Peritonitis: Perioperative Care in Surgical Emergencies CHU Ignace Deen

Objective: Describe the perioperative management of peritonitis in surgical emergencies. Methodology: This was a prospective observational study of the descriptive type over a period of 12 months from January 01 to December 31, 2020 in the surgical emergency room at the CHU Ignace Deen. Included in the study were all patients admitted for peritonitis aged greater than or equal to 18 years. The parameters were epidemiological, clinical and anesthetic. Results: Of the 653 admissions to surgical emergencies in 2020, 185 cases presented with peritonitis, i.e. 29.3%. The average age was 38.6 ± 16.64 years with extremes of 18 and 90 years. The sex ratio was 1.89. The comorbidities were dominated by gastritis and hypertension, i.e. 22%. The patients were classified as ASA 3U (52.4%), ASA2 U (39.5%) and ASA 4 U (8.1%). Preoperative resuscitation was provided only with 100% saline. 25.5% of patients had received a blood transfusion. The response time was less than 48 hours, i.e. 77.6%. General anesthesia was performed for all patients. Ketamine was the most used IV hypnotic (56.3%) combined with 100% halothane. The curares used were suxamethonium at (81.6%), Atracurium (81.6%) and rocuronium at (18.3%). Fentanyl was the only morphine used. Senior anesthesia technicians provided anesthesia in (63.2%). Intraoperative incidents were dominated by hypotension, difficult intubation, cardiac arrest, respectively 10.3%, 8% and 0.5%. The immediate postoperative incidents were arterial hypotension, nausea and desaturation, respectively 52.9%, 80% and 32.4%. Mortality was 3.4%. Conclusion: The perioperative management of peritonitis in the emergency room must be as early as possible in order to reduce morbidity and mortality.

Dengue hemorrhagic fever with rectus sheath hematoma:A case report

Rationale:Acute pain is a medical emergency that requires prompt abdominal evaluation and management.Dengue,a mosquito-borne arboviral infection,can lead to complications such as acute abdominal pain.Patient concerns:A 72-year-old hypertensive female presented with high-grade intermittent fever with chills and rigors for four days.She was diagnosed with dengue fever(NS1Ag-reactive)the day before admission.A contrast-enhanced computed tomography of the abdomen showed a hematoma along the rectus sheath which was managed conservatively as per surgical opinion.Diagnosis:Dengue hemorrhagic fever with rectus sheath hematoma.Interventions:Blood transfusion and fluid therapy.Outcomes:Ten days after discharge,the patient reproted no pain in the right iliac fossa and the size of the hematoma was significantly reduced.Lessons:Although it is rarely seen as a cause of acute abdomen,complaints of adnominal pain should never be ignored in critical or convalescent phase of dengue fever.Radiological investigations should be promptly conducted as hematoma is often difficult to be diagnosed clinically.Delay in diagnosis of rectus sheath hematoma can be fatal.

Management of Pediatric Abdominal Surgical Emergencies in Northern Benin

Background: Pediatric abdominal surgical emergencies are major causes of morbidity and mortality. The goal was to identify the main determinants of their management and access to assess their evolution. Patients and methods: This is a prospective, descriptive and analytical study performed at Parakou teaching hospital and Tanguieta district hospital. It has been conducted from January 1st to July 31st 2016. All children were included aged 0 to 15 years and admitted for an abdominal surgical emergency with a Clinical Classification of Emergency Patients listed from 3 to 5. Results: Pediatric abdominal surgical emergencies accounted for 42.8% of pediatric surgical emergencies. The average age was 9.3 ± 3.5 years old. The sex ratio was 1.7. The most encountered etiologies were peritonitis (36.76%), abdominal trauma (16.17%) and anorectal malformations (14.71%). The comparison of the delay in operative treatment with the World Society of Emergency Surgery shows a delay in 82.35% of cases. Mortality was high preoperatively and was related to the neonatal period (p = 0.027) and to a resuscitation length of stay higher than 36 hours (p = 0.035). Conclusion: Surgical care was delayed, mainly due to the lack of technical capacities. Morbidity and mortality were relatively low.

