Biosimilar versus branded enoxaparin to prevent postoperative venous thromboembolism after surgery for digestive tract cancer: Randomized trial.

Cancer and/or major surgery are two factors that predispose to post-operative thrombosis. The annual incidence of venous thromboembolic disease (VTED) in cancer patients was estimated at 0.5%-20%. Surgery increases the risk of VTED by 29% in the absence of thromboprophylaxis. Enoxaparin is a low molecular weight heparin that is safe and effective. Branded Enoxaparin and biosimilar Enoxaparin are two enoxaparin treatments. This study aimed to compare Branded Enoxaparin with biosimilar Enoxaparin in patients operated on for digestive cancer regarding the prevention of postoperative thrombosis event, to compare the tolerance of the two treatments and to identify independent predictive factors of thromboembolic incident. A randomized controlled trial conducted in a single-centre, surgical department B of Charles Nicolle Hospital, over a 5-year period from October 12th, 2015, to July 08th, 2020. We included all patients over 18 who had cancer of the digestive tract newly diagnosed, operable and whatever its nature, site, or stage, operated on in emergency or elective surgery. The primary endpoint was any asymptomatic thromboembolic event, demonstrated by systematic US Doppler of the lower limbs on postoperative day 7 to day 10. The sonographer was unaware of the prescribed treatment (Branded Enoxaparin [BE] or biosimilar Enoxaparin [BSE]). Of one hundred sixty-eight enrolled patients, six patients (4.1%) had subclinical venous thrombosis. Among those who had subclinical thrombosis, four patients (5.6%) were in the Branded Enoxaparin group and two patients (2.7%) in the Biosimilar Enoxaparin group without statistically significant difference (p = 0.435). Analysis of the difference in means using Student's t test demonstrated the equivalence of the two treatments. Our study allowed us to conclude that there was no statistically significant difference between Branded Enoxaparin and Biosimilar Enoxaparin regarding the occurrence of thromboembolic accidents postoperatively. BE and BSE are equivalent. Trial registration. Trial registration: The trial was registered on CLINICALTRIALS.GOV under the number NCT02444572.

Organ preservation in anorectal melanoma: A tempting challenge-a case report.

Melanoma arising from melanocytes is an uncommon neoplastic lesion, with rare occurrences in anorectal mucosa. While mucosal melanomas constitute a small portion of all melanomas, anorectal cases are even rarer and present with aggressive behavior and poor prognosis. Surgical management is central, with evolving debates regarding optimal approaches. We present a case of a 60-year-old woman with anorectal melanoma. She complained of rectal bleeding and weight loss. Clinical examination and pelvic magnetic resonance imaging revealed a 3-cm budding lesion on the anterior rectal wall. Colonoscopy identified a pedunculated anorectal tumor of 3 cm, situated 4 cm from the anal margin. A biopsy led us to a malignant lesion: anorectal melanoma. Pelvic imaging displayed a localized tumor, prompting wide local excision with millimetric negative margins. These resection margins were estimated insufficient, even in front of R0 resection. Thus, and after multidisciplinary discussion, we opted for abdominoperineal resection after wide local excision. Lymph nodes were biopsied, confirming no residual tumor. Follow-up exhibited no recurrence at 1 year. Our case emphasizes the pivotal role of surgical strategy in managing anorectal melanoma, challenging the paradigm of organ preservation. Despite therapeutic progress, surgery remains integral, contributing to improved outcomes and addressing the metastatic potential inherent to this disease.

A case report of end-stage achalasia: Conservative option as the new surgical standard.

