Evaluation of a new supraglottic airway device in ambulatory surgery: the I-gel[registered sign]

The I-gel[registered sign] is a new single-use supraglottic airway device with a non-inflatable cuff. It is composed of a thermoplastic elastomer and a soft gel-like cuff that adapts to the hypopharyngeal anatomy. Its tube is profiled to facilitate and stabilize its insertion. The aim of our study is to state the efficiency and the place of I-gel[registered sign] in airway management in adult anaesthetic practice. One hundred patients, ASA I-II, scheduled for shortduration elective surgery under general anaesthesia were included in this prospective study. Patients with neck pathology, previous or anticipated airway problems, increased risk of regurgitation or aspiration, ASA III and above and undergoing emergency surgery were not included in the study. We collected the following data: adequacy of the size recommended to the patient, ease in inserting the I-gel[registered sign], leak fraction, gastric leak, complications during insertion and removal, ease in inserting the gastric tube, haemodynamic and ventilatory parameters, stability during patient movement and satisfaction of the anaesthetists. The success rate of insertion and the use of the I-gel was respectively 99% and 96%. The device was inserted at the first attempt in 92% of cases. The introduction of the I-gel[registered sign] was rated easy in 99% of cases taking a median of 13 seconds. Complications of insertion were restricted to coughing in 5 patients and hiccups in 7 patients. There were no significant increase in heart rate and mean arterial blood pressure compared to pre-insertion values. An audible leak was recorded in 14.6% of cases. The need for additional manoeuvres was less than or equal to 2 in 96.9% of patients. The mean of the recorded peak airway pressure values was 18 cmH2O. After a fibreoptic exam via the airway tube, the glottis was completely seen in 74% of cases and partially seen in 14.6%. Two cases of gastric inflation were recorded. There was no case of regurgitation or hypoxemic episode during this trial. Post-operatively sore-throat was reported by one patient in recovery. After I-gel withdrawal, trace of blood was observed in 5 devices. One case of dental trauma was noted. 95% of the anaesthetists were satisfied with the use of the I-gel in their pratice. This study showed that I-gel[registered sign] can be used safely and effectively in patients undergoing short-duration elective surgery because the I-gel[registered sign] has a very good insertion success rate and few complications. The fibreoptic position of the device was correct and the ventilation was highly effective. These elements must be corroborated in larger series

Idiopathic segmental infarction of the greater omentum

Idiopathic segmental infarction of the greater omentum is a rare cause of acute abdomen. The diagnosis is based primarily on the abdominal CT scan. A 20 year old male presented with right lower abdominal pain. Initial examination unremarkable and patient was kept under observation. Symptoms did not abate and CT scan showed an ovoid fat density mass in abdomen. Laparoscopy showed partially twisted omentum which was resected at open surgery

[Predictive factors of esophagojejunal fistula after total gastrectomy in gastric cancer patients]

The main complication observed after total gastrectomy is the oesophagojejunal anastomosic fistla. Its incidence varies between 7.4% and 11.5%. The mortality after anastomic leafage is high at around 20%, representing 30% and 54% of global mortality after total gastrectomy. This study aimed to evaluate mortality and morbidity after total gastrectomy and to determine their predictive factor. This is retrospective study about 80 cases of total gastrectomy for gastric cancer, collected in the departmentof General Surgery of the University Hospital Habib Thameur Tunis during the period 1 January 1995 to 31 December 2010. Reconstruction of the alimentary tract was achieved by Roux-en-Y-jejunal-loop. Esophagojejunal anastomotic leeakage developed in 14 patients [17%]. In 8 patients treatment of anastomotic leakage consisted of re-operation with surgical drainage and confection of jejunostomy. in one patient treatment required resutre of the anastomosis and drainage of an abscess. In one patient treatment required resuture of the anastomosis and drainage of an abscess. In 5 of the 14 patients with a proven leak of oesophagojejunal anastomosis, conservative treatment with parental alimentation, placement of an irrigation-aspiration system and systemic antibiotics was performed. This treatment was successful in all cases. The presence of anastomic fistula extends the median length of post operative stay in the hospital of 20 days compared for the payents withiut fistula.Global mortalilty was 8/80 [10%]. After esophagojejunal anastomotic leakage, the mortality was 3/8 [21%]. Leakage of the oesophago-intestinal anastomosis may occur after total gastrectomy for gastric cancer. It's serious complication contributes to mortality after total gastrectomy. Knowledge of the predective factors of esophagojejunal fistula after total gastrectomy in gastric cancer can decrease its incidence

[Acute mesenteric ischemia: study of predictive factors of mortality]

Acute mesenteric ischemia is a surgical emergency that requires a quick diagnosis and therapeutic care. Without treatment, the outcome is towards intestinal infarction whose prognosis remains grim. To look for predictive factors of mortality of this disease. We retrospectively reviewed the clinical data of patients hospitalized between January 2000 and December 2008 for acute mesenteric ischemia. Univariate and multivariate analysis of factors that could influence mortality was conducted. 26 patients, predominantly male, were included. The mean age was 60 years. These patients were cared for on average 4 days after the onset of symptoms. The diagnosis was made pre-operatively in 9 patients, by CT scan in 8 patients and by Doppler ultrasound in 1 patient. The cause of AMI was arterial thrombosis in 19 cases, venous thrombosis in 4 cases and non occlusive mesenteric ischemia in 3 cases. 25 patients were operated on emergency 24 times by a laparotomy and one time by a laparoscopy. The surgery consisted in bowel resection in 15 patients; an abstention was decided in one case of venous mesenteric ischemia and in 9 cases where necrosis affected all small bowels. Revascularization of the superior mesenteric artery was associated in 4 cases. Outcome was simple in 8 patients. The mortality rate was 69%, death occurred in a period of J0 to J90 after surgery. This rate wasn't influenced by age or sex. It was higher in patients with preoperative collapse [p = 0.02] and having an expansive bowel necrosis [p=.0001]. The prognosis is better in cases of venous infarction with a mortality rate of zero. Prognosis of acute mesenteric ischemia depends on the aetiology and the quickness of treatment. It is directly linked to the extension of intestinal infarction. An urgent and multidisciplinary care is necessary

