Right-sided acute diverticulitis in a North African country: Presentation and management in one surgical center.

PURPOSE: Right-sided diverticulitis is a rare entity in North Africa. Therefore, it is usually misdiagnosed, and the management of cecal diverticulitis is aggressive in most cases, whereas nowadays, most studies recommend a conservative approach with promising results. This study aims to describe the presentation, management, and outcomes of right-sided diverticulitis (RSD) and to present the experience of one surgical center in Tunisia. METHODS: This is a retrospective study including all patients presented with RSD, in the Department of Surgery "A" of the Charles Nicolle Hospital between 2007 and 2021. RESULTS: Forty patients were included in our study. The mean age was 42 years with a standard deviation of 14. The sex ratio was 1.1. Only 2 patients had chronic constipation. All patients presented right-sided abdominal pain, and only 3 patients had diarrhea. Twenty one patients were diagnosed during surgery. Fourteen patients were treated successfully by conservative management. An operative procedure was performed in 26 cases: 21 had a diverticulectomy (80%), two had an ileal resection (8%), and three had a right colectomy (11.5%). No postoperative events occurred with a short hospital stay (5 ± 3 days). Follow-up showed no recurrences. CONCLUSION: Right-sided diverticulitis has a lower incidence and complication rate compared to left-sided diverticulitis. Conservative treatment has demonstrated favorable outcomes in managing RSD, although the available evidence remains limited.

Siewert II esophagogastric junction adenocarcinoma: Still searching for the right treatment transabdominal or transthoracic surgical approaches?

INTRODUCTION: To date, the discussion is still ongoing whether the Siewert II adenocarcinoma of the esophagogastric junction (AEG) should be resected either by thoracoabdominal esophagectomy or gastrectomy with resection of the distal esophagus by transhiatal extension. The aim of our study was to compare the oncological and perioperative outcomes of the transthoracic approach (TTA) and the transabdominal approach (TAA). METHODS: Searches of electronic databases identifying studies from Cochrane, PubMed and Google Scholar were performed. Randomised and non-randomised studies comparing TTA and TAA approaches for surgical treatment of AEG Siewert type II were included. The Newcastle-Ottawa and Jada scales were used to evaluate methodological quality. The risk of bias was assessed using the Rob v2 and Robins-I tools. Meta-analyses were conducted for the outcomes. RESULTS: We included 17 trials (2 randomised controlled trials and 15 cohorts) involving 15297 patients. Longer three-year overall survival, five-year overall survival and R0 resection rates were observed in the TTA group. However, TTA had greater morbidity and pulmonary complications. CONCLUSION: Transthoracic approach appears to be preferable for selected Siewert II tumours. This may lead to higher survival rates and better R0 resection rate. Well-designed studies are needed to confirm the results of this systematic review.

Is There a Role for Mechanical and Oral Antibiotic Bowel Preparation for Patients Undergoing Minimally Invasive Colorectal Surgery? A Systematic Review and Meta-analysis.

INTRODUCTION: To date, all meta-analyses on oral antibiotic prophylaxis (OA) and mechanical bowel preparation (MBP) in colorectal surgery have included results of both open and minimally invasive approaches. Mixing both procedures may lead to false conclusions. The aim of the study was to assess the available evidence of mechanical and oral antibiotic bowel preparation in reducing the incidence of surgical site infection (SSI) and other complications following minimally invasive elective colorectal surgery. METHODS: We searched PubMed, Science Direct, Google Scholar and Cochrane Library from 2000 to May 1, 2022. Comparative randomized and non-randomized studies were included. We reviewed the use of oral OA, MBP and combinations of these treatments. The methodological quality of the included studies was assessed using the Rob v2 and Robins-I tools. RESULTS: We included 18 studies (7 randomized controlled trials and 11 cohort studies). Meta-analysis of the included studies showed that the combination of MBP + OA was associated with a significant reduction in SSI, AL and overall morbidity compared with the other options no preparation, MBP only and OA only.  CONCLUSION: Adding OA with MBP has a positive impact in reducing the incidence of SSI, AL and overall morbidity after minimally invasive colorectal surgery. Therefore, the combination of OA and MBP should be encouraged in this selected group of patients undergoing minimally invasive surgery.