INTRODUCTION AND IMPORTANCE: End-stage achalasia is a rare disease, consisting of a functional impairment of the esophagus which becomes dilated with a sigmoid shape. While esophagectomy was considered for a long time as the principal surgical procedure in end-stage achalasia, recent literature results demonstrate that laparoscopic Heller Dor (LHD) could be an advocated alternative with acceptable functional results. CASE PRESENTATION: We present the case of an eighty-three-year-old male, an elderly patient, who had been complaining for one year of dysphagia and general status loss. Endoscopy, manometry then a barium X-ray confirmed end-stage achalasia. The patient had LHD with an improvement of symptomatology post-operatively. CLINICAL DISCUSSION: Achalasia is a rare disease affecting oesophagal motility. The diagnosis is suggested clinically and confirmed by a wide range of tests notably esophagogastroduodenoscopy, barium swallow and manometry. The diagnosis of achalasia is classically made by demonstrating impaired relaxation of the lower oesophagal sphincter and absent peristalsis in the oesophagal manometry. Esophagogastroduodenoscopy is made mainly to eliminate the diagnosis of oesophagal cancer. Barium swallow, however, is done to appreciate the impact of achalasia on the rest of the esophagus. CONCLUSION: Our case highlights the satisfying results after an LHD which is an alternative to esophagectomy especially in elderlies with high risk.

Paraduodenal hernia: An exceptional cause of acute bowel obstruction.

Internal hernias represent only 0.2%-0.9% of all causes of bowel obstruction. A 59-year-old patient presented urgently with small bowel obstruction. Laparotomy revealed a left paraduodenal hernia with most of the small bowel herniating through a space between the inferior mesenteric vein and duodenojejunal junction.

COVID-19 and gastrointestinal symptoms: A case report of a Mesenteric Large vessel obstruction.

COVID-19 cases are increasing daily worldwide. With such emerging disease, the medical community should be aware of atypical clinical presentations in order to help with correct diagnosis, and to take the proper measures to isolate and treat patients to avoid healthcare professionals being infected and to limit its spread (SARS-CoV-2). Thrombogenesis in COVID-19 has been described in few cases, but a thrombosis of a large digestive vessel has not been documented so far. Mesenteric ischemia due to an obstruction of a large vessel may be a new presentation of COVID-19 infection.

The complications of subtotal cholecystectomy: A case report.

INTRODUCTION: Although the symptoms attributed to gall stones resolve in most patients after cholecystectomy, some may have symptoms that persist or recur. It is known as the post-cholecystectomy syndrome (PCS). The aim of this case was to describe the diagnostic difficulties encountered and to discuss the main etiologies of this entity. CASE REPORT: A 54-year-old man presented for a recurrent right upper quadrant pain despite laparoscopic cholecystectomy five years ago. Imaging showed cystic lesion at the gallbladder fossa with gallstones. We decided to reoperate the patient by laparoscopic approach. It turned to be a residual gallbladder with stones inside. It was confirmed by histopathology. He was asymptomatic after a follow-up of 2 years. DISCUSSION: The PCS should not be trivialized. Most of the causes are allocated to extra biliary etiologies. They must be ruled out first as most of them can be controlled with medication. There are etiologies for which re-operation can be necessary. CONCLUSION: The indication of cholecystectomy must be taken wisely otherwise surgery will not solve the problem. Even though patient may complain of persistence or recurrence of the pain. In this case, it can be a real challenge for both diagnosis and treatment.

A Systematic Review of Laparoscopic Cholecystectomy in Situs Inversus.

Background: In case of situs inversus (SI), laparoscopic cholecystectomy (LC) is challenging. This systematic review aimed to assess the appropriate technique for LC in SI.Methods: An electronic search was carried out using the following keywords: "Situs inversus" and "Laparoscopic cholecystectomy". The main endpoints were surgical procedures, intra-operative cholangiography (IOC) use, common bile detection, operative time, bile duct injury, conversion, mortality, and morbidity.Results: We retained 93 cases. Essentially two types of laparoscopy port placement reported were reported: the "American mirror technique" and the "French mirror technique". One report of a left-handed surgeon was retained. Fourteen cases operated by a right-handed surgeon: "American mirror technique" used in 33 cases and "French mirror technique" used in 7 cases. The operative time was mentioned in 52 cases with a mean of 74 min without any statistical difference between the two techniques. No cases of postoperative death, major complications or bile duct injury were reported. IOC was performed in 16 cases (17.2%). An associated common bile duct stone was found in eight cases (8.6%). ERCP with endoscopic sphincterotomy was used to treat the associated CBD stones in 7 cases and a choledecoscopy was conducted in one case to extract stones. The conversion rate in this systematic review was 1.07%.Conclusions: LC in SI is easier for left-handed surgeons. The fastest technique for right-handed surgeons seems to be the "American mirror technique" and some modifications of the port placement can facilitate it.

