Challenge of gastro-intestinal stromal tumor management in low-income countries: example of Benin.

BACKGROUND: GISTs are rare tumors but the most frequent mesenchymal tumors of the digestive tract. Diagnosis and treatment are challenging in low-income countries due to relatively poor access to immunohistochemistry and targeted therapy. In Africa, there are few studies about it. Imatinib, an oral targeted therapy, has been available in Benin since 2010 and free since 2016. This study describes the diagnosis and therapeutic management of GIST in Cotonou, Benin. METHODS: This is a descriptive cross-sectional study, with retrospective data collection over a 10-year period from 2010 to 2020, focused on patients with histological confirmed gastro-intestinal stromal tumor (GIST). Cases were identified using the registry database and the archival files of the Hubert Koutoukou Maga National University Hospital of Cotonou (CNHU-HKM). RESULTS: Fifteen GISTs were identified during the study period. The median age was 52 and the sex ratio was 2:1 (10 males and 5 females). The most frequent symptom was abdominal pain (n = 12). Delay in care seeking after onset of symptoms ranged from 24 h to 15 years. The most common site for GISTs was the stomach (n = 8). The median tumor size was 11 cm and the majority (n=10) was metastatic or locally advanced at the time of diagnosis. The tumors were often spindle-shaped at histology (n = 13) and the majority expressed KIT (n = 14). Most of the tumors (n = 12) were at high risk of recurrence according to the Joensuu scoring system. The availability of imatinib has improved the outcome of GIST with response in all cases it was used in neoadjuvant setting (n = 7). CONCLUSION: GISTs are rare tumors and preferentially affect the stomach in Cotonou). Most of the tumors were large, unresectable at the time of diagnosis and at high risk of recurrence. Access to imatinib has revolutionized the management of those tumors in our country.

Laparoscopic management of a left hepatic vein injury during one -step laparoscopic Roux-en-Y gastric bypass after adjustable gastric banding removal: A case report.

INTRODUCTION AND IMPORTANCE: The occurrence of a left hepatic vein injury during laparoscopic removal of an adjustable gastric band is exceptional and should be known by any surgeon approaching the hiatal region. We report here the laparoscopic control of such a wound. CASE PRESENTATION: A 39-year-old morbidly obese woman (body mass index 47.7 kg/m2) presented the failure in weight loss following a laparoscopic adjustable gastric banding. It was decided to perform a one-step laparoscopic Roux-en-Y gastric bypass. Laparoscopic exploration showed post-surgical tissular retraction and adhesions. After the lap-band™ removal the left hepatic vein was accidentally bluntly injured while freeing adhesions between left hepatic lobe and the stomach. After a direct hemorrhagic control, intraoperative diagnosis of left hepatic vein injury was confirmed. A laparoscopic repair was performed by two running sutures using absorbable monofilament 4/0. Then, a Roux-en-Y gastric bypass was performed without any other complications. Operative time was 119 min; intraoperative blood loss was estimated as 200 cm3. No blood transfusion was necessary. The total hospital stay was 48 h. The excess weight lost after 10 years was 87,9%. CLINICAL DISCUSSION: Adjustable gastric band can modify anatomic landmarks, leading to a wrong dissection path, with possibility of left hepatic vein injury. CONCLUSION: The left hepatic vein injury can occur during revisional surgery for laparoscopic adjustable gastric banding failure. Its laparoscopic management can be done safely, in trained hands without increasing morbidity.

A giant metastatic low-grade endometrial sarcoma requiring surgical management.

INTRODUCTION AND IMPORTANCE: Low-grade endometrial stromal sarcomas are relatively rare tumors. We here report a case of a woman presenting with a giant metastatic low-grade endometrial stromal sarcoma with thromboembolic complications requiring urgent surgical management. CASE PRESENTATION: A 58-year-old obese female was admitted, with a voluminous abdominopelvic mass, due to complications related to its size and extent. The tumor derived from the uterus and invaded the ureters, bladder and rectum. It compressed the right iliac vessels causing both deep vein thrombosis and pulmonary embolism. She developed a painful irreducible umbilical. We proceeded with a debulking surgery (hysterectomy with bilateral salpingo-oophorectomy). Histological findings were consistent with a low-grade endometrial stromal sarcoma. CLINICAL DISCUSSION: Low-grade endometrial stromal sarcomas are generally low-grade malignant neoplasms with an indolent clinical course. Surgery is the cornerstone of treatment. In low-income countries, malignancies are more often diagnosed at a late stage, which limits therapeutic options. Cytoreduction is recommended in advanced tumors with extrauterine manifestation, depending on symptoms and with palliative intent. CONCLUSION: Low-grade endometrial stromal sarcomas are indolent uterine malignancies with metastatic potential. Even in advanced cases, cytoreduction must be considered.

Sister Mary Joseph's nodule revealing a jejunal adenocarcinoma: A case report.

INTRODUCTION AND IMPORTANCE: Adenocarcinoma of the jejunum is a diagnostic challenge for the physician because of its extreme rareness and the fact that it classically presents with vague clinical symptoms. On the other hand, the Sister Mary Joseph's nodule is a rare clinical sign that refers to umbilical metastasis of an internal malignancy. We here report a rare case of jejunal adenocarcinoma revealed by a Sister Mary Joseph's nodule. CASE PRESENTATION: A 55-year-old man presented with an ulcerated umbilical tumor, which was found to be a secondary lesion of an advanced jejunal adenocarcinoma invading the transverse colon. He underwent surgical resection of the umbilical tumor and the intestinal primitive. CLINICAL DISCUSSION: The presence of umbilical metastasis usually represents advanced disease but can be its first manifestation. Gastro-intestinal tract tumors such as jejunal adenocarcinomas and gynecologic malignancies are the most common primary sites. CONCLUSION: Practicians must be aware of clinical implication of Sister Mary Joseph nodule. Aggressive surgery when feasible can be beneficial for survival.

Perioperative mortality as a meaningful indicator: Challenges and solutions for measurement, interpretation, and health system improvement.

Expanding global access to safe surgical and anaesthesia care is crucial to meet the health targets of the Sustainable Development Goals (SDGs). As global surgical volume increases, improving safety throughout the patient care pathway is a public health priority. At present, an estimated 4.2 million individuals die within 30 days of surgery each year, and many of these deaths are preventable. Important considerations for the collection and reporting of perioperative mortality data have been identified in the literature, but consensus has not been established on the best methodology for the quantification of excess surgical mortality at a hospital or health system level. In this narrative review, we address challenges in the use of perioperative mortality rates (POMR) for improving patient safety. First, we discuss controversies in the use of POMR as a health system indicator and suggest advantages for using a "basket" of procedure-specific mortality rates as an adjunct to gross POMR. We offer then solutions to challenges in the collection and reporting of POMR data, and propose interventions for improving care in the preoperative, operative, and postoperative periods. Finally, we discuss how health systems leaders and frontline clinicians can integrate surgical safety into both national health plans and patient care pathways to drive a sustainable safety revolution in perioperative care.

[Severe acute pancreatitis during pregnancy among black African women: about a case]. / Pancréatite aiguë sévère sur grossesse chez le noir Africain: à propos d'un cas.

Acute pancreatitis is rare during pregnancy. It is associated with high maternofoetal mortality. It is mainly caused by biliary lithiasis but, in many cases, the cause of acute pancreatitis is undetermined. We here report the case of a 37-year old patient presenting with acute pancreatitis revealed by acute febrile bowel obstruction at 29 weeks of amenorrhea. The diagnosis was made during surgery. The patient had a miscarriage in the postoperative period. She died on the 8th postoperative day.