Morbidity and mortality of Hartmann's procedure for sigmoid volvulus at the University Hospital of Cocody, Abidjan.

BACKGROUND: The restoration of intestinal continuity following Hartmann's procedure is associated with high morbidity and mortality rates and low restoration rate. OBJECTIVE: To determine the causes of complications and deaths associated with Hartmann's procedure and the secondary restoration of digestive continuity for sigmoid volvulus. METHODS: This was a retrospective study involving 25 patients treated for sigmoid volvulus according to Hartmann's procedure, from January 1998 to January 2008; at the Cocody university hospital, Abidjan (Cote d'Ivoire). The mortality and morbidity rates were assessed on the basis of the age, the duration of illness, the ASA (American Society of Anesthesiologists) score, the state of the sigmoid colon and peritoneal cavity. RESULTS: The mean age of the patients was 42.52 years (range: 22-77 years). The mean duration of illness was 02.80± 0.71 days (range: 06 hours to 07 days). Sixteen (64%) of the patients had an ASA score lower than III. The mean length of intervention was 209.75 min.±102.530 min. (range: 120 min. to 327 min). The mortality rate was 12% (n=3) in the Hartmann's procedure. The necrosis state of the sigmoid colon was not significantly associated with a higher death risk (p=0.071) but the contamination of the peritoneal cavity by stools (p=0.001) or an ASA score ≥3 (p=0.036) was significantly associated with a higher death risk. Infections of the operative site (42.86%) were the most common complications. The mean length of hospital stay was 12.05 ± 25.45 days. Eleven patients (50%) out of 22 had the intestinal continuity restored. The median time of restoration was 3.43 months (range: 3-12 months).The mortality rate among the restoration group was nil and the morbidity rate was 27.27% represented by parietal suppurations only. The mean length of hospital stay was 14 ± 2.83 days. CONCLUSION: Hartmann's procedure remains associated with an significant mortality. Morbidity, essentially arises from infections of the operative site. However the restoration of the intestinal continuity remains a sure intervention with an acceptable morbidity.

[Colonoscopic perforation: 6 cases in Abidjan, Cote d'Ivoire]. / Plaies coliques per coloscopiques: 6 observations à Abidjan (Côte d'lvoire).

OBJECTIVES: The purpose of this report is to describe diagnostic and therapeutic management of colonoscopic perforation and identify risk factors. MATERIAL AND METHODS: The charts of 6 patients who underwent surgery for colonoscopic perforation between January 2003 and December 2008 were reviewed. Study data included patient age, indication for colonoscopy, operative findings, repair technique, and outcome. RESULTS: All 6 perforations occurred during diagnostic colonoscopy. There were 5 females and 1 male. Endoscopy was performed by an experienced operator in 5 cases and by a training fellow in 1. Preparation of the colon was considered as good in 5 cases. The operator reported procedural problems in only 1 case. Diagnosis of perforation was immediate in 5 cases and delayed for 30 hours in 1. The lesion was located in the sigmoid colon in 5 cases and transverse colon in 1. All patients underwent laparotomy. The repair technique consisted of simple closure in 2 cases, closure with colostomy in one, and bowel resection with anastomosis (n=2). Two deaths occurred intraoperatively in I case and postoperatively in 1. The patient who died intraoperatively had not yet undergone repair when death occurred. In both patients who died, laparotomy was performed late in the presence of co-morbidity. CONCLUSION: Colonic perforation is a rare but severe iatrogenic complication following colonoscopic examination. Early recognition and treatment are essential to optimize outcome. Prevention depends on training to obtain skillful advancement technique.

[Nontraumatic digestive surgical emergencies in elderly patients at the Cocody University Hospital Center in Abidjan, Côte d'Ivoire: etiology and outcome]. / Urgences abdominates digestives non traumatiques chez les sujets âgés au CHU de Cocody à abidjan, Côte d'Ivoire: étiologies et résultats thérapeutiques.