Non-Malformative Emergency Abdominal Surgery in Children Aged 0 - 5 Years

Childhood abdominal surgery emergencies are a major challenge and problematic for the surgeon. The objective is to assess the pattern of non-malformative emergency abdominal surgery in children under 5 years old and to evaluate their management. Patients and Methods: A retrospective study of children under five years of age operated between January 2015 and December 2019 who presented with non-malformative abdominal surgical emergency at the Niamey National Hospital. Results: We collected 327 patients aged 0 to 5 years who underwent surgery for abdominal emergency. The average age was 2.8 ± 0.7 years. Boys accounted for 70.64% (n = 231) of the cases. Non-traumatic emergencies accounted for 97% (n = 317) of the cases. They were dominated by peritonitis in 44.6% (n = 146) and strangulated hernia in 43.7% (n = 143). Peritonitis was attributed to ileal typhoid perforation in 85.61% (n = 125) cases. The strangulated hernias were umbilical at 87.41% (n = 125) and inguinal at 12.59% (n = 18). Abdominal trauma accounted for 3% (n = 10);including 6 cases of abdominal contusion and 4 cases of penetrating wound. Intestinal resection with or without stoma was performed in 28.44% (n = 93). Postoperative complications were observed in 8.5% (n = 28) of the cases and mortality was 5.5% (n = 18). Conclusion: Non-malformative emergency abdominal surgery for children under 5 years was dominated by peritonitis. The morbidity and mortality are high. Fight against disease due to dirty hands and fecal peril like such as typhoid fever will reduce their frequency, but also improve the prognosis.

Digestive Surgical Emergencies at the Commune II Reference Health Centre in the District of Bamako

We conducted a prospective descriptive study from January 1 to December 31, 2018 with the objectives of determining the frequency of digestive surgical emergencies, describing the clinical and para-clinical aspects of the management of digestive surgical emergencies, evaluating the therapeutic aspect of digestive surgical emergencies and analysing the post-operative follow-up of patients operated on in emergencies. We counted 120 patients operated on for digestive surgical emergencies, which corresponds to 5.80% of all consultations and 44.80% of all surgical interventions. The male sex was the most represented with a ratio of 1.80. The average age was 27.5 years. The majority of patients were from Bamako. Abdominal pain was the reason for consultation in 80% of cases. The diagnosis was essentially clinical and paraclinical in doubtful cases. These included ultrasound, unprepared abdomen and sometimes abdominal CT scans. Acute appendicitis was the most common pathology with 42.5%. General anaesthesia and spinal anaesthesia were used with 50% each. The majority of patients were operated on between 30 minutes and 12 hours after their admission to the department (71.7%). Acute peritonitis accounted for 67% of deaths from sepsis. The surgical technique was decided according to the pathology and the surgeon’s choice. The postoperative course was simple in the majority of cases. The prognosis is good when the management is early. The treatment is medical-surgical.

Acute Peritonitis at the Reference Health Center of Commune I of the District of Bamako: Epidemiological, Clinical and Therapeutic Aspects

Acute peritonitis is most often secondary to perforation of the digestive organ and/or the spread of an intra-abdominal septic focus. The objectives of this work were to study acute peritonitis in the general surgery department of the Cs ref of commune I in Mali, to determine the frequency of peritonitis, to describe the epidemiological, clinical and therapeutic aspects in order to analyze the surgical consequences and to assess the additional cost of treating acute peritonitis. This study was prospective, descriptive, cross-sectional involving 40 patients received in the surgery department of the Cs ref of commune I for acute peritonitis from January 1, 2018 to December 31, 2018. There were 40 patients among whom 28 (70%) were men and 12 were women (30%), i.e. a sex ratio = 2.3. The average age was 25 years with extremes varying between 16 and 54 years and a standard deviation of 11.78. Abdominal pain was the main reason for consultation. Clinical examination alone made it possible to make the diagnosis in 75% of cases. Surgical treatment depended on the intraoperative etiology. The clinical diagnosis was supported by ASP and abdominal ultrasound;performed respectively in 10% and 90% of patients. Appendiceal peritonitis was the intraoperative diagnosis observed in 50% of cases. All our patients benefited from a peritoneal toilet with drainage. We noted a morbidity rate of 5% dominated by parietal suppuration. The average cost of care was 175,000 FCFA.

