[Ureterovaginal fistula after caesarean: Diagnosis and management in a resource-constrained hospital in Togo]. / La fistule urétérovaginale après césariennes : diagnostic et traitement dans un hôpital à ressources limitées au Togo.

The purpose of this study is to describe a simple, non-expensive, accessible and effective technique of ureterovaginal fistula diagnosis, and to assess the results of surgical management in a resource-constrained hospital. During a campaign of obstetric fistulas repair, we diagnosed ureterovaginal fistulas by vaginal exam with the blue methylene test associated to abdominal ultrasonography, two simple and non-expensive explorations which permitted to identify ureterovaginal fistula and to do differential diagnosis with vesicovaginal fistula. The management was surgery, by ureterovesical reimplantation. Four ureterovaginal fistulas have been diagnosed in 32 women presented with obstetrical fistula. The mean age of those fistulas was 4.85 years; it was located on the left ureter in three cases, on the right in one case. The ureteral lesion was consecutive to a caesarean section in all patients and sited on the pelvic segment of ureter. In three patients, diagnosis was performed by the negativity of the blue test and unilateral dilation of ureter and kidney while the discovery was done during the treatment of vesicovaginal and rectovaginal fistulas associated in the last patient. After effects of surgery were simple, characterized by disappearance of urine leakage and dilation of ureter kidney. In resources-constrained context, techniques such as blue test and ultrasonography are enough to perform diagnosis of ureterovaginal fistula. Ureterovesical reimplantation is an effective therapeutic method for diagnosing ureterovaginal fistula.

Acute cholecystitis from typhic origin in children

Background: To evaluate the particularities of typhoid cholecystitis in children. Materials and Methods: This was a 5-year prospective study of typhoid cholecystitis in children under 15 years old at Djougou and Sylvanus Olympio teaching hospital. The diagnosis of typhoid cholecystitis was based on clinical and investigation findings; confirmed by operative findings at cholecystectomy. Results: Six children with typhoid acalculous cholecystitis were treated over a five-year period (4 males and 2 females). Their ages ranged from five to 13 years (median 8.8 years). The mean duration of symptoms was six to 21 days. The clinical signs were fever; abdominal pain; which predominated at the right upper abdominal quadrant; and type II Hackett splenomegaly. The diagnosis was confirmed by a positive Widal's test and Salmonella typhi isolation from the culture in all patients; four patients had ultrasound evidence of acalculous cholecystitis. Open cholecystectomy was successful in the six cases. The operative findings were gangrene (3); perforation (2) and empyema (1). All the patients made an uneventful recovery; and have remained symptom free one and three months on follow-up. Conclusion: Typhoid acalculous cholecystitis is a frequent complication in children. Late presentation and diagnosis is associated with complications. Cholecystectomy in association with antibiotic is the treatment of choice

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.

[The circumcision in newborn and infant in the operating room of the Lomé Teaching Hospital: technique using Gomco clamp versus technique using only the grips]. / La circoncision chez le nouveau-né et le nourrisson au bloc opératoire du CHU de Lomé : technique utilisant le Gomco clamp versus technique utilisant uniquement des pinces.

OBJECTIVES: To describe the various techniques used for the circumcision in newborns and infants in the operating room of the Lomé Teaching Hospital (Togo) and to compare their results. PATIENTS AND METHODS: It is about a prospective study carried out in the operating room of the Lomé Teaching Hospital from June 15th, 2007 to December 15th, 2008 (18 months). It concerned newborns and infants circumcised according to two techniques: the technique using grips only (group A: n=138; 69%) and the technique using Gomco clamp (group B: n=62; 31%). The Khi(2) test with the threshold 5% was used for the statistical analysis. RESULTS: According to the duration of the intervention, 34 newborns and infants (24.6%) were circumcised within less than 15 minutes in the group A and 27 (43.5%) in the group B (p<0.05). According to the importance of the bleeding and to the type of material used, 28 newborns and infants (20.30%) had bled much in the group A and one (1,61%) in the group B (p<0.05). According to the postoperative complications and to the technique used, nine newborns and infants (9.4%) had postoperational complications in the group A and two (3.2%) in the group B. The wound had healed within less than 6 days in one infant (0.7%) in the group A and six (9.7%) in the group B (p<0.05). One hundred penises (72.46%) were considered to be very satisfying in the group A and 55 (88.7%) in the group B (p<0.05). CONCLUSION: The technique using Gomco clamp for circumcision had more advantages than that using only the grips. It was much more safe for the child.

