Visceral Leishmaniasis at the National Reference University Hospital Center of N’Djamena (Chad): Epidemiological, Clinical, Diagnostic, Therapeutic and Prognostic Aspects

Introduction: leishmaniasis is a group of parasitic diseases caused by a parasite of the genus Leishmania transmitted by the bite of an infected vector called a sandfly. There are four forms. Visceral leishmaniasis is the most severe form. The aim of our work is to study the epidemiological, clinical, diagnostic, therapeutic and prognostic aspects of the disease in the Infectious Diseases Department of the Centre Hospitalier Universitaire de Référence Nationale in N'Djaména. Methodology: Patients were recruited on the basis of clinical signs suggestive of visceral leishmaniasis, i.e. prolonged fever, splenomegaly and altered general condition. Biological confirmation was performed with a rapid diagnostic test using recombinant K39 parasite antigen, which is known to have good specificity and sensitivity. Epidata version 3.1 software was used to process patient data. Results: From 05/04/21 to 15/12/23, 153 positive cases were managed. The mean age of patients was 18 years, with a sex ratio of 9.2. Of these patients, 103 (67.3%) had recently stayed at gold mining sites. Patients testing positive were treated with sodium stibogluconate combined with paromomycin for 17 days. The mortality rate was 13.2%. Conclusion: Leishmaniasis is a serious and little-known disease in Chad. In order to respond to the disease, it is necessary to reinforce the capacities of health structures and to carry out appropriate actions in the outbreaks.

Evaluating pediatric ureteropelvic junction obstruction:Dynamic magnetic resonance urography vs renal scintigraphy 99mtechnetium mercaptoacetyltriglycine

BACKGROUND Ureteropelvic junction obstruction(UPJO)is a common congenital urinary tract disorder in children.It can be diagnosed as early as in utero due to the presence of hydronephrosis or later in life due to symptomatic occurrence.AIM To evaluate the discrepancy between dynamic contrast-enhanced magnetic resonance urography(dMRU)and scintigraphy 99m-technetium mercaptoacetyltriglycine(MAG-3)for the functional evaluation of UPJO.METHODS Between 2016 and 2020,126 patients with UPJO underwent surgery at Robert DebréHospital.Of these,83 received a prenatal diagnosis,and 43 were diagnosed during childhood.Four of the 126 patients underwent surgery based on the clinical situation and postnatal ultrasound findings without undergoing functional imaging evaluation.Split renal function was evaluated preoperatively using scintigraphy MAG-3(n=28),dMRU(n=53),or both(n=40).In this study,we included patients who underwent surgery for UPJO and scintigraphy MAG-3+dMRU but excluded those who underwent only scintigraphy MAG-3 or dMRU.The patients were divided into groups A(<10%discrepancy)and B(>10%discrepancy).We examined the discrepancy in split renal function between the two modalities and investigated the possible risk factors.RESULTS The split renal function between the two kidneys was compared in 40 patients(28 boys and 12 girls)using scintigraphy MAG-3 and dMRU.Differential renal function,as determined using both modalities,showed a difference of<10%in 31 children and>10%in 9 children.Calculation of the relative renal function using dMRU revealed an excellent correlation coefficient with renal scintigraphy MAG-3 for both kidneys.CONCLUSION Our findings demonstrated that dMRU is equivalent to scintigraphy MAG-3 for evaluating split renal function in patients with UPJO.

Impact of body mass index in elderly patients treated with laparoscopic liver resection for hepatocellular carcinoma

BACKGROUND The impact of obesity on surgical outcomes in elderly patients candidate for liver surgery is still debated.AIM To evaluate the impact of high body mass index(BMI)on perioperative and oncological outcome in elderly patients(>70 years old)treated with laparoscopic liver resection for hepatocellular carcinoma(HCC).METHODS Retrospective multicenter study including 224 elderly patients(>70 years old)operated by laparoscopy for HCC(196 with a BMI<30 and 28 with BMI≥30),observed from January 2009 to January 2019.RESULTS After propensity score matching,patients in two groups presented comparable results,in terms of operative time(median range:200 min vs 205 min,P=0.7 respectively in non-obese and obese patients),complications rate(22%vs 26%,P=1.0),length of hospital stay(median range:4.5 d vs 6.0 d,P=0.1).There are no significant differences in terms of short-and long-term postoperative results.CONCLUSION The present study showed that BMI did not impact perioperative and oncologic outcomes in elderly patients treated by laparoscopic resection for HCC.

