[Negative pressure therapy in precarious situations. Part 1: abdomen and perineum]. / Therapie par pression négative en situation précaire. 1e partie: abdomen et périnée.

Negative pressure therapy (NPT) is a proven safe and effective technique to promote healing of complex adominoperineal wounds using either an open or closed approach. Specifically designed devices are available in industrialized countries but high cost is a limiting factor for their use in developing countries. The purpose of this report is to describe a simple, easy-to-use technique that is suitable for austere environments. In addition to low-cost, the main advantage of this technique is that it can be performed by anyone using resources readily available in any operating room.

[Current management of sigmoid volvulus in the tropics]. / Prise en charge actuelle du volvulus du sigmoïde en milieu tropical.

Sigmoid volvulus is a frequent medical emergency in Africa. Diagnosis is mostly based on clinical examination and plain abdominal films. Emergency surgical therapy is required for patients presenting severe clinical and radiographic signs. Sigmoidectomy can be performed in a single stage with immediate restoration of digestive continuity or in two stages with colostomy followed by reconstruction several months later. The choice of technique depends on the patient's general condition and intestinal viability, but should also take into account the morbidity, cost, and social consequences associated with colostomy. For patients without severe signs, the method of choice consists of initial detorsion using an endoscope, if available. This strategy allows elective single-stage sigmoidectomy, which is the preferred procedure. Ideally sigmoidectomy after detorsion should be carried out within a few days during the same period of hospitalization and, if possible, using the celioscopic approach.

Fortuitous discovery of common bile duct stones: results of a conservative strategy.

OBJECTIVE: The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy. PATIENTS AND METHODS: Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken. RESULTS: Cholecystectomy was performed in 124 patients with symptomatic gallstones and no signs predictive of stones in the common bile duct. A stone was found fortuitously in the common bile duct in 12 patients. The control cholangiogram was normal in two of these patients on day two (16.7%) and in six others (50%) at the six-week control. All 12 patients remained free of symptoms suggesting the presence of a stone in the common duct. Presence of the drain had no impact on quality-of-life. Endoscopic extraction was finally performed for four patients (33.3%) to remove a stone from the common bile duct. CONCLUSION: Early surgical or endoscopic extraction of stones in the common bile duct should not be undertaken systematically in asymptomatic patients. Spontaneous asymptomatic clearance of the common bile duct is observed in about half of patients.

[Abbreviated laparotomy for treatment of severe abdominal trauma: use in austere settings]. / Laparotomie écourtée pour traitement des traumatismes abdominaux sévères: application en milieu précaire.

Abbreviated laparotomy is a recent technique for management of patients with severe abdominal trauma. It is based on a unified approach taking into account the overall extent of injury and the victim's physiologic potential to respond to hemorrhage. It is the first step in a multi-modal strategy. The second step is the critical care phase. The third step consists of "second-look" laparotomy that should ideally be performed on an elective basis within 48 hours and is aimed at definitive treatment of lesions. The goal of abbreviated laparotomy is damage control using temporary quick-fix procedures limited to conspicuous lesions and rapid hemostasis and/or viscerostasis procedures so that the patient can survive the acute critical period. Tension-free closure of the abdominal wall, if necessary using laparostomy, is essential to avoid abdominal compartment syndrome. With reported survival rates of about 50% in Europe and the United States, this simple life-saving technique that requires limited resources should be introduced in Africa where severe abdominal trauma often involves young patients.

[Current management of stab wounds to the colon]. / Prise en charge actuelle des plaies coliques par arme blanche: applications en milieu tropical.

Stab wounds to the colon are a frequent surgical emergency. Local wound exploration under local anaesthesia is not required systematically. We recommend surveillance based on clinical observation and laboratory testing to detect peritoneal signs. If progression of symptoms is suspected, diagnostic peritoneal lavage (DPL) should be performed. Immediate surgical exploration is indicated in two cases, i.e., generalized peritonitis and haemodynamic instability due to internal bleeding. The preferred repair technique is direct suture or resection followed by a handsewn or mechanical anastomosis. The morbidity, cost and social consequences of colostomy must be taken into account. It should be considered as a salvage procedure for patients in critical condition or extensive colonic injury.

[Mesenteric trauma: management in austere environments]. / Traumatismes entéro-mésentériques en situation précaire.