Impact of sleeve gastrectomy on abnormalities in carbohydrate tolerance in obese adult.

INTRODUCTION: Facing the repeated failures of the medical management of obesity, bariatric surgery offers a promising therapeutic option in terms of achieving weight loss and metabolic benefits. AIM: To evaluate the impact of sleeve gastrectomy on the carbohydrate profile of a group of obese subjects. METHODS: It is a prospective study including 40 obese patients (7 Men and 33 Women) who underwent sleeve gastrectomy between 2016 and 2018. Clinical and biological parameters were collected before the intervention, at six months and one year after. Insulin resistance was defined by a HOMA-IR index ≥2.4. Remission of diabetes was determined using the American Society for Metabolic and Bariatric Surgery's (ASMBS) criteria. RESULTS: The mean patients' age was 34.65 ± 8.17 years. The mean body mass index (BMI) was 50.23 ± 8.3 kg/m². One year after sleeve gastrectomy, the frequency of insulin resistance, decreased from 89% to 4% (p<0.05). The evolution of carbohydrate tolerance abnormalities was marked by the diabetes and prediabetes remission in 75% and 100% of cases, respectively. The mean excess weight loss was 55.8% at 12 months. CONCLUSION: These results have expanded our knowledge of the short-term sleeve gastrectomy's effectiveness on the carbohydrate profile of obese subjects. However, it would be interesting to check the durability of this metabolic benefit in the medium and long term.

A meta-analysis comparing hand-assisted laparoscopic right hemicolectomy and open right hemicolectomy for right-sided colon cancer.

BACKGROUND: Mini-invasive colorectal cancer surgery was adopted widely in recent years. This meta-analysis aimed to compare hand-assisted laparoscopic surgery (HALS) with open right hemicolectomy (OS) for malignant disease. METHODS: PRISMA guidelines with random effects model were adopted using Review Manager Version 5.3 for pooled estimates. RESULTS: Seven studies that involved 506 patients were included. Compared to OS, HALS improved results in terms of blood loss (MD = 53.67, 95% CI 10.67 to 96.67, p = 0.01), time to first flatus (MD = 21.11, 95% CI 14.99 to 27.23, p < 0.00001), postoperative pain score, and overall hospital stay (MD = 3.47, 95% CI 2.12 to 4.82, p < 0.00001). There was no difference as concerns post-operative mortality, morbidity (OR = 1.55, 95% CI 0.89 to 2.7, p = 0.12), wound infection (OR = 1.69, 95% CI 0.60 to 4.76, p = 0.32), operative time (MD = - 16.10, 95% CI [- 36.57 to 4.36], p = 0.12), harvested lymph nodes (MD = 0.59, 95% CI - 0.18 to 1.36, p = 0.13), and recurrence (OR = 0.97, 95% CI 0.30 to 3.15, p = 0.96). CONCLUSIONS: HALS is an efficient alternative to OS in right colectomy which combines the advantages of OS with the mini-invasive surgery.

Recurrence Factors of Groin Hernia: a systematic Review.

