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

[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

[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