases of tetanus declared by respective districts, helping to identify districts at high risk of neonatal tetanus (NNT). METHOD: Data analysis of the epidemiological surveillance realized from 2003 to 2009 in 65 districts of Senegal. Data were collected from the reports of vaccination usage and from the Statistical Directories of the National Health Information Services of the Ministry of Health & Prevention. A district is at high risk when the incidence of NNT is ≥1 case per 1 000 Live births (LB). RESULTS: There were 153 reported cases of NNT in Senegal between 2003 and 2009. National incidence decreased from 0.08 to 0.03 case per 1 000 LB (p = 0,0008). The vaccination coverage of the pregnant women by at least two doses of tetanus vaccine (VAT2+) increased from 66% in 2003 to 78% in 2009. The percentage of districts that had reached a vaccination coverage ≥80% was 20% in 2003 compared to 60% in 2009 (p = 0.009). The proportion of deliveries attended by qualified medical staff evolved from 53% in 2003 to 67% in 2009 (p = 0,02). By 2009, the incidence of NNT was less than 1 case per 1,000 LBs in all districts. CONCLUSION: Assessing the elimination of maternal and neonatal tetanus in Senegal shows that progress has been made from 2003 to 2009. This was made possible through the organization of vaccination campaigns for women of childbearing age and the improvements in the conditions of deliveries.

[Management of giant inguinal hernias: five cases]. / Prise en charge des hernies inguinales géantes: à propos de cinq observations.

In Africa, difficulties in health care access and illiteracy promote the development of giant inguinal hernias. Management of these hernias can be very challenging, according to the risk of replacing the intestines into the abdominal cavity. We report five cases in Senegal.

[Efficacy and tolerance of tenofovir-lamivudine-efavirenz combination in HIV-1 patients in Fann Teaching Hospital in Dakar]. / Efficacité et tolérance de l'association ténofovir-lamivudine-éfavirenz chez les patients VIH-1 à la clinique des maladies infectieuses du CHNU de Fann à Dakar.

We conducted a study to evaluate the efficacy and tolerance of the tenofovir (TDF), lamivudine (3TC) and efavirenz (EFV) combination regimen in HIV-1 patients by a descriptive analytical retrospective study of all HIV-1 patients receiving TDF-3TC-EFV combination between 2007 and 2011. Collected data was analysed using EpiInfo™ version 6.04. One hundred patients were included, with an average follow-up duration of 27 months and 19 days (± 21 months and 14 days).We observed an average increase in body weight of about 8 kg per annum, with an average rise in CD4 count of 100/mm(3) by the end of the second year. A reduction in viral load with 71% of patients in therapeutic success at 24 month of treatment was noted. Ninety-two patients presented with at least one side effect, mostly being Grade 1 or 2 (96.36%). Neurological (24 patients) and digestive (20 patients) complaints comprised the commonest reported side effects. Four patients had adverse effects severe enough to warrant a change in treatment regimen, principally due to renal insufficiency. Thirteen subjects died. Patients receiving TDF-3TC-EVF combination therapy need rigorous surveillance because this combination, although efficient, is not without significant adverse effects.

Mesenteric myofibroblastic tumor: NSAID therapy after incomplete resection.

Myofibroblastic tumors are inflammatory tumors that arise in viscera and soft tissue; their etiopathology is poorly understood. They are capable of infiltration of adjacent organs, local recurrence after surgical resection, and even of distant metastasis. These characteristics result in persistent debate as to the nature of these lesions - whether they are inflammatory or neoplastic, benign or malignant lesions? Diagnosis is almost always made based on histopathological findings. Traditional management is complete surgical excision, but this may be difficult or impossible when the lesion develops in proximity to vital structures. We report the case of a 59-year-old man who was treated in our institution for mesenteric myofibroblastic tumor. Complete resection was not possible due to local infiltration of the mesentery. Recurrence was noted 3 months after surgery; treatment with steroidal and then non-steroidal anti-inflammatory medications (NSAIDs) resulted in clinical and radiologic regression of the tumor.

