[Surgical complications of colostomies]

The colostomy may be terminal or lateral, temporary or permanent. It may have psychological, medical or surgical complications. Aim: reporting the incidence of surgical complications of colostomies, their therapeutic management and trying to identify risk factors for their occurrence.A retrospective study for a period of 5 years in general surgery department, Habib Bourguiba hospital, Sfax, including all patients operated with confection of a colostomy. Were then studied patients reoperated for stoma complication. Among the 268 patients who have had a colostomy, 19 patients [7%] developed surgical stoma complications. They had a mean age of 59 years, a sex ratio of 5.3 and a 1-ASA score in 42% of cases. It was a prolapse in 9 cases [reconfection of the colostomy: 6 cases, restoration of digestive continuity: 3 cases], a necrosis in 5 cases [reconfection of the colostomy], a plicature in 2 cases [reconfection of the colostomy] a peristomal abscess in 2 cases [reconfection of the colostomy: 1 case, restoration of digestive continuity: 1 case] and a strangulated parastomal hernia in 1 case [herniorrhaphy]. The elective incision and the perineal disease were risk factors for the occurrence of prolapse stomial. Surgical complications of colostomies remain a rare event. Prolapse is the most common complication, and it is mainly related to elective approach. Reoperation is often required especially in cases of early complications, with usually uneventful postoperative course

[Treatment of acute colonic pseudo-obstruction [Ogilvie's syndrome]. Systematic Review]

Ogilvie's syndrome is acute colonic dilatation without organic obstacle in a previously healthy colon. Surgery is the only treatment of cases complicated by necrosis or perforation. In contrast, treatment of uncomplicated forms is not unanimous, and is the subject of this literature review. Determine the results of different therapeutic methods of uncomplicated forms of Ogilvie's syndrome in terms of efficiency of removal of colonic distension, recurrence, morbidity and mortality. Clarify their respective indications. An electronic literature search in the "MEDLINE" database, supplemented by hand searching on the reference lists of articles, was conducted for the period between 1980 and 2012. Conservative treatment is effective in 53 to 96% of cases with a risk of colonic perforation less than 2.5% and a mortality of 0 to 14%% [level of evidence 4, recommendation grade C]. Neostigmine is effective in 64 to 91% of cases after a first dose, with a risk of recurrence of 0 to 38%. It remains effective in 40 to 100% of cases after a second dose [evidence level 2, grade recommendation B]. Endoscopic decompression is a safe and effective technique with a success rate of 61 to 100% at the first attempt, a recurrence rate of 0 to 50%, a rate of colonic perforation less than 5% and a mortality less than 5% [level evidence 4, recommendation grade C]. PEG may be recommended for the prevention of recurrence of the ACPO after successful treatment with neostigmine or endoscopic decompression [evidence level 2, recommendation grade B]. The cecostomy is more effective and safer than conventional colostomy [level of evidence 4, recommendation grade C]. The cecostomy is highly effective in colonic decompression but associated with a high mortality [level of evidence 4, recommendation grade C]. Conservative treatment is recommended in first intention. In case of failure, neostigmine should be tried. If unsuccessful, the endoscopic decompression is proposed. The cecostomy is indicated as a last resort after failure of endoscopic decompression

[ lithiasic acute cholecystitis: laparoscopic treatment [about 106 cases]]

Summary To assess the feasibility and the advantages of the coelioscopy in the treatment of the acute cholecystitis. From January 1996 to December 2001, 106 laparoscopic cholecystectomies for acute cholecystitis have been collected. The diagnosis of acute cholecystitis has been confirmed for all cases by the pathologic exam. These 106 cases represent 12.4% of the set of the laparoscopic cholecystectomies practiced during the same period of survey. They are 78 women and 28 men. The mean age was 51.7 years. Eight patients [7.6%] presented an elevated operative risk [ASA III]. The diagnosis of acute cholecystitis has been kept before operation in 45.3% of the cases. Major or minor intraoperative incidents have been observed in 18.9% of the cases. The rate of conversion was 17%. The reasons are dominated by the difficulties of dissection in 10 cases [55.5%] and hemorragea in 6 cases. The research of the predictive factors of conversion found 5 factors, the hyperleucocytosis, the operative delay superior to 72 hours, the adhesions around the gallbladder, the gangrenous gallbladder and the pediculitis. The post operative mortality was nul. The morbidity rate was 12.3%. Among the 13 patients who had postoperative complications, 8 were after conversion. These results showed that the laparoscopic cholecystectomy for acute cholecystitis is an effective and good alternative with acceptable morbidity that should decrease with learning curve