[Gastric heterotopia: clinical and histological study of 12 cases]

Gastric heterotopia is a rare congenital lesion, described everywhere in the body, but involves predominantly the digestive tract. Diagnosis is based on histologic examination and requires the presence of gastric mucosa, especially fundic. This diagnosis is usually easy, but sometimes it can be misinterpreted as gastric metapalsia. This latter is an aquired and frequent lesion of the gastrointestinal tract. To determine the relationship between this affection and the other digestive malformations, to describe the clinical characteristics and the evolution of this lesion and to discuss the differential diagnosis particularly the gastric metaplasia. Twelve cases of gastric heterotopia were diagnosed over a 12-year period at Habib Thameur Hospital. Clinical data was obtained and all the slides were reviewed. Nine cases were found in Meckel's diverticulum [75%], one case in intestinal duplication, one case in the esophagus and another in the gallbladder. The mean age of patients at diagnosis was 16 years with a peak of incidence at the first decade of life. Intestinal obstruction and digestive bleeding were the most presenting features. Heterotopic gastric mucosa complicates other congenital anomalies such as common mesentery, vestigial polyp of the liver, appendiceal agenesis and heterotopic pancreas. Differential diagnosis consists in gastric metaplasia was found extensively in a patient with Crohn's disease associated with Meckel's diverticulum. Gastric heterotopia is frequently associated with congenital anomalies especially with Meckel's diverticulum and digestive duplication. Diagnosis relies on histology, mainly on finding heterotopic fundic glands in normal organizational structure. Sometimes, differentiating between gastric heterotopia and gastric metaplasia requires clinical confrontation

[Effectiveness of intravenous magnesium on postoperative pain after abdominal surgery versus placebo: double blind randomized controlled trial]

The purpose of our trial is to evaluate the impact of the intravenous perfusion of magnesium on the morphin consumption and on the control of the stress neuro-endocrine and metabolic reaction in major digestive surgery. prospective, randomized, double blinded study versus placebo .Including 42 ASA I patients, scheduled for major digestive surgery, randomized into two groups: Magnesium, receiving a bolus of magnesium sulfate; 50 mg/kg, followed by a continuous perfusion; 10 mg/kg/h for the 24 postoperative hours. The control group received the same volume of an isotonic saline solution .Postoperative analgesia was assured by morphin PCA. The patients were evaluated by the pain visual analogic scale [Vas], the total dose of morphine consumed and the evolution of the biological markers of stress [glycemia, cortisol, ATH, prolactine and IL6] during the first 24 postoperative hours. Hemodynamic and respiratory parameters, side effects and patient satisfaction were recorded. the total dose of morphine consumed during the first 24 postoperative hours,was equivalent in the two groups [44.49 +/- 6.4 vs 45.26 +/- 9,1 mg; p= 0.59].the initial pain VAS means were equivalent [68mm +/- 15 vs 71mm +/- 14]. Ulterior pain VAS means,after morphin titration then with PCA were also equivalent and less to 40mm. the global amplitude and the evolution of the stress markers evaluated by the surface under curbs were comparable in the two groups, despite a magnesemia twice higher than the normal values in the magnesium group .the satisfaction and the incidence of side effects were similar. association of magnesium to morphin PCA does not help to reduce morphin consumption, and does not affect the control of the stress reaction in major digestive surgery

[Laparoscopic treatment of duodenal ulcer feasibility and results: about 160 cases]

The objective of this study is to evaluate the feasibility, efficacy and safety of laparoscopic repair for perforated duodenal ulcer. One hundred and sixty patients were treated by coelioscopic procedure for a perforated duodenal ulcer. The procedure consists of a suture of perforated ulcer associated with a peritoneal lavage. A medical treatment of Helicobacter pylori associated with an inhibitor of the protons pump was conducted. The coelioscopic procedure permitted to confirm the diagnostic of perforated duodenal ulcer in all cases. A simple suture of the ulcer was done in 155 cases. The conversion was compulsory in 5 cases, because of difficulties of the peritoneal lavage in 2 cases, a bleeding associated with perforation of the ulcer in one case and associated stenosis in 2 cases. Mean duration was 90 min [extremes 50 - 120 min]. Complications occur in 3.1%. There were post - operative peritonitis in 3 cases and duodenal fistulae in 2 cases. All patients were reviewed at 16 months. A recurrence, either clinical or endoscopic occured in 4 cases because of no adhesion to medical treatment. Coelioscopic treatment of perforated duodenal ulcer is a safe and efficacy method. It permits to avoid potential septic and parietal complications of laparotomy. The actual efficacy of medical treatment mustn't allow place to the radical treatment of ulcerous illness

[Common bile duct distomatosis managed by coelioscopic arroach]

Biliary distomatosis is caused a parasitis of trematode family: the fascialo hepatica. It is a rare affection in Tunisia. The diagnostic is often done in the status phase. Adult parasite stay preferentially at biliary ducts, cause obstruction and cholangitis. The authors report a case of biliary treated successfully by laparoscopic procedure

[Cholangitis reveling an intrahepatic Osler's disease]

Osler Weber Rendu Disease is a hereditary haemorrhagic telangectasia habitually revealed by reccurent bleeding [epistaxis]. Hepatic involvement in Osler disease is found in 8 to 31%, manifested by cholestasis. We report an original observation of a cholangitis revealing Osler disease