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

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

[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

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

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

Rare cause of a lower gastrointestinal bleeding

Leiomyoma of the colon are rare benign smooth muscle tumours. Report a new case of colic leiomyoma revealed by gastrointestinal bleeding. A 71-year-old man, diabetic, consulted the emergencies for acute per-rectal bleeding. The physical examination was essentially normal. Haemoglobin level was 3.7g/dl.. The upper digestif endoscopy was normal. The colonoscopy showed an active bleeding from the right colon but it was enable to specify the nature and the exact seat of the bleeding lesion. An emergent operation showed a tumor of the right colic angle of 8 cm. A right hemicolectomy was performed with immediate ileocolic anastomosis. Pathology showed a leiomyoma. Postoperative course mentioned a nosocomial pneumopathy. Colic leiomyomas are rare benign tumours. The determination of the mitotic index is of primary importance to differentiate them from the leiomyosarcomas of low rank of malignancy whose prognosis is unfavourable

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

[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