Surgical management of recto-vaginal fistula (about 6 cases).

INTRODUCTION: Recto-vaginal fistula (RVF) is defined as a pathological epithelialized communication between the posterior wall of the vagina and the anterior wall of the rectum through the recto-vaginal septum. RVFs are rare and represent less than 5% of rectal fistulas. Occurring after childbirth or during a proctological pathology, they create a deep distress for the patients. The aim of our work is to analyze the epidemiological particularities and the risk factors of occurrence of RVF as well as the modalities and results of our therapeutic management. MATERIALS AND METHODS: Our work is retrospective analytic and comparative concerning 6 cases operated in the department of general surgery 3 of the UHC Ibn Rochd of Casablanca for recto vaginal fistula or recidive over a period of 7 years from 2012 to 2018. RESULTS: The analysis of the results of our study allowed us to note: A frequency of occurrence of RVF of about 0.48%. The average age at diagnosis was 55 in our patients. The etiologies were dominated by post-radiation (33.33%) and post-operative (16.66%) RVFs. The predominant mode of delivery in our study was vaginal delivery (83.33%). The antecedents were dominated by pelvic irradiation in 50% of patients, and pelvic surgery for cervical cancer and/or rectal cancer (50%). The diagnosis was revealed by a vaginal stool output in all patients. Surgical treatment was performed in all our patients. The surgical technique of choice in our series was drainage by Stenon, in 83.33% of patients. A protective stoma was performed in all our patients studied, a colostomy in 66.66%, and an ileostomy in 33.33% of patients. The immediate postoperative evolution was excellent in all our patients, while the short- and medium-term evolution revealed the occurrence of recurrence in one third of the patients (33.33%). The treatment of choice for recurrence was the interposition of a pedicled fat flap of the labia majora, known as the modified Martius technique. The morbidity, represented mainly by recurrence, was 25%, with a mortality rate of 0%. DISCUSSION: The occurrence of RVF in all its etiologies seems to be infrequent. However, its real incidence remains poorly documented in the literature, it varies between 0.3% and 15.3%. RVFs are considered simple or complex depending on their size, location and etiology. The high or low location and the etiology of the RVF determine the choice of the approach during surgical management. The diagnosis is most often clinical. The examination will try to find the cause of the RVF and the associated lesions. RVF can be asymptomatic. The importance of the symptoms depends on the topography of the fistula, the diameter of the orifice, and the quality of the intestinal transit. No additional investigations are required to confirm the diagnosis of RVF, since the positive diagnosis is essentially clinical. However, in the case of a high or complex fistula, the clinician can support his or her pre-therapeutic assessment with the exploration of imaging data, especially those of the digestive opacification, MRI and pelvic CT. The causes of RVFs are multiple. However, their proportions are difficult to establish. Post-obstetrical RVFs, those due to Crohn's disease, and post-op are probably the most frequent. The literature describes a variety of surgical approaches and treatment options for RVF. However, there are no treatment recommendations. The available data are vague and do not define an optimal treatment. Medical treatment with antibiotics and sitz baths is often necessary to control the local infection. The surgical management of RVFs is complex and follows several principles. The therapeutic arsenal is very varied and constitutes a real "escalation", ranging from simple drainage by suture to the radical treatment represented by abdominal-pelvic amputation. The results of the treatment of simple VF are excellent in all studies. The healing rate varies from 75 to 100% depending on the authors. CONCLUSION: The results of this study confirm the low incidence of RVF, and show that vaginal delivery and a history of pelvic surgery (for rectal or cervical cancer) are the most frequent predictors of RVF. Thus, from a therapeutic point of view, medical treatment is always required, it allows the flow of the fistula to be reduced, which facilitates preparation for the surgical procedure.

Retrorectal cystic hamartoma: A case report.

Retrorectal tumors are a rare group of tumors that can be of benign or malignant origin, the differential diagnosis concerns all retrorectal tumors. We report a case of a huge retrorectal cystic hamartoma in which surgical excision was performed. A 58 years-old female presented with a low back pain and constipation. Digital rectal examination found a renitent cystic mass compressing the posterior wall of the rectum. Colonoscopy showed a tumor compressing the rectum. Magnetic resonance imaging (MRI) scan showed a presacral cystic formation. Surgical resection using laparotomy was performed. The patient made a full recovery and was released eight days after the surgery. Histological examination of the mass revealed a retrorectal cystic hamartoma.

[Evaluation of preoperative nutritional status in visceral surgery Correlational study]. / Evaluation de l'etat nutritionnel préopératoire en chirurgie viscérale Etude corrélationnelle.

