Perioperative outcomes of the surgical management of achalasia in two tertiary Cameroonian hospitals: a cohort study.

INTRODUCTION: Achalasia is a rare esophageal disease with potentially lethal complications. Knowledge of the outcomes of the different surgical treatment modalities for achalasia by Heller's cardiomyotomy (HCM) helps to choose the safest and most effective option. However, data on the management of achalsia using a Heller myotomy is limited in Africa. Thus, our aim was to determine the perioperative morbidity, mortality and short-term functional outcomes of HCM in Cameroon. METHODOLOGY: We conducted a cohort study throughout a 10-year chart review of patients who underwent HCM for achalasia and were followed up postoperatively for at least three months at two tertiary health centers in Cameroon. We analyzed demographic data, preoperative clinical and imaging data, treatment details, and outcomes at three to twelve months after HCM using the Eckardt score. RESULTS: We enrolled 29 patients with achalasia having a mean age of 24 ± 16 years and predominantly females (M/F of 1/3.8). The mean symptom duration was 51 ± 20 months. In 80% of cases, the diagnosis was made through a conventional x-ray contrast imaging or "barium swallow test" (93%) and/or an upper gastrointestinal endoscopy (86%). The gold standard diagnostic method via esophageal manometry was unavailable. Preoperatievly, all patients had symptoms suggestive of an active achalasia. HCM was performed via laparotomy in 75% as opposed to 25% laparoscopic HCM procedures. Dor's anterior partial fundoplication was the main anti-reflux procedure performed (59%). Mucosal perforations were the only intraoperative complications in eight patients (2 during laparoscopy vs. 6 during laparotomy; p > 0.5) and were managed successfully by simple sutures. Postoperative complications were non-severe and occurred in 10% of patients all operated via laparotomy. The mean postoperative length of hospital stay was 7 ± 3 days for laparotomy vs. 5 ± 2 days for laparoscopy; p > 0.5. The perioperative mortality rate was nil. Overall, the short-term postoperative functional outcome was rated excellent; average Eckardt score of 1.5 ± 0.5 (vs. preoperative Eckardt Score of 9 ± 1; p < 0.0001). CONCLUSION: Achalasia is diagnosed late in this resource-limited setting. HCM yields satisfactory outcomes, especially via laparoscopic management. An improvement in diagnostic esophageal manometry and mini-invasive surgical infrastructure and the required surgical training/skills are needed for optimal achalasia care.

Obstructive lithiasis of the lower bile duct discovered four decades after cholecystectomy and its management by ideal choledochotomy: a case report.

BACKGROUND: Residual lithiasis is the presence of stones in the common bile duct, ignored after one or more biliary interventions. We report an atypical case of chronic symptomatic lithiasis of the lower bile duct occurring 41 years after biliary surgery, managed successfully by ideal choledochotomy. CASE PRESENTATION: A 68-year-old Black African female with several past laparotomies including a cholecystectomy forty-one years ago presented with hepatic colic-type pain that had been intermittent for several years but worsened recently. Her clinical, biological, and imaging test assessments were suggestive of a residual obstructive lithiasis of the lower common bile duct. Through an open right subcostal laparotomy approach, a dilated bile duct of approximately 3 cm was found and managed by transverse choledochotomy in which the stone was extracted in retrograde manner. After confirmation of disobstruction, a primitive bile duct suture without biliary drainage was performed and a tubular drain was positioned under the liver. The postoperative course was uneventful at follow-up of 30 days. CONCLUSION: Residual choledocholithiasis can be avoided. We performed an ideal choledochotomy, of which the follow-up was simple.

Sleeve gastrectomy in the surgical management of obesity in Cameroon (a sub-Saharan country): A single-institute retrospective review of 30-day postoperative morbidity and mortality.