Primary Echinococcus Hydatid Cyst of the Uterus: An Unusual Location.

Hydatidosis is a widespread anthropozoonosis. It can affect almost any part of the body, but it occurs most commonly in the liver (75%) and the lungs (15%). Its occurrence in female genital tract, especially the uterus, is very rare. Diagnosing hydatid disease at these unusual locations can be difficult. Hereby, we report two cases of primary hydatid cyst of the uterus. The first case is that of a 62-year-old woman, G7P5A2, who presented with an eight-month history of chronic pelvic pain. Clinical examination and radiological explorations revealed the presence of a uterine fibroid and a serous cystadenoma of the left ovary. She underwent a hysterectomy and a bilateral adnexectomy. Anatomopathological examination concluded that a serous cystadenoma of the left ovary was a calcified subserous hydatid cyst of the uterine fundus. The second case is that of a 69-year-old woman, G6P4A2, who consulted for chronic pelvic pain that had been evolving for 3 months. The clinical examination and radiological explorations doubted a hydatid cyst of the uterus, with a positive hydatid serology. She underwent a resection of the salient dome. The anatomopathological examination was in favor of a hydatid cyst of the uterus. Hydatid disease is endemic in Tunisia. The pelvic region is rarely affected with an incidence ranging from 0.3 to 0.9%, 80% of which involves the genitals. The uterus is more rarely affected than the ovaries. Most often, it is a contamination secondary to the intra-abdominal rupture of a hydatid cyst of the liver. However, primary uterine hydatid cysts have been reported. Surgery is the Gold Standard for the treatment of uterine hydatid cysts. Exploration of the abdominal cavity is essential in the search for other localizations, particularly hepatic. Postoperative medical treatment with Albendazole can be discussed. The ideal approach to deal with this public health concern is to emphasize the need for improved preventive measures. Modern imaging techniques have significantly improved the detection rates of hydatid cysts in atypical localizations. Indeed, the preoperative diagnosis of uterine hydatidosis requires a meticulous approach which is necessary to initiate an adequate treatment and thus guarantee a better management of the patient.

Can we predict mediastinal lymph nodes metastasis in esophagogastric junction cancer? Results of a systematic review and meta-analysis.

PURPOSE: The aim of this systematic review and meta-analysis was to define clinical indicator that predicts mediastinal lymph nodes metastasis (MLNM) in patients with Esophagogastric junction cancer (EGJC) to select patient population requiring esophagectomy. METHODS: A systematic and electronic search of several electronic databases was performed up to August 2020. Studies containing information on risk factors for MLNM in patients diagnosed with EJGC and who underwent curative surgery were included. RESULTS: Two predictors, including undifferentiated type (OR = 1.82, 95% CI = 1.07-3.10, p = 0.03) and esophageal invasion length (EIL) (OR = 10.95, 95% CI = 6.37-18.82, p < 0.00001) were identified as significant predictors for the risk of MLNM. CONCLUSION: Knowledge of the associations of these clinicopathological features with MLNM can be useful in determining operative strategy for EGJC.

Intussusception through an ileostomy: A case report and literature review.

INTRODUCTION: Intussusception through an ileostomy is one of the rarest complications of stomas. In this study we report a case and a brief update of the literature to focus on the clinical level of this pathology and the therapeutic attitudes. PRESENTATION OF CASE: a 44-year-old man who underwent a small bowel resection with double stoma for tuberculosis peritonitis presented with stomatal prolapse. On examination of the stoma, small bowel mucosa appeared to have evident rather than serosa. The patient had an elective reduction of the proximal stoma under anesthesia. CONCLUSION: A review of the literature shows that Intussusception through an ileostomy can occur at any time after the first surgery. The cause is still unclear. Urgent conservative surgical management based on manual reduction should be preferred.

Vaginal cuff dehiscence and evisceration 11 years after a radical hysterectomy: A case report.

