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African Annals of Thoracic and Cardio-Vascular Surgery Annales Africaines de Chirurgie Thoracique et Cardio-Vasculaire

ISSN 1994-7461

Directeur de publication / Managing Editor

Rédacteur en Chef / Editor-in-Chief

Rédacteur en Chef délégué / Assistant Editor-in-Chief

Hervé YANGNI-ANGATE

François ONDO N’DONG

Martin AGHAJI

Comité de Rédaction / Editorial Board- M. AGHAJI- M. AHMED- NASR- K. FRIMPONG- BOATENG- M. NDIAYE- F. ONDO N’DONG- O. OSINOWO- KH. YANGNI-ANGATE- C. YANKAH

Nigeria Egypte Ghana Sénégal Gabon NigeriaCôte d’Ivoire Ghana

USA France France France FranceUSA France USA USA

Adresse du Rédacteur en Chef / Adress of Editor-in-ChiefProf. François ONDO N’DONG

Fondation Jeanne Ebori B.P 306 Libreville Gabon

Email: [email protected]

Adresse du Rédacteur en chef-délégué / Addresse of Assistant Editor-in-ChiefProf. Martin AGHAJI

Dept of Surgery UNTH Enugu Nigeria

Email: [email protected]

- S. ADEBONOJO- C. DESPINS- M. DUMONT- P.E. MAGNAN- M. MARCHAND- T. PEZZELLA- P. THOMAS- R. JONAS- J. MARSHALL

Ann. Afr. Chir. Thor. Cardiovasc. 2018; 13(1)

1Afr.Ann Thorac.Cardiovasc.Surg. 2018; 13(1)

INSTRUCTIONS AUX AUTEURS

Les Annales Africaines de Chirurgie Thoracique et Cardio-Vasculaire publient des articles originaux, des éditoriaux, des revues générales, des faits cliniques, des lettres à la rédaction, des notes de technique et des articles de pédagogie médicale.

Conditions générales de publication

Les manuscrits ne doivent avoir fait l’objet d’aucune publication antérieure ni être en cours de publication dans une autre revue. Les textes doivent être saisis en double interligne, de police de caractère 12 minimum, 25 lignes par page maximum, et adressés en triple

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auteur , l’adresse complète avec numéro de téléphone et de fax de l’auteur à qui doit être envoyé la correspondance. La disposition

-systématiquement une introduction, un chapitre matériel et méthodes, suivi des résultats et une discussion

- Les éditoriaux sont sollicités par la Rédaction, et n’excèdent pas 6 pages, références comprises, et limitées à 10. - Les faits cliniques et les notes de technique ne doivent pas dépasser 6 pages, références non comprises mais limitées à 15. - Les revues générales peuvent être sollicitées par la rédaction. Elles ne doivent pas dépasser 20 pages. Les références ne

sont pas limitées. - Les lettres à la rédaction doivent compter au maximum 2 pages, et 5 références. - D’une façon générale, les abréviations doivent être évitées autant que possible. Elles doivent être indiquées ą leur première

apparition dans le texte, après l’expression ou le mot qu’elles abrègent. Il faut éviter de les employer dans le titre et le résumé.

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Un résumé en Anglais et un résumé en français n’exédant pas 250 mots accompagnent le manuscrit. Ce résumé doit être structuré de la faćon suivante, pour les travaux originaux : objectifs méthodes, résultats et conclusions. Pour les faits cliniques et les notes

doivent être extraits de la liste des mots-clés de l’Index Medicus

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Les références sont numérotées dans l’ordre d’apparition dans le texte, en chiffres arabes et entre parenthèses.

le style dit de Vancouver :

- Pour une revue : MORTINIERA N.C., MBAMEND AME S., OKOME P., et al. Le syndrome de Cockett : à propos de deux cas. Bull . Med. Ow endo, 2002, 20 : 3 6-38. Lorsqu’il y a plus de 6 auteurs, citer les 3 premiers, suivis de «et al».

- Pour un chapitre d’un livre : HUANG GJ, WU YK. Operative technique for carcinoma of the esophagus and gastric cardia. In : HUANG GJ , WU YK, editors. Carcinoma of the esophagus and gastric cardia. Berlin. Spriger, 1984 : 313-34 8

-

Les tableaux sont numérotés en chiffres arabes dans l’ordre de leur première citation dans le texte. Chaque tableau est dactylographié en double interligne sur une feuille séparée, mentionnant le numéro du tableau et son titre. Le contenu des tableaux ne doit pas faire double emploi avec celui du texte. Les courbes, schémas, dessins, diagrammes et autres illustrations sont numérotés en chiffres arabes dans l’ordre de leur première citation dans le texte. Les documents doivent être de qualité professionnelle. Ils sont fournis sur papier photo noir et blanc, glacé, en format 13 x18cm. Les indications sont inscrites au verso sur une étiquette adhésive indiquant le

La fourniture de documents de toute nature implique l’autorisation de publication et de reproduction uniquement par la Revue, sauf convention particulière préalable entre l’auteur et l’éditeur.



INSTRUCTIONS TO THE AUTHORS

African Annals of Thoracic and Cardio-Vascular Surgery publish original articles, leading articles, general reviews, clinical facts, letters to editor, notes of technique and articles of medical pedagogy.

General conditions of publication

The manuscripts should have been the subject of no former publication nor to be in the course of publication in another review.The text s must be seized in double space, of bil l of character 12 minimum, 25 lines per m aximum page, and be addres sed in

on diskette is re quired. The diskettes must be of type IBM or IBM-compatible, software Word 98 or 2000. They must carry a label

Layout of texts

each author, the complete address with fax and telephone number of the author, who must be sent the corre spondence.

- The provision of the manuscripts is as follows: title page, summaries and key words, text, references, tables, and legends of the

-comprise an introduction, a material and method chapter, followed by results, and a discussion.

- The leading articles are requested by the drafting, and do not exceed 6 pages, references included, and limited to 10. - The clinical facts and the notes of technique should not exceed 6 pages, references not included, and limited to 15. - The general reviews can be requested by the drafting. They should not exceed 20 pages. The references are not limited. - The letters to the editor must count to the maximum 2 pages, and 5 references. Generally, the abbreviations must be avoided

shorten. It is necessary to avoid employing them in the title and the summary.

Summaries and key words

An English summary and a French summary not exceeding 250 words accompany the manuscript. This summary must be stru ctured in the following way, for original work : objectives, methods, results and conclusions. For the clinical facts and the technical notes, the summary should not excced 100 words. 3 to 5 English and French key words must appear under thesummaries.They must be extracted from the list of the key words of the Medicus Index

References

The references are numbered in the order of appearance in the text, in Arab numerals and between brackets. The abbreviations of the titles of the newspapers must be those which appear in the Medicus Index. The references are presented according to the style known as of Vancouver:

- For a review: MORTINIERA N.C., MBAMENDAM E S., OKOME P., et al. The Syndrome of Cockett: report of two cases. Bull.

- For a chapter of a book : HUANG GJ. WU YK Operative for carcinoma of the esophagus and gastric cardia. In HUANG GJ. WU YK, editors. Carcinoma of the esophagus and gastric cardia. Berlin. Springer, 1984 ; 313-348

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separeted sheet, mentioning the number of the table and its title. The contents of the tables should not not make double employment with that of the text. The documents must be of professionnal quality. They are provided of photo paper black and white, frozen,

reproduction only by the review, except preliminary particular convention between the author and the editor.




ANNALES 1er SEMESTRE 2018/ ANNALS 1st SEMESTER 2018

ANNALES AFRICAINES DE CHIRURGIE THORACIQUE ET CARDIO-VASCULAIRE/

AFRICAN ANNALS OF THORACIC AND CARDIO-VASCULAR SURGERY

Volume 13 Numéro 1, 2018/ Volume 13 Issue 1, 2018

SOMMAIRE / CONTENTS

SOMMAIRE / CONTENTS

CHIRURGIE CARDIAQUE / CARDIAC SURGERY

CHIRURGIE THORACIQUE / THORACIC SURGERY

CHIRURGIE VASCULAIRE / VASCULAR SURGERY


1- Using technology and innovation to address the three delays in access to cardiac surgery

D. Vervoort, MD (United States of America)

4- Chest surgical approaches in Africa: A constant challengeKH.Yangni-Angate et al (Cote d’Ivoire)

Vinicius Nina MD (Brazil)

3- The diagnosis and comprehensive management of congenital heart diseases in nations with severely restricted general and specialist healthcare services.

2- Prise en charge des varices des membres inferieurs au centre hospitalier universitaire de brazzaville

R. Atipo-Galloye (Congo-Brazzaville)

Pages

5-10

11-18

19-26

27-37

CHIRURGIE CARDIAQUE / CARDIAC SURGERY

5Afr.Ann Thorac.Cardiovasc.Surg. 2018; 13(1) 5-9

USING TECHNOLOGY AND INNOVATION TO ADDRESS THE THREE DELAYS IN ACCESS TO CARDIAC SURGERY

D. VERVOORT, MD1.J. KPODONU, MD2

1 Program in Global Surgery and Social Change, Harvard Medical School 2 Beth Israel Deaconess, Harvard Medical School

Jacques Kpodonu, MDBeth Israel Deaconess Medical Center Division of Cardiac Surgery110 Francis Street, Suite 2ABoston, MA 02215Email: [email protected]

Correspondence:

Introduction

Ann. Afr. Chir. Thor. Cardiovasc. 2018; 13(1) 5-9

Cardiovascular diseases (CVD) make up the leading cause of mortality in the world with 17.65 million deaths every year, of which more than 80% occurs in low- and middle-income countries (LMICs).(1) With the ongoing shift of the global burden of CVD towards low-re-source settings, a mortality rate of 25 million deaths is projected in these regions by 2030.(2) Nevertheless, it is estimated that 93% of the population in LMICs do not have access to safe cardiac surgical care, due to lack of nearby faci-lities, limited specialist and allied health workforce, and high risk of catastrophic expenditure. As such, there is a pressing need to address the barriers in receiving cardiac surgi-cal care. The Three Delays Framework can be used as a model to examine the barriers underlying access to cardiac care.The First Delay, the delay in recognizing the disease and seeking care, com-prises health illiteracy, stigma of the condition, misperceptions of or lack of trust in modern me-dicine, and economic barriers. The Second Delay, the delay in reaching care,

includes the time and difficulty reaching the nearest facility providing cardiac surgical care, dependent on road infrastructure, climate conditions, availability of private vehicles, public transport, or ambulatory ser-vices, and the geographical distance to the facility. The Third Delay, the delay in receiving care, includes a four-fold delay: a delay in receiving appropriate care at the initial facility, delay in timely referral to another facility to receive definite care, delay in receiving appro-priate definite care at a second facility, and a delay in post-operative care and long-term follow-up in the setting of cardiac diseases. The availability of workforce, in particular surgical specialist workforce, is a constant and widespread issue in LMICs. Sub-Saharan Africa, for example, relies on only 1 cardiotho-racic surgeon per 4 million people.(3) In total, they possess only 1% of the world’s total cardiothoracic surgical workforce. In addition, lack of surgical and medical infrastructure imposes an additional barrier for receiving care. For example, in LMICs, dedicated cardiac