[Complications of the Meckel's diverticulum, about 42 cases]

Our aim was to report the main complications of the Meckel's diverticulum. Our retrospective study concerns 42 cases of complicated Meckel's diverticulum, collected during one period of 18 active years from January 1988 to December 2005. The yearly impact is 2, 33 cases / year. We excluded the asymptomatic Meckel's diverticulum, of fortuitous discovery during intervention. The middle age of our patients is 25 years, with extremes going from 2 to 74 years. The sex-ratio is 3, 2. The diagnosis before intervention of the complicated Meckel's diverticulum was not evoked in any time. The clinical features were an acute intestinal closure in 22 cases, an appendicitis in 13 cases, an appendicular peritonitis in 6 cases, and an acute intestinal intussusceptions in one case. In any case, it is the surgical exploration that permitted to confirm the diagnosis of a complicated Meckel's diverticulum. The approach way was median in 27 cases, Mac Burney in 13 cases, and laparoscopic in 2 cases. The surgical exploration showed peritonitis in 16 cases, one diverticulitis in 23 cases, an acute intestinal intussusception in one case, a tumour in one case, and haemorrhagic diverticulum's ulcer in one case. The treatment consisted in a segmental resection of ileum with end to end anastomosis [37 cases] and a cuneiform resection [5 cases]. The histological exam showed heterotopy of gastric tissue in 12 cases, of pancreatic tissue in two cases, and a Burkitt's lymphoma on a diverticulum in one case. We noted a precocious death following a septic shock. The Meckel's diverticulum constitutes a most common benign malformation of the digestive tube. The prognosis is related extensively to the gravity of its complications that can benefit, not only of the contribution of the laparoscopic diagnosis, but also therapeutic

[Clinical and therapeutic results of a retrospective study about 62 cases of epithelial ovarian carcinomas]

To report retrospectively the therapeutic results and prognostic factors of epithelial ovarian carcinomas throughout a series of 62 patients treated between 1993 and 2002. Patients were treated with primary surgery classified as optimal [complete], sub-optimal or minimal. Adjuvant ciplatin based poly chemotherapy [6 cycles] was indicated in FIGO stage Ic or more. Patients with minimal surgery received 3 or 4 cycles of chemotherapy followed by an interval debulking surgery. Overall survival was calculated according to Kaplan-Meier and univariate analysis done by the Log-Rank test for the following factors: age group, surgical excision, stage, histological type and presence or not of ascitis at diagnosis. Fifty five patients were operated. The excision was optimal, suboptimal and minimal in respectively 19,3%, 33.8% and 40.3% of the cases. Adjuvant or neoadjuvant chemotherapy was given to 50 patients [93,5%]. Interval debulking surgery was complete in 7 among 13patients. At the first evaluation, 14/58 patients were in complete response. The 3 and 5 years overall survival rates were respectively of 25% and 13%. Advanced stage was the only pejorative prognostic factor [P= 0.0002]. Incomplete surgery [minimal] and chemotherapy without taxanes based chemotherapy were associated with poor outcome in our patients. Our study confirmed the importance of disease stage as a prognostic factor

Sexual disturbances secondary definitive colostomy

Sexual disturbances after colostomy are various. However, they probably remain underestimated in societies where sexuality is still a taboo issue. The aim of this prospective study was to evaluate the possible sexual behaviour and the post operative sexual disturbances in patients whome underwent colostomy. The group was devided in 10 male and 11 female patients. Seventeen patients [81%] were married, 3 widowed and 1 unmaried. Sexual disturbances were found in 47% of patients. There was a lack of interest in sexual relations in 2 women, a resolved premature ejaculation in one case, post operative dysparenia in 2 female patients, a retrograde ejaculation in a 60-year-old man, impotence in a 46 years old patient, and a premature ejaculation in a 36-year-old man. The frequency of sexual disturbances [47%] in our series was close to that reported in the literature [50%]. The sexual disorders are more common in male patients, the most frequent being ejaculatory dysfunction. In women, dyspareunia is the most common disorder. The particular case of colostomy in homosexuals remains a current issue

acute hyperlipemic pancreatitis [2 cases]

