Thoracoscopy in Cameroon: Indications, Technics and Short Term Results

Introduction: Thoracoscopy is a video-assisted surgical approach that mirrors the techniques used in thoracotomy. Our aim is to map the current state of thoracoscopy practice in Cameroon’s hospitals. Methods: This was a descriptive study that collected both retrospective and prospective data over 57 months across four hospitals in Cameroon. It included 13 patients and focused on variables such as socio-demographic factors, clinical profiles, surgical procedures, and postoperative follow-up. Results: Thirteen patients, predominantly male (84.6%, n = 11), with a mean age of 37.5 ± 16 years, were enrolled. Alcohol use (61.5%) and smoking (38.5%) were the most common past histories. The major complaints were dyspnea (84.6%) and chest pain (58.3%). The primary surgical procedure was clot-free thoracoscopy in 30.8% of cases, mainly for persistent hemothorax (41.8%). Most surgeries were elective (76.9%) and performed under general anesthesia with selective intubation (61.5%). The most common approach was single-port thoracoscopy (U-VATS) (76.9%), with no reported difficulties;however, one intraoperative incident occurred and was successfully treated. Drainage was performed systematically in all patients, and one case required conversion to open surgery. Postoperative complications were minor (Clavien-Dindo grade I) and mainly consisted of pain, with a mortality rate of 15.4%. No significant association was found between risk factors and the occurrence of complications or postoperative mortality. Conclusion: Thoracoscopy, a novel approach in our context, primarily focuses on minor thoracic surgeries.

Parenchymal-sparing liver surgery in patients with colorectal carcinoma liver metastases

Liver resection is the treatment of choice for patients with colorectal liver metastases(CLM).However,major resections are often required to achieve R0 resection,which are associated with substantial rates of morbidity and mortality.Maximizing the amount of residual liver gained increasing significance in modern liver surgery due to the high incidence of chemotherapyassociated parenchymal injury.This fact,along with the progressive expansion of resectability criteria,has led to the development of a surgical philosophy known as "parenchymal-sparing liver surgery"(PSLS).This philosophy includes a variety of resection strategies,either performed alone or in combination with ablative therapies.A profound knowledge of liver anatomy and expert intraoperative ultrasound skills are required to perform PSLS appropriately and safely.There is a clear trend toward PSLS in hepatobiliary centers worldwide as current evidence indicates that tumor biology is the most important predictor of intrahepatic recurrence and survival,rather than the extent of a negative resection margin.Tumor removal avoiding the unnecessary sacrifice of functional parenchyma has been associated with less surgical stress,fewer postoperative complications,uncompromised cancer-related outcomes and higher feasibility of future resections.The increasing evidence supporting PSLS prompts its consideration as the gold-standard surgical approach for CLM.

ANA-HEp2 pattern evaluation in pancreatic cancer:What can the autoantibodies tell us?

To the Editor:Pancreatic neoplasms are mainly diagnosed by imaging methods and confirmed by biopsies[1].Imaging techniques and the tumor markers carbohydrate antigen 19-9(CA19-9)or carcinoembryonic antigen(CEA)used for follow-up,are expensive and of low sensitivity and specificity[2].

Accuracy of magnetic resonance cholangiography compared to operative endoscopy in detecting biliary stones, a single center experience and review of literature

AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography(MRCP) without contrast medium and endoscopic ultrasound(EUS)/endoscopic retrograde cholangiopancreatography(ERCP) for biliary calculi. METHODS: From January 2012 to December 2013, two-hundred-sixty-three patients underwent MRCP at our institution, all MRCP procedure were performed with the same machinery. In two-hundred MRCP was done for pure hepatobiliary symptoms and these patients are the subjects of this study. Among these two-hundred patients, one-hundred-eleven(55.5%) underwent ERCP after MRCP. The retrospective study design consisted in the systematic revision of all images from MRCP and EUS/ERCP performed by two radiologist with a long experience in biliary imaging, an experienced endoscopist and a senior consultant in Hepatobiliopancreatic surgery. A false positive was defined an MRCP showing calculi with no findings at EUS/ERCP; a true positive was defined as a concordance between MRCP and EUS/ERCP findings; a false negative was defined as the absence of images suggesting calculi at MRCP with calculi localization/extraction at EUS/ERCP and a true negative was defined as a patient with nocalculi at MRCP ad at least 6 mo of asymptomatic followup. Biliary tree dilatation was defined as a common bile duct diameter larger than 6 mm in a patient who had an in situ gallbladder. A third blinded radiologist who examined the MRCP and ERCP data reviewed misdiagnosed cases. Once obtained overall data on sensitivity, specificity, accuracy, positive predictive value(PPV) and negative predictive value(NPV) we divided patients in two groups composed of those having concordant MRCP and EUS/ERCP(Group A, 72 patients) and those having discordant MRCP and EUS/ERCP(Group B, 20 patients). Dataset comparisons had been made by the Student's t-test and χ2 when appropriate.RESULTS: Two-hundred patients(91 men, 109 women, mean age 67.6 years, and range 25-98 years) underwent MRCP. All patients attended regular follow-up for at least 6 mo. Morbidity and mortality related to MRCP were null. MRCP was the only exam performed in 89 patients because it did show only calculi into the gallbladder with no signs of the presence of calculi into the bile duct and symptoms resolved within a few days or after colecistectomy. The patients remained asymptomatic for at least 6 mo, and we assumed they were true negatives. One hundred eleven(53 men, 58 women, mean age 69 years, range 25-98 years) underwent ERCP following MRCP. We did not find any difference between the two groups in terms of race, age, and sex. The overall median interval between MRCP and ERCP was 9 d. In detecting biliary stones MRCP Sensitivity was 77.4%, Specificity 100% and Accuracy 80.5% with a PPV of 100% and NPV of 85%; EUS showed 95% sensitivity, 100% specificity, 95.5% accuracy with 100% PPV and 57.1% NPV. The association of EUS with ERCP performed at 100% in all the evaluated parameters. When comparing the two groups, we did not find any statistically significant difference regarding age, sex, and race. Similarly, we did not find any differences regarding the number of extracted stones: 116 stones in Group A(median 2, range 1 to 9) and 27 in Group B(median 2, range 1 to 4). When we compared the size of the extracted stones we found that the patients in Group B had significantly smaller stones: 14.16 ± 8.11 mm in Group A and 5.15 ± 2.09 mm in Group B; 95% confidence interval = 5.89-12.13, standard error = 1.577; P < 0.05. We also found that in Group B there was a significantly higher incidence of stones smaller than 5 mm: 36 in Group A and 18 in Group B, P < 0.05.CONCLUSION: Major finding of the present study is that choledocholithiasis is still under-diagnosed in MRCP. Smaller stones(< 5 mm diameter) are hardly visualized on MRCP.

Assessment of diagnostic capacity and decision-making based on the 2015 American Thyroid Association ultrasound classification system