BACKGROUND: Obesity is a major public health concern even in sub-Saharan Africa. In this part of the world, characterized by limited technical platform and resuscitation facilities, sleeve gastrectomy in the surgical management of obesity is a quite new procedure. We aimed to assess intraoperative complications and 30-day postoperative morbidity and mortality of this procedure in our setting. METHODS: This study was conducted in the digestive and laparoscopic surgery unit of the National Insurance Fund Health Centre of Essos (Cameroon, Central Africa region). Retrospectively, we reviewed the medical reports of all patients who had undergone a bariatric surgery through a sleeve gastrectomy from January 2016 to December 2020. The 3 end points were intraoperative complications, postoperative 30-day morbidity, and postoperative 30-day mortality. RESULTS: We included 21 patients among whom 19 were female (90.5%). Their mean age and body mass index were 40.3 ± 10.8 years and 44.9 ± 7.4 kg/m2, respectively. All of them presented with at least 1 comorbidity. All procedures were totally completed laparoscopically with 3 cases of intraoperative complications (14.3%) consisting on bleeding in all of them. The mean operative time was 192.2 ± 52.8 minutes, and the mean hospital stay was 4.7 ± 1.1 days. Eight patients (38.1%) presented a total of twelve 30-day postoperative complications, all of them classified as minor according to the Clavien-Dindo method. The main postoperative morbidity was represented by nausea and vomiting (n = 3, 14.3%). No 30-day readmission was recorded, and the 30-day mortality was nil. CONCLUSION: Sleeve gastrectomy in the management of obesity is a safe procedure even in a limited setting like our own.

Transvaginal strangulated bowel evisceration through uterine perforation due to unsafe abortion: a case report and literature review.

BACKGROUND: Induced abortion, whether therapeutic or elective, is a surgical procedure frequently practiced worldwide. It is a significant cause of maternal morbidity and mortality. When the procedure is performed in precarious conditions, by unqualified personnel, it leads to serious consequences, including uterine perforation and its associated lesions. Its management remains a medico-surgical emergency. CASE PRESENTATION: We present two cases of unsafe abortions performed by cervical dilatation and intrauterine curettage which resulted in uterine perforation and intestinal evisceration through the vagina leading to acute intestinal obstruction. Both patients underwent intensive resuscitation followed by an emergency laparotomy. The first case was a 26-year-old woman living in rural Cameroon. Following a procedure of termination of her pregnancy, the patient noted the presence of bowel at the vaginal introitus associated with signs of intestinal obstruction. She was transferred to a specialized center was after 4 days later of the onset of the evisceration. Considering the gangrened eviscerated terminal ileum, a right hemicolectomy with anastomosis was performed, as well as a suture of the uterine perforation. The second patient was an 18-year-old African living as a refugee in Cameroon. She was referred for abdominal pain in the context of intestinal obstruction with a viable jejunal loop extruding through the vagina. A simple jejunal resection was performed with end-to-end anastomosis and suture of the uterine perforation. In both cases, the postoperative course was uneventful. CONCLUSIONS: Uterine perforation is a serious complication of intrauterine gynecological procedures and instrumental abortion in particular. It can lead to evisceration of the intra-abdominal viscera through the uterine perforation. It is therefore a real surgical emergency with multiple and fatal consequences.

[Complications of surgical management of non-traumatic acute abdomens of digestive origin at the Yaoundé central hospital, Cameroon (November 2019 - July 2020)]. / Complications des prises en charge chirurgicales des abdomens aigus non traumatiques d'origine digestive à l'hôpital central de Yaoundé, Cameroun (novembre 2019 - juillet 2020).