BACKGROUND: Groin hernia repair is a common intervention and reoperation rate for recurrence reachs 15%. Recurrence can be attributed to patients related factors  or influenced by the surgical technique. Furthermore, treating recurrence can be challenging with the risk ratio of developing a second recurrence equal to 2,7. Identifying those factors is the first step to improve hernia repair results. AIM: This systematic review aimed to identify  recurrence risk factors of groin hernia and to determine adequate treatment for recurrence. METHODS: We conducted a literature search on the Pubmed and Cochrane databases. Keywords used were: "inguinal hernia", "groin hernia", "recurrence" and  "surgical repair". Were included meta-analyses,  systematic reviews, randomized and non-randomized clinical trials, from 2008 to 2017, with their available  english full text which methodoly was evaluated. RESULTS: We identified 67 articles. Twenty-four articles were not eligible. Three articles were not available in full-text. We analyzed 40 articles. After evaluation of the methodology, six articles were excluded: these were randomized trials with a Jadad score inferior to 3. We finally selected 34 articles. The qualitative analysis of the literature revealed that heredity, female gender, obesity and smoking were general recurrence factors of groin hernia  with a level 2 of evidence. Non mesh-repair and « TEP ¼ approach for unilateral inguinal hernia favor groin hernia recurrence with a level 1 of evidence. Nor the surgical approach (laparoscopic, open), nor the mesh type, nor its fixation does affect recurrence with a level 1 of evidence. In treating  groin hernia recurrence, the inverted approach (anterior-posterior and posterior-anterior) recommended in the guidelines is questionable. CONCLUSION: This systematic review allowed us to recommand weigh loss and smoking cessation for patients undergoing groin hernia surgery. As concerns groin hernia recurrence treatment, the inverted approach (anterior-posterior and posterior-anterior) recommended in the guidelines is questionable. The choice of the adequate technique depends on the primary repair and also includes the surgeon preferences.

Predictive factor of recurrence after curative resection for stage I-II colon cancer.

BACKGROUND: Colon cancer has become a common malignant neoplasm in Tunisia. Patients with negative lymph node have a 5 years recurrence rate of 21.1%. Studies reporting the prognostic factors of recurrence for patients with stage I-II colon cancer are limited. AIM: This study aimed to determine factors predicting recurrence for patients with stage I-II colon cancer after curative resection. METHODS: This was a retrospective cohort study. Were included patients who underwent curative surgery for stage I or II colon cancer. Enrolled variables were subdivided into: Pre-operative, Intraoperative and Post-operative variables. Main outcome measures were local recurrence and distant metastasis detected during follow-up. RESULTS: Eighteen men and 17 women with median age of 61 years, ranging from 33 to 89, were enrolled in this study. Twenty-eight patients out of 35 were classified T3 and T4 colon cancer. The mean number of lymph nodes harvested was 16.23 (median= 17; range: 4-44). Ten patients (28%) had colloid component in the tumor. At a median follow-up of 23 months (range: 6-56 months), recurrence was observed in five cases (14%). Variables associated to recurrence were Carcinoembryonic antigen level (p= 0.03), serum albumin level (p=0.029) and the presence of colloid component (0.02). Multivariate logistic regression retained colloid component as the only predictive factor of recurrence (OR=1.2, 95%CI [1.019-1.412], p=0.028). CONCLUSIONS: This study showed that the percentage of mucinous component equal or greater than 25% was the only predictive factor of recurrence for curatively resected, stages I and II, colon cancer.

Self-directed learning digital tool versus tutorials under the guidance of an educator: Randomized trial.

INTRODUCTION: Self-directed learning digital tool aims to enable students to acquire skills in an autonomous way. The aim of this work was to compare a self-directed learning digital tool in non-traumatic abdominal emergencies with tutorials under the guidance of the educator in two parallel groups of second-year of second-cycle of medical students selected by means of a draw. METHODS: We performed a controlled trial with draw comparing the self-directed learning digital tool and tutorials under the guidance of a teacher. Second-year of second-cycle medical students under training in general surgery from February, 20, 2017 to May, 7, 017 were included. Main judgment criterion was the assessment of the skills gained by students by means of the total score got at the objective structured clinical examination. We have carried out a descriptive survey, kappa statistics to study agreement between examiners, followed by an ANOVA test. We have compared the total score for the self-directed learning digital tool group with the total score of the tutorials group by using the « t ¼ test of Student and the « U ¼ test of Mann-Whitney. We performed a ROC curve for the total score. We have also achieved a satisfaction survey. RESULTS: Twenty seven students were enrolled: 14 in the « self-directed learning digital tool ¼ group and 13 in the « tutorials ¼ group. The average total score for all the students was 230 ± 52 points [extremes: 71,5 - 318,5]. There was no difference between examiners (kappa test and ANOVA test). The univariate analysis showed a total score and a score by examiner higher in a statistically significant way for the « self-directed learning digital teaching tool ¼ group. The ROC curve allowed us to conclude that the self-directed learning digital tool had an important discriminating power[an area under the curve equal to 0,791, (CI95%: 0,616-0,966) with p=0,010]. CONCLUSION: Self-directed learning digital tool has allowed second-year of second-cycle medical students to acquire skills in matters of interpretation of medical imaging in non-traumatic abdominal emergency with a higher rate compared with tutorials.