BACKGROUND This study evaluates the American Thyroid Association(ATA)ultrasound(US)classification system for the initial assessment of thyroid nodules to determine if it indeed facilitates clinical decision-making.AIM To perform a systematic review and meta-analysis of the diagnostic value of the ATA US classification system for the initial assessment of thyroid nodules.METHODS In accordance with the PRISMA statement for diagnostic test accuracy,we selected articles that evaluated the 2015 ATA US pattern guidelines using a diagnostic gold standard.We analyzed these cases using traditional diagnostic parameters,as well as the threshold approach to clinical decision-making and decision curve analysis.RESULTS We reviewed 13 articles with 8445 thyroid nodules,which were classified according to 2015 ATA patterns.Of these,46.62%were malignant.No cancer was found in any of the ATA benign pattern nodules.The Bayesian analysis post-test probability for cancer in each classification was:(1)Very-low suspicion,0.85%;(2)Low,2.6%;(3)Intermediate,6.7%;and(4)High,40.9%.The net benefit(NB),expressed as avoided interventions,indicated that the highest capacity to avoid unnecessary fine needle aspiration biopsy(FNAB)in the patterns that we studied was 42,31,35,and 43 of every 100 FNABs.The NB calculation for a probability threshold of 11%for each of the ATA suspicion patterns studied is less than that of performing FNAB on all nodules.CONCLUSION These three types of analysis have shown that only the ATA high-suspicion diagnostic pattern is clinically useful,in which case,FNAB should be performed.However,the curve decision analysis has demonstrated that using the ATA US risk patterns to decide which patients need FNAB does not provide a greater benefit than performing FNAB on all thyroid nodules.Therefore,it is likely that a better way to approach the assessment of thyroid nodules would be to perform FNAB on all non-cystic nodules,as the present analysis has shown the ATA risk patterns do not provide an adequate clinical decision-making framework.

Molecular Microbial Diagnostic in Lung Transplant Recipients

The appearing of microbial lineages carrying multiple dangerous loci are results from the extensive use of antibiotics and has brought a huge increase in the infections-derived morbidity and mortality, which is critical in the hospital setting. Etiologic agents of these non easily tractable infections include bacteria, such as the genus Staphylococcus, but also fungi and virus. Alterations in the immune system allow these organisms to invade and affect the functionality of any tissue, organ or system of the human being. Pulmonary infection occurs as result of deficient lung systemic defence mechanisms which could be altered by medical treatments or by environmental factors. The infective agents commonly gain access to the lung by air, but also by blood or lymphatic system. Staphylococcus aureus strains that share antibiotic resistance and virulence factors represent the aetiological agent responsible of many cases of bacterial pneumonia, thoracic surgery postoperative infections, and diverse tissue infections, resulting in significant disease and morbidity in recipient patients after lung transplantation. The control and treatment of Staphylococcus infections, especially methicillin resistant strains, need for developing reliable and rapid methods of detection and characterization of these microorganisms. Nowadays, new insights into the diagnostic and epidemiology of MRSA and other pathogenic staphylococci have been developed employing molecular methods. This has meant an important advance in the diagnostic and treatment plans of such infective bacteria.

Evisceration of the Small Bowel in the Vagina Following Endo-Uterine Maneuvers for Clandestine Abortion (APC) at CHU Gabriel Touré, Bamako, Mali

Intra-uterine manual aspiration is the recommended maneuver for abortive endo-uterine evacuation. It must be performed in a medical setting for therapeutic purposes, while respecting its contraindications and asepsis rules essential for its implementation. The ignorance of anatomical structures by the authors of clandestine abortions is marked by the presence of utero-adnexal lesions, digestive lesions and vesical lesions or evisceration by the vagina. Vaginal evisceration of the small bowel is a rare and serious complication of manual intrauterine aspirations and induced abortions. Their late diagnosis and clandestine practice are responsible for unpredictable severe secondary complications and remain an important cause of morbidity and mortality. The development of a policy of continuous training of agents on the technique of manual intrauterine aspiration, broad information on contraceptive methods and a multidisciplinary, rapid and adequate management of complications will provide minimum morbidity and mortality. Conclusion: Abortion is a serious source of life-threatening complications.

The Rare Thoracic Tumor, Askin Tumors 7 Cases Report

The Askin tumour is a highly malignant rare tumour with small cells, pertaining to the group of the primitive neuroectodermal tumours. It develops with the costs of the soft parts of the thoracic wall and it’s characterized by extra and endothoracic fast extension. We report seven cases colliged in our service by specifying the role of the imagery in the diagnosis but especially the assessment of extension of these tumours.