Objective: Acute non-traumatic digestive surgical emergencies are a frequent cause of emergency in Africa. We undertook this study to investigate the morbidity and mortality of these patients in Cameroon, a developing country in Central Africa. Patients and methodology: This was an analytical cross-sectional study with prospective data collection, over a period of eight months (November 2019 to July 2020), at the Yaoundé central hospital (Cameroon). The latter is a second category (intermediate) public health facility in the Cameroon health pyramid, mainly welcoming patients without health insurance. All patients operated on for an acute non-traumatic digestive abdomen were included. The patients were followed up until the 12th postoperative week. We used Cox univariate regression to determine factors associated with the occurrence of postoperative complications. The significance threshold retained was 0.05. Results: We collected 120 patients, representing 14.6% of all surgical emergencies. The mean age of the patients was 37.6 ± 13.5 years. Eighty (66.7%) were male with a sex ratio of 2. The two main preoperative diagnoses were acute generalized peritonitis (n = 58 or 48.3%) and intestinal obstruction (n = 38 or 31.7%). The two main etiologies were peptic ulcer perforation (n = 35) and acute appendicitis (n = 24). The delay between the onset of symptoms and consultation was 1.9 day and an average of 36.8 hours elapsed between diagnosis and surgery. During postoperative time the morbidity and mortality rates were 33.3 and 10%, respectively. Postoperative complications were mostly minor according to the Clavien-Dindo classification, with 21 cases of grade I (33.8%) and 12 cases of grade II (19.3%). The main cause of death was sepsis (8 out of 12 cases). We identified seven factors significantly associated with an increased risk of postoperative complications among whom three were modifiable: The consultation delay greater than 72h (p = 0.02), the time between diagnosis and the surgical intervention greater than 48h (p = 0.01) and the operating time greater than 2h (p = 0.05). Conclusion: In our context, the results of the surgical management of acute non-traumatic abdomens of digestive origin are marked by high morbidity and mortality. The possible solutions are: the organization of public awareness campaigns to prompt rapid consultation in the event of acute abdominal pain, the establishment of universal health coverage as well as the improvement of technical platforms.

Anal/anogenital lesion revealing child sexual abuse: A case series of an unusual situation in a black African setting.

INTRODUCTION: Child sexual abuse (CSA) remains a big taboo in black Africa with an underestimated prevalence. In our context, the majority of cases are known by revelations of the child at least one year after the facts. PRESENTATION OF CASES: We report three cases of CSA revealed by an anal/anogenital lesion requiring surgery. All of these patients were female with ages ranging from 20 months to 8 years. The lesions encountered were: an anal abscess, a fissure-in-ano with permanent anal mucosal eversion and a complex perineal tear including partial anal sphincter rupture with partial section of the rectovaginal septum. The outcome was favorable in all cases after surgery. The abuser was subsequently able to be identified after the statements of two of these three children. DISCUSSION: Detection of anogenital lesions during a pediatric consultation should make practitioners aware of the possibility of sexual abuse. Surgical repair of these lesions can be simple or complex, requiring major reconstructions. In such cases, it's important to listening to the child's voice. CONCLUSION: Anogenital lesions discovered during pediatric consultation must evoke sexual abuse. The silence and the taboo surrounding these abuses in Africa must be break down.

Clinical epidemiology and mortality risk factors of gastric cancer in a sub-Saharan African setting: a retrospective analysis of 120 cases in Yaoundé (Cameroon).

INTRODUCTION: in sub-Saharan Africa, there is scare published data on cancer in general and gastric cancer in particular. METHODS: we conducted a multicenter retrospective analysis of the medical records of patients followed for gastric cancer in 5 hospital departments in the city of Yaoundé (Cameroon) over 6 years. RESULTS: we recorded a total of 120 patients with a mean age of 53.4 ± 13.7 years. There were 62 females (51.7%). The most common risk factors for gastric cancer in our patients was Helicobacter pylori infection (59 cases, 49.1%). Seventy-six patients (63.3%) consulted within 1 to 6 months of symptoms on set at the forefront of which chronic epigastralgia (74.1%). At endoscopy, the tumor was mostly located at the antrum and was locally advanced or metastatic in 25.8% and 58.4 of cases respectively. Adenocarcinoma was the main histologic type found in 105 (87.5%) cases. Curative treatment could only be implemented in 26.7% of patients. We noted a total of 85 deaths (70.8%) with a mean survival time of 5.91 ± 7.51 months. Survival rate at 3 and 5 years was 10.1% and 4.6%, respectively. On multivariable analysis, variables independently associated with overall survival included: WHO stage 3 performance status (p = 0.042), palpable epigastric mass on examination (p = 0.042), pyloric localization (p = 0.007), and liver metastasis (p = 0.012). CONCLUSION: clinical epidemiology of gastric cancer in our study is comparable to those of other African studies with a predominance of locally advanced/metastatic forms. Prognosis is grim with diagnostic delay behind all of the identified mortality risk factors.