INTRODUCTION: Vaginal cuff dehiscence (VCD) and evisceration (VCDE) are rare but rather serious complications of hysterectomy procedures. We aimed to report a case of VCDE happening eleven years after the initial surgery and review a treatment protocol of this rare complication. CASE: A 68 years old Tunisian female patient In 2004, the patient underwent concomitant chemoradiation followed by total abdominal radical hysterectomy for a squamous cell carcinoma of the cervix. Eleven years later, after an abdominal thrust due to a strong cough the patient had a protrusion of the two small bowels. Patient was surgically treated following a combined approach. The follow-up did not show any sign of relapse. CONCLUSION: VCDE is a rare complication of hysterectomy that carries a lot of mobimortality if not treated on time. Surgery without delay is usually a guarantee for a god outcome.

An unexpected cause of retroperitoneal gangrene.

Retroperitoneal Gangrene is a serious condition whose causes are many. We report three originally cases of anorectal suppuration complicated by retroperitoneal gangrene without Fournier's gangrene until there ever described in the literature. The diagnosis was made in all cases on CT because of atypical clinical presentation. The surgical approach was carried out in different ways to treat perineal and retroperitoneal lesions.

Internal transfistulary drainage for intrabiliary rupture of hydatid cyst of the liver: Analysis of the indications and the results. Report of 50 cases.

BACKGROUND: The rupture of hydatid cyst of the liver into the biliary tracts through a large fistula is one of the most difficult complications to treat. The techniques are various and each has its own morbidity. Internal transfistulary drainage is a surgical method of treatment of hydatid cysts of the liver opening in the biliary tract. AIMS: The aim of this study was to identify the risk factors of specific postoperative complications of this surgical technique Methods: During the period's study, 823 patients with liver hydatid cyst were operated. 86 (11 %) of them were opened in the bile ducts through a large fistula. 50 patients (58 %) had internal transfistulary drainage. RESULTS: The sex ratio was 1.6. The population was young with an average age of 40.8 years. The most frequent clinical feature of the opening in the biliary tract was acute cholangitis (42 %). The most common location of hydatid cyst was at the hepatic dome. The pericyst was flexible in only 62 % of cases. Thick pericysts were made flexible in 20% of cases and partly resection of protruding dome was made in 36 % of cases. Specific morbidity rate was 16% with no mortality. The uni and multivariate analysis had identified as risk factors for specific complications: the thick pericyst (P = 0.04), a size of the residual cavity ≥ 9cm; non visualization of the residual cavity on the post operative cholangiography was of borderline statistical significance (P = 0.049). CONCLUSION: The internal transfistulary drainage is an easy and reliable surgical technique, its morbidity is low. It's indicated in the cases of large fistula with a thin pericyst and a diameter of the residual cavity less than 09 cm. Making thick pericyst flexible is a false security for the indication of internal transfistulary drainage and the non visualization of the residual cavity on the post operative cholangiography impose more frequent control for these patients since they are at risk of complications.

Multiple bile duct stones: Comparison of two surgical techniques done at laparotomy.

BACKGROUND: Biliary lithiasis is the most common surgical disease in Tunisia. Multiple bile duct stones are one of his most rare complications.It poses real problems with the best therapeutic approach. AIMS: To analyze the results of conventional surgery for multiple bile duct stones by comparing two techniques: The choledochotomy for stoneextraction followed by external biliary drainage and biliary-enteric anastomosis, to identify and to analyze the factors influencing the therapeuticchoice. METHODS: During study period spanning 16 years, 137 choledochotomy were made for multiple bile duct stones. These patients had either acholedochotomy with stone extraction and then drained through a T-tube or a biliary-enteric anastomosis. RESULTS: Preoperative diagnosis of multiple bile duct stones has been made in 32.1 % of patients. Cholangiography was found in all casesmultiple bile duct stones and had demonstrated an association with intrahepatic stones in 18.2 %. External drainage by a Kehr drain wasperformed in 39.4 % and biliary-enteric anastomosis in 60.6 %. Univariate and multivariate analysis had identified three factors significantlyassociated with external drainage: age ≤ 65 years, bile duct diameter < 15 mm and the existence of a pronounced inflammatory reaction of thecholedochal wall. No factors had influenced the choice between different bilio-enteric anastomosis techniques. These three techniques did notdiffer from the post operative morbidity (p = 0.84) or mortality (p = 58). CONCLUSION: Basing on the analysis of our series and the comparison with other series reported in the literature, we recommend biliary drainagewith a T-tube in young people under 65 years who have a little dilated bile duct, not exceeding 15mm. In patients aged over 65 years or thosewith a CBD dilated more than 15 mm, even with intrahepatic stones, in cases of distal bile duct stricture or periampullary diverticulum, biliaryentericanastomosis seems to be the safest technique.

