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

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

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

[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

[Laparoscopic cholecystectomy on previous operated abdomen]

laparoscopic cholecystectomy is the "gold standard" reference treatment of gall bladder stones. Laparoscopy is still contra-indicated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. This study aimed to assess outcomes of laparoscopic cholecystectomy on a scarred abdomen. We have carried out a retrospective study on a number of consecutive patients operated between the first januar 2000 and 31 december 2006, who underwent laparoscopic cholecystectomy with previous abdominal surgery [one or several].during this period, laparoscopic cholecystectomy was performed on 2281 patients, including 233 patients who had at least one abdominal scar [10%]. We have noted on the records of these patients all the data relating to the epidemiological, clinical and therapeutical aspects. We have worked out a descriptive analysis of the series and we have thus studied the rate of operative and post-operative complications, the rate of conversion, the duration of the operation and the duration of post-operative stay. Then we have compared two groups of patients, those with an upper abdominal surgery: group 1[G1] and those with lower abdominal surgery: group 2 [G2]. The groups consist of 200 women and 33 men aged on average 13, 8 +/- 49, 6 years. The indication for cholecystectomy was a symptomatic cholelithiasis in 78%of cases [n=181], an acute cholecystitis in 22%of cases. The adhesions were believed numerous or very numerous in only 46 patients [20%]. Four patients had interventional adverse events: a small intestine injury, a choledoch injury, a gastric injury and a least known colic injury. The rate of open conversion was 2, 1%. Post-operative complication was 2, 1%. The evolution was satisfactory in all cases. Mean operating time was 50 minutes [15-230]. Mean post operative stay was one day [1-29 days]. When comparing the above mentioned two groups of patients [G1: 45 patients and G2:188 patients], we can conclude that the first group [G1] is made up of more male patients aged over 60 years [p<10-3] It also appears that the existence of an upper umbilical scar is correlated to a, greater number of adhesions [p<10-3], an increased risk of operative complications [p=0, 01], a greater conversion rate [p<10-4], a prolonged operating time [p<10-3] and a longer stay [p=0, 017]. On the other hand, post-operative complications was similar in group I and 2. Previous abdominal operations, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a higher rate of adhesions, an increased risk of operative complications, a greater conversion rate, a prolonged operating time and longer stay

[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

Adreno-cortical oncocytoma: a case report

Adrenal oncocytoma is a very rare lesion, non functioning and benign in most cases. Only 46 cases have been reported in the medical literature. This study aimed to report a new case of adrenal oncocytic tumor with uncertain malignant potential. A 72 year-old- man, consulted for renal fossa pain. Ultrasonography and omputed tomography scan revealed a large mass in the right adrenal gland with extension to the right kidney. A right adrenalectomy and nephrectomy was performed. The diagnosis of adrenal oncocytoma with malignant potential was confirmed by pathology. Patient had a well recovery and left hospital on the fifth day post operatively. He was followed up for 8 months, no tumor recurrence detected. Adreno cortical oncocytoma is a rare tumor. The majority of reported cases had good prognosis

[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

Facteurs predictifs de morbidite et de mortalite de la chirurgie du vieillard

The aim of the study was to determine prognostic factors of post operative morbidity and mortality for patients aged 80 years and older. We compared two groups of patients aged 80 and over operated to determine predictive factors of morbidity and mortality group of patients who presented post operative complication within 30 days after surgery and group of patients without any complication. Comparison of the two groups for global morbidity using univariate analysis showed only one prognostic factor: surgery of diabetic foot [p = 0.034]. Predictive factors of mortality according to univariate analysis were: pre-operative shock [p = 0.001], abdominal wall pathology [p = 0.027], gastric or duodenal ulcer diseases [p= 0.011] and global morbidity [p = 0.006]. After logistic regression, only pre-operative shock was an independent predictive factor of mortality [p = 0.0023]. Risk for morbidity after surgery in the elderly 80 years and over is linked with type of surgery and not with soil. Likewise, risk for mortality is linked with advanced stage of disease that is presence of pre-operative shock and not with soil