Giant sixteen kilogram lymphangioma mesenteric cyst: An unusual presentation of a rare benign tumour.

BACKGROUND: Mesenteric cysts are rare abdominal benign tumours with an incidence of 1:100.000-250.000 surgical admissions located in the mesentery. Theirs presentations may range from incidental asymptomatic discovery during imaging to non-specific abdominal symptoms. CASE PRESENTATION: We present the case of a 46 year old female who presented with 9 months history of progressive abdominal distension. CT scan showed a giant abdominal mass. After the necessary preoperative work up, a midline incision laparotomy was performed. Intraoperative findings were a mesenteric cyst originates from the transverse mesocolon. The cyst weighed 16 kg and histopathology analyses confirmed a lymphangioma mesenteric cyst. DISCUSSION: In low incomes countries like our own, the interval between the onset of symptoms and consultation is often significant, leading to unusual and sometimes spectacular presentations at the time of diagnosis. To our knowledge, it is the heaviest mesenteric cyst reported in the literature to date. CONCLUSION: Mesenteric cysts may present as giant abdominal masses. The publication of this atypical case is a plea for us for the establishment of universal health coverage in our country in particular and in Africa in general.

Brachiocephalic A-V fistula through the median cubital vein; A reliable option to failure of forearm fistulas. A case report from CHU Yaoundé.

INTRODUCTION: Renal replacement therapy in end-stage kidney disease relies on dialysis in low-income countries. This maintenance treatment needs a reliable vascular access and is done through central venous catheter or creation of A-V fistulas. Several types of A-V fistulas can be done but due to some individual conditions, those possibilities may be exhausted rapidly. CASE PRESENTATION: A 31 year old female was diagnosed with an end stage renal disease for which she was prescribed maintenance dialysis. She first denied her condition and went to traditional healer. After some months her clinical state worsened and she was dialyse with catheter and refer to us for A-V fistula construction. The first two attempts on the forearm failed and we found small radial artery both proximally and distally on the left forearm. We finally did a left brachiocephalic fistula with initial retrograde flow on the median cubital vein. DISCUSSION: Despite arm base fistula may be theoretically easy to build because of bigger size vessels, brachiobasilic fistula may be less effective due to difficult venipuncture. Brachiocephalic fistula through median cubital vein may be more effective option with no further procedure needed. CONCLUSION: Brachiocephalic fistula should be considered as option in vascular access especially when a reliable option is needed after previous attempt failure.

Complex Pulmonary Aspergilloma: Surgical Challenges in a Third World Setting.

BACKGROUND: Surgery for pulmonary aspergilloma (PA), especially complex forms, is greatly challenging in a resource-poor setting such as Cameroon. We report our experience of surgical management of PA in this environment. METHOD: We prospectively assessed patients who underwent surgery for PA from January 2012 to May 2015, at the University Hospital Center of Yaoundé. Records were reviewed for demographics, history and physical examinations, radiological findings, surgical procedures, and outcomes. The study has received approval from the institutional ethics committees. RESULTS: In total, 20 patients (17 males and 3 females (sex ratio, 5.66); mean age, 30 years; range, 23-65 years) with a past history of tuberculosis were assessed. The median follow-up was 21.5 months. The primary symptom was hemoptysis, followed by cough and chest pain. All patients underwent surgical treatment and lung resection. Postoperative complications (bleeding, air leak, empyema, and severe anemia) occurred in 4 patients and 1 patient died. Although 3 patients were lost to follow-up, the survival rate was 80% with improvement of the preoperative symptoms. CONCLUSION: Although surgery for complex aspergilloma is very challenging in environments such as ours, we believe that it is the best treatment modality for symptomatic diseases in our setting.