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intensive care units (CICUs) with specialized personnel is limited, but dramatically improves outcomes in patients following cardiac surgery.(4) Telemedicine is a useful tool to overcome geo-graphical barriers and lack of workforce in order to provide quality care and medical edu-cation from a distance. Clinicians are able to use mobile videoconference systems to remo-tely access a patient’s room and monitor vital signs. This, in turn, can allow for better care and service for the patient, whilst saving time and reducing costs of clinicians, patients, and their families.(5) For heart failure, telecare decreased hospitalization and mortality rates by 20% with corresponding reduction in medical expenses and increase in the quality of life.(6) Similarly, the use in follow-up after cardiac surgery has proven effective in reducing readmission rates and preventing unnecessary visits (and related costs and anxiety), with high levels of satisfaction by both surgeons and patients.(7) Moreover, the use of “electronic CICUs” (e-CICUs) serviced through telemedicine and adapted to local needs has proven logistically feasible and effective in reducing CICU and hospital length-of-stay for both adult and paediatric cardiac care com-pared to pretelemedicine periods.(4,8) In a day and age of widespread cellular use and expan-ding internet connectivity, the use and develop-ment of mobile health (mHealth) innovations to scale up access to healthcare in low-resource settings becomes increasingly important. mHealth devices allow for reductions in costs, higher ease of use, and portability to help bridge existing gaps in cardiac care through decentrali-zing diagnostics and medical management to health professionals and CHWs in remote loca-tions.(9) In this study, we review existing and potential technological innovations to address the three delays limiting access to cardiac surgi-cal care in low- and middle-income countries.

MethodsA focused literature review was done searching the medical database PubMed using the keywords“technology”,“innovation”,“low-in-come”,“low-resource”,“developing country”, “rheumatic heart disease”, “congenital heart defect”, and “cardiac surgery” to identify litera-ture on low-cost innovations and technology to bridge the gap to accessing cardiac surgical care.

ResultsThe First Delay - Delay in Seeking Care Any delay in recognizing existing disease or being aware of the availability of necessary treatment increases the likelihood of not recei-ving timely care and thus negatively influences outcomes and long-term prognosis. Although cost is traditionally mentioned as an important factor in deciding to seek care, other factors, such as recognizing the disease and the perception of the quality of the available care, influence this decision more.(10,11) For the former, training community health workers (CHWs) to timely detect signs of cardiac surgi-cal disease is an effective and low-cost way to reduce the delay in seeking care. The use of handheld echocardiography, rather than sole auscultation, is an effective and low-cost innovation to detect early cardiac disease, in particular RHD, by trained non-physicians.(12,13) This can be stren-gthened through web-based evaluation of echocardiograms using a cloud-based server through specialists from a distance.(14) More broadly, using mHealth kits able to monitor vital signs (e.g., mobile blood pres-sure, oxymetry, pocket echocardiography, iPhone electrocardiogram, and point-of-care BNP) allows for timely referral for cardiac interventions and lower probability of hospita-lization or death.(15)

The Second Delay - Delay in Reaching Care Identifying and reaching the nearest facility able to provide affordable and quality cardiac care relies upon the organization of the prehospital chain to access the clinical set-ting. Initiating effective pre-hospital care through training lay first responders has proven to improve survival by reducing the time to treatment in trauma care.(16) Mobile surgical units for cardiovascular disease further reduce the time to treatment and can serve as a bridge between immediate life-sa-ving care in the pre-hospital setting and more complex permanent interventions upon reaching the surgical facility.(17)

The Third Delay - Delay in Receiving Care In order to avoid delays in care and prevent nee-dless suffering, decentralizing diagnosis and management of cardiac with appropriate me-dical therapy and timely referral to surgical facilities is possible and necessary.(18)



Conferencing between remote hospitals and cardiac centers allows for the optimization of and reduction in (unnecessary) patient trans-fers.(19) After receiving surgical care for cardiac diseases, immediate and long-term medical care and follow-up screening is essential to warrant optimal health outcomes. Cardiac rehabilitation, due to the costs and lack of widespread specia-lized centers, is traditionally hardly accessible for patients in LMICs. Through telemedicine using videoconferencing, patients are able to access rehabilitation at distant sites with similar results as conventional rehabilitation sites.(20) For example, the eRegister system by the World Heart Federation ensures real-time patient data collection and secondary prophy-laxis, whilst keeping patients reminded of appointments through the use of SMS remin-ders and CHWs compliant with diagnostic guidelines through electronic forms.(21)

Discussion Technological innovation has the ability to reduce all three delays in accessing cardiac surgical care, in addition to strengthening post-operative and long-term primary health systems to ensure optimal short-and long-term outcomes. The use of digital health kits inclu-ding portable echocardiography and mHealth devices able to monitor oxymetry, blood pres-sure, ECG, and point-of-care BNP allows for efficient and cost-effective early diagnosis and follow-up of cardiac conditions ranging from RHD to heart failure. In addition, the wides-pread use of smartphones, cellular use, and internet connectivity allows for remote monito-ring and conferencing of experienced specia-lists with less experienced specialists in rural hospitals or community health workers in com-munity facilities. Moreover, patients are able to be reminded of medication use, rehabilitation instructions, or screening reminders through mobile texting. Altogether, mHealth can bridge the gap in accessing cardiac care. One barrier in receiving care for cardiac surgical disease is the availability of equipment, in particular to replace valves in patients with severe aortic stenosis or mitral stenosis, the latter commonly due to rheumatic heart disease (RHD). Every year, over 290,000 valve replacements are done around the world, the majority taking place in Europe and the United States, accoun-ting for a US$2 billion market.

Due to the high costs, use in LMICs remains scarce in the light of the higher need due to RHD. The creation of low-cost biomolecularly enhanced polymeric heart valve with hyalu-ronan, as opposed to traditional use of tissue valves, allows for high biocompatibility and lifelong durability, able to be placed using trans-catheter aortic valve replacement (TAVR). In addition, the polymeric heart valve material does not require anticoagulation the-rapy, minimizing costs and need for close monitoring and follow-up of patients. In addi-tion to potential widespread use of technology to improve patient care, the ability to improve the skills and opportunities for surgeons arises in a similar manner. Mobile applica-tions have allowed students and health pro-fessionals around the world to practice their medical and surgical knowledge and skills outside the clinical setting. For example, Touch Surgery, a free mobile application with over 2 million users worldwide, lets users learn, prepare, and test for surgical proce-dures at any given location at any given time through a library of over 150 interactive, cognitive surgical simulations.(22) Virtual reality is slowly becoming used to give students, residents, and surgeons remote access to surgical procedures elsewhere in the world to learn from experts in a virtual real-time manner. Moreover, a digital health platform can connect cardiac specialists all over the world through a collaborative platform for training, education, research, and patient care, with the ability to expedite information sharing and service coordination to create a practical pathway for the delivery of cardiac care in LMICs. Lastly, such a platform would promote the establishment of a coalition of stakeholders, including, but not limited to cardiothoracic surgeons, cardiologists, indus-try, governments, and funders, to discuss and advance cardiac care around the world.

Conclusion Access to cardiac surgery in developing coun-tries remains scarce and delays in accessing treatment and follow-up care occur at all levels of the care pathway. Innovative mHealth and technological strategies to promote early dia-gnosis of surgical cardiac conditions, reduce readmission rates, and ensure proper



postdischarge management of patients are fea-sible and affordable in bridging the current gaps in LMICs. In addition, mobile connectivity allows for remote interaction between patients and medical specialists, as well as the creation of a web-based community of health professionals and stakeholders to improve cardiac care around the world.

References 1.IHME GHDx. GBD Results Tool [Internet]. 2016. Available from: http://ghdx.healthda-ta.org/gbd-results-tool 2.Yusuf S, Rangarajan S, Teo K, Islam S, Li W, Liu L, et al. Cardiovascular Risk and Events in 17 Low-, Middle-, and High-Income Countries. N Engl J Med [Internet]. 2014 Aug 27;371(9):818–27. Available from: https://doi.org/10.1056/NEJMoa1311890 3.Yankah C, Fynn-Thompson F, Antunes M, Edwin F, Yuko-Jowi C, Mendis S, et al. Cardiac surgery capacity in sub-Saharan Africa: Quo Vadis? Thorac Cardiovasc Surg. 2014;62(5):393–401. 4.Otero AV, Lopez-magallon AJ, Jaimes D, Motoa MV, Ruz M, Erdmenger J, et al. Internatio-nal Telemedicine in Pediatric Cardiac Critical Care: A Multicenter Experience. 2014;20(7):619–25. 5.Lopez-Magallon AJ, Otero AV, Welchering N, Bermon A, Castillo V, Duran Á, et al. Patient Out-comes of an International Telepediatric Cardiac Critical Care Program. Telemed J e-Health [Internet]. 2015 Aug 1;21(8):601–10. Available from: http://www.ncbi.nlm.nih.gov/pmc/ar-ticles/PMC4523040/ 6.Paré G, Jaana M, Sicotte C. Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base. J Am Med Inform Assoc [Internet]. 2007 Sep 8;14(3):269–77. Available from: http://www.ncbi.nlm.nih.gov/pm-c/articles/PMC2244878/ 7. Park DK, Jung E-Y, Park RW, Lee YH, Hwang HJ, Son IA, et al. Telecare System for Cardiac Surgery Patients: Implementation and Effective-ness. Healthc Inform Res [Internet]. 2011 Jun 30;17(2):93–100. Available from: http://www.nc-bi.nlm.nih.gov/pmc/articles/PMC3155172/

8.Gupta S, Dewan S, Kaushal A, Seth A, Narula J, Varma A. eICU Reduces Mortality in STEMI Patients in Resource-Limited Areas. Glob Heart [Internet]. 2014;9(4):425–7. Available from: http://www.sciencedirect.com/science/ar-ticle/pii/S2211816014026040 9.Agarwal S, Perry HB, Long L-A, Labrique AB. Evidence on feasibility and effective use of mHealth strategies by frontline health workers in developing countries: systematic review. Trop Med Int Heal [Internet]. 2015 Apr 16;20(8):1003–14.Available from: https://doi.org/10.1111/tmi.12525 10.Leigh B, Kandeh HB., Kanu M., Kuteh M, Palmer I., Daoh K., et al. Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone. Int J Gynecol Obstet [Internet]. 1998 Feb 5;59(S2):S55–65. Available from: https://doi.org/10.1016/S0020-7292(97)00148-3 11.Thaddeus S, Maine D. Too far to walk: Mater-nal mortality in context. Soc Sci Med [Internet]. 1994;38(8):1091–110. Available from: http:/ /www.sciencedirect.com/science/ar-ticle/pii/0277953694902267 12.Godown J, Lu JC, Beaton A, Sable C, Mirem-be G, Sanya R, et al. Handheld Echocardiogra-phy Versus Auscultation for Detection of Rheu-matic Heart Disease. Pediatrics [Internet]. 2015 Apr 1;135(4):e939 LP-e944. Available from: h t t p : / / p e d i a t r i c s . a a p p u b l i c a -tions.org/content/135/4/e939.abstract 13.Ploutz M, Lu JC, Scheel J, Webb C, Ensing GJ, Aliku T, et al. Handheld echocardiographic screening for rheumatic heart disease by non-ex-perts. Heart [Internet]. 2016 Jan 1;102(1):35 LP-39. Available from: http://heart.b-mj.com/content/102/1/35.abstract 14.Singh S, Bansal M, Maheshwari P, Adams D, Sengupta SP, Price R, et al. American Society of Echocardiography: Remote Echocardiography with Web-Based Assessments for Referrals at a Distance (ASE-REWARD) Study. J Am Soc Echocardiogr [Internet]. 2013;26(3):221–33. Available from: http://www.sciencedirect.com/s-cience/article/pii/S0894731712009819