Peri-operative score for elderly patients with resectable hepatocellular carcinoma

BACKGROUND Liver resection is the mainstay for a curative treatment for patients with resectable hepatocellular carcinoma(HCC),also in elderly population.Despite this,the evaluation of patient condition,liver function and extent of disease remains a demanding process with the aim to reduce postoperative morbidity and mortality.AIM To identify new perioperative risk factors that could be associated with higher 90-and 180-d mortality in elderly patients eligible for liver resection for HCC considering traditional perioperative risk scores and to develop a risk score.METHODS A multicentric,retrospective study was performed by reviewing the medical records of patients aged 70 years or older who electively underwent liver resection for HCC;several independent variables correlated with death from all causes at 90 and 180 d were studied.The coefficients of Cox regression proportional-hazards model for sixmonth mortality were rounded to the nearest integer to assign risk factors'weights and derive the scoring algorithm.RESULTS Multivariate analysis found variables(American Society of Anesthesiology score,high rate of comorbidities,Mayo end stage liver disease score and size of biggest lesion)that had independent correlations with increased 90-and 180-d mortality.A clinical risk score was developed with survival profiles.CONCLUSION This score can aid in stratifying this population in order to assess who can benefit from surgical treatment in terms of postoperative mortality.

Cytoreductive surgery and hyperthermic intraperitonealchemotherapy in gastric cancer

Gastric cancer associated peritoneal carcinomatosis(GCPC) has a poor prognosis with a median survival of less than one year. Systemic chemotherapy including targeted agents has not been found to significantly increase the survival in GCPC. Since recurrent gastric cancer remains confined to the abdominal cavity in many patients, regional therapies like aggressive cytoreductive surgery( CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC) have been investigated for GCPC. HIPEC has been used for three indications in GC- as an adjuvant therapy after a curative surgery, HIPEC has been shown to improve survival and reduce peritoneal recurrences in many randomised trials in Asian countries; as a definitive treatment in established PC, HIPEC along with CRS is the only therapeutic modality that has resulted in longterm survival in select groups of patients; as a palliative treatment in advanced PC with intractable ascites, HIPEC has been shown to control ascites and reduce the need for frequent paracentesis. While the results of randomised trials of adjuvant HIPEC from western centres are awaited, the role of HIPEC in the treatment of GCPC is still evolving and needs larger studies before it is accepted as a standard of care.

Quantitative analysis using ELISA of vascular endothelial growth factor and basic fibroblast growth factor in human colorectal cancer,liver metastasis of colorectal cancer and hepatocellular carcinoma

Angiogenesis consists of the sprouting of capillaries from pre-existing vessels. It is well-known that tumor growth is angiogenesis-dependent. Vascular endothelial growth factor （VEGF） and basic fibroblast growth factor （bFGF） stimulated vascular endothelial cell proliferation and are involved in the neoplastic angiogenesis of several types of tumors including those of the intestinal tract. Authors usually investigated VEGF and using immunohistochemistry bFGF protein expressions or Western blotting and VEGF and bFGF transcripts using reverse transcriptase Dolymerase chain reaction （RT-PCR）.

Platelet-activating factor in cirrhotic liver and hepatocellular carcinoma

AIM： Platelet-activating factor （PAF） is a pro-inflammatory and angiogenic lipid mediator. Here we aimed to investigate levels of PAF, lyso-PAF （the PAF precursor）, phospholipase A2 （PLA2, the enzymatic activity generating lyso-PAF）, acetylhydrolase activity （AHA, the PAF degrading enzyme） and PAF receptor （PAF-R） transcripts in cirrhotic liver and hepatocellular carcinoma （HCC）. METHODS： Twenty-nine patients with HCC were enrolled in this study. Cirrhosis was present in fourteen patients and seven had no liver disease. Tissue PAF levels were investigated by a platelet-aggregation assay. Lyso- PAF was assessed after its chemical acetylation into PAR AHA was determined by degradation of [^3H]-PAE PLA2 levels were assessed by EIA. PAF-R transcripts were investigated using RT-PCR. RESULTS： Elevated amounts of PAF and PAF-R transcripts 1 （leukocyte-type） were found in cirrhotic tissues as compared with non-cirrhotic ones. Higher amounts of PAF and PAF-R transcripts 1 and 2 （tissue-type） were found in HCC tissues as compared with non-tumor tissues. PLA2, lyso-PAF and AHA levels were not changed in cirrhotic tissues and HCC. CONCLUSION： While the role of PAF is currently unknown in liver physiology, this study suggests its potential involvement in the inflammatory network found in the cirrhotic liver and in the angiogenic response during HCC.