Ectopic Pregnancy: Epidemiological, Clinical, Therapeutical, Anatomopathological Aspects and Prognosis at the Department of Obstetrics and Gynecology of the Teaching Hospital Souro Sanou of Bobo-Dioulasso: About 79 Cases and Literature Review

Objective: To study the epidemiological, clinical, therapeutical, anatomopathological aspects and prognosis of the ectopic pregnancy. Methodology: It was a transversal and descriptive study from January 1st to December 31st 2018 at the department of obstetrics and gynecology of the Teaching Hospital Sourô Sanou of Bobo-Dioulasso. Results: During the study period, we registered 4706 deliveries with 1272 cases of cesareans and 79 cases of ectopic pregnancy with a frequency of 1 ectopic pregnancy for 60 deliveries and 6 ectopic pregnancies for 100 caesareans. The average age of the patients in our study was 28.66 years old (19 - 45 years) and the average parity of 1.96 [0 - 6]. Married women represented 83.54 % of the workforce. The risk factors were dominated by sexual transmitted diseases (25.31%) and abortions (20.25%). Clinical signs were dominated by pelvic pain (100% of cases), metrorrhagea (86.5% of cases) and amenorrhea (64.6% of cases). Culdocentesis brought lysed incoagulable blood in 83.7% cases. The immunological pregnancy test was positive in 100% of cases. Plasma beta dosage was carried out in 2 cases. Salpingectomy was performed in 97.4% cases. The site of the ectopic pregnancy was interstitial in 11.3% cases, isthmic in 8.86% cases, infundibular in 11.3% cases, ampullar in 77.22% cases. On the anatomopathological level, we noted an acute salpingitis in 23.38% cases and a chronic salpingitis in 44.94% cases. Postoperative were simple in 97.7% of cases and we deplored one case maternal death. Conclusion: Ectopic pregnancy is a surgical emergency of the first trimester pregnancy. The delay in diagnosis is common in our context, with as consequence a mutilated treatment. The etiological factors are dominated by the chronic salpingitis and the acute salpingitis. The prevention is based on combatting genital infections, promoting contraceptive methods and a good post abortion care.

Peritonitis Management through Appendicular Perforation in the Department of Surgery Bougouni Hospital (Mali)

Introduction: Appendicular peritonitis is a complication of acute appendicitis characterized by the spread of the infectious process in the peritoneal cavity thus achieving wide spread or localized purulent peritonitis;it’s a medico-surgical emergency. Our objectives are to determine the frequency, describe the clinical, therapeutic and prognostic aspects of peritonitis by appendicular perforations. Patients-Method: This was a 24-month retro, prospective, descriptive study from January 1, 2018 to December 31, 2019;conducted in the Bougouni Reference Health Center Surgery Unit. All patients of appendicular peritonitis at the Bougouni Reference Health Centre were included. Results: During the study period, 68 cases of generalized acute peritonitis including 30 appendicular peritonitis cases were collected. Appendicular peritonitis accounted for 44.1% of surgical procedures. Males accounted for 71.0% with a sex ratio of 1.2 at risk of men, the average age was 26.07 years. Abdominal pain and vomiting were the reasons for consultation in 86.7% and 76.7% of cases. Physical examination was used in most cases to make the diagnosis. X-ray of the abdomen without preparation, and abdominal ultrasound were performed systematically. Surgical treatment consisted of an appendectomy with peritoneal toilet followed by drainage. The average length of hospitalization was 8.8 days with extremes of 1 - 44 days. Hospital mortality was 3.3%;morbidity and high mortality were related to delayed consultation. Conclusion: Appendicular generalized acute peritonitis is a medical-surgical emergency with a high mortality rate associated with delayed management.

