Bacteriological and therapeutic profile of diabetic foot infection: a prospective study of 100 patients

Introduction: Identifying the infecting bacterial flora is one of the main rules to be followed to ensure the success of antibiotherapy in the treatment of the infected diabetic foot

The aim of the work was to define the bacteriological profile of the bacteria causing the infection of the diabetic foot at the surgery unit B of Charles Nicolle's hospital in Tunis and determine the prognostic factors of this condition

Methods: It was an open prospective study. It concerned 100 diabetic patients operated on for diabetic foot infection. All patients had bacteriological samples taken through deep scraping and swabing carried out in the operating room

Results: The average age of patients was 59,5 +/- 11 years, with a sex-ratio of 2,4. The foot infection was represented in 82 % of cases by a wet gangrene. The enterobacteria were the most frequently isolated bacteria [73%], followed by streptococcus [10%], Staphylococcus aureus [9%]. The rate of multidrug-resistant bacteria was of 9,5%. The empiric antibiotic therapy used [fusidic acid +amoxicillin/ clavulanic acid] was inactiveon 44,1% of the isolated bacteria. When we compared the group of patients with unfavourable development [who have been reoperated] and the group of patients with favourable development, we have found two poor prognosis factors: arteritis [p=0,018 ; OR=23,7] and presence of multidrug-resistant bacteria [p=0,027 ; OR=5,8]

Conclusion: The enterobacteria were the main bacteria causing the infection of diabetic foot. The prognostic factors found, arteritis and isolation of multidrug-resistant bacteria, outpoint the importance of multidisciplinary care

"Gastric bypass" or "sleeve gastrectomy" for morbid obesity: a systematic review

Background: Introduction: Bariatric surgery represents an efficient treatment of morbid obesity allowing not only weight loss but also the control of comorbidities related to obesity. Although the sleeve gastrectomy and gastric bypass are currently the two most common procedures, the superiority of one over another and the indications remain imprecise

Aim: The aim of this work was to provide an evidence based answer to the following questions: What is the most efficient surgical procedure: gastric bypass or sleeve gastrectomy regarding weight loss, postoperative morbidity and remission of comorbidities related to obesity?

Methods:A literature search has been conducted in the data bases of Pubmed, Cochrane Library and Scopus during the period between January 2008 to March 2015, with the keywords "Gastric Bypass" and "Sleeve Gastrectomy"

Results: the results of sleeve gastrectomy and gastric bypass regarding weight loss and remission of comorbidities are comparable in the short and medium terms. Gastric Bypass is associated with a longer duration of surgery, a slightly higher early morbidity and more frequent deficiencies in vitamins D and B12 but it allows a better control of a pre-operative gastroesophageal reflux disease

Conclusion: Sleeve gastrectomy and gastric bypass are equivalent in terms of loss of weight and control of comorbidities but longer term studies are needed to refine the indications depending on the characteristics of the patient

Predictive factors of mortality in Fournier's gangrene

Background: Fournier's Gangrene is a rare but serious condition accounting for a high death rate. Several predictive factors of mortality have been reported from retrospective series but more often these factors vary from one study to another

Aim: The aim of this work is to assess the clinical and therapeutic characteristics of patients treated for Fournier's gangrene in order to determine the predictive factors of mortality

Methods: The study enrolled retrospectively all patients admitted in the surgery 'B' unit of Charles Nicolle hospital for Fournier's gangrene during the period ranging between January, 1st, 2000 and December, 31st, 2010. The diagnosis of Fournier's gangrene has been retained each time a tissue necrosis has been noted in perineum, whether during physical examination or intraoperatively. For all patients, clinical variables and treatments were collected. A comparative study was carried out between the group of survivors and deceased

Results: Forty one patients have been included. The univariate analysis identified the following predictive factors of mortality: extension of lesions outside the perineum [p=0,002], severe sepsis and/or a septic shock [p=0,006], heart rate greater than 90/min [p=0,001], white blood cell count higher than 20000/mm3 [p=0,043] and urea level higher than 7 mmol/l [p=0,009]. The multivariate analysis retained the extension of gangrene beyond the perineum as an independent predictive factor of mortality [p=0,004]

Conclusion: Improving prognosis of Fournier's gangrene requires early diagnosis ahead of the extension of lesions beside the perineum which is associated with a higher mortality risk despite optimal care and treatment

Management of liver metastases from gastric carcinoma: Where is the evidence?

Liver metastases of gastric carcinoma are often the synonym of advanced neoplastic disease which has long justified the indication of palliative chemotherapy. However, inspired by the good results of the management of liver metastases of colorectal cancers, several surgeons have focused on the treatment of liver metastases of gastric carcinoma. The different therapeutic modalities used are surgery, radiofrequency ablation, hepatic arterial infusion and palliative gastrectomy. To provide evidence based answer to the following questions regarding liver metastases from gastric carcinoma: 1. What is the indication of surgery? 2. Does radiofrequency ablation useful? 3. What is the contribution of the hepatic arterial infusion? 4. Is there any benefit to palliative gastrectomy? A literature search on PubMed database over the period from January 1990 to December 2011 was conducted using as key words "gastric cancer" and "liver metastases". Surgery of a single liver metastasis smaller than 5 cm and not associated with another metastatic site offers better results in terms of 5-year survival rate than palliative chemotherapy. Intra hepatic arterial chemotherapy offers an alternative to surgery in inoperable patients and can be proposed as neo adjuvant treatment to surgery. The interest of radiofrequency ablation and palliative gastrectomy remains unproven. Surgery is a good indication for single liver metastasis of gastric carcinoma less than 5 cm and not associated with another extra hepatic metastasis

[Is there a place for the glasgow-blatchford score in the management of upper gastrointestinal bleeding?]

