[Toxic multinodular goiter]. / Les goitres multinodulaires toxiques.

OBJECTIVES: We report a series of 70 patients with toxic multinodular goiter (TMNG) and analyze results after surgical removal. PATIENTS AND METHODS: Over a 15-year period, patients underwent thyroid surgery for TMNG. The large majority, 85.5% were women and mean age was 40 years. All patients had had goiter for more than 5 years. Clinical signs of toxicity were present in all patients, 100% presented tachycardia and palpitations. Nodules were identified at ultrasound in 95% of the patients and at scintigraphy in 90%. Serum T4 was elevated in 40 patients and THS was depressed in all. The chest x-ray revealed a plunging goiter in 10 patients. All patients were given medical treatment prior to surgery for total thyroidectomy in 15 and subtotal thyroidectomy in 55. There were no deaths. Two patients developed hematomas, to suffered injury to the recurrent nerve, and five developed acute hypoparathyroidism. Three cases of thyroid carcinoma were observed. DISCUSSION: TMNG is an indication for radical treatment, generally surgery. Medical treatment is required in preparation for surgery. Total thyroidectomy is used increasingly, providing a definitive cure of toxic hyperthyroidism and avoiding the risk of recurrence. With increasing surgical skill, the risk of recurrent or parathyroid injury is greatly decreased.

La gangrene perineo-scrotale : etiologies et therapeutiques : a propos de 60 cas

Objective To assess the epidemiological and diagnostic aspects; treatment and early and late outcomes of perineo-scrotal gangrene. Patients et Methods We report on 60 cases collected over a period of 14 years. The patients' mean age was 40 years. All patients were males. Twenty of them had diabetes. An aetiology was found in 47 cases. It was a urologic aetiology in 27 cases and a proctologic aetiology in 20 cases. 13 cases were considered as primitive and classified as Fournier's Gangrene. All patients were admitted to the emergency unit and underwent a large debridement with urinary diversion. A colostomy was done in 25 cases. A hyperbaric oxygenotherapy was administered in 30 cases. Results Ten patients died after a week due to a delayed diagnosis. 39 patients were cured primarily without sequelae and 11 others after reconstructive surgery using a cutaneous graft in 10 cases and a musculo-cutaneous graft in one case. Conclusion 20of cases of perineo-scrotal gangrene are idiopathic. Given the high mortality and morbidity; an early treatment associating intensive care; triple antibiotherapie; large debridement and; if possible; hyperbaric oxygenotherapy is necessary

[Moroccan experience in the surgical treatment of multiple hydatid cysts in the liver]. / L'expérience marocaine dans le traitement chirurgical des kystes hydatiques multiple du foie: à propos de 94 cas.

We studied 94 cases of multiple hydatid cysts in the liver, over a period of ten years. These cases accounted for 31.3% of all cases of hydatid cysts treated surgically in the Visceral Surgery Department of Avicenne Military Hospital in Marrakech. In these patients, who were often young and male, the principal symptoms were pain in the right hypochondrium (71.3%) and hepatomegaly (24.5%). In about 10% of cases, the cysts were discovered by chance. Ultrasound and CT scans facilitated diagnosis and determination of the position of the cysts, with reliability reaching 100% for CT scans. The cysts had burst in the bile ducts in 26.6% of cases and were infected in 8 cases. They were multivesicular in 77.5% of cases. Association with hydatidosis at another site was observed in 28 cases: in the peritoneum in 15, the thorax in 7, the diaphragm in 4, the spleen in 2 and the kidney in 1 case. Surgically, the route most frequently used was double incision below the rib cage (49.5%). It is not possible to recommend one particular way to treat cysts and the most appropriate approach to treatment depends on the site, type and number of cysts. Resection of the prominent dome is the technique most frequently used (57.25%). However, in recent years, the use of cystectomy has been increasing (20.2%) due to the considerable decreases in post-operative morbidity and duration of hospital stay that it affords. The principal post-operative complications observed were abscesses under the diaphragm (6 cases), biliary leakage (5 cases), pleurisy (6 cases) and the formation of abscesses in the vestigial cavity (4 cases). The rate of morbidity in the RDS appeared high, accounting for 75% of total morbidity. Only one patient died. This patient died from severe hepatic insufficiency due to the near destruction of the liver by the hydatosis. We observed two recurrences during follow up. Both underwent further surgery and neither suffered complications.

[Renal lymphangioma]. / Le lymphangiome rénal.

The authors report the case of a 39-year-old man presenting with renal colic attributed to a renal tumour diagnosed on CT scan. Treatment consisted of total nephrectomy in the absence of a definitive intraoperative histological diagnosis of renal lymphangioma. Renal lymphangioma is a rare benign tumour, probably derived from a congenital malformation of the lymphatic system. Medical imaging has certain limits for the diagnosis which can be confirmed by renal needle biopsy. Treatment must always be as conservative as possible. The clinical course is always favourable.

[Hydatid cysts of the liver opening in the biliary tract. Report of 64 cases]. / Les kystes hydatiques du foie rompus dans les voies biliaires. A propos de 64 cas.

