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Over a period of 12 years, 24 burns have been treated by a cambodgian and French team (doctors of the world). This experience has revealed some characteristics of this population: (1) a majority of young women (2/3) (2) victims of a assault (20 cases). These notions are found in the medical literature particularly South East Asia . All cases are of a third degree. Every surgeon, every anesthetist should apply emergency measures which are recalled here. The aims is to close all the burns surface through a skin graft within a month. However the patients are treated 6 months to 2 years after the burn and have, at this stage, terrible sequella (22 patients). Treating them requires the coordinated efforts of a multidisciplinary specialized team. The challenge is to save the eyes, the mouth, the nose and give back a “human” face to these young burns who are often rejected because of their handicap. Enabling them to smile again is a strong commitment from the surgeon and from the patient who has to undergo multiple operations and a long treatment over the years. [Copyright &y& Elsevier]

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Introduction: A solitary fibrous tumor is a rare circumscribed neoplasm that was long known in the pleura and has now described in many organs and soft tissues. Prognosis is favorable after complete excision., Case: We report a solitary tumor fibrous located in the bladder of a 38-year-old man with dysuria and a palpable abdominal mass., Discussion: Solitary fibrous tumors are reported very rarely in the urinary bladder. They may mimic other nonepithelial tumors in this site. Diagnosis based only on pathological features is difficult. When complete excision is possible, prognosis is generally good. Outcome is more serious in approximately 10-20% of cases, and strict follow-up is required.

Schistosomiasis mekongi was shown to be endemic, along the Mekong River, in northern Cambodia, affecting many patients with portal hypertension. Surgical procedures were proposed to some patients with digestive haemorrhage history to avoid fatal recurrence. The aim of our study was to evaluate the intensity of the liver fibrosis among these patients. During surgical treatment, liver biopsies were collected, fixed in Bouin or in formalin and processed at the Institut Pasteur of Cambodia. Sections were stained by H&E, Masson's trichrome, PAS, Ziehl-Neelsen's method and Congo Red. A total of six biopsies from patients aged 16-36 were analysed. There was complete disorganization of hepatic architecture with fibrous enlargement of portal tracts and some portal-portal bridging fibrosis, but there was no cirrhosis. In portal areas, there was blood vessel congestion and thrombosis with inflammation. Bile ducts were normal. In the parenchyma, congestion of sinusoidal capillaries was combined with focal mononuclear inflammatory infiltrate. There was no steatosis, no necrosis, no cholestasis, no iron accumulation and no amyloidosis. Numerous eggs of Schistosoma mekongi were observed in five cases, mostly in fibrous areas and more rarely in the parenchyma. Eggs were round or oval, measuring 60 x 40 microns with an acid-fast thin hyaline wall. Some eggs were surrounded by epithelioid and giant cell reaction. In conclusion, our findings illustrated a surprisingly high degree of fibrosis among young adults which contrasts with other schistosomiasis.

In spite of a decrease of the prevalence of hepato-splenic schistosomiasis thanks to mass-treatment with Praziquentel from December 1994 till now (CNM - MSF - WHO - Health Provincial Director) of target-populations in Kratie Province, severe cases of portal hypertension are not exceptional (digestive bleedings, after rupture of oesophageal varices). Out of 106 cases of portal hypertension: alI patients have had clinical survey biological tests (liver function, haematology and serology). Most of them had ultrasonography (Aloka 55,500 Sound 3.5 MHz). Nearly half of the group of 153 patients has never had bleedings. More than 45 were not eligible for surgery for different reasons: severe anaemia (few possibilities for massive transfusion in Cambodia), serology (S. mekongi) + but also hepatitis B or C +, hepatic biological exams (hepatic insufficiency). So we decided for eleven of them to use a surgical decompression procedure in order to decrease portal hypertension and the porto-systemic gradient. After defining portal hypertension, specific clinical features of portal hypertension (secondary to Schistosomiasis) the authors report eleven cases who were operated on (2000-2002): 4 mesenterico-cave shunt with interposition of a graft (Drapanas' procedure), 1 operation of HASSAB (after splenectomy), 6 proximal spleno-renal diversion (after splenectomy). After studying the results of the eleven patients, discussion with other surgical procedures, particularly endoscopic procedures is developed. The follow-up of these patients during at least five years is mandatory to give guidelines for post-systemic shunts to prevent rebleeding (near other methods). Treated too late, schistosomiasis has no benefit from drugs (Praziquentel). After a mean period of forty two months, the following results are: mortality: one case (10 days after operation): hepatic insufficiency (group Child B/C). morbidity: one occlusion of the small intestine, after 4 months (debridment), operated at the Provincial hospital of Kratie (case no1). Ten patients resume work, family and social life between Kratie and Sambor in 2002. No rebleeding. No encephalopathy.