15.Bhavnani SP, Sola S, Adams D, Venkateshva-ran A, Dash PK, Sengupta PP, et al. A Rando-mized Trial of Pocket-Echocardiography Inte-grated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics. JACC Cardiovasc Imaging [Internet]. 2018;11(4):546–57. Available from: http: / /www.sciencedirect.com/science/ar-ticle/pii/S1936878X17307210 16.Murad M, Husum H. Trained lay first respon-ders reduce trauma mortality: a controlled study of rural trauma in Iraq. Prehosp Disaster Med. 2010;Nov-Dec;25. 17.Itrat A, Taqui A, Cerejo R, al et. Telemedicine in prehospital stroke evaluation and thrombolysis: Taking stroke treatment to the doorstep. JAMA Neurol [Internet]. 2016 Feb 1;73(2):162–8. Avai-lable from: http://dx.doi.org/10.1001/jamaneu-rol.2015.3849 18.Kwan GF, Bukhman AK, Miller AC, Ngoga G, Mucumbitsi J, Bavuma C, et al. A Simplified Echocardiographic Strategy for Heart Failure Dia-gnosis and Management Within an Integrated Noncommunicable Disease Clinic at District Hos-pital Level for Sub-Saharan Africa. JCHF. 2013;1(3):230–6.

19.Nagayoshi Y, Oshima S, Ogawa H. Clinical Impact of Telemedicine Network System at Rural Hospitals Without On-Site Cardiac Sur-gery Backup. Telemed e-Health [Internet]. 2016 May 5;22(11):960–4. Available from: https://doi.org/10.1089/tmj.2015.0225 20.Dalleck LC, Schmidt LK, Lueker R. Cardiac rehabilitation outcomes in a conventional versus telemedicine-based programme. J Telemed Telecare [Internet]. 2011 Apr 20;17(5):217–21. Availablefrom: https://doi.org/10.1258/jtt.2010.100407 21.Dam J Van, Musuku J, Zühlke LJ, Engel ME, Nestle N, Tadmor B, et al. Cardiovascular Topics An open-access , mobile compatible , electronic patient register for rheumatic heart disease (“ eRegister ”) based on the World Heart Federation ’ s framework for patient registers. 2015;(October):1–7. 22.Brewer ZE, Ogden WD, Fann JI, Burdon TA, Sheikh AY. Creation and Global Deploy-ment of a Mobile, Application-Based Cognitive Simulator for Cardiac Surgical Procedures. Semin Thorac Cardiovasc Surg [Internet]. 2016;28(1):1–9.Available from:htp://www.sciencedirect.com/science/ar-ticle/pii/S1043067916000277


Ann. Afr. Chir. Thor. Cardiovasc. 2018; 13(1):19-26

10Afr.Ann Thorac.Cardiovasc.Surg. 2018; 13(1): 19-26

THE DIAGNOSIS AND COMPREHENSIVE MANAGEMENT OF CONGENITAL HEART DISEASES IN

NATIONS WITH SEVERELY RESTRICTED GENERAL AND SPECIALIST HEALTHCARE SERVICES.

VINICIUS NINA MD., PHD 1,2, EMILY FARKAS MD, FACS 3,4, RACHEL H NINA MD., PHD 5,6, JANINE HENSON RN., BSN., CCRN7, AUBYN MARATH., MBBS., MS., FRCSED., ATLS8

1 Universidade Federal do Maranhão (UFMA), São Luís, MA, Brazil. 2 Member of the Board of Trustees for CardioStart International, Tampa, FL, USA. 3 Cardiothoracic Surgeon at the ThedaCare Heart Institute, Appleton, WI, USA. 4 Member of the Board of Trustees for CardioStart International, Emergency USA, Italy and VOOM Foundation, USA. 5 Universidade Ceuma, São Luís, MA, Brazil. 6 Volunteer for CardioStart International, Tampa, FL, USA. 7 Executive Vice-President of CardioStart International, Tampa, FL, USA 8 Founder and President of CardioStart International, Tampa, Fl, USA.

SummaryDisease (CHD) in clinically sub-optimal settings. It is presented to provide simple diferences between certain conditions commonly seen in children with CHD for training doctors and nurses and other staff working within the speciality. In the majority of clinical presentations, a comprehen-sive, well structured training of a multidisciplinary team and carefully chosen hospital equip-ment and resources, can permit CHD to be safely and effectively treated by palliative or curative procedures. In our experience using this strategy, outcomes are almost comparable to those in advanced centers across the world. Among nations with severely restricted general and spe-cialist healthcare resources, several issues must be overcome to diagnose and treat children with congenital heart diseases (CHD). The principal challenges to address are: Provider issues 1. Lack of primary and tertiary specialist facilities to support, diagnose, treat, implement follow-up care and preventive measures within the community so that avoidable complications of these diseases can be identified and minimized. 2. Lack of trained personnel in most of the specialties needed to support pediatric cardiac services Patient related issues 1. Maternal health issues affecting prematurity, dysmaturity, nutrition inadequacy during pregnancy threatening fetal development; 2. Child development issues: from insufficient nutritional support during post-natal growth; regionally limited, poor or absent primary healthcare; lack of preventative measures to reduce complications in such presentations ((for example, rheumatic fever, complicating CHD); With careful prepara-tion using the algrorithms designed by CardioStart International, safely conducted complex operations can lead to good clinical outcomes throughout the peri-operative period. A vitally important component of these, is the “Dry Run Checklist” which allows the local team to confirm ade-quacy of equioment and disposables throughout the perioperative period. *[These are available on request] Key-words: congenital heart diseases, surgery, healthcare deprived or restricted, review

IntroductionCongenital heart diseases (CHD) are made up of structural or functional heart, defects which are present from birth and give rise to disease as growth takes place. The worldwide prevalence of CHD is 8-10/1000 live births; among these, 33% to 50% of such defects may be considered criti-cal: they normally require intervention within the same hospital admission, and ideally, are dealt

-cations across the globe in which healthcare re-sources are poor, several related and unrelated issues may prevent diagnosis and treatment being available to those children in an adequate time period:1. Poor ante-natal performance during pre-gnancy;2. Malnutrition; 3. Medications, alcohol, recreational drugs and smoking history during pregnancy leading to co-existing morbidities4. (Frequent) late presentation of CHD beyond infancy;5. Lack of early referral;6. Illiteracy of the parents;7. Large numbers of births taking place wit-hin homes lacking adequate sanitation;8. Large numbers of births that are unsuper-vised by a doctor familiar with neonatal care;9. Inadequate number of cardiologists and cardiac surgeons;10. Lack of regional specialized cardiac cen-ters;11. Limited understanding and knowledge of CHD by local primary health care providers (phy-sician, pediatrician, internist, etc.)To overcome these obstacles the optimal strate-gy should involve the training and education of the local teams. Thus, a review of the essentials for the treatment of the most prevalent CHD is presented in following sections. A: Understanding congenital heart diseasesMeasurement of oxygen saturation by clinical observation and bedside pulse oxygenation tes-ting, assists separation of congenital heart di-seases into two main categories:1- Acyanotic CHD: included in this category are children with near normal or normal arterial oxy-gen saturation shortly after birth. Examples: Some ventricular septal defects (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), coarctation of aorta, moderate pulmonary stenosis, and some mild cases that

belong to the spectrum of Tetralogy of Fallot.2- Cyanotic CHD: In this category are those with clearly reduced arterial oxygen saturation that does not improve. Examples: Tetralogy of Fallot (TOF), transposi-tion of great arteries, tricuspid atresia, truncus arteriosus, total anomalous pulmonary venous drainage, hypoplastic left or right heart, and cer-tain peri-natal cardiac tumors

B: Basics of Surgery for Congenital Heart Di-seasesAccording to the clinical presentation, the surgi-cal treatment of CHD can be grouped into two main approaches: 1- Palliative Procedures (staged) 2- operation)As a surgical program grows and becomes more established, some of the techniques described

and from personal choice and preferences of in-dividual surgeons.

1.1. Palliative Procedures for Congenital Cardiac LesionsA palliative operation is chosen to produce an improvement on abnormal circulation and heart function, minimize some of the anatomical and functional features of the disorder and worse-ning of abnormal growth; it is usually peformed in children who are considered to be too young for corrective surgery at the regional center dea-ling with complex pediatrc heart disease. The goal is to lessen cyanosis, control heart failure and prepare the circulation for later correction, anticipating natural growth. Each procedure is chosen to bring relief of symptoms, improvement

the child’s growth, and absence of co-morbidities (and new onset diseases that commonly occur in most children).It is anticipated that as the infant grows, age and body weight development índices will then per-mit a fully corrective surgical technique to be em-ployed. The objectives in performing a palliative procedure are: a] To provide symptomatic relief; b] Allow the impact of the cardiac malformation to be better tolerated;c] Produce an improvement in the patient’s ge-neral clinical condition.



Discussion Technological innovation has the ability to reduce all three delays in accessing cardiac surgical care, in addition to strengthening post-operative and long-term primary health systems to ensure optimal short-and long-term outcomes. The use of digital health kits inclu-ding portable echocardiography and mHealth devices able to monitor oxymetry, blood pres-sure, ECG, and point-of-care BNP allows for efficient and cost-effective early diagnosis and follow-up of cardiac conditions ranging from RHD to heart failure. In addition, the wides-pread use of smartphones, cellular use, and internet connectivity allows for remote monito-ring and conferencing of experienced specia-lists with less experienced specialists in rural hospitals or community health workers in com-munity facilities. Moreover, patients are able to be reminded of medication use, rehabilitation instructions, or screening reminders through mobile texting. Altogether, mHealth can bridge the gap in accessing cardiac care. One barrier in receiving care for cardiac surgical disease is the availability of equipment, in particular to replace valves in patients with severe aortic stenosis or mitral stenosis, the latter commonly due to rheumatic heart disease (RHD). Every year, over 290,000 valve replacements are done around the world, the majority taking place in Europe and the United States, accoun-ting for a US$2 billion market.


