Laparoscopic cholecystectomy decreases extra surgical site morbidity compared with open cholecystectomy: a propensity matched analysis

Background: The ideal way to show treatment effectiveness is through randomized controlled trials the 'gold standard' in evidence-based surgery. Indeed, not all surgical studies can be designed as randomized trials, sometimes for ethical and otherwise, for practical reasons. This article aimed to compare laparoscopic cholecystectomy to open cholecystectomy, according to data from an administrative database, managed by a propensity matched analysis

Methods: Were included all patients with cholelithiasis admitted in Department B between June 1st, 2008 and December 31st, 2009. In this study, the propensity score represented the probability that a patient would be treated by a procedure based on variables that were known or suspected to influence group assignment and was developed using multivariable logistic regression used here to match patients who had laparoscopic cholecystectomy to a control patient who had open cholecystectomy. The main outcome measure was morbidity. This was expressed as the number of patients with 1 or more complications occurring during the hospital stay or within 30 days following discharge

Results:According to intention to treat, 535 patients had a laparoscopic approach [LC group] and 60 patients had a traditional open approach [OC group] regarding associated cardiac disease, previous laparotomy or when choledocholithiasis was suspected, however intra operative cholangiography showed that there was no choledocolithiasis. According to the propensity score, 28 patients in OC were matched with 58 in LC. Comparison between OC and LC before and after propensity matched analysis showed that OC was associated with a higher rate of Extra Surgical Site morbidity [p= 0.010], a longer median duration of intervention, post-operative stay and overall hospital stay [p= 0. 0001]

Conclusion: LC should be considered as first-line therapy to treat cholelithiasis surgically even if it becomes necessary to convert to OC because of intra operative findings

[Assessment of care quality in department of general surgery: usefulness of administrative database]

Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting informations in the field of descriptive and analytic epidemiology with less cost. To assess the usefulness of administrative database for quality of care and research. It was a prospective study concerning 4690 hospitalisations in Department B of General Surgery of hôpital Charles Nicolle during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a pronostic study with a univariate and multivariate analysis was performed. Our study showed the usefulness of an administrative database in assessing the quality of care, it allowed us to determine postoperative mortality rate [2.7%], deep morbidity [2.5%], parietal morbidity [1.2%], medical complications [6%], nosocomial infections [3.6%] and re intervention [2.7%], with independent predictive factors of these events. To reduce the incidence of these events we should reduce length of pre-operative stay, prevent intra operative accidents, avoid intra operative bleeding in order to reduce intra operative transfusions and avoid as far as possible the stay in ICU Independent predictors of post trauma death are multiple trauma [OR: 6.14, 95% [from 1.68 to 16.94], p = 0.002], a traumatized patient in distress on arrival [OR: 8.74, 95% [3.59 -27.77], p = 0.000] and overall medical complications [OR: 13.18, 95% [from 4.01 to 31.25], p=0.000]. The ISS is a good discriminative indice to assess the severity and life-threatening risk. Administrative databases provide information on the efficiency of care, it helps to realise observational studies on large samples representative of the population at low cost. They are very useful in the research, despite the lack of clinical data

[Spinal anesthesia versus general anesthesia for inguinal hernia repair: propensity score analysis]

Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting information's in the field of descriptive and analytic epidemiology with less cost. To compare spinal to general anesthesia for inguinal hernia repair concerning a population extracted from administrative database after propensity matched analysis. Prospective study concerning 4690 hospitalizations in Department B of General Surgery of Charles Nicolle hospital during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a comparison between spinal and general anesthesia according propensity matched analysis were performed. 595 inguinal hernias were operated on. Mean age was 55 +/- 15.We mentioned a male predominance: 326 men [84.2%] and 61 women [15.8%]. 137 patients had previous medical diseases [35.4%]. 47[12.1%] patients were operated on in emergent situation on the other hand 340[87.9%] had elective surgery. 264[68.2%] were ASA I, 110[28.4%] ASA II, 13[3.4%] ASA III. Post operative course were uneventful in 96.1% [372] and complicated in 11 patients [2.9%].Four deaths were observed [1%]. Comparison before and after propensity matched analysis showed a statistical difference regarding postoperative stay and all hospital stay in favor of spinal anesthesia [p=0.007]. Postoperative stay is significantly shorter in the group of spinal anesthesia [p=0.007]. A randomized clinical trial comparing spinal anesthesia to general anesthesia is needed

Gastrointestinal stromal tumor mimicking peritoneal hydatid cyst

A 63-year-old woman, with a significant past medical history for hypertension, was admitted to surgical department B of Charles Nicolle Hospital suffering since twenty years from diffuse abdominal pain and progressive increase in abdominal volume. No general state deterioration was reported. Abdominal exam showed two palpable masses. The first one localized in the upper right quadrant and measuring 15cm. The second mass, palpable in the left paraumbilical quadrant, measured 20cm. No jaundice was found. Computed tomography evidenced two septated cystic lesions in segment IV and VIII of the liver with peripheral calcification [Fig 1], a multi-cystic formation in the left sub hepatic area and a huge splenic cyst with multiple- septa [Fig 2]. Regarding high prevalence of hydatid disease in Tunisia, all cysts were considered as hydatid cyst. Patient received preoperatively albendazole [10mg/kg/day] during two weeks and was operated on through a median laparotomy. Intraoperative exploration found in the liver four contiguous cysts sitting on segment IV. After sterilization with hypertonic solution, multiple daughter cysts were evacuated. No communication between biliary ducts and cyst cavities was mentioned. Liver cysts were treated by unroofing procedure combined with omentoplasty. In the spleen, there was a cyst of 20cm of diameter suspended to its lower part. A partial resection of splenic cyst was performed after sterilization of cyst cavity and evacuation of daughter cysts. The cyst of the left sub hepatic area measured 10cm of diameter and had a partial contact with the posterior wall of the stomach. After the sterilization of the cyst, its content was aspirated but no hydatid liquid or daughter cyst was recuperated. A cystectomy was performed with a remnant cavity of only 2cm against the posterior wall of the first part of duodenum. The patient had an uneventful postoperative course and was discharged six days later. Pathology of this peritoneal cyst concluded to stromal tumor. The resection of this tumor was incomplete, since then patient was treated with imatinib-mesylate, 400 mg once daily. Computed tomography performed six months post operatively showed no residual tumor [Fig 3]