Objective Is to evaluate the nutritional status of preoperative patients in the visceral surgery department III of CHU Ibn Rushd of Casablanca and to correlate to postoperative length of stay. Patients and methods Prospective observational study of six months from February 2015 to late July 2015, in patients from being operated in the visceral surgery department II1. The nutritional status of 151 patients preoperatively was evaluated the correlation between the various diagnostic tests and clinical and biological parameters was investigated and postoperative length of stay was calculated. Results 151 patients predominantly female (72.84%1, reporting their consent, were selected for this study. 51.56% of patients had risk factors for undernutrition. The cholelithiasis was the most responded diagnosis (57.61%). The Nutritional Risk Index (NRII allowed to identify 13 low nutritional risk patients, 7 moderate-risk and 3 major risk. According to the Mini Nutritional Assessment (MNA two elderly people [over 70 years] were at risk of undernutrition and one person had a bad nutritional status. Nutritional risk stratification identified 19 patients with postoperative nutritional grade 3. The average length of stay was variable; it was not correlated with the nutritional status of patients against it is based on the type of surgery. Conclusion The risk of undernutrition was high; however, a single parameter is insufficient for the diagnosis of preoperative undernutrition, a combination of different parameters would be a more reliable method.

[A late post-traumatic diaphragmatic hernia revealed by a tension fecopneumothorax (a case report)]. / Hernie diaphragmatique post-traumatique révélée par une pleurésie stercorale (à propos d'un cas).

INTRODUCTION: Post-traumatic diaphragmatic hernia is a particular lesion in traumatology that may be neglected. Thus, the diagnosis may be delayed for a few days to several months and only be made following a complication. The left diaphragmatic cupola is the most touched. Tension fecopneumothorax following diaphragmatic hernia perforation in the pleural cavity is a rare but particularly severe complication of traumatic diaphragmatic hernia. CASE REPORT: A 68-year-old man was admitted for acute intestinal occlusion with respiratory distress. A history of a violent blunt thoraco-abdominal traumatism resulting from a traffic accident eight years before was noted. The chest x-ray revealed an abundant hydropneumothorax and the thoracic scan revealed abundant effusion with heterogeneous density in the left pleural cavity, associated with an intrapleural hernia of the large intestine. An emergency thoracolaparotomy discovered tension fecopneumothorax secondary to intrathoracic perforation of the transverse colon through a left hemidiaphragm defect. The surgical treatment consisted of hernia reduction, pleural drainage, colostomy and repair of the diaphragmatic defect. CONCLUSION: The possibility of diaphragmatic hernia should be kept in mind in case of violent blunt thoraco-abdominal traumatism or basithoracic wound. In this way, complications such as tension fecopneumothorax that could threaten the functional and vital prognosis may be prevented.

[Non operative management of blunt splenic trauma in adults]. / Traitement non-opératoire des traumatismes fermés de la rate chez l'adulte.

Nonoperative management of blunt splenic injury allows preservation of the immune function of the spleen while avoiding unnecessary laparotomy. The aim of our study was to evaluate the feasibility and the results of conservative management of adult blunt splenic trauma in the context of a developing country. Nonoperative management was proposed for 52 out of 62 patients with blunt splenic trauma treated at the Casablanca University Hospital, Morocco. Motor vehicle-road accidents (88%) were the most common etiology. Multiple trauma was present in 79% of the cases. 15% of the cases had hemodynamic instability. Ultrasonography was performed in 52 patients; it showed splenic contusion in 45 patients and subcapsular hematoma in 7 patients. CT scan showed splenic contusion in 11 patients. Four cases ultimately required operative management with one death. Of the remaining 48 patients, 45 had an uneventful course with observation, but there were two deaths in the observation group.

[Spontaneous diaphragm rupture during delivery. Case report]. / Rupture spontanée du diaphragme pendant l'accouchement. A propos d'un cas.

We report a case of spontaneous diaphragm rupture during delivery in a 42-year-old woman. The patient presented at surgical emergency department with abdominal pains, vomiting and dyspnea, three days after full-term delivery. The X-ray of the chest and computed tomography showed symptoms of a left diaphragmatic rupture. Laparotomy confirmed the diaphragmatic rupture with herniation of portion of the stomach in the left pleural cavity. Spontaneous diaphragmatic rupture during delivery is uncommon and would result from a sudden sharp rise in the intra-abdominal pressure during the second stage of labor, exacerbated by application of external pressure to the uterine fundus or the upper abdomen. Diaphragmatic rupture during labor is a serious but rare complication that requires emergency surgery to prevent visceral perforation and cardiorespiratory failure. To prevent this complication, the delivery conditions should be improved.