A reduction in degree of cyanosis and improved hemodynamics usually produce a lowering in resting respiratory rate and effort of breathing, which leads to better food intake. A growth spurt may therefore be achieved during the interval before the child undergoes complete repair.In the twentieth century, two classic palliative procedures emerged during development of neonatal and pediatric cardiac surgery proce-dures which are performed in clinical practice.

-cal technique have evolved: Aortopulmonary shunt:This procedure aims to directly connect blood from the ascending aorta or its branches to the pulmonary artery at the point distal to any obs-truction: the operation is designed to increase

-

TOF and pulmonary atresia.

Figure 1- Aortopulmonary shunts: classic and

Pulmonary artery banding -

cessive due to the intra-cardiac lesion, and if

will allow pulmonary hypertensive changes to occur. This operation is designed to carefully

-reby protecting the pulmonary vasculature from progression towards irreversible pulmonary vas-cular disease. Multiple or large VSDs in infants weighting less than 3kg may present so, and the improvement in pulmonary dynamics and drop in respiratory rate may assist with better feeding, particularly at the breast. More complex palliative procedures including the staging for the Norwood operation for hypoplas-tic left heart syndrome and the Glenn operation are outside the scope of this review.

Indications and timing of palliative proce-dures:Aortopulmonary shuntMost patients with pulmonary obstruction, pre-senting with cyanosis, dyspnea, and/or failure to

This is a frequent operative choice in centers with limited experience, facilites or support staff, and/or when the patient may be judged as too small for adequate total repair. Examples are Tetralogy of Fallot less than 3 months of age; and Pulmonary Atresia with or without VSD.

Surgical techniquesAn aortopulmonary shunt can be performed through a mid-line sternotomy or through a right

or left thoracotomy using one of the techniques described below:I- Classic Blalock-Taussig-Thomas shunt:This technique is now less commonly used. It consists of anastomosing the subclavian artery to the pulmonary artery on the side opposite the aortic arch.

subclavian artery can be anastomosed to the pulmonary artery on the same side of aortic arch. The surgical approach is usually carried out through an upper thoracotomy centered on the upper border of the 3rd or 4th intercostal space. Among the essential surgical instruments are a straight and curved (Cooley) vascular clamps to permit uncluttered surgical access and retain he-mostatic control throughout. A surgical headlight is also required. If performed on the left, careful attention must be given to avoid strenuous re-traction of the left lung against the heart, which may produce poor venous return (Figure 2).

Figure 2- Classic Blalock-Taussig-Thomas shunt



Shunt)

(PTFE) tube graft (3-5mm, depending on age at presentation) is interposed between the subcla-vian or innominate artery and the right or left pul-monary artery using the same left or right thorac-tomy access as described above. The surgical procedure requires the surgeon to apply careful judgment of the length of the graft chosen to

(too long) or puckering of the native vessels (too short) as the child grows during the “surgical in-terval” between operations. It is the most com-

monly performed shunt procedure (Figure 3).

shunt

2.1. Complete Repair of Congenital Cardiac LesionsA Complete repair is feasible in many extra-car-diac as well as intra-cardiac congenital anoma-lies.A- Repair of extra-cardiac lesions: In these presentations, there is usually no need for cardiopulmonary bypass. The commonest examples are PDA, and coarctation of aorta.PDA :A spontaneous closure can be reasonably ex-pected in small PDAs in full term babies at the age of 3 months; however, large PDAs are unli-kely to close.The timing for PDA closure is as follows:• Large/ moderate PDA, with conges-tive heart failure (CHF) and/or pulmonary hy-pertension (PAH): Early closure (by 3-6 mon-ths) is recommended.• Moderate PDA, no Congestive Heart Failure (CHF): closure at 6 months-1 year of age. If the infant is exhibiting failure to thrive, closure can be accomplished earlier.• Small PDA: closure can be caried out at 12-18 months of life.• Silent PDA: Closure is not recommended.

with normal pulmonary artery pressure which

echocardiography.

The defect is best approached through a limited left posterolateral thoracotomy based on the up-per boarder of the 4th interspace, and is usually divided between clamps or ligated (Figures 4a and 4b) taking care to avoid the phrenic nerve and Abott’s artery. If ligation only is chosen, the separate ligating sutures should be 2/0 or 3/0, carefully tied without subtraction to avoid “cheese-cutting” the friable duct, pulling on the vessel or worse, causing tearing off from the pul-monary artery or aorta. The surgeon should be prepared to immediately open the adjacente pe-ricardium in that scenario to retrieve the retrac-ted PA segment.

Figure 4a – PDA: surgical view Figure 4b – PDA ligation

Coarctation of aorta Surgical treatment currently represents the pre-ferred option for the correction of coarctation of aorta (CoAo).

The timing of intervention should be based on the clinical status at presentation, rather than waiting for developing hypertension and left ventricle dysfunction:



• Low gradient: Intervention is not indicated if Doppler gradient across coarct segment is <20 mmHg with normal LV function. It should be reas-sessed at regular intervals as the child grows and blood pressure measurements should be taken from right, left arms and one leg. Pulse delay should be checked and recorded if found. • CoAo with LV dysfunction / CHF or severe upper limb hypertension (for age): Immediate in-tervention. In this scenario, considerable care should be taken dyring the operation to avoid retraction of the lung against the pericardium

-ling and subsequente bradycardia). • CoAo with normal LV function, no CHF and mild upper limb hypertension: Intervention may be undertaken beyond 3-6 months of age • CoAo with no hypertension, no CHF, nor-mal LV function: Intervention can be made at 1-2 years of age.The defect is best approached through a left posterolateral thoracotomy centered on the up-per border of the 3rd left interspace using one of the following techniques (if made lower, it is very

surgical access). • ressection and end–to-end anastomosis (Figure 5a and 5b), • augmentation of the coarcted segment

-

Note: Occasionally, it may be necessary to in-troduce one of the clamps through a lower inter-costal space to gain a suitable clamp position. The use of silastic slings after careful, discrete (localized) dissection of the proximal and distal aortic segments is an important adjunct to the surgical technique.

Figure 5a – Juxta-ductal coarctation of aor-ta. Figure 5b - End–to-end anastomosis of

the coarcted segment.

B- Repair of intra-cardiac lesions: These usually require cardiopulmonary bypass. The commonest defects are VSD, ASD, and Tetra-logy of Fallot.Atrial Septal Defect (ASD)A spontaneous closure is rare if the defect is >8 mm at birth and if still evident after age 2 years.The timing of repair is based on the symptomato-logy secondary to pulmonary blood overload, as follows. (If a child is well and the lesion is picked up by auscultation on routine review, many surgeons will choose to do this operation during school holidays or at parents’ convenience. It is usually non-urgent):• Asymptomatic ASD: These can be re-paired at 2-4 years.• Symptomatic ASD in infancy - CHF, severe Pulmonary Artery Hypertension (PAH): (8%-10% of cases). For these, early closure is recommended,

cardiac lesion present. • Late presenting ASD: Elective closure should be carried out at presentation irrespective of age and, especially, if there is right heart vo-lume overload and pulmonary vascular resistance

(PVR) is within operable range (PVRIO<10WU.m2 – PVRIO. Pulmonary vascular resistance index can be assessed using a pure oxygen inhalation challenge). ASD closure is most commonly approached through a median sternotomy under cardiopulmo-nary bypass. In centers with a large experience it is occasionally managed by upper right thoracotomy, centered on 4/5th interspace. This can be a helpful operative approach in girls who may seek to avoid a central chest scar. If the later procedure is done, very careful cannulation techniques must be used to avoid acidental line loss; the incision must not be placed anteriorly so to avoid risking a dimpling deformation of the right breast later on, when the patient reaches puberty. An autologous pericardial patch is usually used to close the defect. (Figure 6a and 6b). If future surgery is anticipated for an additional cardiac le-sion, it is best to also use commerical pericardial patches to then draw the pericardium closed, (if such materials are available). This is carried out on terminating cardiopulmonary by-pass and de-can-nulation.



Figure 6a – Secundum ASD. Figure 6b – ASD: patch repair

Ventricular Septal Defects (VSD)Approximately 30%-40% of moderate or small defects (restrictive) close spontaneously, the majority closing by 3-5 years of age or becoming

on serial echocardiographic assessments. Spon-taneous closure is uncommon in large VSDs,

year of life, primarily due to CHF when the VSD is large and non-restrictive (= diameter of the

The timing of repair is based on the symptomato-logy characterized by the presence of CHF, res-piratory infection and/or PAH. In those children presenting with cardiac or other comorbidities, a careful review of the peri-operative management in Intensive Care equipment, nursing skills and medications that are available should be made. Even after a perfect surgical result, in the OR, a child’s most challenging time may be in the post-operative period.

• Large VSD with uncontrolled CHF: Re-pair should be carried out as soon as possible, after accomplishing maximizing general hemo-dynamic improvement before the child under-goes anesthesia.• Large VSD with severe PAH: Repair at 3-6 months.• Moderate VSD with PASP 50%-66% of systemic pressure: Repair is recommended between 1-2 years of age or earlier if one epi-sode of life- threatening lower respiratory tract infection or failure to thrive.• Small sized VSD with normal PAP, left to right shunt >1.5:1: Closure by 2-4 years.• Small outlet VSD with any degree of aortic regurgitation (AR): Surgery whenever AR is detected.• Small VSD with one previous episode of infective endocarditis: Early VSD closure is re-commended.

Surgical technique

The VSD is approached through a median ster-notomy under cardiopulmonary bypass and closure is accomplished by use of a pericardial patch, (autologous pericardium, Dacron patch or PTFE membrane are popular). (Figure 7a and 7b). Great care should be given in regard to

suture placement to avoid ensnaring one of the aortic cusp, conduction system, and deforming the tricuspid valve leading to valvular incom-petence. Some surgeons do not use pledgets throughout. Some prefer a single, continuous suture technique.



This may suffer from the risk of rupture and un-zipping which can cause dynamic sub-aortic obs-truction (and require emergente re-operation). A four-quadrant interval continuous technique reduces the probability of this complication oc-curing. Surgical approaches are now most com-monly carried out by opening the right atrium and

gentle upward retraction of the septal cusp of the tricuspid valve, but some circumstances may require right ventriculotomy or, by direct access through na aortotomy/pulmpnary truncal ope-ning to gain access to the immediatre sub-aortic or sub-pulmonary margin of the defect.

Figure 7a – Perimembranous VSD. Figure 7b – VSD: patch repair.

