Adult groin hernia surgery in sub-Saharan Africa: a 20-year systematic review and meta-analysis.

PURPOSE: To realize a systematic review to evaluate groin hernia surgery for adults in sub-Saharan Africa. METHODS: We conducted a systematic review and meta-analysis, the primary objective of which was to determine the surgical techniques used for unilateral groin hernia surgery in sub-Saharan Africa. Studies published in the last 20 years were considered. A meta-analysis estimated the pooled prevalence with 95% confidence interval (CI) of mortality, chronic pain and recurrence. A subgroup analysis compared the rate of complications between complicated or uncomplicated hernia. RESULTS: We included 113 articles. The most used technique was Bassini in 40.1%, followed by Lichtenstein in 29.9% and Shouldice in 12.6%. The overall mortality rate was 0.6% (95% CI 0.4-0.9). The pooled recurrence rate was 1.4% (95% CI 1.05-1.9). The pooled rate of chronic pain was 2.7% (95% CI 1.9-3.7). We found that mortality rate for complicated hernias (6.4%) was higher compared to uncomplicated hernias (0.2%). This difference was statistically significant [p ≤ 0.001; OR = 47.7; 95 CI (27.2-83.47)]. CONCLUSION: This review showed that pure tissue repairs are the most used techniques with Bassini and Shouldice as leading procedures. The post-operative rates of recurrence and chronic pain are low. However, there is a high heterogeneity between studies than can underestimate these pooled prevalences. The consultation at complication stage remains frequent and associated with a higher mortality. Futures studies should focus on improving the quality of studies in terms of design and follow-up to increase the degree of evidence.

Pancreatic heterotopia in mesentery.

INTRODUCTION: The pancreatic heterotopia of fortuitous operational discovery remains rare because of the medical imagery progress. We report a mesenteric localisation of aberrant pancreas identified during the assumption of responsibility of an abdominal emergency. OBSERVATION: A 26-year-old man was allowed with the urgencies for an acute obstruction of the small bowel. Surgical exploration revealed a distal support an ileo-parietal adherence near to an inflammatory hearth of appendicular origin. We noted, in addition to the mesentery of the first jejunal loop, a bilobate mass of glandular-like tissue with a pancreatic aspect. The adjacent jejunal handles were macroscopically healthy. The Pathological examination of the mass confirmed the existence of a mixed glandular exocrine and endocrine origin of pancreatic tissue, type I of the Heinrich's classification. CONCLUSION: This rare topographic entity of fortuitous discovery underlines the need for a meticulous surgical exploration of the abdominal cavity particularly in urgency when a summarized radiological assessment does not permit a complete morphological study.

[Gynaecological and breast cancers at the Dakar Cancer Institute]. / Les cancers gynécologiques et mammaires à l'Institut du cancer de Dakar.

OBJECTIVE: To determine the frequency of gynaecological and breast cancers among women and to study their risk factors and diagnostic aspects at the Institut Curie of Dakar. PATIENTS AND METHOD: This retrospective study included all cancers seen at the Institute in 2001. Epidemiological and clinical variables were collected from the patients' medical records and analysed. RESULTS: This study showed that of all 786 cancers in women, 507 were gynaecological or breast cancers. Cancer of the uterine cervix accounted for 240 cases (47.3%), followed by 213 cancers of the breast (42%), 35 of the ovaries (6.9%), 10 of the corpus uteri (2%) and 7 of the vulva (1.4%). Mean age was 49.9 years old. There was a statistically significant (p<0.05) between primary tumour sites and all of the following: age at menarche, age at first sexual relations, and number of sexual partners. Mean time until consultation for all patients was 8.24 months and 96% had clinical signs before diagnosis. The histological confirmation rate was 73%. Local or regional tissue involvement was noted in 60% of cases. CONCLUSION: Gynaecological and breast cancers are frequent in Dakar and have the characteristics common to cancers in developing countries. Further efforts are needed to study their risk factors and effective screening for them.

[Choledocho-duodenal fistula due to perforating duodenal ulcer disease. Report of 3 cases]. / Fistule choledoco-duodenale par perforation d'ulcere duodenal. A propos de 3 observations.

