Predictive factors of failoure and mortality after CT-guided percutaneous drainage of infected pancreatic necrosis

Background: The traditional approach to the drainage of infected pancreatic necrosis [IPN] is open necrosectomy. As an alternative to open necrosectomy, percutaneous drainage is the first-line treatment of IPN

This study is aimed to identify predictive factor of failure after CT-guided percutaneous catheter drainage [PCD] of IPN

Methods: Between June 1st 1988 and October 31th 2011, 26 patients with IPN were treated by PCD. The outcome measures were the failure of the PCD and/or death. A descriptive analysis was performed followed by a comparative analysis of alive versus deceased patients and success group versus failure group. Univariate and multivariate analysis were performed to determine predictive factors of failure after percutaneous drainage or death

Results: The failure and mortality rates were respectively 38% and 34%. The size of catheter inferior to 10 French was the only variable associated with the percutaneous drainage failure [OR=27, CI95% [2.5-284.6], p=0.006]. The collection number on CT scan was associated with mortality [OR=2.2, IC95% [1-5.1], p=0.050]

Conclusion: PCD with catheter size equal or greater than 10 French is efficient tool for the treatment of IPN. Collection number on CT scan is an independent predictive factor of mortality

[Critical study of pathology theses supported at the medical university of Tunis [2000-2010]]

Background: Medical writing is a coded language; its purpose is to convey a scientific message. In pathology, specialty involving the study of cell and tissue, quantitative and qualitative production of medical doctoral theses and their thematic focus has not been studied

The aim of this study was to analyze the pathology theses on the level of form, the background and methodology

Methods: Descriptive retrospective study of medical doctoral theses in the specialty "Pathology", listed in the catalog of theses of the library of the Faculty of Medicine of Tunis and supported between 2000 and 2010. Each thesis has been subject of a direct reading, systematic and thorough

Results: The study involved 189 pathology theses. The average overall productivity per academic pathologist was 5.5 theses. Gastrointestinal pathology was the most studied theme [24.9%]. Tumor pathology was addressed in 74.1% of the theses. The IMRAD structure was respected in 57.7% of theses; by assistant professor than by associate professor and professor [p = 0.005]. The summary was structured in 88.3% of theses, comparably with the grade of the thesis director [p = 0.5] and with the grade of PhD student [p = 0.08]. The transcript of references did not meet the recommendations of Vancouver in 87.8% of theses and irrespective of the rank of director of thesis [p = 0.2]

Conclusion: The pathology theses presented some shortcomings, particularly in the quality of medical writing. To remedy this problem, our faculty should increase efforts to improve the quality of scientific work, in order to have a better view of medical research in Tunisia

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

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

"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

[Stromal gastrointestinal tumors: retrospective study about 24 cases]

Gastrointestinal stromal tumors [GIST] are the most common digestive sarcomas. They develop in most cases in the stomach and small intestine, more rarely rectum, colon, esophagus or mesentery. These tumors typically express the phenotype CD117/KIT + and CD34 +.To evaluate epidemiologic, clinical, pathologic, therapeutic, characteristics and evaluative pattern of gastrointestinal tumor treated in our surgical department. We collected 24 cases of GIST [confirmed by the positivity of CD 117 and/or CD 33] treated between 1997 and 2010 in the department of surgery B of Charles Nicolle's Hospital. We analyzed demographic characteristics, clinic pattern, investigations treatment and therapeutic variables of our patients. We calculated the survival rate and identified prognostic predictive factors of survival. Our retrospective study interested, during 13 years, 24 patients presenting GIST with a median age of 66 years and a sex ratio of 0.8. The median time for diagnosis was two months [3 days to 24 months]. Abdominal pain, gastrointestinal bleeding and vomiting were the most common symptoms. The endoscopic appearance was tumor arising from muscular layer found in the stomach [13/24 cases; 54%], small bowel in four cases [16.5%] and duodenal or rectum three patients [12,5%]. Twenty three within 24 patients underwent surgical resection with R0 in 20/23 cases. Three patients were treated with neoadjuvant imatinib for an average of 12 months, one patient had adjuvant treatment and four patients in locoregional evolutive tumor and / or metastatic. The overall survival was 70% at one year and 65% at two years with a pejorative impact, in univariate analysis of abdominal pain, asthenia, anorexia, weight loss, cytonuclear atypia, tumor size >/= 10 cm and a mitotic index >/= 5/50. Multivariate analysis showed that tumor size [Hazard Ratio = 6 if size >/= 10 cm 95% CI [1,539-24,017]] and weight loss [Hazard Ratio = 7 95% CI [1,664-29,100]] were influential factors on overall survival and recurrence-free survival. The prognostic predictive factors identified were the size of tumor >/= 10cm and the mitotic index