The aim of this work was to study the clinical and therapeutic features of this affection. Our retrospective study concerned two cases of hyperlipemic pancreatitis treated during 6 years from 1998 to 2003. The incidence of this affection was 1.42%. Our patients were respectively a man aged 32 years without any significant history and a pregnant woman aged 24 years with a positive history of dyslipidemia. Clinical, biologic and radiological data didn't differ from those of other causes of acute pancreatitis. The hyperlipemic origin was confirmed by a lactescent serum and a rate of triglycerides greater than 10 g/1. The course was characterized by the recurrence of pancreatitis related to the increased triglycerid serum level over 10 g/1. Plasmapheresis and administration of heparin and/or insulin seem to be efficient in reducing the serum level of triglyceride and in improving the course. Hygieno-dietary measures and hypolipemiant treatment were necessary for the level of triglyceirdes in serum below 10 g/1. We in the absence of comolicatons, surgery seemed umnecessry in the two cases. the clinical pattern of acute hyperlipemic pancreatitis doesn't include any specific elements, but its treatment and prevention must take into account the associated hyperlipidemia

results of Laparoscopic treatment of the gallbladder lithiasis about 500 cases

Laparoscopic cholecystectomy is at present the gold st and ard treatment of gallbladder lithiasis. Assesment of Laparoscopic cholecystectomy. Through a retrospective series of 500 laparoscopic cholecystectomies during a period going from January 1996 to March 2000, we tried to evaluate our experience by comparing our results to the literature data. There were 420 women and 80 men with a sex ratio of 0.19. Average age was 50 years. 16.2% of our patients were obese. 13 patients had a history of respiratory disease and 122 history of a cardiovascular pathology essentially arterial hypertension. All our patients benefited from at least one hepatobiliary ultrasound examination before the intervention. Antibioprophylaxy was administrated in 93.8% of cases. In 23 cases [4.6%], a conversion was necessary for different causes. We noted 11 surgical complications [2.2%] among which 2 required a surgical resumption, and 11 medical complications dominated by broncho-pulmonary infections. We had no death

[Retro-Peritoneal liposarcoma. About 5 cases and revue of literature]

Liposarcomas are malignant mesenchymatous tumors developed from elements constituting the greasy tissue in various stages of differentiation. It is one of the most frequent mesenchymatous sarcomas. Retro-peritoneum is a privileged site of development in 12 to 15% of cases. During 9 years, from 1994 till 2002, we have colligated and operated 5 cases of retro-peritoneal liposarcomas. Average age was 50 years [extremes 34 to 79 years] with a sex-ratio of 1.5. Diagnosis was late beyond 6 months. Abdominal pain and the appearance of an enormous mass [20 cm] were the revealing signs. No imagery method allowed to evoke the diagnosis. The cyto-puncture realized once, was not able to determine with precision the histological type. Immunohistochimy occupies nowadays an important place to classify a sarcoma. Large surgical resection realized in 5 cases did not allowed the complete ablation of the tumour in 3 cases considering the advanced loco-regional extension, which was at the origin of 3 recurrencs. Well differentiated histological type was noted in 3 cases, myxoid type in a case and not differentiated type in a case

[pyogenic liver absecesses: a study of 25 cases]