[Typhoid intestinal perforation in children: renewed interest in the Veillard technique in tropical zones]. / Les perforations typhiques du grêle chez l'enfant: un regain d'intérêt de la technique de Veillard en milieu tropical.

GOAL: to value the results of the ileo colic intubation of Veillard in relation to the resection anastomosis and the ileostomy. PATIENT AND METHOD: It is about a randomised survey on 12 months (January 1st to December 31st, 2006). This study took place in the St. Jean de Dieu hospital of Afagnan. It was about children aged of less than 15 years having presented more a perforation of bowel. The diagnostic methods of the spindly shackle perforation were clinics and radiographic. It is about an observational randomized study in simple insu for the choice of the technique (resection anastomosis or ileostomy and ileo colic intubation). It was about a choice with two arms: ileo colic intubation versus resection anastomosis and ileostomy. The realization of the resection anastomosis or the ileostomy was left to the choice of the surgeon. Forty patients have been drawn by lot and have been distributed in tow groups: Group A (ileo colic intubation), group B (resection - anastomosis and ileostomy). The patients were distributed in 28 boys (70%) with 20 boys in the group A and 8 in group B and 12 girls (30%) with 8 girls in group A and 4 in group B whose middle age was of 8 years and 5 months (ranges: 4 to 14 years). The middle age were 8 years 10 months (ranges: 4 to 14 years) in group A and 8 years (ranges: 5 to 13 years) in group B. In operative meadow, a standard antibiotherapy was instituted in all patients: Ciprofloxacin and Metronidazole in 24 patients (60%), and Ceftriaxone and Metronidazole in 16 patients (40%). We have used the statistic test of KHI2 with a threshold 5% for statistical analysis. RESULTS: The ileo colic intubation technique has been practiced 22 times (55%), the resection - anastomosis technique has been practiced 15 times (37.5%) and the ileostomy technique has been practiced three times (7.5%). The middle length of hospitalization of the patients was of 15 days (ranges: 10 to 45 days) with 13 days (ranges: 10 to 25 days) in group A and 19 days (ranges: 15 to 45 days in group B. The post operative complications were significantly more frequent with the resection anastomosis (53.3%) than with ileo colic intubation (4.5%). CONCLUSION: The ileo colic intubation still rivets an interest in the intestinal typhoid perforation in tropical environment.

[The circumcision: why and how is it practiced in the newborn and the infant in the Lomé teaching hospital?]. / La circoncision: pourquoi et comment est-elle pratiquée chez le nouveau-né et le nourrisson au CHU de Lomé ?

OBJECTIVE: To identify the different indications, to analyze the conditions of realization of the circumcisions and to evaluate the results. PATIENTS AND METHOD: It is about a prospective survey study done in the operative room of the Tokoin teaching hospital (Lomé) and on a period of 12 months (15th June 2007 to 15th June 2008). It was about newborns and infants circumcised in the operative block by a pediatric surgeon. One hundred and thirty-four newborns and infants were circumcised during the period of our study. The medan of age was of 5.86 months (range: 1 to 27 months). RESULTS: One hundred and seven newborns and infants (79.85%) were circumcised for religious motive, 20 (14.92%) for hygiene motive, one (0.75%) for a lesion of the foreskin (burn of the foreskin by hot water), five (3.73%) for a phimosis and one (0.75%) for a paraphimosis. One hundred newborns and infants (74.63%) were circumcised under anesthesia by the fluothane associated to a caudal block, 29 (21.64%) were under local anesthesia (infiltration of anesthetic to the base of the penis) and five (3.73%) under general anesthesia by fluothane only. One hundred and two children (76.12%) were circumcised by the technique using the clamps and 32 (23.88%) by the technique using the Gomco clamp. CONCLUSION: The circumcision is a surgical act whose indications are variable in our surroundings. It is mainly practiced for a religious motive.