[Web site of "La Tunisie Medicale" was created two years ago]

La Tunisie M‚dicale, official journal of Tunisian Society for Medical Sciences and Tunisian Medical Organization, born in 1903 with ISSN number 0041-4131and INIST code 4691 of French Pascal database, had since September 2009 its website: www.latunisiemedicale.com. To assess the editorial policy of "La Tunisie M‚dicale". A descriptive analysis was performed to evaluate different categories of articles and number of papers written with English language. mdweb society, which created the website site www.latunisiemedicale.com, planned to have instantaneously a descriptive analysis concerning the number of consultants per article. The site www.scopus.com helped us to have the number of articles citations which was useful to calculate Impact Factor [IF]. National Center for Biotechnology Information [NCBI] of National Library of Medicine provided monthly number of hits. Number of published articles increased regularly to reach 250 and 300 between 2009 and 2011. Beside original articles, cases report, overviews, continuing medical education and editorials, we introduced systematic reviews of literature, letters to editors, historical notes, section reserved for images in clinical practice, point of view, technical novelty and section for " Pro and Cons" in which readers could present their opinions with reply of authors. Articles written in English have increased to reach the number of 60 between 2010 and 2011. Visitors number of "la Tunisie M‚dicale" website, from 195 countries, was 465 596 between January 1st 2011 and December 22nd 2011. Half of consultants [51.06%] came from several sources such as "Google/organic" and "ncbi.nlm.nih.gov/ referral". Number of visits from NCBI was about 3000 per month from June 2010 to December 2011. The ten first visited articles concerned sexual organ and tuberculosis. Articles citations of "laTunisie M‚dicale" are in constant progress and Impact Factor, increased from 0.054 in 2004 to 0.277 in 2011. We succeeded to increase the number of articles written in English. Results are interesting Impact Factor of 2011 is 0,277; however we should be modest because we still have a very long way, we should help authors to perform systematic reviews with a sound methodology

[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

[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

[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

Alimentary factors promonting colorectal cancer risk: a prospective epidemiology study

Some foods are incriminated in the genesis of colorectal cancers [CRC], on the other hand, other foods are considered as protectors. This study aimed to determine the alimentary factors influencing the risk of CRC. We conducted an epidemiologic prospective study. We performed firstly a descriptive analysis of the CRC group [32 patients] and we compared this group to a control group of 61 patients subdivided into two subgroups [Non tumoral digestive disease [31 patients] and a subgroup of trauma patients [30 patients]]. Factors, retained by the univariate analysis were introduced into a logistic regression model which identified the independent factors influencing the risk of CRC. Univariate analysis identified 12 factors influencing the risk of CRC with p

[Parietal abscess revealing calculation forget eight years after laparoscopic cholecystectomy]

Laparoscopic cholecystectomy is the treatment of choice for symptomatic gall stone disease. The perforation of the gallbladder happens in 40% of cases. Stones spilled remain there in 20% of cases in view of their number and location. These lost stones can cause adhesions, abscess, peritonitis, digestive fistula or else cutaneous fistula. to report a new observation of a cutaneous fistula resulting from a gallstone lost during laparoscopic cholecystectomy, eight year later. A 57-year-old women, underwent 8 years ago laparoscopic cholecystectomy for acute cholecystitis. A cholecystectomy was performed without incidence and with uneventful post-operative course. She was admitted to hospital again for an inflammatory painful swelling of the right renal fossa which had been developing for one week without any fever or transit disorder. The abdominal C.T.scan performed revealed a subcutaneous collection of 8 CM. She underwent an excision of the collection with drainage of pus and numerous small stones. She was diagnosed with lost gallstone complicated with cutaneous fistula. The control C.T scan made 3 months later showed a small collection at the level of the right parieto-colic gutter. She was operated on again, laparoscopy excision of the fistulous tract was performed without showing stones. Healing was achieved two months later. She re-presented 3 months later for a swelling of the old scar which fistulized spontaneously with pus leaking. The abdominal C T scan was normal. She underwent an excision of a collection wish containing a large stone of two centimetres. The patient was regularly seen afterwards at the outpatients' department. She was feeling well 18 months later. A lost gallstone can cause serious complications. Spillage of gallstones should be avoided. When does occur, every effort should be made to withdraw spilled gallstones and especially to mention the event in the post-operative report

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]