Gallbladder Adenosquamous Carcinoma Associated with Biliopancreatic Maljunction and Cystic Metastases of the Liver Miming Abscess.

Gallbladder adenosquamous carcinoma is a rare tumor with glandular and squamous malignant components. We report a special case of this rare tumor with cystic metastasis of the liver miming hepatic abscess and associated with biliopancreatic maljunction.

Spontaneous fistulization of hepatic hydatid cyst into the duodenum: an exceptional complication.

Hydatid disease is a worldwide zoonosis and is localized in the liver in most cases. Its complications are numerous and include those related to the compression of adjacent viscera, infection of the cyst's contents or perforation of the cyst. Spontaneous rupture of the hepatic hydatid cyst into the duodenum is an extremely rare complication. The communication is, typically, not discovered until surgery. We present two cases of perforation of a liver cyst into the duodenum. One of them was diagnosed pre-operatively by a barium study. The surgical treatment of the lesion and its complications was complex but successful in both cases.

Jejunal GIST causing acute massive gastrointestinal bleeding: role of multidetector row helical CT in the preoperative diagnosis and management.

In this report, we describe a 34-year-old man with a jejunal gastrointestinal stromal tumour (GIST) accompanied by an unusual severe haemorrhage. Because oesophagogastroduodenoscopy proved inconclusive in determining the source of the bleeding and also because of gradually dropping haemoglobin levels and persistence of the melena not allowing colonic preparation, colonoscopy was cancelled and a mesenteric angio-computed tomography (angio-CT) was deemed necessary. The results of this analysis showed a 5-cm heterogeneous mass located in the jejunal loop surrounded by abnormal arterial structures. This multidetector computed tomography (MDCT) appearance was highly suggestive of GIST. The patient then underwent an urgent laparotomy and, peroperative findings being compatible with angio-CT descriptions, a small-bowel resection was performed. The results of the histopathological examination confirmed the diagnosis of GIST. Angio-CT helps define the size of GIST as well as its range and location and can be used as the primary routine test for patients suffering from lower-GI bleeding.

Unusual presentation of a colonic sarcoidosis.

Sarcoidosis is a multisystemic disorder of unknown cause that affects almost every tissue in the body. Colon is an extremely rare location of this disease. Clinical presentation, endoscopic appearances, and radiologic findings are not specific and may mimic much other affection. We report the case of a 64-year-old woman with inactive pulmonary sarcoidosis who presented alternating constipation and diarrhea. Colonoscopy revealed a stenotic tumor in the ascending colon. Histology failed to determine the nature of the lesion. Radiologic findings are those of a long stenotic tumor of the ascending colon associated with a multiple satellite lymphadenopathy. Endoscopic and radiologic descriptions are highly suggestive of a malignancy. The patient underwent a laparotomy, and a right hemicolectomy was performed. Examination of the resected specimen showed follicular structure with central epitheloid and giant cells and surrounding fibroblasts. These findings made the diagnosis of colonic sarcoidosis. The nonspecificity of the endoscopic and radiological signs of gastrointestinal sarcoidosis and the extreme rarity of colonic location make the preoperative diagnosis unlikely. The diagnosis will be then made only on histological examination of surgical specimens. We describe, through this observation, the results of paraclinical investigations that can suggest diagnosis and perhaps avoid surgery.