Transfer of surgical competences in the treatment of intersex disorders in Togo.

BACKGROUND: To evaluate the impact of scientific seminar on the sexual ambiguity on patients and paediatric surgeons in French-speaking African countries. MATERIALS AND METHODS: This was a report of the proceeding of a teaching seminar on intersex management, which was held from December 4 th to 8 th , 2006, in the Paediatric Surgery Department of Tokoin Teaching Hospital and the Surgery Department of "Saint Jean de Dieu" Hospital of Afagnan, Togo. RESULTS: There were 107 participants [five professors of paediatric surgery, 62 African paediatric surgeons (including 15 from African French-speaking countries), and 40 general surgeons]. The workshop involved a two-day theoretical teaching session (aimed at understanding, recognising, and treating the sexual ambiguities), and practical session; during these sessions different intersexes (one case of mixed gonadal dysgenesis, two of female pseudohermaphroditism, and two of male pseudohermaphroditism), were operated free of charge. Participants expressed satisfaction and confidence with regard to the management of intersex after the seminar. CONCLUSION: This scientific forum allowed possible exchange of competence among the paediatric surgeons with regard to efficient treatment of sexual ambiguities.

[Acute scrotum in children]. / Les grosses bourses douloureuses de l'enfant.

AIMS: To evaluate the frequency, to identify the aetiologies of the acute scrotum and to describe their treatment in children. MATERIAL AND METHOD: Fifty seven children treated for acute scrotum in the paediatric surgery department of the Tokoin teaching hospital (Lomé) between January 2003 to December 2007 were studied. RESULTS: The frequency of acute scrotum was 5.80%. The average age was of 4.75 years (range: 7 days to 15 years). The aetiologies were: incarcerated inguino scrotal hernia (49.12%); spermatic cord torsion (29.83%); epididymo-orchitis (17.54%) and testicular trauma (3.51%). The delay of treatment was superior of 72 hours in 49.12%. The pain and the increase of the volume of the scrotum were present in all the patients. The emergency operation was performed in the spermatic cord torsion and the testicular trauma. The medical treatment was performed in the epididymo-orchitis cases. The patients presenting an incarcerated inguino-scrotal hernia benefited from a surgical cure in a delay of eight days after the acute episode. The operative continuations were in any cases simple. CONCLUSION: The diagnosis and the treatment must be precocious in the acute scrotum in order to avoid possible complications.

Transfer of surgical competences in the treatment of intersex disorders in Togo

Background: To evaluate the impact of scientific seminar on the sexual ambiguity on patients and paediatric surgeons in French-speaking African countries. Materials and Methods: This was a report of the proceeding of a teaching seminar on intersex management; which was held from December 4 th to 8 th ; 2006; in the Paediatric Surgery Department of Tokoin Teaching Hospital and the Surgery Department of ""Saint Jean de Dieu"" Hospital of Afagnan; Togo. Results: There were 107 participants [five professors of paediatric surgery; 62 African paediatric surgeons (including 15 from African French- speaking countries); and 40 general surgeons]. The workshop involved a two-day theoretical teaching session (aimed at understanding; recognising; and treating the sexual ambiguities); and practical session; during these sessions different intersexes (one case of mixed gonadal dysgenesis; two of female pseudohermaphroditism; and two of male pseudohermaphroditism); were operated free of charge. Participants expressed satisfaction and confidence with regard to the management of intersex after the seminar. Conclusion: This scientific forum allowed possible exchange of competence among the paediatric surgeons with regard to efficient treatment of sexual ambiguities"

[Rectal prolapse of intussusception in infants]. / Invagination intestinale avec boudin prolabé par l'anus chez le nourrisson.