[Current profile of HIV-infected patients hospitalized in Dakar (Senegal)]. / Profil actuel des patients infectés par le VIH hospitalisés à Dakar (Sénégal).

Ten years after the introduction of the Senegalese Antiretroviral Drug Access Initiative in 1998, we conducted a retrospective study of the epidemiological and clinical profiles and outcome of HIV-infected patients hospitalized in the Infectious Diseases Clinic of Fann Teaching Hospital in Dakar between 2007 and 2008. During these 2 years, 527 HIV-positive patients were included. The average age of the patients was 41 ± 10 years, and the sex-ratio (F/M) was 1.1; 56% of patients were married. The average interval before admission was 40 ± 57 days. Fever (83%), loss of weight (83%) and cough (54%) were the principal symptoms. Tuberculosis (40.9%) and gastrointestinal candidiasis (38.9%) were the commonest opportunistic infections. Most patients were diagnosed at the AIDS stage (88%) and the CD4+ T lymphocyte count was ≤ 200/mm3 in 86% of cases. Hospital fatality was 44% (231/527). Tuberculosis (36%), bacterial pneumonia (18%) and encephalitis (12%) were the most frequent causes of death. Despite the availability of and free access to antiretroviral drugs in Senegal, the mortality associated with HIV infection remains very high due to late diagnosis. The population must be educated to boost early screening and care.

[Human rabies: diagnostic pitfalls]. / La rage humaine, un diagnostic parfois difficile.

The purpose of this report is to describe two cases of human rabies in Senegal that illustrate possible diagnostic and therapeutic pitfalls even in an endemic area. Although outcome is almost always fatal and interhuman transmission is uncommon, prompt diagnosis of rabies is important since delay increases the risk of exposure to the virus for the entourage.

Indirect inguinal hernia masquerading as a Spigelian hernia.

Inguinal hernia usually developed and descended into scrotum. The clinical presentation is inguinal or inguino-scrotal swelling. Abdominal wall weakness as it is frequently seen in African tropical zones produces often rare clinical case. We report a case of inguinal hernia presented as an abdominal wall swelling clinically suggestive of a Spigelian hernia and discuss the mechanism.

[Aetiology of AFB negative pneumonias in hospitalized HIV patients in Dakar]. / Étiologie des pneumonies BAAR négatives chez les patients infectés par le VIH hospitalisés à Dakar (étude ANRS 1260).

A prospective study was carried out in two tertiary hospitals in Dakar to determine the main causes of sputum acid-fast bacillus (AFB) smear-negative pneumonia in HIV-infected patients. All clinical and microbiological records were reviewed by experts. Seventy patients were finally enrolled. Most of them were hospitalized at an advanced stage of AIDS. The median CD4 cell count was 62/mm(3) and the median body mass index (BMC) was 18 kg/m(2). Thirty-one patients (44 %) were known as seropositive for HIV infection prior to admission. Radiological opacities were localized in 70 % of patients and diffuse in 21 %. Fiberoptic bronchoscopy was performed in 50 patients (71 %). A definite or probable diagnosis was obtained in 55 patients (79 %). Bacterial pneumonia (usually due to Enterobacteriaceae and Pseudomonas aeruginosa), tuberculosis, Pneumocystis pneumoniae and other causes (Kaposi's sarcoma, atypical mycobacteria) were diagnosed in 67 %, 24 %, 5 %, and 13 % of these patients respectively. In conclusion, pneumonia of bacterial origin and tuberculosis can be incriminated in the majority of cases of AFB negative pneumonia observed in HIV patients in Dakar.

[Maternal tetanus in Dakar from 2000 to 2007]. / Tétanos maternel à Dakar de 2000 à 2007.