Is the new surgical training program at the University of Phom-Penh, Cambodia a unique experience or can it serve as a model for developing countries? This report describes the encouraging first results of this didactic and hands-on surgical program. Based on their findings the authors recommend not only continuing the program in Phom-Penh but also proposing slightly modified versions to new medical universities not currently offering specialization in surgery.

Over a period of 12 years, 24 burns have been treated by a Cambodgian and French team (Doctors of the World). This experience has revealed some characteristics of this population: (1) a majority of young women (2/3), (2) victims of assault (20 cases). These notions are found in the medical literature particularly South East Asia. All cases are of a third degree. Every surgeon, every anesthetist should apply emergency measures which are recalled here. The aims is to close all the burns surface through a skin graft within a month. However the patients are treated 6 months to 2 years after the burn and have, at this stage, terrible sequella (22 patients). Treating them requires the coordinated efforts of a multidisciplinary specialized team. The challenge is to save the eyes, the mouth, the nose and give back a "human" face to these young burns who are often rejected because of their handicap. Enabling them to smile again is a strong commitment from the surgeon and from the patient who has to undergo multiple operations and a long treatment over the years.

The lower urinary tract is injured in less than 1% of all firearm wounds in men. In war medicine, blast wounds occur in 75% of the cases while in civil medicine ballistic injuries are more frequent. When the bladder and the posterior urethra is involved, the projectile usually follows a path through the gluteal muscles and pelvis. A perineal genital path is usually found for injuries to the anterior urethra. This explains the frequency of associated vascular and colorectal lesions in pelvic wounds and genital injuries in perineal wounds. Bone and muscle injuries occur in both situations. A mental reconstruction of the projectile path is required for a precise diagnosis of the lesions, together with the clinical examination (urine outlet, miction impossible with or without bladder extension, urethral bleeding) and most importantly standard x-ray of the pelvis in search of bone lesions and the projectile. Urethrography should always be performed whenever the urethra is injured in all civil wounds. However, the final diagnosis of the lesions can only be made at surgery. Urology procedures, usually performed by polyvalent surgeons, should be simple, rapid and reliable. It is important to preserve urinary and genital functions in these young subjects usually under 30 years of age. Cystostomy and drainage is the strict minimum. In addition, depending on the infectious and hemodynamic status, conservative excision of damaged tissue is needed prior to primary closure. Wounds involving the bladder can be closed in 95% of the cases. Closure is simple for wounds involving the superior portion of the bladder. For deeper wounds involving the trigone endovesical suture is used after intubing the ureters. Ureteral drainage is mandatory when the bladder is highly damaged and cannot be closed. Urethro-prostato-membranous wounds should also be repaired to avoid inevitable fibrosis of fistulization. However, access to the apex of the prostate causes major bleeding and there is a risk of injuring the sphincter or erection nerves, particularly by surgeons inexperienced in urogenital surgery. When massive bleeding cannot be controlled by clamping the two hypogastrics, symphysiotomy, rather than symphysectomy, is recommended. In other cases, aligning the urethral extremities may be sufficient. Short wounds to the anterior urethra should be cleaned and the extremities spatulated and anastomosed on a guide when they can be closed. In other cases, a perineal or penile urethrostomy is created. Associated wounds involving the anus and rectum require colostomy, emptying the excluded rectum and wide pelvic-perineal drainage. An attempt should be made to repair the rectum or the sphincter. Genital lesions require early repair: tight suture of the albuginea of the cavernous bodies with or without a patch, preservation of viable testicular parenchyma and adnexal tissues (but orchidectomy is necessary in 50% of the cases).

Perineo-genital wounds involving the anterior perineum or the urogenital perineum are uncommon; 1-4% of all war wounds. We report 18 cases observed in war situations. Isolated uretrogenital wounds are rarely life-threatening, but the functional prognosis is always compromised in these men whose mean age is under 30 years. Debridements should be limited and all isolated lesions should be repaired early with tight suture of the cavernous body albuginea, preservation of viable testicular and adnexal tissue (but the rate of orchidectomy is greater than 50%), and immediate suture of any wound to the urethra rather than simple alignment. In war situations, these wounds are usually caused by perforating or blast trauma. The wounds are complex, with damage to the soft tissues, sometimes involving lesions to the anal sphincter, the gluteal masses or the abdomino-pelvic structures. Laparostomy for hemostasis is justified. The risk of sepsis is high, requiring triple antibiotics, cystostomy, careful debridement, discharge drainage or possibly colostomy. Treatment of urogenital lesions is a secondary operation in these cases but must not be neglected if the mictional and sexual functions are to be preserved.