VEGF in hepatocellular carcinoma and surrounding cirrhotic liver tissues

We read with a great interest the recent work of Deli and colleagues. in the World Journal of Gastroenterology reporting vascular endothelial growth factor （VEGF） expression in hepatocellular carcinoma （HCC） and cirrhotic liver tissues. This well-documented work shows that VEGF was significantly higher in surrounding cirrhotic liver tissues than in HCC. Authors assessed VEGF expression using immunohistochemistry. The immunohistochemical staining is an efficient tool to assess the percentage of cells stained positively for VEGF but is not really efficient to estimate their true VEGF content. Evaluation of the VEGF protein by an enzyme-linked immunosorbent assay 0ELISA） has been reported, by us and others, to be an efficient tool in order to assess tissue VEGF expression. We have, thus, tested whether the ELISA method might be an efficient tool in order to confirm data reporting higher amounts of VEGF in surrounding cirrhotic liver tissues than in HCC. Deli and colleagues. also correctly pointed out that basic fibroblast growth factor （bFGF） has been reported to act cooperatively on VEGF expression. We have, thus, also assessed bFGF tissue levels in order to search for a putative link between VEGF and bFGF levels in cirrhotic tissues.

Double ischemic ileal stenosis secondary to mesenteric injury after blunt abdominal trauma

The authors describe a rare case in which blunt abdominal trauma resulted in mesenteric injury with delayed double ischemic ileal stenosis. Abdominal computed tomography demonstrated stenotic ileal loop with mural thickening. At surgery, a double stenotic bowel loop was found adjacent to a healed defect in the mesentery. Histological examination of the two resected segments showed fibrotic and ischemic lesions within the mesentery. Ischemic intestinal stenosis from mesenteric injury should be considered in the differential diagnosis in patients suffering from intestinal occlusion with a history of blunt abdominal trauma.

Choledochal cyst: A difficult diagnosis

Choledochal cyst is defined as a cystic dilatation of the distal common bile duct protruding into the duo- denum. It is considered as the rarest congenital cyst of the biliary tract by 1.4%. We report a 46 years old woman who presented with recurrent jaundice associated with abdominal pain of 07 years duration. The liver function tests showed cholestasis. The abdominal scan and Biliary MRI revealed a dilatation of intrahepatic, pancreatic ducts and a dilatation of the common bile duct with a stenosis in its the lower part. The diagnosis of a common bile duct cholangiocarinoma was mentioned. The gastroscopy revealed a stenosed duodenal bulb not allowing us to perform an echo endoscopy and ERCP. An intraoperative cholangiography illustrating a cystic dilatation of the papillary region in which exist a separate protrusion of the choledochal and wirsung ducts. Therefore, we didn’t accomplish the cephalic duodeno-pancreatectomy and we decided to realize a partial resection of the papilla. The histolological examination proved the absence of any tumoral lesion and the presence of biliary mucosa layered the internal surface of the cyst. The patient is still asymptomatic after one year of the surgery.

肝癌射频热消融治疗:前瞻性研究82个肝损害

Objectives - The aim of this prospective study was to evaluate the feasibility of radiofrequency ablation of hepatic tumors. We studied the rates of mortality, morbidity, and recurrence and recorded overall and disease-free survival. Methods - All patients aged over 18 years with histologically proven malignant liver disease inaccessible to surgical treatment (one to four tumor localizations) were eligible for inclusion in the study. Child-Pugh score > B9, platelets count ≤ 50× 103/mm3, prothrombin index ≤ 50% and pregnancy were exclusion factors. Results - Between July 2001 and June 2004, 51 patients (13 women, 38 men, mean age 66 ± 9 years) were included and underwent 61 radiofrequency thermal ablation procedures for 82 hepatic lesions: hepatocarcinoma (N = 44), cholangiocarcinoma (N = 1), metastasic tumors (N = 37). Hospital morbidity and mortality were 11.5% and 2% respectively. Recurrence rate at 3 years was 20.6% . In multivariate analysis, only tumor size > 3 cm was correlated significantly with recurrence (P = 0.03). Actuarial 1- , 2- and 3- year survival rates in the hepatocarcinoma group (N = 31) were 84.7% , 57.7% and 34.6% respectively. Actuarial 1- , 2- and 3- year survival rates in the metastasis from colorectal adenocarcinoma group (N = 14) were 90% , 54% and 54% respectively (P = 0.72). Conclusion - Radiofrequency thermal ablation is an effective treatment for hepatic tumors measuring less than 3 cm. There is a low risk of complications and open surgery can be associated. However in the Absence of randomized studies comparing radiofrequency and surgery, respective indications cannot be defined in detail.

Meckel Diverticulum Carcinoid Tumor Complicated by Ileal Invagination. About One Case at Vichy Hospital

Meckel’s diverticulum is a common pathology in children and rare in adults. We present a case of a 79-year-old patient in which a significant gastrointestinal bleeding, whose paraclinical explorations confirmed a fatty tumor of the terminal ileum. The exploratory coelioscopy revealed a tumor of the Meckel diverticulum complicated of intestinal invagination, resected at the same time with resection and extracorporeal anastomosis by mini coelio-guided laparotomy. Histology confirmed the presence of heterotopical tissue of the duodenal mucosa with Brunner cells and a carcinoid tumor. In conclusion, this clinical case shows that coelioscopy can be considered a very important diagnostic and therapeutic tool in this pathology especially in the elderly.