The authors report three (3) cases of choledoco-duodenal fistula due to perforating duodenal ulcer disease. All of them were male, aged from 35 to 55 years. The ulcer symptomatology summarised the clinical feature. They presented respectively a prestenosis, a stenosis and a chronic ulcer The fistula diagnosis was estasblished at the oesogastro-duodenal radiologic exploration showing an opacification of the common bile duct. The surgical treatment concerned bnly to the ulcer. A gastrectomy of exclusion with digestive continuity re-establishment according to FINSTERER in the pre-stenosis, vagotomy associated to gastrojejunostomy and the pylore closing at both other were performed. After 24, 23 and 5 months follow-up all the patients were disease free; classified VISICK I. Rarely reported among the complications of the duodenal ulcer the choledoco-duodenal fistula is a reality. Currently the majority of the authors recommend the respect of the fistula in the event of surgical operation.

[Anastomotic method of the gastro-omental arterial circle: interest in the transillumination method at the gastric esophagoplasty]. / Le mode anastomotique du cercle arteriel gastro-omental: interet de la transillumination lors d'une oesophagoplastie gastrique.

The gastroomental (gastroepiploic) arterial circle of the stomach is the main vascular axis of the gastroplasty use as esophagus substitute after esophagectomy. The aim of this anatomoangiographic study is to study the anastomosis between the right and left gastroomental arteries and emphasize interest of the transillumination: an ordinary anatomic method use in surgical practice. We use forty five fresh cadaveric stomach of adult for determine the anastomotic fashion of the arterial circle of the great gastric curvature. About three models of gastric esophagoplasty we verify similarity of vascular transillumination results and we compare with the radiographic exploration. The thickness of the gastrocolic ligament in which progress the gastroomental arterial circle can lead astray for macroscopic determination of anastomotic mode. Thus the type I, II, III and IV which are of 60%, 22,2%, 13,3% and 4,4% at macroscopic observation become 64,1%, 15,4%, 15,4% and 5,1% after arteriographic analysis. Even if the submucosal arteriolar network and the rich parietal anastomosis confer at the stomach the best qualities for esophageal replacement, the multifactorial particularity of success in esophagogastroplasty require identification and preservation of the gastroomental arterial circle. The transillumination which facilitate evaluation of this arterial axis is a simple and accessible process which we advocate.

Cancer du sein chez l'homme africain : 46 observations dakaroises

Il s'agit d'une etude retrospective de 46 cas de cancers du sein survenus chez l'homme et colliges a l'institut du Cancer de Dakar de 1957 a 1999. L'age moyen des malades etait de 60;7 ans et la duree moyenne des symptomes etait de 37;5 mois. La repartition des malades selon la classification TNM de l' UICC revelait : 1T1; 1T2; 4T3; 40T4; 40N1; 1N2; SN3; 10M1 PUL; 8M1 OSS et 2M1 HEP. Le carcinome canalaire invasif representait 78;2 pour cent de l'ensemble des lesions histologiques. Nous avons realise 32 mastectomies dont 23 etaient associees a un curage axillaire. La chirurgie etait associe a une chimiotherapie dans 25 cas et a une radiotherapie dans 14 cas. Le traitement hormonal au Tamoxifene fut institue dans 7 cas. Le suivi moyen des malades etait de 24 mois. Le pronostic de ces cancers pourrait etre ameliore par une meilleure education et un diagnostic plus precoce

[Laparoscopic cholecystectomy in sickle cell disease]. / La cholécystectomie laparoscopique dans la drépanocytose.