STUDY AIM: The aim of this retrospective study was to report a series of patients with hydatid cyst opened in the biliary tract, who were operated in Morocco. PATIENTS AND METHOD: From 1991 to 1998, among 250 hydatid cysts of the liver operated in the same center, 64 were in communication with the biliary tract (25%). There were 39 men and 25 women. The mean age was 34.2 years (range: 6-60). The revealing symptoms were abdominal pain, jaundice or cholangitis, but the biliary fistula was asymptomatic in more than 50% of the patients. The hydatid cysts were recognized by ultrasonography in all the patients but the biliary fistula was only suspected in 17 patients. The surgical procedure included drainage and sterilization of the cyst, resection of the protruding wall of the cyst (84.4%), unblockage of the main hepatic duct (n = 21) associated with a Kehr drainage, and treatment of the bilio-cystic fistula with suture (n = 23) or double side drainage (n = 24) or cystobiliary disconnection (n = 15). RESULTS: There were two postoperative deaths due to septic shock (n = 1) and encephalopathy secondary to a biliary cirrhosis (n = 1). The morbidity rate was 25%. Among complications, there were four subphrenic abscesses, four prolonged biliary leakages and two intestinal obstructions. The main hospital stay was 20 days. CONCLUSION: The opening of hyatid cysts of the liver into the biliary tract may be silent or revealed by biliary symptoms. The results of this series favour a conservative procedure, including resection of the protruding wall of the cyst and cysto-biliary disconnection, in spite of a high morbidity rate and a long hospital stay.

[Primary tuberculosis of the breast]. / La tuberculose primitive du sein.

BACKGROUND: Despite generalized BCG vaccination, tuberculosis remains a public health issue in France. Breast localizations are exceptional and constitute a diagnostic and therapeutic challenge. CASE REPORT: A 34-year-old woman who was nursing her 3-month old infant underwent emergency surgery for a breast abscess that had been incised one month earlier and treated with non-specific antibiotic therapy without success. All necrotic tissue was removed. Pathology provided the diagnosis of tuberculosis. An anti-tuberculosis regimen (INH + rifampicin + PZA + ethambutol for two months followed by INH + rifampicin for 7 months) was instituted. The epidemiology search was negative and no extension was found. The clinical course was favorable at 6 months. DISCUSSION: Tuberculosis is rarely localized in the breast. The main differential diagnosis is breast cancer. Pathology examination is required for diagnosis. Anti-tuberculosis antibiotic therapy may be associated with surgery in case of extension.

[Peritoneal hydatidosis: a study of 25 cases in Morocco]. / Hydatidose péritonéale. A propos de 25 cas marocains.

We carried out a retrospective study of 25 cases of peritoneal hydatidosis. The incidence of this disease was 6.9%, the sex ratio of the patients was about 2/1 and the mean age of the patients was 31.8 years. Peritoneal echinococcal disease was most frequently secondary to the rupture or splitting of hydatid cysts in the liver (84% of cases) or, more rarely, in the spleen (4% of cases). The principal symptoms were unusual abdominal pain and abdominal masses. Ultrasound scan is the radiological method of choice for investigation and for assessing the number of hydatid cysts in the abdomen. It was used in 20 cases in this series and led to diagnosis of the disease in 95% of these cases. The sensitivity of CT scan for topographical diagnosis was about 90%. Serological tests were negative for the five remaining patients. Surgical management depends on the location and number of hydatid cysts and on the general state of the patient. Total cyst removal was performed in ten patients, pericystectomy in nine cases and marsupialization in six cases in which the cysts were located in the Douglas cul-de-sac. None of the patients was treated with albendazole. None of the patients died and the morbidity rate was 20%, due mainly to the hepatic location of the cysts. We observed one case of small bowel occlusion due to a missed daughter vesicle, two abscesses of the residual cavity, one case of pleurisy and one case of unexplained febrile syndrome. No recurrence was observed over a follow-up period of five years.

[Muscle hydatidosis. 15 cases]. / L'hydatidose musculaire. 15 cas.

OBJECTIVES: The aim of this study was to analyse the epidemiological, diagnostic and therapeutic aspects of muscle hydatidosis. PATIENTS AND METHODS: This retrospective study included a series of 15 patients with hydatic muscular cysts operated on in our service over an eight year period. Five cysts were superficial and ten were deep. Patients were predominantly young adults (10 cases); M/F sex ratio was 2/1. Clinical signs included atypical pain, particularly for the deep localizations, and tumoral formations, particularly for superficial localizations. Diagnosis of muscle hydatidosis was made in some patients seen for complications or systematic search for another localization. A second hepatic localization was found in 5 cases and a splenic localization in one. Sonography provided the diagnosis in all cases although the exact localization could not be determined. A CT scan was performed in half the cases. Localizations included the diaphragm 7 cases, psoas 3 cases, and buttock, triceps, sartorius, anterior tibial and intercostal muscles 1 case each. RESULTS: Surgical treatment was the same for all abdominal localizations, although different access routes were used. Partial pericystostomy was the basic procedure and gave excellent results. One case was complicated by a crural nerve lesion that recovered spontaneously. Recurrence in the diaphragm occurred in two cases and was successfully treated surgically two years later. One patient died due to acute liver failure subsequent to multiple cysts which had destroyed the entire liver.

[Ileal lipoma: a cause of severe lower digestive tract hemorrhage]. / Le lipome iléal: cause d'hémorragie digestive basse grave.

We report a case of major lower digestive tract hemorrhage caused by an ileal lipoma. The main clinical signs of this uncommon pathology are presented together with the necessary paraclinical investigations. Ileal lipoma may be spontaneously complicated and requires surgical treatment.