Tetralogy of FallotThis accounts for 15% of all cyanotic heart di-seases. All patients need surgical repair but in patients coming from rural locations, the primary diagnosis may be sometimes delayed well into the patient’s teen years. The timing of repair is often based on the seve-rity cyanosis if the patients are seen soon after birth. They may require a different peri-operative strategy depending on factors relating to surgi-cal and anesthetic perfusion and nursing expe-rience, and the availability of specialist manage-ment, operative and perfusion equipmen in such small sized patients.1- TOF stable, minimally cyanosed: Total correction can be usually, safely carried out at 1-2 years of age or earlier according to the insti-tutional policy. 2- 70%) or spells despite therapy• <3 months: A BT shunt may be performed, scheduling full correction after a growth period.• >3 months: shunt or correction depending on anatomy, growth, co-morbidities and surgical centers’ experienceTOF is approached through a median sterno-

tomy under cardiopulmonary bypass. The repair consists of closure of VSD with a patch (usually bovine pericardium or Dacron patch) and aug-

-nosed pulmonary valve and arteries (Figures 8a and 8b).

Figure 8a – RVOT obs-truction: surgical view.

Figure 8b – RVOT: patch augmentation.


The results of surgery usually show substantial improvement in patient’s tolerance to exercise, improved growth and resolution of cyanosis. Ptients should be advised that there may be some distortion of the pulmonar artery following growth and that surgical revion may be required.

4. Ongoing training of those involved in spe-cialist pediatric care and collaboration with other centres in the region. There are three aspects of this essential practice: A] local team encouragement and support throughout the year so those entering the spe-

-nue. All team members (doctors, nurses, per-fusonists, technicians, respiratory therapists, biomedical and other supporting staff) should be treated with equal respect as vital members. B] Regional collaboration should be fostered to share experience and care pathways with other emerging centres; colleagues must encourage each other and celebrate innovative and new techniques in overall clinical care; there should be general agrément that all should work hard to reduce any competitive activity which might lead to discouragement and/or failure. C] A database (e.g. The World Database) should be introduced into the program as soon as is possible to track and provide quality assurance standards that can be followed and guarded.

AcknowledgmentsThe authors would like to thank J.B.Bastos for his assis-tance in the illustrations of this manuscript.



References1.Working Group on Management of Congenital Heart Diseases in India. Consensus on Timing of Intervention for Common Congenital Heart Diseases. Indian Pediatrics. 45: 117-126, 2008. Guidelines2.Shi-Min Yuan , Hua Jing. Palliative procedures for congenital heart defects Archives of Cardiovas-cular Disease. 102: 549—557,2009. Review3.Tchervenkov C, Jacobs JP, Bernier PL, Stellin G, Kurosawa H, Mavroudis C, Jonas RA et al. The improvement of care for paediatric and congenital cardiac disease across the World: a challenge for the World Society for Pediatric and Congenital Heart Surgery. Cardiology in the Young 19(Suppl. 2): 112–117, 2009.4.Talwar S, Choudhary SK, Airan B, Juneja R, Kothari SS, Saxena A, Kumar AS. Reducing the costs of surgical correction of congenitally malfor-med hearts in developing countries. Cardiol Young 18: 363–371,2008.5. Brown KL. Socioeconomic status and outcomes of paediatric cardiac surgery.The Lancet Child & Adolescent Health, 2018. Available at:

Summary1. PDA, CoAo, ASD & VSD with their respective anatomic variants and the lesions found in TOF represent > 80% of all CHD for which a center that is ocated in a resource-poor environment may reasonably develop the capability to repair them2.Pediatricians/ cardiologists/ other health care providers should strive to get a complete diagnosis on a child suspected of having heart disease, even if that requires referral to an advanced center.3.Development of surgical protocols: these are vital tools to help with in pre-operative planning, peri-operative management; they also help provi-de a smooth passage through the essential fatures of management in each clinical presenta-tion: diagnosis and surgical decision, the optimal timing of intervention. Such a strategy will help achieve good outcomes in the more common congenital heart diseases which present to resource-poor centers.

https://doi.org/10.1016/S2352-4642(18)30134-26. ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). European Heart Journal (2010) 31, 2915–2957.7.Setty HSSN, Patil SSG, Ramegowda RT, Vijayalakshmi IB, Manjunath CN. Comprehensive Approach to Congenital Heart Defects. J Car-dio-vasc Disease Res., 2017; 8(1): 1-58. Linde D, Konings E E M, Slager MA, Witsen-burg M, Helbing WA, Takkenberg JJM, Roos-Hes-se-link JW. Birth Prevalence of Congenital Heart Disease Worldwide:A Systematic Review and Me-ta-Analysis. J Am Coll Cardiol 2011;58:2241–79.Hui-Li Gan, Jian-Qun Zhang, Qi-Wen Zhou, Lei Feng, Fei Chen, and Yi Yang. Patients with Congenital Systemic-to-Pulmonary Shunts and Increased Pulmonary Vascular Resistance: What Predicts Postoperative Survival? PLoS One. 2014; 9(1): e8397610.Fortescue EB, Lock JE, Galvin T, McElhin-ney DB. To close or not to close: the very small patent ductus arteriosus. Congenit Heart Dis. 2010 Jul-Aug;5(4):354-65.

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Afr.Ann Thorac.Cardiovasc.Surg. 2018; 13(1):11-17

PRISE EN CHARGE DES VARICES DES MEMBRES INFERIEURS AU CENTRE HOSPITALIER

UNIVERSITAIRE DE BRAZZAVILLE ATIPO-GALLOYE R1,2, KOMBO BAYONNE S3, NGOUNDA MONIANGA S A2, OKIEMY GODEFFROY2

1- Université Marien Ngouabi, Faculté des Sciences de la Santé, Brazzaville 2-Service de chirurgie polyvalente, CHU de Brazzaville, BP 32 Brazzaville, Congo 3- Service de Dermatologie-maladies infectieuses, Hôpital de référence de Talangai, Brazzaville

Résumé Objectif : Décrire les aspects épidémiologiques, cliniques, étiologiques et thérapeutiques des varices des membres inferieurs. Patients/méthodes : Il s’est agi d’une étude rétrospective, réali-sée au CHU de Brazzaville, entre Mai 2016 et Juin 2018. Tous les patients ayant été opérés durant cette période pour varices, et dont le dossier médical comportait un compte-rendu opéra-toire ont été inclus. Les patients ont été répartis suivant la classification CEAP d’Hawai 2004 mo-difiée. Les deux techniques opératoires employées ont été la chirurgie et la sclérothérapie, soit sous rachianesthésie ou sous anesthésie locale. Les variables analysées ont été : sociodémographiques, cliniques, étiologiques, et thérapeutiques. Résultats : Au total quarante cinq patients ont été opérés, avec un âge moyen de 42+/-2,5 ans, et un sexe ratio à 0,8. Plus de 90% de nos patients étaient symptomatiques avant la chirurgie. Le principal motif de consultation a été la lourdeur des membres inferieurs, et plus d’un quart de nos patients avaient consulté au stade C3. L’origine a été essentielle dans 55,5%, suivie des causes post thrombotiques dans 17,8%. Les veines superficielles ont été les plus touchées. Le mécanisme physiopathologique en a été le reflux dans 68,5%. Le geste le plus réalisé a été la ligature de la jonction sapheno-fémorale associée à un stripping et des phlebectomies chez vingt cinq patients. Deux cas de récidives ont été rapportés après sclérotherapie. Conclusion : La prise en charge des varices dans notre contexte reste dominée par la chirurgie. L’adoption des nouvelles techniques endovasculaires permettrait d’en améliorer les résultats.

Mots clés : Varices, membres inferieurs, CHU de Brazzaville.


Correspondance: Atipo-Galloye R Université Marien Ngouabi, Faculté des Sciences de la Santé, Brazzaville Congo



Summary : Aim : To describe epidemiological, clinical, etiologic, and therapeutic aspects of lower limbs varicose veins. Patients-methods : It was a retrospective study, carried out from May 2016 to June 2018 at Brazzaville teaching hospital. All patients who has been operated and medical records had surgical approach data were included. Patients were classified according to modified Hawai 2004 classifica-tion. Surgery and sclerotherapy were principals approaches used. Variables were ;demographic, clinicals etiologic, and therapeutic.Results : Forty five patients were operated, with average age of 42+/-2,5 ans. Sex ratio was 0,8. More than ninety percent of patients were symptomatic before treat-ment. Heaviness limbs was the most representative symptoms. Twenty six-seven percent of patients were admitted in stage C3. Varicose veins were essential in 55,5%, follow by post thrombotic varices with 17,8%. Superficial venous were more affected, and reflux was mojor pathophysiologic mecha-nism in 68,5%. Saphenous-femoral ligation with strippind and phlebectomies was the principal surgi-cal technic. There were two cases of recidivism varicose veins after sclerotherapy. Conclusion : Varicose veins treatments in our context are still dominated by surgical approach. It will be better to add new vascular technics in our facility. Key words : Varicose veins, lower limbs, Brazzaville teaching hospital.

Introduction

La prévalence de l’insuffisance veineuse chro-nique est d’une façon générale entre 30-60% dans les pays industrialisés ; cette prévalence augmenterait avec l’âge, qui en constitue le premier facteur de risque. La pathologie vari-queuse est très présente dans la population, selon une étude Américaine, sa prévalence serait de 10,4-23,0% et 29,5-30,0% ; respecti-vement chez les hommes et les femmes [1]. Dans les pays sous-développés, sa prévalence est mal inconnue. Les varices constituent un motif fréquent de consultation dans notre exer-cice. D’après les données hospitalières (CHU de Brazzaville, Service de chirurgie polyva-lente), en 2016, elles ont représentées environ 40% de l’ensemble de l’activité vasculaire en chirurgie polyvalente. Les patients consultent le plus souvent à un stade de complications ; cela peut s’expliquer par l’errance diagnostique et thérapeutique, car le plus souvent, ils débutent par un traitement traditionnel. Dans les pays développés, l’arsenal thérapeutique actuel des varices, comprend la thérapie thermique (Ra-diofréquence et Laser), l’ablation chimique (Sclérothérapie), et la chirurgie conventionnelle [2,3].Dans notre service, seules la chirurgie et la sclérothérapie sont disponibles.

L’objectif de ce travail était de présenter les aspects épidémiologiques, cliniques, étiolo-giques et thérapeutiques des varices des membres inférieurs au centre hospitalier uni-versitaire de Brazzaville.

Patients et Méthodes Il s’est agi d’une étude rétrospective, transversale, réalisée au centre hospitalier universitaire de Brazzaville entre Mai 2016 et Juin 2018, dans le service de chirurgie polyvalente. Les données des patients ont été extraites à partir des observations médicales et compte-rendus opératoires. Les patients hospi-talisés durant cette période d’étude, ayant bénéficié d’un traitement des varices, et dont le dossier médical avait un compte-rendu opéra-toire ont été inclus. Les patients dont le dossier médical ne disposait pas d’information sur la nature des lésions, et l’absence de compte-ren-du opératoire, ont été exclus. Tous nos patients ont bénéficié d’une échographie doppler préopé-ratoire, pour cartographie et repérage.Nos patients étaient repartis en différents stades, selon la classification CEAP d’Hawaï modifié de 2004. Le choix entre les deux techniques chirurgie ou sclérothérapie, était basé sur le caractère systématisé ou non des varices, le diamètre des veines variqueuses.