OBJECTIVES: The purpose of this retrospective report is to describe etiologies and therapeutic outcomes of nontraumatic abdominal surgical emergencies in elderly patients. MATERIAL AND METHODS: The charts of patients aged 60 years or more who underwent emergency surgery for nontraumatic abdominal disorders at a Teaching Hospital in Abidjan, Cote d'Ivoire from August 1998 to July 2008 were reviewed. Demographic data, clinical findings, operative protocols, and postoperative outcomes were noted. RESULTS: A total of 137 patients with a mean age of 68.3 years (range, 60-93 years) underwent emergency surgery for nontraumatic abdominal disorders during the study period. The underlying etiologies were strangulated hernia (n = 40), abdominal parietal abscess (n = 6), bowel obstruction (n = 32), acute diffuse peritonitis (n = 29), acute appendicitis (n = 23), acute cholecystitis (n = 6) and massive rectorragy from colonic diverticulitis (n = 1). Coexisting medical problems (n = 84) were noted in 69 patients. Surgical procedures were tailored to operative findings. Twenty-seven patients were admitted to the intensive care unit in the immediate postoperative period. Mean hospital stay was 7.7 days (range, 2-23 days). Surgical complications included wound infection (n = 14), stoma-related complications (n = 7), digestive fistula (n = 4), scrotal hematoma (n = 5) and postoperative evisceration (n = 2). The mortality rate was 10.21% (n = 14) mainly due to postoperative peritonitis. CONCLUSION: The findings of this study indicated that most nontraumatic abdominal surgical emergencies in elderly patients were related to complications of neglected or undiagnosed preexisting disease. Prognosis was related to the stage of the disorder, initial surgical management, and deterioration of the coexisting medical problems.

[Strangulated groin hernia still frequent in tropical milieu]. / Les hernies étranglées de l'aine : une urgence chirurgicale toujours d'actualité en milieu tropical.

This study aimed to describe the epidemiological, clinical, therapeutic and postoperative data of strangulated groin hernia. Details of consecutive adults patients admitted to our emergency wards for strangulated groins hernia and operated on from august 1998 to december 2007 were recorded. In addition the mode of presentation, hernia type, treatment and outcome were also recorded for each case. The statistical analysis used the Chi2 test and the Fischer test. 149 strangulated groin hernias were recorded in 135 men and 14 women. Inguinal hernias were seen in 143 patients and femoral hernia in 6. Median age was 40 years. The mean delay for consultation was 2 days. Richter hernia, Maydl hernia and hernia abscess were seen in eight, two and three cases each. Bowel resection was required in 30 patients. Inguinal hernia underwent Bassini's procedure, Shouldice procedure and Mac Vay's procedure. While femoral hernia underwent only Mac Vay's procedure. No hernia repair was undergone in hernia abscess. Mortality was 10%. Bowel necrosis, long duration of symptoms, ASA class, bowel resection and strangulated groin hernia with hernia abscess, peritonitis and occlusion were found to be significant factors linked with unfavorable outcome. Morbidity was 16.7% and required reoperation in 9 patients; sepsis and hematoma were the most frequent complication. In conclusion, strangulated groin hernia still remain a frequent matter of consultation in visceral ward in tropical milieu. The high morbidity and mortality rate are unacceptable because of the possibility of avoiding them by early consultation and elective repair of groin hernia.

[Early oral feeding versus classic oral feeding after appendicectomy for acute appendicitis]. / Réalimentation orale précoce versus réalimentation orale classique après appendicectomie pour appendicite aiguë.

The appendectomies for acute appendicitis are the most frequent surgical interventions (43.6%) in our service. The recent studies demonstrated the feasibility and the economical gain of the early oral feeding vs. classic oral feeding, after elective digestive surgery. We wanted to spread these results therefore to the appendectomy for acute appendicitis. It is about a prospective survey carrying on 110 patients also left in two groups, and comparing the classic postoperative oral feeding vs. the early postoperative oral feeding on one year. The two groups were comparable and the studied parameters were : the length of the postoperative ileus, the hospitable morbidity, the length of the hospitalization and the cost of the hold in charge. The length of the postoperative ileus was not different in the two groups as well as the morbidity. The difference of the median length of hospitalization in the two groups was not meaningful. The cost of the hold in charge was meaningfully more elevated in the group with classic postoperative feeding. In conclusion, the early postoperative oral feeding in our survey doesn't reduce the length of the postoperative ileus and don't drag a morbidity anymore that the classic oral feeding. However if it doesn't shorten the length of the hospitalization, it drags a reduction of the cost of the hold in charge. There is a gain therefore precociously to nourish the patients after appendectomy for acute appendicitis.

[Acute intestinal intussusceptions in adults: analysis of 20 cases]. / Invaginations intestinales aiguës de l'adulte: analyse d'une série de 20 cas.