Mesenteric trauma, i.e., injuries located in the bowel or organs supplied by the superior mesenteric artery, can be life-threatening. The incidence of these lesions is low. Most occur as result of blunt and penetrating abdominal trauma due mainly to gunshot wounds or road accidents. Management of these serious injuries can be challenging in the military field hospitals. The major problem in austere environment is the unavailabiity of computerized axial and other tools gene rally used for diagnosis. As an alternative to tomography diagnostic peritoneal lavage can be used with a high sensitivity for the detection of mesenteric trauma. The second difficulty is technical. General surgeons without vasular training or supplies must prepared to suspect and reonstuct lesions of the superior mesenteric available resources.

Long-term results of preoperative radiotherapy for 113 cases of UT3 and UT4 rectal cancer: a need for long-term follow-up.

PURPOSE: Eighty percent of local recurrence after resection of rectal adenocarcinoma classically occurs within two years of surgery. Pretherapeutic staging is frequently limited to clinical examination, although the accuracy of endoanal ultrasonography has been demonstrated. The aim of this study was to report the long-term results of preoperative radiation therapy and resection of pretherapeutic endoanal ultrasonography-staged T3 and T4 rectal adenocarcinoma. METHODS: This retrospective review analyzed a series of 113 patients who underwent radiation therapy followed by surgery. All patients underwent an endoanal ultrasonography. Median follow-up was 75 months. RESULTS: Fifty-seven percent of patients were pT3 or T4. Thirty-six percent had involvement of lymph nodes. Five-year rates of survival, local recurrence-free survival, and disease-free survival were 79, 73, and 68 percent, respectively. Ten-year rates were 65, 63, and 62 percent, respectively. Median time to detection of local recurrence was 39 months. Eight of ten local recurrences occurred after two years of follow-up. Eight of ten patients with local recurrence had pretherapeutic endoanal ultrasonography-staged N+ tumors. CONCLUSION: These results appear to justify a follow-up program for patients with pretherapeutic endoanal ultrasonography-staged N+ tumor. However, a minimum of seven years of follow-up is needed to obtain an accurate assessment of results.

[Truncal vagotomy using videothoracoscopy without gastric drainage. A prospective study of 250 cases surgically treated in Senegal]. / Vagotomie tronculaire par vidéothoracoscopie sans drainage gastrique. Etude prospective de 250 cas opérés au Sénégal.

AIM OF THE STUDY: The aim of this prospective study was to report early results of videothoracoscopic truncal vagotomy in non-complicated chronic duodenal ulcers. PATIENTS AND METHODS: From 1995 to 1998, 250 patients suffering from chronic duodenal ulcer without pyloric stenosis were operated on in the main hospital of Dakar. They underwent videothoracoscopic truncal vagotomy without gastric drainage. The quality of gastric emptying and the incidence of secondary side-effects were assessed in the postoperative course and after one and three months. RESULTS: There were two intraoperative deaths, one due to aortic wound and the other one due to a poor surveillance after premature extubation. Postoperative complications included bronchopulmonary infection (n = 9), one septic pleural effusion and one chylothorax. A postoperative gastroplegia occurred in 12 patients, which was always spontaneously regressive without endoscopic pyloric dilatation. After one month, 204 patients (82%) were classified Visik 1, and 44 (18%) classified Visik 2. An endoscopic control examination showed a healed peptic ulcer and open pylorus in all patients, and a gastric stasis present in 40 cases (16%). After three months and a new evaluation, 234 were classified Visik 1 (94%) and 14 Visik 2 (6%). Dumping syndrome was not observed in this series and the incidence of diarrhea, which was 40% after one month, decreased to 3% after three months. CONCLUSION: The functional results of truncular vagotomy without gastric drainage were good or very good and improved with time. The quality of digestive comfort and the low frequency of side-effects are good arguments in favor of this procedure as an elective treatment of duodenal ulcers in developing countries.

[Treatment of bilateral inguinal hernia by subperitoneal prosthetic parietoplasty. Value of PTFE]. / Cure de hernie inguinale bilatérale par pariétoplastie prothétique sous péritonéale. Intérêt du PTFE.

This retrospective study reviews 211 patients having sustained a bilateral groin hernia repair during a 3 year period. The procedure was the same for all the patients: via a Pfannensteil approach, a pre peritoneal prosthetic repair is performed, using two ePTFE patches, after resection of the hernial sacs and closure of the parietal gaps. The mean follow up was 2 years. During the post operative course, thirty seven of 211 patients sustained 10 local complications, 9 urethral catheter related complications and 11 residual pain. No prostheses infection or testicular atrophy was observed. Nine patients had recurrences (2.2% of 422 repairs). All the recurrences were due to incorrect technique, eight were successfully re operated on--Expanded PTFE is a reliable prosthetic material, easy to handle and well adapted to preperitioneal hernia repair.