Appendicular Peritonitis in the General Surgery Department of Gabriel TOURE CHU

The appendicular peritonitis is complications of acute appendicitis which are characterized by the diffusion of the infectious process to the peritoneal cavity thus carrying out a generalized or located purulent peritonitis. It can appear from the start or follow the stage of appendicular abscess. Our objectives were to determine the frequency, to describe the clinic and para clinic aspects, to identify the principal germs and their sensitivities to antibiotics and to describe the operative continuations. Our prospective and descriptive study focused on patients treated for appendicular peritonitis, from January 1st to December 31st 2016, in the General Surgery Department of the Hospital of Sikasso. During the period of our study, 31 cases of appendicular peritonitis were collected, which represented 4.36% of surgical interventions, 19.25% of urgent surgeries. The male sex accounted for 71.0% with a sex-ratio of 2.44 at the risk of males, the average age was of 20 years ± 12.99, the abdominal pain + vomiting was the reason for consultation in 54.8% of cases. The physical examination allowed in most cases to make the diagnosis. In doubtful cases some additional examinations have been requested (abdomen without preparation, abdominal ultrasound). The surgical treatment consisted of an appendectomy with peritoneal lavage followed by drainage. The average length of hospital stay was 8.8 days with extremes of 1 - 44 days. Hospital mortality was 9.7%. Delay in consultation and age were factors of morbidity and high mortality.

Sigmoide Volvulus on Pregnancy in the General Surgery Service of the Sikasso Hospital,Mali

Sigmoid volvulus on pregnancy is a rare surgical emergency. We report two cases treated in the General Surgery Department of Sikasso Hospital between January 2009 and December 2017. The mean age was 34.8 years and the gestational age ranged from 28 to 30 weeks. The evolution time was 4 days. The 2 patients were referred to us by gynecologist-obstetricians. They were operated after a short-term resuscitation. Inoperative the volvulus of the sigmoid was alone in 1 case;he was associated with a hail volvulus in the other. The volvated loop was necrotic in 1 case (small and sigmoid). A patient benefited from the Hartmann operation associated with a small bowel resection with end-to-end anastomosis. Simple sigmoidal detorsion was performed in one patient. We did not register a maternal death. The follow-up was simple in the 2 patients who gave birth vaginally.