AIM OF THE STUDY: To report our experience in the management of acute intestinal intussusceptions in adults. PATIENTS AND METHODS: Retrospective study of data of patients older than 15 years who were operated on for acute intestinal intussusceptions from January 1997 to December 2001. RESULTS: Twelve of the patients were males and eight females with an average age of 41 years (range: 16-71). The clinical and radiological findings were suggestive of bowel obstruction (N = 14), peritonitis (N = 5) and appendicular abscess (N = 1). Correct preoperative diagnosis of acute intestinal intussusceptions was established in 6 cases. Type of intussusception was jejunojejunal (N = 1), ileo-ileal (N = 8), ileocolic (N = 1), ileocecocolic (N = 7) and colocolic (N = 3). Necrosis was found in the intussusceptum in 10 cases and a tumor on the lead point in 14 cases (5 benign lesions and 9 malignant ones). For intussusception involving the colon, all patients underwent en bloc resection with immediate anastomosis, while intussusception located on the small bowel were treated by surgical reduction (N = 1), en bloc resection (N = 8) with immediate (N = 7) or delayed (N = 1) anastomosis. The mortality rate was 15%. CONCLUSION: In our experience, intussusceptions in adults is not an uncommon clinical entity but correct diagnosis is often established peroperatively. En bloc resection is recommended because of the frequency of neoplasms and bowel ischemia.

Effects of supplemental pantothenic acid on wound healing: experimental study in rabbit.

The effect of pantothenic acid supplementation and deficiency on wound healing was investigated over a one month postoperative period in rabbits. The supplemented group was injected with pentothenate (20 mg/kg of body weight/24 h) for three weeks and compared to a placebo group (0.5 ml of distilled water). Deficient animals were fed with a pantothenate free diet also for three weeks. These three experimental groups were matched against a control group. The degree of wound healing was determined by the mean of postoperative breaking strength and wound fibroblast population changes. Pantothenic acid urinary excretion measured by gas chromatography served as control of pantothenate consumption. With regard to these three parameters no significant difference has been found between placebo and controls. The average urinary elimination in the pantothenic acid group was significantly higher as far as the pantothenate supplemented group was concerned, while the deficient group showed no significant decrease when compared to controls. Chronic pre- and postoperative pantothenic acid supplementation significantly increased aponeurosis strength after surgery; it improved slightly, but not significantly the strength of the skin. Furthermore, the fibroblast content of the scar became significantly greater during the fibroblast proliferation phase after pantothenic supplementation. These data suggest that pantothenic acid induces an accelerating effect of the normal healing process. The mechanism responsible for this improvement seems to be an increase in cellular multiplication during the first postoperative period. But the exact intimate mechanism of the beneficial effect of pantothenate remains unclear.

[An uncommon complication of unsafe induced abortion: bowel prolapse through uterine perforation]. / Une complication rare mais grave des avortements provoqués clandestins : l'évisceration iléale per vaginum.

The authors report one case of bowel prolapse through uterus following induced abortion. The eviscerated bowel was completely gangrenous, devoided from its mesentery and entrapped in the uterus wall. The treatment was a bowel resection and ileo-ileum anastomosis; the uterus was evacuated of retained products of conception and then sutured. The patient recovered uneventfully; fertility prognosis is expected to be poor because of abortion sequelae. If the abortion law still remains in Ivory Coast, more effort should be directed at reducing the incidence of unwanted pregnancy. This could be best archived by a better information on contraception and better health education programs.

[Gunshot wound to gravid uterus: a case report]. / Plaie Balistique Pelvi-Abdominale Chez une Gestante.

The authors report the case of a 24-years old pregnant woman gravida 2 para 1 who sustained a gunshot injury at 23 weeks gestation. The bullet injured the rectosigmoid jonction, the jejunum and traversed the uterine cavity with resultant of fatal injury of the fetus. Laparotomy was required for treatment of the maternal injuries. Although a fetus demise was delivered by caesarian section a review of literature indicated that operative delivery should be avoided when the fetus has died already and the gravid uterus don't impaired the surgeon's ability to repair other visceral injuries. But the patient should be followed closely for signs of coagulopathy and intra uterine infection.

[Post-operative morbidity and mortality in non traumatic colon emergencies]. / Morbidite et mortalite post-operatoire des urgences coliques non traumatiques a propos de 85 interventions.

UNLABELLED: This study aimed to evaluate emergency non traumatic colonic surgery mortality and morbidity in our practice MATERIAL AND METHODS: Data of all 85 patients who underwent an emergency non traumatic colonic surgery during the period from August the 1st 1998 to June the 30th 2006, were retrospectively reviewed. Surgical procedures included either colonic resections with (n = 33) or without (n = 47) immediate anastomosis or, ileostomies (n = 3) or colostomies (n = 2) without colonic resection. RESULTS: A 16.5% (n = 14) mortality rate was recorded due to septic shock (n = 6), postoperative peritonitis (n = 2), stroke (n = 2) and cachexia, malnutrition, acute anemia, acute heart failure (n = 1 each). Morbidity rate was 38.8% (n = 33). Surgical complications (n = 29 34.1%) were related to wound infection (21.1% n = 18), stoma related (n = 6), post-operative peritonitis due to an anastomotic dehiscence and prolonged ileus (n = 2 each), rectorragy (n = 1). Medical complication reached a 4.7% rate and included malaria (n = 2), acute pulmonary edema, diabete acido cetosis (n = 1 each). Seven patients (8.2%) needed a reoperation for post operative complication. Hospital stay was 19.4 days. CONCLUSION: Post-operative morbidity and mortality in non traumatic colon emergencies still remain high owing to anastomotic leak, patients comorbidities and infectious complications.