The objective of this study conducted between January 2000 and December 2007 was to assess the current epidemiological, clinical and outcome features of maternal tetanus (MT) observed in the Infectious Diseases Clinic of Fann University Hospital in Dakar, Senegal. A total of 1156 patients were admitted for tetanus during this period including 9 (0.8%) presenting MT. A progressive decrease in the annual number of MT cases was observed. The mean age of MT patients was 28.3 years [range, 18 to 40 years]. Most cases (n=6) involved persons living in suburban areas, as did tetanus in women of childbearing age (WCBA) (51.9% of 129 cases) and in neonates (63.1% of 103 cases) admitted during the same period. All patients had fallen behind the vaccination schedule. Septic abortion (n=7) was the main etiological factor. Although tetanus was graded as moderate in 8 patients (Mollaret stage 2), the death rate was high (44.4%) due to infectious and obstetric complications. This rate was similar to that associated with tetanus in newborns (48.5%), but higher than that associated with tetanus in WCBA (25.6%). The incidence of life-threatening MT is declining in the Infectious Diseases Clinic of Fann University Hospital in Dakar. A systematic immunization program along with campaigns to prevent unwanted pregnancy in women of childbearing age will be needed to eliminate maternal and newborn tetanus in Dakar.

[The fight against rabies in Africa: from recognition to action]. / Lutte contre la rage en Afrique: du constat à l'action.

As a follow-up to the first AfroREB (Africa Rabies Expert Bureau) meeting, held in Grand-Bassam (Côte-d'Ivoire) in March 2008, African rabies experts of the Afro-REB network met a second time to complete the evaluation of the rabies situation in Africa and define specific action plans. About forty French speaking rabies specialists from Northern, Western and Central Africa and Madagascar met in Dakar (Senegal), from March 16th to 19th, 2009. With the participation of delegates from Tunisia, who joined the AfroREB network this year, 15 French speaking African countries were represented. Experts from the Institut Pasteur in Paris, the Alliance for Rabies Control, and the Southern and Eastern African Rabies Group (SEARG, a network of rabies experts from 19 English speaking Southern and Eastern African countries) were in attendance, to participate in the discussion and share their experiences. AfroREB members documented 146 known human rabies cases in all represented countries combined for 2008, for a total population of 209.3 million, or an incidence of 0.07 cases per 100,000 people. Even admitting that the experts do not have access to all reported cases, this is far from the WHO estimation of 2 rabies deaths per 100,000 people in urban areas and 3.6 per 100,000 in rural Africa. It was unanimously agreed that the priority is to break the vicious cycle of indifference and lack of information which is the main barrier to human rabies prevention.

[Tetanus in women of childbearing age at the infectious diseases clinic in Dakar]. / Le tétanos de la femme en age de procréer a la clinique des maladies infectieuses de Dakar.

The objective of this article was to describe the epidemiological and outcome features of tetanus in the woman of childbearing age (WCBAT) and compare them with neonatal tetanus (NT) and other tetanus cases in a hospital department in Dakar from 1998 to 2007. A retrospective study was conducted using the files of WCBAT (15 to 49 years old), NT (3 to 28 days old) and other tetanus cases admitted at the Infectious Diseases Clinic, in Fann University Hospital, from 1998 to 2007. 1484 cases of tetanus were admitted in 10 years, with 176 cases of tetanus of WCBAT (11.8%) and 178 cases of NT (11.9%). In comparison with WCBAT the NT annual hospital rate significantly decreased during the study period whereas other tetanus cases rate remained stable. The average age of WCBAT was 26.1 year old and 57.9% were between 15 and 25 years old. The geographical origin was identical for all patients, with more than 71% coming from suburban areas. Most of the WCBAT cases were housewives (50.9%), single women (75%) without updated tetanus immunization (92%). The main portals of entry of WCBAT were injuries and wounds (67.4%) and maternal tetanus cases were rare (8%), mainly post-abortum. At admission, WCBAT cases were less severe than NT cases but more severe than other tetanus cases. The lethality rate of WCBAT cases (28.4%) was significantly lower than NT cases (50%, p = 0.00003), but higher than the other tetanus cases (22.2%; NS). Prognostic factors were: non-identified or intramuscular injection portal of entry and a Mollaret state III at admission. An intensification of the extended immunization program associated with supplementary immunization campaigns targeting women of child bearing age in high risk districts, are necessary to eradicate neonatal and maternal tetanus in Dakar.