Our aim was to study the anatomo-clinic particularities and the therapeutic modes of the infectious abscesses of the liver. Our retrospective study concerns 25 cases of the infectious abscesses of the liver collected on one period of 12 years from January 1992 to December 2003. They are 11 primitive abscesses and 14 secondary abscesses. We noted 14 women and 11 men, median age was 51,5 years. The Fontan triad was present in 7 cases. A liver mass with an abdominal sensitivity was found in 14 cases. Anomalies in the biologic exam of the liver were present in the 1/3 of the cases. We noted a double right and left localization in 3 cases and a multiple localization in 1 case. The hemoculture and the pyoculture permitted a bacteriological diagnosis in 52%. The percutaneous treatment achieved in 7 cases, permitted the recovery in 2 cases. One dead was noted following a severe cardiopathy. A surgical drainage has been achieved at 22 patients, 4 cases after the failure of the percutaneous treatment. Mortality rate was 20% [5 cases] related to the delay of diagnosis. The gravity of the septic shock, the advanced age and the flaws associated. The infectious abscess of the liver was a serious affection that affects the vital prognosis. The percutaneous treatment associated to the antibiotherapy, is the method of choice in the treatment of the abscesses of the liver. The surgical treatment must be reserved to the failure of the percutaneous treatment

[Tuberculous encapsulating peritonitis, about 18 cases]

Our goal is to study the circumstances of diagnosis and the therapeutic modes of encapsulating peritonitis of tubercular origin. We report in this retrospective study 18 cases of encapsulating peritonitis of tubercular origin collected from 1982 to 2000. Symptoms and signs are dominated by the general signs of tubercular nature, found isolated or in association with other, in 14 patients. Abdominal pain was found in all patients. Gastrointestinal disorders were found in 11 patients. A typically sound abdominal mass was found in 3 cases. The ultrasonographic data associated with the biologic data, helped in making the diagnosis. Confirmation of the tubercular origin was provided by histological examination of the biopsies. Treatment was based on the anti-tuberculosis chemotherapy associating four antitubercubus drugs taken daily during two months repeated by the association of two antituberculous drugs during a period of six to 13 months. The outcome was favourable in 16 patients but the two patients died. Histological diagnosis and more rarely bacteriological examination, would be essential in order to start an early treatment. This diagnosis is confirmed by open coelioscopy when the ascitis is septated or by exploratory laparotomy in the fibro-adhesive forms. Radical surgery is indicated in case of complications

traumatismes doudeno-pancreatiques, a propos de 14 cas

Through a series of 14 cases brought over a period of 12 years, we realized a retrospective, analytical and descriptive study of these traumata. We aimed to release recommendations to improve their management. It was 2 women and 12 men, whose mean age was 24.4 years [extremes: 50 and 60 years], divided into 10 pancreatic injuries, 2 duodenal injuries and 2 duodeno-pancreatic injuries. Etiology was dominated by traffic accidents 7 cases [50%]. Trauma was closed in 13 cases [92%]. -Associated lesions were present among 13 patients [92%]. The traumatism appeared by an urgent surgical abdomen among 9 patients, secondarily in 3 cases, tardily in 2 cases: a case of deep suppuration 3 months after a traumata treated into ambulatory and a case of persistent ascites after a past unperceived traumata. Abdominal ultrasonography was made among 4 patients. It allowed diagnosing only a case. Scanner was made among 4 patients. It allowed diagnosing all the cases. Only a patient was treated medically, it was a post-traumatic acute pancreatitis. Surgical treatment was made in 13 cases: conservative in 7 cases and radical in 6 cases. Follow-up was complicated in 11 cases [78%] and non-complicated in 3 cases. Mortality rate was 7.1%

[Anastomotic ulcer after vagotomy for duodenal ulcer]

Between January 1981 and December 2000, 2609 patient underwent surgery for duodenal ulcer. 2274 underwent isolated vagotomy; 1590 had vagotomy associated with GI anastomosis. Only relapses of anostomic ulcers after vagotomy associated with gastrojejunal anastomosis were included in this study. 22 patients [20 males, 2 females] aged between 26 and 79 years had anastomic ulcer relapses [1.38%] after vagotomy and GI anastomosis. Incomplete vagotomy was diagnosed in 14 cases [93%] associated with a defect in setting in 2 cases. Despite the ongoing controversy about the role of Helicobacter in the pathogenesis of anastomotic ulcers, medical treatment remains the primary therapy, and a partial gastrectomy alone or with vagotomy is necessary only in unresponsive cases