[Splenectomy for splenomegaly in Ivory Coast. Indications and short term results]. / Splenectomies pour splenomegalie en Cote d'Ivoire. Indications et résultats précoces.

AIM: To study the indications and evaluate the short term results of splenectomy for splenomegaly. PATIENTS AND METHODS: This retrospective analysis concerned 31 males and 21 feméles with a mean age of 30,5 yersin old, from February 1998 to December 2003. The aetiologies of splenomegaly were parasites (n=6), benign haematological diseases (n= 24), haematological malignancies (n=6), infections (n=3) and cysts (n=3). The indications were due to hypersplenism in 39 cases (79,5%), risk of splenic rupture in 46 cases (88,5%), infection or risk of infection in 3 cases and painful splenomegaly in 3 cases. 49 nine patients underwent complete splenectomy and the 3 remaining had a partial splenectomy. A spleno-renal shunt in three cases, mesenterico-adrenal shunt and mesenterico-cave shunt were associated for portal hypertension. A lengthy penicillinotherapy in all the patients and thromboembolic prevention in some were performed. RESULTS: The mean hospital stay was 6.3 days. Correction of cytopenia and permanent pain relief occurred in all cases. One patient died from intraoperative haemorrhage and 2 other from unknown cause postoperatively (09%). Morbidity was due to hyperthermy in 3 cases, abdominal haemorrhage by splenic vessel ligation leakage and bridles obstruction in one case. CONCLUSION: This study shows that hypersplenism constituted the mean indication of splenectomy. Its low mortality and morbidity suggest that it might be usually used in our practice. These results may be improve by laparoscopic splenectomy and systematic prevention of postoperative complications.

Morbidite et mortalite post-operatoire des urgences coliques non traumatiques a propos de 85 interventions

Evaluer la mortalite et la morbidite de la chirurgie des urgences coliques non traumatiques dans notre pratique. Methodologie : Dans une etude retrospective couvrant la periode du 1er aout 1998 au 30 juin 2006; nous avons revu les dossiers de 85 patients operes pour une urgence colique non traumatique. Les methodes chirurgi- cales etaient soit des resections coliques avec (n=33) ou sans (n=47) anastomoses; soit des ileostomies (n=3) ou colostomies (n=2) sans resection. Resultats : La mortalite post-operatoire a ete de 14 deces (16;5) par choc toxi-infectieux (n=6); peritonite post-operatoire (n=6); accident vasculaire cerebral (n=2) et; par anemie aigue; insuffisance cardiaque; denutrition et cachexie (un cas chacun). Des complications non mortelles ont ete notees chez 33 patients (38;8). Celles liees a la chirurgie (n= 29 ; 34;1) regroupaient 18 suppurations parietales (21;1; n=18) ; trois necroses stomiales; deux abces peristomiaux; une dermite peristomiale; deux ileus prolonges; deux peritonites post-operatoires par lachage d'une anastomose colorectale et un cas de rectorragie . Les complications medicales (4;7n=4) etaient deux acces palustres; une acidocetose diabetique et un oedeme aigue du poumon. Des reinterventions ont ete necessaires chez sept patients (8;2). La duree moyenne d'hospitalisation a ete de 19;4 jours. Conclusion : La mortalite et la morbidite de la chirurgie des urgences coliques non traumatiques sont elevees; en rapport avec les complications infectieuses; les decompensations de tares et les fistules coliques

Traitement du plastron appendiculaire .[Lettre]

Soixante-quinze patients porteurs d'un plastron appendiculaire ont ete traites au cours d'une seule hospitalisation. Le traitement medical reposant sur une double antibiotherapie (Cefuroxime et Metronidazole) faisant place a l'appendicectomie des la disparition clinique de la masse. Un abces appendiculaire est survenu au cours du traitement medical soit 1;3 pour cent d'echec. La disparition clinique de la masse a eu lieu en 11 jours en moyenne. Le traitement chirurgical a ete entrepris en moyenne apres 24 jours d'hospitalisation. La mortalite operatoire a ete nulle. La morbidite; representee exclusivement par des abces de paroi sans gravite; a ete de 8 pour cent. Le traitement chirurgical des plastrons appendiculaires ''refroidis'' peut donc etre realise de facon efficace et en toute securite au bout de trois semaines