STUDY AIM: Sickle cell affection is a public health problem in Africa. The aims of this prospective study were to evaluate the early results of laparoscopic cholecystectomy in sickle cell patients in Senegal. METHOD: From January 1998 to June 2002 all the sickle cell patients undergoing a laparoscopic cholecystectomy were included. Intra- and post-operative protocol (blood transfusion if Hb < 9 g/dl, rehydration, oxygenotherapy) was standardized. RESULTS: Forty-two patients with sickle cell of types SS-33 and AS9 were operated upon by same surgeon. One case of conversion due to an effraction of biliary junction was reported. One homozygote patient died post-operatively because of peritonitis. Two acute thoracic syndromes, three vaso-occlusive crisis, and two cases of wound infection constituted the post-operative morbidity. No case of complication was noted in those who underwent pre-operative transfusion. CONCLUSION: Laparoscopic cholecystectomy can be carried out in sickle cell patients with biliary lithiasis provided that general anaesthetic rules are respected.

[Penetrating wounds of the abdomen. Evaluation of conservative treatment in 40 cases]. / Plaies pénétrantes de l'abdomen. Evaluation du traitement conservateur à propos de 40 cas.

Stabbed penetrating abdominal wounds are becoming more and more frequent in our emergency surgical unit due to increase of aggressions. The goal of our study is to evaluate the conservative treatment of these wounds. This concerns a study carried out between January 1997 and October 1998. Exploratory laparotomy was proposed at each time when one or more of the following criteria was noticed: choc, evisceration of intestines, digestive hemorrhagy or hematuria, outlet of digestive fluids, sign of peritoneal irritation, wounds by gunshots or wounds at the frontal regions. In the other cases, the conservative treatment with wound dressing following an antibiotic and serovaccination therapy of tetanus was the therapeutic option. Our study was carried out on 40 patients of whom were 37 males and 3 females of average age 24.9 years with extremities of 7 to 52 years. It arrived to the following results: 32 of the patients (80%) were victim of aggression and 29 cases were stabbed wounds. The wounds were in the central region (umbilicus 29.5%) and superior to the abdomen and were associated with outlet of the omentum (50%) outlet of the intestines (12.5%), peritoneal irritation (27.5%), digestive hemorrhagy (10%), hematuria (2.5%) outlet of faeces (2.5%). 17 patients (42.5%) underwent exploratory laparotomy on the basis of criteria afor mentioned and the 23 others (57.5%) underwent medical surveillance and 3 of them developed peritonitis and underwent surgery. The rate of negative laparotomy was 5% and retarded interventions was 13%. The morbidity was also 13% and mortality 2.5%. The average period of internship in hospital was 11,4 days with extremities of 1 to 101 days. The conservative treatment of penetrating stabbed abdominal wounds out of the criteria mentioned were quite satisfactory.

[Complications of colpohysterectomy with lymph node dissection in the cervix carcinoma at the Cancer Institute of Dakar: report of 412 cases]. / Les complications des colpohystérectomies élargies avec lymphadénectomie pour cancer du col utérin à l'Institut du Cancer de Dakar: à propos de 412 cas.

The wertheim complications are dominated by the urinary dysfonction and the lymphocele which are linked at this procedure. This study reported 412 Wertheim associated to the radiotherapy. The purpose was to evaluate the complications among patients who underwent the Wertheim and to analyse the differents factors promotions the complications. The diagnosis was always late and the disease stage was advanced. The stages II, III and IV represented more than 80%. We found 86 complications (20.87%) distributed as follow: 17 urinary (19.76%), 30 secondary infections (34.88%), 8 colonic fistula (9.30%), 7 hemorrage (8.13%), 6 lymphedema (6.97%), 3 occlusions (3.48%), 1 phlebitis (1.16%), 1 lymphocele (1.16%). among all patients, 17 died, the mortality rate was 4.12%. A very good dissection preceded by radiotherapy may reduce the complications rate.

[Cancer of the uterine cervix in pregnancy: report of 50 cases]. / Cancer du col de l'utérus et grossesse: à propos de 50 cas.