The development of a pressure sore carcinoma in scars of spinal cord injury patients is a rare event (less than 0.5%) and occurs late (more than 30 years after the spine injury) but the prognosis is very poor. Five cases are reported and different aspects are reviewed: anamnesis, clinical features, and follow-up studies. The association of surgery and radiotherapy is usual but is not very successful. Local-regional chemotherapy and a better approach concerning immunological mechanisms may improve survival. Scar prevention and surgical management of chronic scars treated unsuccessfully by medical methods are the best means to prevent malignant changes in chronic pressure sores. Biopsy should be mandatory for all pressure sores after the first decade.

The authors report 24 cases treated with an gluteus maximus musculocutaneous flap. The gluteus maximus is generally used as a VY flap. Our technique uses the superior part of the muscle with the overlying skin as a rotation flap. The upper part of the muscle is supplied by the superior gluteal artery. A good knowledge of the anatomy makes this flap easy to perform. The skin part of the flap is drawn over the trochanter. It is generally a 8 cm diameter circle. We then create a subcutaneous tunnel to prepare the rotation. The muscle is then freed from its lateral origin. The separation from the gluteus medius is made by blunt dissection and the superior gluteal artery can then be seen. The myocutaneous flap can now be raised and transferred to the defect. This flap has, in our experience, many advantages especially in paraplegic patients: large skin defects can be covered with a single flap, the perisacral skin is free of any scar, the lower part of the muscle can still be used to cover ischial ulcers. Since 1987 we have treated 24 patients with good results. The reliability and the great technical simplicity makes us think that the superior gluteus maximus musculocutaneous island flap is optimal for the coverage of sacral pressure sores.

Sixteen patients with thyrotoxicosis were admitted during a period of eighteen months (1984-1985) in Central Hospital of N'Djamena (Chad). Clinical features, laboratory investigations are reported. Ten patients had a surgical treatment:subtotal thyroidectomy. A review of literature in Africa was made. Whereas thyrotoxicosis was rare among Africans before 1970, there has been an increase of frequency for twenty years. Many hypotheses are proposed, among them the possibility of the role of Epstein-Barr's virus, frequent in Africa.

A series of 51 cases of thyrotoxicosis gathered during a period of 6 years in a department with a cardiological orientation is analysed. This peculiar form of thyrotoxicosis is often unrecognized in view of its frequent occurence in aged subjects (which is misdiagnosed as "senile heart") and of the incidence in its causality of a toxic adenoma, the endocrine semiology of which is often reduced. In front of any case of heart failure of unknown cause, one should systematically think of a thyroid aetiology. A persistent sinus rhythm is not enough to discard it. A low cholesterol rate should induce to continue the investigation. The subnormal character of the classical laboratory parameters (including the thyroid hormone assay) does not always make it possible to exclude definitely the diagnosis. When the clinical picture is suggestive, only the radio-isotope examination with dynamic tests is liable to provide decisive data.

The authors report their surgical experience of complicated stenosis of urethra in the Department of Urology of the Central Hospital of N'Djaména (Tchad) from 1984 to 1987 (July). The surgical treatment was indicated for the complicated cases of stenosis of the urethra, which were obstructed (less than a quarter of the patients who were admitted for urethra stenosis). Before 1984 the only surgical procedure was called "Chemin de fer: a blind pull-through method with a lot of complications. After 1984 the one stage urethroplasties were used in forty four cases: either with a free full thickness skin graft (DEVINE), or with a vascularized flap (BLANDY'S or ORANDI'S technique). The results are studied with a follow up of 18 months. The urethroplasties with a vascularized flap have had less failures (16%) than with a free full thickness skin graft (33%).

The war ureteral gunshot wounds (W.U.G.W.) are, in practice, scarce but not an exception. They are to be suspected in every war abdominal injury. Urethral catheterization, microscopic hematuria research, simple X-Ray and I.V.P. have to be undertaken; but it's never easy in wartime circumstances. Investigation must be carried out during intervention: ureteral exploration in case of retroperitoneal hematoma or wound. Three observations illustrate these main difficulties. Unfortunately diagnosis is often done in post-operative time when a complication arises. The treatment is now well known: adequate debridement, anastomosis or reimplantation and drainage.

Out of a series of 103 patients operated on for peptic stenosis of the oesphagus, we carried out 63 conservative operations, 29 by the thoracic route, 34 by the abdominal route. The operation consists of retrograde dilatation, by finger or by instrument, combined with an anti-reflux arrangement. Among the various technics of the latter, plicature of the fundus has proved the most effective. Gradually, the indications for the abdominal approach have become dominant, even if the cardia cannot be lowered. One may then use a sleeve on the gastric cone, which until now, in 23 cases has given excellent results. One may thus carry out by an extremely benign operation without any mortality, a surgical cure not only of supple stenoses, but also of certain tight fibrous stenoses, considered insuperable. Postoperative dilation was rarely necessary. The results of which some are 8 years old, seem stable in the vast majority of cases. The proportion of excellent results was 81 p. cent of the series. It was higher in the group of plicatures of the fundus where there were only two failures. No case of cancer was observed in the remaining oesphagus.