RésultatsA) Données sociodémographiques


Dans certains cas, le traitement fut hybride. Ainsi, pour les varices diffuses, réticulaires avec un diamètre inférieur à 3 mm (C1-C2), la sclérothérapie combinée à des phlebectomies furent prati-quées. Les patients C3, avec varices systématisées sur un réseau saphène, ont bénéficié soit d’une ligature de la jonction saphèno-fémorale ou saphèno-poplitée avec stripping et phlebecto-mies étagées, ou d’un stripping avec phlebectomies ; en fonction de l’anatomie des lésions. Les gestes étaient réalisés sous rachianesthésie ou anesthésie locale. L’abord du pli de l’aine, en dedans du pouls fémoral était pratiqué pour la ligature de la jonction saphèno-fémoral (Iconogra-phique 1a). Nous réalisâmes les phlebectomies stripper en place, avant de réaliser le stripping par invagination à la fin de l’intervention (Iconographique1b). Le stripper que nous avions utilisé était un semi-rigide (Icono 2a). Les patients ont bénéficiéd’une héparinothérapie à base d’hépa-rine de bas poids moléculaire (HBPM) pendant 24 heures. La sclérothérapie à Aetoxiscérol*en anesthésie locale par détumescence, complétée par des phlebectomies a été réalisée chez les patients répondant aux caractères anatomiques, avec un diamètre du segment variqueux inférieur à 6 mm. Les variables analysées ont été : sociodémographiques, cliniques, étiologiques et thérapeutiques. L’analyse statistique a été faite avec le logiciel Epi-info, version 7.2.2.6.

Vingt hommes et vingt cinq femmes (sexe ratio : 0,8)2) Age des patientsUn total de quarante-cinq patients inclus (75 membres inférieurs concernés), l’âge moyen était de 42+/-2,5 ans (extrêmes 11- 69 ans). Le tableau I, illustre la répartition des patients selon les tranches d’âge, et du sexe.

Tableau I : Répartition selon les tranches d’âges et le sexe

Figure 1:Répartition des patients selon le sexe Vingt hommes et vingt cinq femmes (sexe ratio : 0,8)

14

B) Données cliniques1) Motif de consultation

Autres : Syndrome de jambes sans repos, prurit,…

2)

a) La présentation clinique (C)

Figure 3 : Répartition clinique



Sur le plan clinique plus de 90% de nos patients étaient symptomatiques, les pourcen-tages étaient les suivants : C0.2, 2% ; C1.13, 3% ; C2.17, 8% ; C3.26, 7% ; C4a.11, 1% ; C4b.6, 7% ; C5.4, 4% ; et C6.17, 8%.

b) Etiologies (E)Parmi les quarante-cinq patients, vingt-cinq (55,5%) avaient des varices essentielles, et huit patients (17,8%) elles étaient secondaires ; dominées par la maladie post thrombotique. L’ori-gine a été congénitale chez cinq patients (11,1%); parmi eux, quatre cas du syndrome de Klip-pel-Trenaunay , (Iconographique 2b) enfin chez sept patients (15,6%) la cause a été par com-pression extrinsèque et post traumatiques.

References1.Working Group on Management of Congenital Heart Diseases in India. Consensus on Timing of Intervention for Common Congenital Heart Diseases. Indian Pediatrics. 45: 117-126, 2008. Guidelines2.Shi-Min Yuan , Hua Jing. Palliative procedures for congenital heart defects Archives of Cardiovas-cular Disease. 102: 549—557,2009. Review3.Tchervenkov C, Jacobs JP, Bernier PL, Stellin G, Kurosawa H, Mavroudis C, Jonas RA et al. The improvement of care for paediatric and congenital cardiac disease across the World: a challenge for the World Society for Pediatric and Congenital Heart Surgery. Cardiology in the Young 19(Suppl. 2): 112–117, 2009.4.Talwar S, Choudhary SK, Airan B, Juneja R, Kothari SS, Saxena A, Kumar AS. Reducing the costs of surgical correction of congenitally malfor-med hearts in developing countries. Cardiol Young 18: 363–371,2008.5. Brown KL. Socioeconomic status and outcomes of paediatric cardiac surgery.The Lancet Child & Adolescent Health, 2018. Available at:

Figure 2 : Repartition selon le motif de consultation



c) Anatomie (A) Les lésions étaient réparties de la manière suivante : Les veines superficielles dans 66,7%, les veines perforantes dans 11,1%, et veines profondes dans 22,2%.

d) Physiopathologie (P) De Soixante-dix membres inferieurs classés II et III CEAP : 40 (57,1%) avaient un reflux, 12 (17,1%) avaient une obstruction, 8 (11,4%) avaient à la fois reflux et obstruction, et 10 (14,2%) n’avaient pas d’insuffisance veineuse identifiable. Au total, 48 (68,5%) membres inferieurs avaient un reflux. En ce qui concerne la location de la veine, la plus atteinte a été la grande saphène au-dessus du genou (Veine N0.2 selon la nomenclature veineuse internationale CEAP) n=25 (52%) ; suivi par la grande saphène au-dessous du genou (Veine N0.3) n=10 (20,9%) ; puis par la veine fémorale commune (Veine N0.11) avec 8 (16,7%), et enfin, la petite saphène (Veine N0.4) n=5 (10,4%). Vingt (28,5%) membres inférieurs avaient une obstruction, 9 (45%) concernaient la veine N0.11 ; 5 (25%) la veine N0.13 ; 3 (15%) la veine N0S.2, 3,14, and 3 (15%) la veine AP18.

C) Données thérapeutiques 1) Type d’intervention réalisé

Figure 4 : Type d’intervention réaliséLJSF=Ligature de la jonction saphèno-fémoraleLJSP=Ligature de la jonction saphèno-poplitée



Parmi les patients ayant bénéficié d’une LJSF associée à un Stripping et Phlebecto-mies, un avait une thrombose superficielle localisée au niveau de la jarretière. Une seule patiente a bénéficié d’une LJSF associée à des Phlebectomies, avec une ectasie de la jonc-tion saphèno-fémorale (Icono 2c). 2) Séjour hospitalier La durée moyenne d’hos-pitalisation a été de 3 jours (extrêmes 1- 6 jours). L’héparinothérapie à base d’héparine de bas poids moléculaire (HBPM), à dose préventive a été systématique pendant vingt-quatre heures chez tous les patients. Une contention élastique systématique était réalisée durant le séjour hos-pitalier à l’aide d’une bande à contention (Bande Velpeau®). Les suites opératoires ont été simples. Il n’y a eu aucune reprise opératoire.3) Suivi à moyen terme. Le suivi moyen était de 10+/- 1,5 mois (extrêmes 3- 20 mois). Trois patients étaient perdus de vue. Parmi les qua-rante-deux patients restants, deux ayant été traités préalablement par sclérothérapie, avaient été repris pour récidive. Discussion Limites de l’étude : Il s’est agi d’une étude rétrospective ; avec comme limite principale le biais de sélection dépendant de la qualité d’ar-chivage des dossiers médicaux. C’est ainsi que, certains dossiers incomplets n’ont pu être exploités, donc exclus de l’étude. En outre, les conditions d’archivage étant encore en format papier non numérisé ; cela pourrait aussi expliquer la faible taille de l’échantillon, vu la prévalence de l’insuffisance veineuse chronique dans la littérature. Interprétation des résultats Notre population d’étude comprenait vingt hommes et vingt cinq femmes, avec un âge moyen de 42+/-2,5 ans. Il s’agit d’un échantillon constitué plus de sujets jeunes, à la différence des séries occidentales constituées plus de cohortes de sujets âgés. Notre sexe ratio a été de 0,8. L’étude camerounaise de Fokou et al [4], rapporte une légère supériorité masculine. Plus d’un quart de nos patients ont consulté au stade C3 de la classification CEAP d’Hawaï modifiée, et 22,2% au stade C5-C6, avec complications à type d’ulcère variqueux. Ces stades tardifs de consultations peuvent aussi s’expliquer par des pesanteurs culturelles, où les patients passent par les guérisseurs

traditionnels avant de décider de venir à hôpital ; car ils associent à la maladie une connotation mystique. Parfois, il peut s’agir des patients se présentant avec des ulcères, comme le rapportent certains auteurs asiatiques [5]. Plus de la moitié de patients avaient des varices essen-tielles. Chez cinq patients l’étiologie a été congénitale, parmi eux, quatre cas du syn-drome de Klippel-Trenaunay. Certains cas de varices survenant dans le contexte d’anoma-lies capillaires, du tissu conjonctif et une hypertrophie osseuse [6-9]. Sur le plan anato-mique, les veines superficielles ont été les plus touchées. Le reflux a été le mécanisme physio-pathologique le plus rencontré dans notre étude. Certains auteurs rapportent les mêmes constats. Dans les reflux pelvi-perineaux, com-pliqués de varices de membres pelviens, le plus souvent le mécanisme lésionnel en est le plus souvent, une compression de la veine rénale gauche par l’aorte et l’artère mésenté-rique supérieure ; qualifiée du nom de syn-drome de Nutcracker [10,11]. La chirurgie a été la principale stratégie thérapeutique ; notamment la ligature de la jonction saphèno-femorale asso-ciée à un stripping plus des phlebectomies étagées. La sclérothérapie a été réalisée chez cinq patients. Actuellement, d’après les recom-mandations des sociétés savantes, la séquence idéale de la stratégie thérapeutique serait ; les thérapies thermiques, suivies de la sclérothérapie, puis la chirurgie qu’en troisième position [12]. Mais cela dépend d’une grande partie du plateau technique local, et aussi des courbes d’apprentissages des chirurgiens. Cer-tains auteurs pensent qu’il n’existerait pas la suprématie d’une approche par rapport à l’autre. Les données cliniques, anatomiques, étiolo-giques, et voir même physiopathologiques selon la classification CEAP d’Hawai modi-fiée, sont d’un apport considérable pour le choix d’une approche par rapport à une autre. C’est ainsi que, le diamètre des veines, leur caractère tortueux ou non, l’existence d’un reflux ou d’une obstruction sont à prendre en compte avant d’opter pour une sclérothérapie,d’éviter les risques d’échecs et récidives [2]. Une étude brésilienne, sur deux cohorte bien sélection-nées comparant la chirurgie à la sclerotherapie, a aboutit à une conclusion sur la supériorité de la chirurgie sur la radiofréquence sur le plan hémo-dynamique [13].


Afr.Ann Thorac.Cardiovasc.Surg. 2018; 13(1) 24

La sclérothérapie a des indications biens pré-cises ; Certains auteurs ont pensés a des tech-niques modifiées de la sclérothérapie, aussi des modalités anesthésiques ; pour en augmenter les taux de succès [14]. Dans le cas des varices secondaires à un reflux pelvi-périnéal la tech-nique la plus utilisée est l’embolisation le plus souvent de l’artère gonadique concernée avec du coils [15,16]. La radiofréquence parait être une approche inoffensive, dont le résultat est le plus souvent excellent ; mais dans de rares cas, comme celui rapporté par l’équipe tunisienne certaines complications peuvent subvenir [17]. Conclusion Les varices des membres pelviens sont une réa-lité dans notre pratique chirurgicale. Avec une population jeune par rapport aux cohortes occi-dentales, la pratique des nouvelles techniques vasculaires seraient l’idéal dans l’amélioration de leur prise en charge ;la reduction du sejour hospitalier et surtout de la reprise rapide de l’activité professionnelle.