Through a retrospective study of 50 cervix carcinoma during pregnancy, the authors determine the epidemiology, discuss the therapeutic and the pronostic. The mean age of patients were 36 years and the clinical staging of FIGO found : 3 stages Ia, 3 Ib, 7 IIa, 14 IIb, 7 IIIa, 7 IIIb, 4 IVa, 5 IVb The diagnosis of carcinoma was in 6 cases(12%) at first trimester, in 6 cases(12%) at midtrimester, in 13 cases(27%) at third trimester, in 19 cases(28%) after delivery. The termination of pregnancy was an abortion in 6 cases(12%). The treatment was: 29 delivery whose 12 followed bycolpohysterectomy,1 byconisation and 16 had not a colpohysterectomy. 5 cesarean section whose 2 followed by colpohysterectomy in the same time and 3 in the second time. The radiotherapy was neoadjuvant in 3 cases and adjuvant in 3 cases. The mortality was 4 % and the global survival at 5 years was 30%. The prognostic of the cervix carcinoma during pregnancy would get better by Pap test which must be systematic at the pregnant woman.

[Breast cancer and pregnancy: about 60 cases collected at the Cancer Institut of Dakar]. / Cancer du sein et grossesse: à propos de 60 cas colligés a l'Institut du Cancer de Dakar.

The purpose of this retrospective study of 60 breast carcinoma during pregnancy collected at the Cancer Institut of Dakar from 1962 to 1998 was to determine the epidemiology, the clinical appearance and to discuss the pathogeny, the diagnosis, the prognosis and the treatment. The mean of age of patients was 34.5 years. The number of parity was 5 and the first pregnancy at 20 years. The authors arrived at diagnosis in the post partum in 28 cases (47.45%), in the first trimester in 8 cases (13.55%), in the midtrimester in 13 cases (22.03%) and in the third trimester in 11 cases (18.64%). The polychemotherapy preceded the surgery in 30 cases and succeded in 16 cases. The hormonotherapy with Tamoxifen prescribed in 17 cases after the delivery. The mastectomy and axillary lymphadenectomy was realised in 26 cases in the post partum. The adjuvant radiotherapy was done in 12 cases. The mortality was 31% and the global survival at 2 years, 34.6%.

[Vulvar cancers. Retrospective study of 23 cases at the Cancer Institute of Dakar]. / Les cancers de la vulve. Etude rétrospective à propos de 23 cas colligés à l'Institut du Cancer de Dakar.

The vulvar cancer is an uncommon disease which is beginning mostly on vulvar intraepithelial neoplasma and it keeps a very bad prognostic. The purpose of this study is to report the epidemiological, the anatomo-clinic and and to discuss the treatment. We tell about 23 vulvar cancer from 1956 to 1995 which were followed at the cancer Institut of Dakar. The mean age of patients is 47 years and they are on menopause in 78.6%. The most of the tumors are ulcerate (96%). The clinical investigation find according the staging of FIGO: 15 tumors (T2), 8 tumors (T3), 6 tumors (N1), 9 tumors (N2) and 1 tumor (M1b). The surgery is the principal treatment with 6 radical vulvectomy and 17 palliative vulvectomy. The surgery was associated with radiotherapy and chemotherapy. So the vulvar cancer is uncommon in our country and concern the young wives. The vulvectomy with lymphadenectomy is the principal treatment; the prognostic still very bad because the diagnostic is often later.

[Epidemiological and therapeutic aspects of rectal cancer in Senegal: 74 cases at the Cancer Institute of Dakar]. / Aspects épidémiologiques et thérapeutiques des cancers du rectum au Sénégal: à propos de 74 cas colligés a l'Institut du Cancer de Dakar.

Through a retrospective study of 74 cancer of rectum the autors determine the epidemiology, the anatomic appearance and discuss the treatment, the prognostic. The mean age of patients was 48 years and the Duke's staging found: 16 stages B, 46 stages C and 12 stages D. The pathological anatomy showed: 58 adenocarcinoma, 9 colloïdal adenocarcinoma, 4 epidermoïdal carcinoma, 2 lymphosarcoma, 1 anaplasic adenocarcinoma. The operability rate was 66.2%, the resectability was 40.8% and the sphincteral preserving was 8.1%. The radiotherapy preceded the surgery in 6 cases and associated the chemotherapy. The chemotherapy preceded the surgery thein 14 cases and succeeded in 2 cases. The mortality was 24.4% and the recidivation 35%. The global survival 5 years was 32%. The prognostic could better by an earlier diagnostic and a multidisciplinary treatment.