Rectal prolapse is a rare complication of intussusception in infants. This complication is most often secondary to a side by side placing defect of the caecum and a long mesenter. Three cases of rectal prolapse of intussuception are reported herein and the pathologic and therapeutic aspects of the intussucseption complicated by rectal prolapse, as well as the particularities of intussusception diagnosis in an African country, are reviewed.

[Hip septic arthritis in young children with sickle-cell disease]. / L'arthrite septique de hanche chez l'enfant drépanocytaire.

PURPOSE OF THE STUDY: Sickle-cell anemia is an inherited disorder exposing patients to diverse complications, particularly bone and joint disease. Septic arthritis of the hip joint is a frequent infection in sickle-cell anemia. Without early management, there is an important risk of invalidating hip dysfunction. The purpose of this study was to analyze the epidemiological, clinical and therapeutic aspects of septic arthritis of the hip joint in order to focus on the need for early diagnosis, the best way to improve the prognosis of hip function. MATERIAL AND METHODS: This was a retrospective study over a 10 year period (1987-1996) which included nine children (seven boys and two girls), mean age six years who were managed in our hospital for septic arthritis of the hip joint. These children had at least one hemoglobin S: phenotypes SS (n=5), SC (n=2), AS (n=2). RESULTS: In these sickle-cell anemia children, the septic arthritis developed in a non traumatic context with osteonecrosis of the femoral head. One hip was involved in six children and both in three (12 hips). Mean time from symptom onset to consultation was eight days. Salmonella sp. were identified in nine hips (including all of the bilateral cases) and Staphylococcus sp. in three. The treatment included antibiotics for six weeks, puncture-drainage, and immobilization for three to four weeks. Outcome was excellent in nine hips and good in three. DISCUSSION: The diagnosis of septic arthritis of the hip joint must be made early, based on ultrasound or scintigraphic findings. Bacteriological samples of joint fluids are required to adjust the antibiotic regimen. Salmonella sp. were the most common agents in our patients, but other series have reported Klebsiella pneumoniae and Staphylococcus or Pneumococcus sp. Drainage is preferred, if possible by arthroscopy. Arthrotomy should be reserved for cases with a thick discharge which is difficult to evacuate via puncture drainage. Early diagnosis, careful evacuation of the joint collection, and adapted antibiotic therapy with hip immobilization are the keys to good functional outcome.

Avulsion fractures of the tibial tubercle.

PURPOSE: To retrospectively study the epidemiology and treatment of acute avulsion fractures of the tibial tubercle in 12 patients. METHODS: Records of 12 patients aged 11 to 17 (mean, 14) years with avulsion fractures of the tibial tubercle presenting to our hospital from April 1998 to September 2004 were studied. Patient age, gender, involved side, injury mechanism, clinical and radiographic records, treatment, complications, and outcomes were reviewed. RESULTS: Eight patients injured the right side, 3 the left side, and one both sides. They all engaged in sports or active play during the injury. Two fractures were type IA, one type IB, 2 type IIB, 5 type IIIA, 2 type IIIB, and one type IV. Three patients with type-I fractures and one with a type-IIB fracture were treated with closed reduction and cast immobilisation for 3 to 4 (mean, 3.8) weeks. The remaining 9 fractures were treated with open reduction and internal fixation. The mean follow-up period was 39 (range, 23-59) months. No complications were noted. Ten patients had excellent results and 2 had fair results. CONCLUSION: Closed reduction and cast immobilisation for minimally displaced fractures, and open reduction and internal fixation for displaced fractures resulted in favourable outcomes.