Références 1.Medical Services Advisory Committee. Endo-venous Laser Treatment (EVLT) for Varicose Veins. MSAC Application 1059, Assessment Report. Canberra: MSAC, 2003, 2.R.Jacquet.Traitement des varices des membres inférieurs en 2015 : le présent et l’avenir. Annales de dermatologie et de vénéréo-logie (2015) 142, 483—492, 3.M. Perrin. Traitement endovasculaire des varices des membres inférieurs. Annales de chirurgie 129 (2004) 248–257, 4. Marcus Fokou., MDA., Boniface Moifo., MDB et al., Emmanuel Fongang., MDC. Cha-racteristics of patients and patterns of chronic venous disease of the lower limbs in a referral hospital in Cameroon.J Vasc Surg Venous Lym-phat Disord 2018 Jan;6(1):90-95, 5. Kanchanabat B., Wongmahisorn Y., Stapana-vatr W., et al. Clinical presentation and patterns of venous reflux in Thai patients with chronic venous insufficiency. Eur J Vasc Endovasc Surg 2010;40:399-402, 6. Anthonia Asanye Ikpeme1*., Usang Edet Usang2, Akan Wilson Inyang2 et al.Klippel Tre-naunay Syndrome: A Case Report in an Adoles-cent Nigerian Boy. OA Maced J Med Sci. 2015 Jun 15; 3(2):322-325,

7. Carlos Alberto Araujo Chagas1*, Lucas Alves Sarmento Pires1, Marcio Antonio Babinski1 et al.Klippel-Trenaunay and Parkes-Weber syn-dromes: two case reports. J Vasc Bras. 2017 Out.-Dez.; 16(4):320-324, 8. Malgor RD1., Gloviczki P2., Fahrni J3 et al. Sur-gical treatment of varicose veins and venous malformations in Klippel-Trenaunay syn-

drome.Phlebology.2016 Apr;31(3):209-15, 9. Noel AA1, Gloviczki P, Cherry KJ Jr et al. Sur-gical treatment of venous malformations in Klip-pel-Trénaunay syndrome. J Vasc Surg. 2000 Nov;32(5):840-7,10.Andrew K. Kurklinsky., MD, MACP., and Thom W. Rooke., MD. Nutcracker Phenomenon and Nutcracker Syndrome. Mayo Clin Proc. 2010;85(6):552-559,11.DavidM Riding1,Vivak Hansrani2 ;Charles McCollum1. Pelvic vein incompetence:clinical perspectives. Vascular Health and Risk Manage-ment 2017:13 439–447, 12. B.Campbell.New evidence on treatments for varicose veins. BJS 2014; 101: 1037–1039. 13. Cynthia de Almeida MendesI,III, Alexandre de Arruda MartinsI,III, Juliana Maria FukudaI,* et al.Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency:if you don’t tell, they won’t know. Clinics. 2016;71(11):650-656, 14. ALBERT-ADRIEN RAMELET., MD*†.Scle-rotherapy in Tumescent Anesthesia of Reticu-lar Veins and Telangiectasias. Dermatol Surg 2012;38:748–751. 15. Sonya Koo., MD, PhD., and Chieh-Min Fan., MD., FSIR. Pelvic Congestion Syndrome and Pelvic Varicosities. Tech Vasc Interventional Rad 17:90-95, 16. O Hartung. Embolization is essential in the treatment of leg varicosities due to pelvic venous insufficiency.Phlebology 2015, Vol. 30(1S) 81–85, 17. A. Abdi., C. Belghith ., S. Ayechi et al. Traite-ment des varices des membres inférieurs par radiofréquence : indications et limites. À propos d’une complication rare.Phlébologie 2015, 68, 1, p.37-40.



Iconographie 1a : Vue per opératoire d’une jonction sapheno-femorale Iconographie1b : Vue opératoire avec

introduction du stripper par voie retrograde

Iconographie 2b : Aspect préopératoire du syndrome de Klippel-Trenaunay

Iconographie 2a : Vue opératoire avec réalisation des phlebectomies stripper en place

Iconographie 2c : Vue préopératoire d’une jonction sapheno-fémorale ectasique

CHIRURGIE THORACIQUE / THORACIC SURGERY

26Afr.Ann Thorac.Cardiovasc.Surg. 2018; 13(1): 26-37

SummaryObjective: Thoracic surgical approach has taken a decisive turn since videoscopy utilization for cardiac and non-cardiac thoracic surgery. This study aims to present indications and results of chest surgical approaches performed in Cote d’Ivoire. Methods: Using the 1998 and 2014 nationwide inpatient database, we identified retrospectivly 814 patients including 475 men and 339 women who underwent a cardiothoracic surgery. Mean age was 32.73 years; range was: 2 months - 88 years. Results: Cardiac Surgery was performed on 473 patients (58.10%) and Gene-ral Thoracic Surgery on 341 patients (41.89%). For Cardiac Surgery, median vertical sternotomy was the most surgical approach performed (n=250; 52.85%), while classic postero-lateral tho-racotomy was the most surgical approach performed in General Thoracic Surgery (n=321; 94.13%). Immediate postoperative pain required opioids administration in 84.39% of cases. Ave-rage length of hospitalization and healing were respectively 9.43 days (range: 2-50 days) and 18.30 days (range: 1-56 days).Conclusion: Development of minimally invasive chest approaches remains one of our challenges because those currently practiced are uncomfortable for patients and make longer hospital stay and wound healing.

Keywords: Surgical Approach, Thorax, Minimally Invasive Procedures.

Ann. Afr. Chir. Thor. Cardiovasc. 2018; 13(1): 26-37

CHEST SURGICAL APPROACHES IN AFRICA: A CONSTANT CHALLENGE

MENEAS GC, ABRO S, YANGNI-ANGATE KH. Department of Cardiovascular and Thoracic Diseases, Anatomy Unit,Bouake Teaching Hospital, Cote d’Ivoire

Correspondence: Koffi Herve Yangni-Angate Cardiothoracic and Vascular Surgery Depart-ment and Anatomy Unit, Bouake Teaching Hospital, Cote d’Ivoire. Email: [email protected]


Introduction For about two decades, thoracic surgical approach has taken a decisive turn with videoscopy introduction in cardiac and non-cardiac thoracic surgery. This thri-ving technique becomes gradually a refe-rence technique in thoracic surgical approach and is a minimally invasive approach to the thorax with minimal post-operative pain, reduc-tion of the duration of hospitalization and a post anaesthetic procedures. However, this thoracic approach requires a specific techni-cal and ancillary material that limits diffu-sion in developing countries. Chest surgi-cal approaches are surgical accesses to the chest and its content. Two major groups of chest approaches are described: conventional or classic and minimally invasive" surgical approaches (1). The conventional surgical approaches are anterior approaches (2) such as the vertical median sternotomy, the Cham-ber-lain anterior mediastinotomy, the anterola-teral thoracotomy, the partial Sternotomy with anterolateral thoracotomy "Hemiclam-shell", the bilateral transverse Sterno-thora-cotomy "clamshell"; the side approaches (3) such as the lateral thoracotomy, and poste-ro-lateral approaches (3). "Minimally invasive" (1) chest approach tracts involve direct thoracos-copy, video-assisted thoracospic surgery, video-assisted thoracic surgery, video-as-sisted in conventional surgery, minimally invasive cardiac surgery assisted by video-assisted thorascopic surgery, ap-proaches tracts for diagnostic biopsies (the “traditional” mediastinoscopy; video me-diastinoscopy) and robotics (4). This study aims to report indications of chest surgical approach tracts performed in Cote d’Ivoire and post-operative results.

Methods Using the 1998 and 2014 nationwide inpatient database, we identified retrospectively, 814 patients including 475 men and 339 women who underwent a cardiothoracic surgery. Mean age was 32.73 years; range was: 2 months - 88 years. Postoperative pain was treated according to two

different protocols depending on the ladder of the WHO analgesic activity scale [5] Protocol 1 begins with the WHO analgesic ladder III (lad-der 3) i.e. intravenously injected morphine by syringe pump at a dose of 0.3 mg·kg-1·d-1 from D0-D3 postoperative then nefopam by slow intravenous injection at a dose of 20 mg x 4. D-1 associated with paracetamol intrave-nously at a dose of 1g x 4.d-1 from post-opera-tive D4-D6; then an oral treatment with para-cetamol associated with codeine (500/30mg) at a dose of 1capsule x 3.d-1 or by tramadol 50 mg at a dose of 1 capsule x 2/day, from D6 to discharge. Protocol 2 begins with the WHO analgesic ladder II (ladder 2) i.e. neoplasm by slow intravenous injection at a dose of 20 mg x 4. D-1 associated with intrave-nously injected paracetamol at a dose of 1g x 4.d-1 from postoperative D0-D4; then an oral treatment with paracetamol associated with codeine (500/30 mg) at a dose of x 1cap-sule 3.d-1 or 50 mg of tramadol at a dosage of 1 capsule 2 x/d, from D4 to the exit. No epidu-ral analgesia or intercostal nerve block was used. Chest tubes were set in continuous aspi-ration to -25 mmHg except in case of pneu-monectomy. Chest surgical approaches perfor-med, their indications, post-operative results regarding intensity of post-operative pain as-sessed by analgesic protocol used, length of stay, time of healing and the appearance of the postoperative scar had been studied.

Results Eight hundred and fourteen (814) chest surgical approaches were performed (Fig.1), including 422 (51.84%) classic posterolateral thoracotomies, 265 (32.55%) vertical median sternotomies, 120 (14.74%) xiphoid incisions for pericardial drainage by Marfan retro-xi-phoid approach and 7 (0.85%) other thoracic surgical approaches. These chest approaches were used either for Cardiac Sur-gery (n = 473; 58.10%) or for non-cardiac chest surgery (n = 341; 41.89%). In Cardiac Sur-gery, 250 (52.85%) vertical median sternoto-mies, 101 (21.35%) posterolateral thoracoto-mies, 120 (25.36%) xiphoid incisions and 2 (0.42%) video-aided thorascopic surgery were performed (Fig.2).