Volvulus of Sigmoid Colon at Sikasso Hospital

The sigmoid volvulus is an acute strangulation of the colon by the twisting of the sigmoid loop around its mesenteric axis resulting in partial or complete obstruction of the colonic lumen. It is the most common intestinal volvulus and is an absolute medical and surgical emergency. Objectives: Determine the frequency of sigmoid colon volvulus, describe clinical and para-clinical signs, describe treatment, and determine morbidity and mortality. Methodology: This was a retrospective and prospective study performed in the General Surgery Department of Sikasso. This study concerned patients admitted and operated for sigmoid volvulus from January 1, 2014 to December 31, 2017. Retrospective Phase: We have created survey cards to study the following parameters: 1) The age and the sex;2) The clinical signs and associated defects;3) The radiological examinations, endoscopic;4) The established treatment whether medical, or surgical;5) The evolution and the postoperative consequences;6) The admission period. Prospective Phase: At the admission each patient to benefit: a complete interrogation, a complete physical examination, additional examinations including radio of the abdomen without preparation, the rate of hemoglobin and hematocrit, grouping/rhesus. Support: Our data were collected from medical records and operating records of patients in the department. Results: We collected 54 cases of sigmoid volvulus (the annual frequency was 13.5 cases for year), which accounted for 58.1% of colonic occlusions 19.6% of intestinal occlusions and 5.9% of operative operations in emergency. The average age was 47.13 with extremes of 18 and 102 years, The sex ratio is 4.40% in favor of men. Abdominal pain, vomiting, stopping of materials and gases were present in 32 (59.3%) patients. Von Wahl’s triad was present in 36 patients (66.7%), the rectal ampoule empty in 92.6%. On the X-ray of the abdomen without preparation, 70.37% of the image was recorded as a double leg. The sigmoid was necrotic in 37% of cases, and a sigmoid volvulus and necrotic hail in 7.4% of cases. We found a simple sigmoid volvulus in 61% of cases. We performed an immediate anastomosis resection in 63%, a Hartmann resection in 29.6%, an immediate anastomosis resection plus an ileostomy in 7.4%. Operative follow-up was simple in 85.2%, with a morbidity of 11.1%, and a mortality of 14.8%. Conclusion: Sigmoid volvulus is a serious surgical emergency requiring early diagnosis and management to improve prognosis. Pre-, postoperative and postoperative resuscitation associated with immediate anastomosis resection, or resection plus Hartmann, would reduce morbidity and mortality.

Which objective emergency department parameters leads to expedited intervention in patients with acute urinary tract calculi

Objectives:To retrospectively determine which objective measurements had an increased likelihood of requiring immediate surgical intervention in patients presenting to the emergency department(ED)with acute ureteral calculi.Materials and methods:Employing our institution's electronic medical record system,we conducted a retrospective cohort study of 4366 patients who presented to the ED with an acute ureteral calculus over an 8-year period.Data consisting of relevant demographic information,vital signs,laboratory parameters,and interventional history was obtained and analyzed.Results:This study consisted of 4366 patients presenting to the ED with acute ureteral calculi,of whom 312(7%)required a procedure prior to being discharged.Of these 312 patients,290(6.6%)underwent cystoscopy with ureteral stent placement and 22(0.5%)were sent to interventional radiology for percutaneous nephrostomy tube placement.Patients who tested positive for nitrites in their urine had a relative risk of 3.48 of receiving intervention when compared to the nitrite negative group.Conclusions:Through this retrospective cohort study,we were able to find what objective measurements were associated with an increased need for immediate surgical intervention in patients who presented to the ED with acute ureteral calculi.With this data,urologists can be better equipped to identify the patients that present in the emergency setting that will require urgent intervention.

Emergent treatment of patients with traumatic aorta ruptures

Objective ： To discuss our experience on the diagnosis and treatment of thoracic aorta rupture （TAR） that is one of the main common causes of death in the victims under blunt chest trauma. Methods： Between July 2001 and March 2006, 9 patients （6 men and 3 women, aged from 20 to 54 years ） suffering from acute traumatic aorta rupture after motor vehicle accidents received emergent surgical treatments in our hospital. Based on our experience in the rescue of the first TAR patient we introduced a practical procedure on the diagnosis and treatment of TAR in our department. All the other patients generally followed this procedure. Eight patients received contrast material enhanced helical computerized tomography scan before the operation. The leakage of coustrast medium from the aorta isthmus was found, and diagnosis of TAR was confirmed. Seven patients underwent immediate operation within 14 hours after accidents. One patient was treated on the 5th day of the accident because of delayed diagnosis of aortic rupture. All patients received general anesthesia with double lumen endotracheal tube and normothermic femoro-femoral partial cardiopulmonary bypass, with beating heart and aortic clamping. One patient received simple repair, and others received partial replacement of thoracic aorta with artificial vascular graft. Results： Seven TAR patients were successfully salvaged. Three patients combined brain injury as well as extremitiy hemiplegia before operation. After treatments one was fully and two partially recovered without paraplegia. Conclusions： Proper practical protocol is emphasized for the surgical repair of TAR because it will reduce the mortality of severe blunt chest injury.