[Cancers in the scars of thermal burns (apropos of 67 cases)]. / Les cancers sur cicatrices de brulures thermiques: (àpropos de 67 cas).

Burns are very frequent. Skin cancer on burns scars are one of the known complications. The mechanisms and the risk factors of this disease are not very well known. To review the risk factors and the mechanisms of transformation of burn scars into cancer, we analyzed 67 retrospective cases of Marjolin's ulcer to describe the epidemiological features of the disease in our practice and identify the factors of relapse. Our patients are young (means age 41), mainly male (54%), with disease localized on arms and legs (88%). The initial burn was from flames (54%), charcoal or hot cooking oil (19.5%) and never from ionizing radiation. It was never a superficial burn and covered from 4 to 37% of the body surface (mean 14%). The initial treatment was medical in only 9% of cases and ended with 85% of complete healing. After 4 to 67 years of evolution, 95% of re-ulceration occurred. Abnormal lymph node and distant metastasis were diagnosed in respectively 68 and 7% of the cases. Amputation and groin dissection were respectively done in 63 and 50%. One third of patients were lost during the follow up. 25% of the cases are still alive and free of disease. We found 30% of local recurrence and 17.5% of regional recurrence. By univariate analysis we found that the factors significantly associated to loco-regional relapse are: male status (p = 0.0327), burns by cooking oil (p = 0.0118), lack of treatment during initial burn (p = 0.0001), sclerous scar (p = 0.0281), supra regional lymph nodes (p = 0.028) lack of treatment during re ulceration (p = 0.0308). Squamous cell carcinomas on burn scars are rare diseases and of bad prognosis. Mainly associated to domestic accidents they frequently occur on limbs and arms on an articulation. Metastasis is not frequent. Conservative treatment is associated with 30% of recurrence. In our practice, the relapse risk factors are male status, burns by cooking oil, lack of treatment during the initial burn, sclerous scar, supra regional lymph nodes, lack of treatment during re ulceration.

[Risk factors for lymphedema of the arm after mastectomy for breast cancer]. / Les facteurs de survenue des lymphoedèmes du membre supérieur après mastectomie pour cancer du sein.

Postmastectomy lymphedema of the arm is frequently associated to different factors including axillary node involvement and local and regional treatment of breast cancer. Our aims was to identify risk factors of postmastectomy lymphedema. From a retrospective analysis of 735 breast cancers treated in our institute, we found 61 lymphedema of the arm. We then describe our study population and identify by univariate et multivariate analysis the factors significantly associated to the disease. The majority of the patients were young black African female found to have locally advanced breast cancers (88% of T3 et T4 UICC 1988), inflammatory diseases (46% of PEV 2 and 3 of Gustave ROUSSY Institute classification of inflammatory breast cancers). Ulceration is found in half of the patients, metastasis in 20%. The patients first underwent chemotherapy mainly with cyclophosphamide alone (56%). Only 59 patients (8%) had preoperative radiation. Surgery consisted mainly in modified radical mastectomy and lymph node dissection (95%). Residual disease is left in 50% of the cases. Only 35% had post-operative chemotherapy and 9% postoperative external beam radiation therapy. From that population, during the follow up, 61 patients were found to have postmastectomy lymphedema. The disease was asymptomatic in 60% of the cases and painful in 26%. 30% of all the patients spontaneously partially regressed. From univariate analysis we found 7 factors associated with lymphedema: The big size of the tumor (p = 0.005), clinically involved axillary lymph nodes (p = 0.001), metastatic disease (p = 0.0046), traditional or inadequate surgery out of the Institute (p = 0.001), lack of post-operative chemotherapy (p = 0.002), postoperative external beam radiations (p = 0.005), relapse (p = 0.002). From logistic regression analysis three independent factors were found: clinically involved axillary lymph nodes (p = 0.0267), metastasis (p = 0.0002) and local or regional relapse (p = 0.0405). In our practice we found that advanced disease, treated by traditional healers or surgery nurses who had relapsed after mastectomy and external beam radiations without chemotherapy have higher risks of lymphedema.