28


Afr.Ann Thorac.Cardiovasc.Surg. 2018; 13(1)

The vertical median sternotomy was indicated for surgical correction of 87 (18.39%) valve diseases, 121 (25.58%) congenital heart disease, and other 42 (8.87%) acquired heart diseases. All pericardial drainages (N = 120; 25.36%) were performed by a classic xiphoid incision according to MARFAN retro-xiphoid approach. The classic postero-lateral thora-co-tomy was prescribed for the correction of 98 (20.71%) congenital heart disease and 3 (0.63%) surgical explorations for post-operative bleeding. Video-assisted tho-rascopy was prescribed 2 times (0.42%) for ductus arteriosus closure by clips. In non-car-diac thoracic surgery, 321 (94.13%) posterola-teral thoracotomies, 15 (4.39%) vertical median sternotomies (1.46%) and 5 (1.46%) other surgical approaches were done (Fig.2). The postero-lateral thoracotomy technique was prescribed for the surgical treatment of 121 (35.48%) pleural diseases, 133 (39.00%) diseases, 19 (5.57%) mediastinal disorders, 34 (9.97%) parietal diseases, and 14 (4.10%) other non-cardiac chest diseases. Conventional vertical median sternotomy was prescribed for the surgical treatment of 7 (2.05%) and mediastinal disorders and 8 (2.34%) parietal conditions. The previous Chamberlain me-dia-stinotomy (n = 2; 0.58%), and mediasti-no-scopy (n = 3; 0.87%) were prescribed to carry out mediastinal tumor biopsies. The intensity of postoperative pain after the verti-cal median sternotomy and posterolateral thoracotomy (n = 687; 84.39%) was sharp and required the administration of morphine by injection (WHO analgesic ladder 3), while minimally invasive approaches such as Chamberlain anterior mediastinotomy, me-dia-stinoscopy and video-assisted thoracos-copy were less painful and required the ad-mini-stration of tramadol by injection (analge-sic WHO ladder 2) (Table I) . The hospital stay was 5.25 days (4-7 days) for vertical median sternotomy, 13.68 days (3-31 days) for pos-terolateral thoracotomy, 9.37 days (4-14 days) xiphoid incisions and 3.5 days (2-4 days) for minimally invasive approaches such as Chamberlain anterior mediastino-tomy, mediastinoscopy and video-assisted thoracoscopy (Table I).

The hospital varied depending on the type of surgical procedure performed (Table II and III). Healing time was 22.25 days (17-30 days) for vertical median sternotomies, 27.69 days (13-60 days) for posterolateral thoracoto-mies, 17.5 days (10-20 days) for xiphoid inci-sions with a highly visible and unsightly scar while it was 7.5 days (6-10 days) for minimal-ly invasive approaches such as Chamber-lain anterior mediastinotomy, mediastinosco-py and video-assisted thoracoscopy with a less visible and anaesthetic scar.

29



Table I: Postoperative results according to chest approach

Table II: Postoperative results according to procedure in Cardiac Surgery



Table III: Postoperative results according to non-chest cardiac procedures



the lack of suitable equipment and training of the surgical team while according to several authors (17-41) the minimally invasive thoracic surgery remains the technique choice to sur-gically treat almost all pleural, pulmonary and mediastinal diseases. However, according to Joshua Neto et al (42) in 2014 in Brazil and Thomas Kirby [30] in 1995 in the USA, regardless of the type of surgery, the minimal-ly invasive approaches are used in two forms. In one hand, in a direct form or by mini-thora-cotomies or by the technique by muscular savings and in other hand, in an indirect form with the video-assisted performed safely. Intensity and duration of post-operative pains are less important in chest minimally invasive approach versus conven-tional thoracic approach. So, Santambrogio (37) in 1995 in Italy, administered 106 mg of ketorolac versus 143 mg, Ayed (38) in 2000 in Kuwait, used Demerol 75 mg (45-150) versus 150 mg (40-300) and Abdala [35] in 2001 in Spain administered painkillers for 38 hours versus 77 hours. As for Kuhlman (43) in 1999 in France, asserted that given the various back-grounds of pain after thoracic surgery, it is rare that a single technique, even the most sophisticated, brings about a total control of painful manifestations and namely shoulder pains. Also, regardless of the choice of a postoperative local analgesia technique, the association with a parenteral supplement administered on demand should be prescribed systematically. According to V Joshi (44) in England in 2013, Video-Assisted Thoracic Surgery reduces length of hospital stay. Brevity of hospital stay for minimally invasive thoracic approach versus conventional chest approach was also dealt with by other authors namely Santambrogio (37) in 1995 in Italy, Ayed (38) in 2000 in Kuwait, Abdala (35) in 2001, in Spain. They respectively found it for pulmonary segmentectomy, an average length of 4.6 versus 7.8 days; 3 versus 5 days; 5.3 versus 7.5 days. Other authors like Ayed (31) in 2000 in Kuwait, Waller [33] in 1994 in England and Gebhard (34) in 1996 in Germany, reported hospital stay length as follows in order: 6.5 versus 10.7 days, 4 versus 5 days and 5 versus 7 days for the surgical treatment of pneumothorax (with talc)

Discussion Cardiac and non-cardiac thoracic surgery in Cote d’Ivoire is carried out mainly through traditional surgical approaches. Minimally invasive thoracic surgical approaches are almost non-existent. This situation is contrary to that of the developed countries where the minimally invasive thoracic surgery and minimally invasive cardiac surgery are gro-wing for over 15 years [6]. According to Jougon and colleagues [2], previous chest surgical approaches are the preferred approaches for mediastinal surgery, cardiac surgery, and pulmonary and cardiopulmonary transplan-tations while the posterolateral thoracotomy has always been considered as the preferred approach for lung surgery. For cardiac surgery, we have addressed all valvular diseases acquired by vertical median sternotomy to carry out a valve replacement or a valvular plasty. Our practice was different from Obadia J-F’s [7; 8] in France in 2006 and 2010. He has used video-assisted thorascopy to carry out valve replacement, even complex valvular plasties, and tumor resections. As for American authors like Alexander Iribane [9; 10]; they extend the prescriptions for minimally invasive cardiothoracic surgery to repairs or replacements of the aortic valve, to the repair or replacement of the mitral valve, and to aor-tocoronary bypass. According to literature [8; 10; 11; 12], the minimally invasive mitral valve surgery is the most performed practice of the minimally invasive cardiothoracic surge-ry. Regarding congenital heart diseases, they were addressed either through a sternotomy or through a conventional posterolateral tho-racotomy, except 2 (0.42%) cases of arterial channels that were addressed by video-as-sisted thoracoscopy which is below the current trend whereby some congenital heart diseases such as inter-atrial and inter-ventri-cular communications are operated from a minimally invasive thoracic approach (8; 9; 13; 14;

15).Unlike Hui-Ping Liu (16) in 1994 in China, who proposed a pericardial surgical drainage by video-assisted thoracoscopy in particular for patients with pleural and pericardial effu-sion,we have realized all pericardial surgical drainages by Marfan retro-xiphoid approach. Regarding the non-cardiac thoracic surgery, the minimally invasive approach is almost nonexistent in our practice because of



Considering these results in literature, the average hospital stay is 9.43 days (range 2-50 days) in our practice remains excessive. The hospital stay in our study was comparable to the length of hospital stay found by other authors for conventional chest approaches while it was too long compared to the mini-mally invasive approaches with the same authors. Regarding the rate of wound infections to abscesses type of the wound found in 7.6% of cases, our results were comparable to those of Grossi [51] in 1999 who reports an incidence of 5.7% for conventional sternotomy versus 0.9% for the mini-thoracotomy. The cost of minimally inva-sive approaches remains questionable. Actually according to Swanson SJ (52) in the USA, hospital costs of conventional thoracotomy for lobectomy ($ 21,016) are higher than those of Video-assisted Thoracic Surgery ($ 20,316) for the same intervention (p = 0.027). These results tally with the findings of Casali (53) in 2009, in England, who indicated that the overall cost of Video-assisted Thoracic Surgery for a lobectomy was lower (8023 € ± 565) compared to the cost of a lobec-tomy (8178 € ± 167) (P = 0.0002)

by conventional thoracotomy; and that, due to the reduction in the duration of the patient’s postoperative stay in intensive care for Video-assisted Thoracic surgery. The author concludes that the video-assisted Thoracic Surgery for a lobectomy is cheaper than lobectomy by conventional approach; and the increased costs of surgical procedure due to consumables is offset by a shorter hospital stay. Rodriguez E (54) drew the same conclu-sion in September 2014, in the USA. He found out that the aortic valve replacement by right anterior minimally invasive approach is less expensive than that achieved by conven-tional median sternotomy ($ 38,769 versus $ 42,656; p <0.01). In our developing countries, this practice of minimally invasive chest approach is possible as it has already been carried out in South Africa (55), Turkey [56] and Brazil (57), but unlike Western countries, in developing countries like ours, the video-as-sisted Thoracic Surgery is more expensive than the conventional thoracotomy approach because of consumables cost (56, 58). Thus, the practice of these minimally invasive ap-proaches in our developing countries will require a good strategy for patient selection (58, 59). However, to start this minimally invasive thoracic approach in our developing countries, the Brazilian model of Cardiac Surgery could be encouraged because it provides direct mini-mally invasive thoracic without video-assistan-ce and gives satisfactory results (57). In non-Thoracic Cardiac Surgery, the thoraco-tomy with Muscular Saving (30) could be recom-mended because it gives encouraging re-sults. Moreover, as argued by Frank Edwin (60), in 2011, in Ghana; the development of Car-dio-Thoracic Surgery seems closely parallel to the country's economic development and patients’ ability to honor the cost of this surgery. In our developing countries, health insurance seeing to be an essential condition for the Car-dio-Thoracic Surgery and Minimally invasive Cardio-Thoracic Surgery development. Accor-ding to Joshi V (44) in England in 2013, the Video-Assisted Thoracic Surgery has a similar recurrence rate with that of the conventional thoracotomy; it reduces the risk of intra-ope-rative bleeding.

by video-assisted Thoracic surgery versus thoracotomy. S for Thomas Kirby [30] in 1995 in the USA, it is 7.1 versus 8.3 days for pulmona-ry lobectomy by video-assisted thoracic surgery versus thoracotomy. In cardiac surgery, the same observations were made by authors like Lin PJ (45) in 1997 and Murat Basaran (46) in 2008 found respectively hospital stays of 5.1 days versus 8 days and 5.4 days versus 7.2 days for surgical closure of an Inter-Ear Com-munication by Anterolateral Mini-thoracotomy versus conventional vertical median sternotomy. As for Sung-Ho Jung (47), in 2009, he mentioned a 3.6-day hospital stay versus 6.1 days for surgical closure of an Inter-Ventricular Commu-nication by Antero-lateral thoracotomy versus conventional vertical median mini-sternotomy. Other authors (48, 49, 50) were also unanimous on the fact that minimally invasive approaches decreased post-operative complications, reduced the duration of chest tube and the length of stay in hospital while success of the surgical procedure is comparable to traditional surgical approaches.



Conclusion The development of minimally invasive approaches for thoracic and cardiovascular surgery remains a challenge in Cote d’Ivoire. Thoracic approaches being currently used in Cote d’Ivoire are uncomfortable, extend hos-pitalization and healing time, leave unsightly scars and sometimes turn excessive. Therefore, we need to convert our classical option to a minimally invasive approaches which remains a challenge for us.

Conflicts of interest: The authors did not report any conflict of interest in connection with the writing of this scientific article.

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