Upper gastrointestinal bleeding is a frequent cause for emergency hospital admission. Most severity scores include in their computation the endoscopic findings. The Glasgow-Blatchford score is a validated score that is easy to calculate based on simple clinical and biological variables that can identify patients with a low or a high risk of needing a therapeutic [interventional endoscopy, surgery and/ or transfusions]. To validate retrospectively the Glasgow-Blatchford Score [GBS]. The study examined all patients admitted in both the general surgery department as of Anesthesiology of the Regional Hospital of Sidi Bouzid. There were 50 patients, which the mean age was 58 years and divided into 35 men and 15 women. In all these patients, we calculated the GBS. Series were divided into 2 groups, 26 cases received only medical treatment and 24 cases required transfusion and / or surgery. Univariate analysis was performed for comparison of these two groups then the ROC curve was used to identify the 'Cut off point' of GBS. Sensitivity [Se], specificity [Sp], positive predictive value [PPV] and negative predictive value [NPV] with confidence interval 95% were calculated. The SGB was significantly different between the two groups [p <0.0001]. Using the ROC curve, it was determined that for the threshold of GBS 3 7, Se = 96% [88-100%], Sp = 69% [51-87%], PPV = 74% [59 -90%] and NPV = 95% [85-100%]. This threshold is interesting as to its VPN. Indeed, if GBS <7, we must opt for medical treatment to the risk of being wrong in only 5% of cases. The Glasgow-Blatchford score is based on simple clinical and laboratory variables. It can recognize in the emergency department the cases that require medical treatment and those whose support could need blood transfusions and / or surgical treatment

Stromal tumor of the ampulla of vater: report of a case and systematic review of reported cases

Gastrointestinal stromal tumours are a large category of primary no epithelial neoplasms of the digestive tract. The localization of stromal tumours in the ampulla of Vater [STAV] is very rare. The aim of this study was to describe clinical, endoscopic and therapeutic particularities of STAV. We reported a new case and we carried out an extensive electronic search for the relevant literature using Medline. Key words used were "ampulla of Vater" and "Gastrointestinal stromal tumor" and "CD 117". With our case, we collected seven other cases in the literature. The analysis of the sample of these eight cases leads us to propose the following conclusions. STAV is a tumor of adult after the age of fifty. There is no specific symptomatology. Gastroduodenal endoscopy with biopsies and immunoassaying allows positive preoperative diagnosis in the 5 cases. Treatment should be duodenopancreatectomy since the tumor is often malignant [5 cases]

[Odontogenic descending necrotizing mediastinitis]

Descending necrotizing mediastinitis [DNM] following an oropharyngeal infection is a rare disease with a rapid course and a mortality rate of up to 40%. The aim of this study, is to outline the diagnosis and the appropriate treatment of DNM. A retrospective study [1986-2007] of patients with DNM was made. Only patients with cervical cellulitis associated with DNM were included. Eight men and two women with an average age of 43 years were treated. Five had diabets. The average for diagnosis and treatment was eight days. In eight cases, we found a dental origin and in two cases a pharyngeal origin. The diagnosis of DNM was made thanks to cervico thoracic CT scan in six cases. In the others patients. they had at presentation clinical and radiological evidence of mediastinal diffusion. All patients were treated by broad spectrum antibiotherapy. All had cervical drainage. Mediastinal drainage was made by cervical approach in 2 two cases and via a right thoracotomy in eight cases. Eight patients died. Odontogenic DNM is a rare disease with rapid course Clinical diagnosis is difficult and early recognition with a lowi thresold for CT scanning is essential. CT is also useful for the treatment and in the post operative assessment. All affected tissue plane must be debrided. Surgical management and mediastinal drainage remain controversial about the indication of thoracotomy

[Primary carcnoid hepatic tumour: a case report]

Primary carcinoid tumour of the liver is rare and poses a diagnostic and management dilemma. Report a new cases. A 48 year-old patient man, with a 8-months history of abdominal pain and weight loss, was operated on in December 2000, in another centre with the diagnosis of caudate pancreatic cancer. At laparotomy, Resection was deemed to be not feasible. Histological examination of biopsy was for carcinoid tumor. The patient underwent post operative radiotherapy and four courses of chemotherapy and he was referred to our hospital. Physical examination was normal. Based on radiological examination, the diagnosis was endocrine tumor of the pancreas. The patient underwent relaparotomy, the lesion was independent from the pancreas but linked to the liver; the caudate lobe. Complete macroscopic resection was performed. Histological examination of operative specimen concludes to carcinoid tumor with invasion of hepatic margins. The patient underwent adjuvant chemotherapy; he was free from disease 6 months after surgery. The diagnostic of primary carcinoid tumors is based principally in the histopathological confirmation of neuroendocrine origin and the exclusion of non hepatic primary tumour. This requires preoperative imaging but most importantly a thorough laparotomy and rigorous follow-up. Surgical resection if possible is recommended