Recurrent and Invasive Primary Squamous Cell Carcinoma of the Chest Wall: A Case Report

Squamous cell carcinoma is a type of skin cancer with abnormal proliferation of keratinocytes. Its incidence reaches approximately 20% of cases of non-melanoma skin cancer, which has increased in recent decades due to growth in life expectancy, increased sun exposure, the use of tanning beds and improved detection of this type of tumors. We present a patient who was diagnosed with a squamous cell skin carcinoma in the chest wall, treated initially with surgical resection. A few years recurred in the same place, so the patient received radiotherapy with poor response. Ultimately a new surgical approach was performed with a wide margin resection by a multidisciplinary surgical team. Multidisciplinary management in this type of procedure is important so that the long-term result is optimal for the patient.

Ectopic Pregnancy Combined with Intra-Uterine Pregnancy with a Full-Term Live Baby: A Case Report and Review of Literature

Heterotopic pregnancy is no more a medical breakthrough. It combines intrauterine pregnancy and extra-uterine pregnancy regardless of location. We report a case of intra-uterine pregnancy associated with a ruptured abdominal ectopic pregnancy located on the pelvic colon in a 29-year-old patient, third gestation, primigravida, having a live baby and a prior history of two abortions. She has blood group O negative of Rhesus. It has been diagnosed at the stage of the rupture of ectopic pregnancy. An emergency laparotomy performed under blood transfusion has revealed heavy hemoperitoneum (1100 ml), a ruptured abdominal extra-uterine localized on the pelvic under blood transfusion and a bulging uterus. We have proceeded with the aspiration of hemoperitoneum, the ablation of the extra-uterine pregnancy and the hemostasis of the section part. The post-operative follow-up has been easy. The intra-uterine pregnancy has developed normally and has given birth to a full-term live, and healthy baby.

Isolated Autoimmune Orchitis Due to IgG4 Hypersecretion Presenting as Tumor-Like Mass: Case Report and Review of Literature

Background: IgG4-related disease is a rare autoimmune condition that presents with lymphoplasmacytic infiltrate and fibrosis in the organ affected. Isolated testicle involvement is uncommon and there are only a few cases reported in the literature. Case Presentation: We report a case of isolated chronic orchitis due to IgG4 hypersecretion in a 61-year-old patient that evolved with asymptomatic tumor-like mass growth and was treated with left orchiectomy. Histopathological study revealed orchitis related to IgG4 hypersecretion disease. Conclusion: IgG4-related disease can be manifested as a multi or single-organ disorder. Most diagnoses are made after surgery with histopathological analysis. Most of the cases in literature stand out the difficulty in diagnosis and necessity of high suspicion due to this condition’s similarity with neoplasm presentation.

Inguinal Hernia Repair with Local Anesthesia in the Outpatient—10 Year Experience

Objective: To demonstrate the feasibility of inguinal hernia repair with local anesthesia in an out-patient regime, with safety, efficacy and short learning curve. Methods: We prospectively evaluated 1186 patients undergoing inguinal hernia repair under local anesthesia on an outpatient basis between November 2004 and March 2014. Of the total number of hernias surgically treated in this period, 755 were operated on the right, 394 on the left and 37 bilateral. We used clinical, surgical and psychosocial criteria for inclusion in the procedure. The parameters for exclusion were complex, irreducible or recurrent hernia, obesity (BMI greater than 30 kg/m2), patient’s refusal and psychiatric disorder. All patients underwent elective surgery and were analyzed regarding surgical outcome, complications and hospital stay. Results: All operations were completed successfully. In no case there was a need to change the anesthetic method. Surgical time was similar to that conducted with other methods of anesthesia and there were no cases of adverse effects of local anesthetics. Intra-operative complications amounted to approximately 2.64%. There was no need for hospital admissions greater than 24 hours. Conclusion: The procedure is feasible and causes no perioperative significant pain, is safe, can be performed by residents under supervision, has satisfactory patient acceptance and complications similar to those observed in a conventional herniorrhaphy, allowing lower time and cost of hospitalization and faster access to treatment.