[Intraductal papillary mucinous tumor of the pancreas mimicking pancreatic pseudocyst]

Most of pancreatic cysts are in fact pseudocysts. Only 10 to 20% are real cystic tumors. Intraductal papillary mucinous tumors of the pancreas represent nearly 15% of them. To illustrate, by an observation, the difficulties to diagnose a cystic tumor of the pancreas. We report the case of a 55 year old woman complaining of epigastric pain for one month with an elevated pancreatic enzymes level. Ultrasonography and computed tomography scan showed two cystic formations measuring 6 and 7cm localized respectively in the head and the body of the pancreas. The diagnosis of pancreatic pseudocysts was maintained. The appearance of a jaundice made us think about a pseudocyst's compression of the common bile duct. A cysto-gastric anastomosis was made. The recurrence of the jaundice associated to diabetes and a general state deterioration led to the practice of magnetic resonance cholangiopancreatography. It revealed an intraductal papillary mucinous tumor of the pancreas affecting secondary ducts. The presence of a peritoneal carcinosis led to therapeutic abstention. The diagnosis of intraductal papillary mucinous tumor of the pancreas must be referred to in case of pancreatic cystic tumor without extrapancreatic necrosis. This kind of tumor can simulate a pancreatic pseudocyst

aggressive course of de novo ulcerative colitis after renal transplantation: colonic adenocarcinoma with choriocarcinomatous differentation

A rare case of colonic carcinoma arising in de novo ulcerative colitis after renal transplantation in a 42-year-old woman is reported. Clinically, the patient presented ulcerative colitis 8 years after renal transplantation, developed colonic cancer with liver metastasis 2 years later and died one month post operatively. Histologically, the removed tumor was composed of two distinctive elements consisting of adenocarcinoma and choriocarcinoma. The metastatic foci in the liver were composed exclusively of choriocarcinoma. Identification as choriocarcinoma was made on the basis, of typical histological appearance, immunohistochemical demonstration of human chorionic gonadotropin [hCG] in the tumor cells and the high serum hCG level, unrelated to trophoblastic disease. In this report, pathogenesis is briefly discussed and clinical conditions are reviewed. In conclusion, the issue of de novo UC after organ transplantation is still a matter of debate. Further investigations are necessary to understand the tumorogenesis of colorectal cancer in de novo UC after renal transplantation

[Hydatid cysts of the pancreas, report of two cases]

Hydatid cyst of the pancreas is a rare affection with a frequency less than one percent of the various sites of hydatid disease. Rreport two cases of hydatid cyst of the pancreas. A 49 year old woman with a history of laparotomy for liver and peritoneal hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 3 cm in size. Surgical treatment consisted in a resection of the protruding dome with uneventful postoperative course. A 45 year old man who underwent laparotomy four years ago for hepatic hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 4 cm in size. At laparotomy it was a head pancreatic hydatid cyst without duct pancreatic lesion. The treatment consisted in the resection of the protruding dome. The postoperative evolution was simple. Hydatid cyst of the pancreas is rare. If associated with another hydatid localization, the diagnosis is generally easy. It can however be more difficult if the pancreatic localization is isolated. In most cases, resection of the protruding dome is sufficient

[Myofibroblastic tumor of the great omuntum]

Myofibroblastic tumors are a spindle cell lesion at indeterminate malignant potential. Abdominal location was rare. We report a case of an unusual location at myofibroblstic tumors in the great omuntum. A 63-year-old women presented with a one year of isolated left hypochondrium pain. Physical examination was normal. CT scan of the abdomen showed a multicystic and a multilocular building-up of the great omentum suggestive of a peritoneal haemolymphangioma. Besides, at the MRI, this lesion showed up with threefold component: cystic, plump and fibrous, all leading towards a myofibroblastic tumor. At laparotomy, there was already a 10 cm diameter cystic tumor of the great omentum, composed of numerous cystic sockets, all filled with a thick brunish substance. A total resection of the great omentum was done, thus taking away the whole tumor. The histological examination confirms the diagnosis of myofibroblastic tumor of great omentum. Post operative evolution was uneventful. One year later there were no signs of recurrence. Myofibroblastic tumors of the great omentum are rare. The diagnosis is often confirmed by careful microscopic examination or immunohistochemical markers. Treatment consists on a complete surgical resection and life time follow-up is needed because the risk of recurrence

[Squamous cell carcinoma arising in Verneuil's disease]

Verneuil's disease or hidradenitis suppurativa is a chronic suppurative, and cicatricial inflammatory disease, mainly affecting apocrine-bearing area of the skin. Squamous cell carcinoma is an uncommon but a frightening complication of hidradenitis suppurativa. To report a new case of squamous cell carcinoma arising in Verneuil's disease. We reported a case of 60 year old man with a 30 years history of hidradenitis suppurativa in which squamous cell carcinoma arise. A wide surgical excision removing the tumour and leaving a large defect was performed. The patient had a well recovery, wounds healed well by primary intention. No recurrence observed at 18 months of follow up. Squamous cell carcinoma is an uncommon complication of hidradenitis suppurativa. Surgical excision represents also the treatment of choice