Laparoscopic Versus Open Complete Mesocolon Excision in Right Colon Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Laparoscopic complete mesocolon excision (LCME) for right colonic cancer improves oncological outcomes. This systematic review and meta-analysis aimed to compare intraoperative, postoperative, and oncological outcomes after LCME and open total mesocolon excision (OCME) for right-sided colonic cancers. METHODS: Literature searches of electronic databases and manual searches up to January 31, 2019, were performed. Random-effects meta-analysis model was used. Review Manager Version 5.3 was used for pooled estimates. RESULTS: After screening 1334 articles, 10 articles with a total of 2778 patients were eligible for inclusion. Compared to OCME, LCME improves results in terms of overall morbidity (OR = 1.48, 95% CI 1.21 to 1.80, p = 0.0001), blood loss (MD = 56.56, 95% CI 19.05 to 94.06, p = 0.003), hospital stay (MD = 2.18 day, 95% CI 0.54 to 3.83, p = 0.009), and local (OR = 2.12, 95% CI 1.09 to 4.12, p = 0.03) and distant recurrence (OR = 1.63, 95% CI 1.23-2.16, p = 0.0008). There was no significant difference regarding mortality, anastomosis leakage, number of harvested lymph nodes, and 3-year disease-free survival. Open approach was significantly better than laparoscopy in terms of operative time (MD = - 34.76 min, 95% CI - 46.01 to - 23.50, p < 0.00001) and chyle leakage (OR = 0.41, 95% CI 0.18 to 0.96, p = 0.04). CONCLUSIONS: This meta-analysis suggests that LCME in right colon cancer surgery is superior to OCME in terms of overall morbidity, blood loss, hospital stay, and local and distant recurrence with a moderate grade of recommendation due to the retrospective nature of the included studies.

Endogenous hyperinsulinism: diagnostic and therapeutic difficulties.

Endogenous hyperinsulinism is an abnormal clinical condition that involves excessive insulin secretion, related in 55% of cases to insulinoma. Other causes are possible such as islet cell hyperplasia, nesidioblastosis or antibodies to insulin or to the insulin receptor. Differentiation between these diseases may be difficult despite the use of several morphological examinations. We report six patients operated on for endogenous hyperinsulinism from 1st January 2000 to 31st December 2015. Endogenous hyperinsulinism was caused by insulinoma in three cases, endocrine cells hyperplasia in two cases and no pathological lesions were found in the last case. All patients typically presented with adrenergic and neuroglycopenic symptoms with a low blood glucose level concomitant with high insulin and C-peptide levels. Computed tomography showed insulinoma in one case out of two. MRI was carried out four times and succeeded to locate the lesion in the two cases of insulinoma. Endoscopic ultrasound showed one insulinoma and provided false positive findings three times out of four. Intra operative ultrasound succeeded to localize the insulinoma in two cases but was false positive in two cases. Procedures were one duodenopancreatectomy, two left splenopancreatectomy and two enucleations. For the sixth case, no lesion was radiologically objectified. Hence, a left blind pancreatectomy was practised but the pathological examination showed normal pancreatic tissue. Our work showed that even if morphological examinations are suggestive of insulinoma, other causes of endogenous hyperinsulinism must be considered and therefore invasive explorations should be carried out.

A case report of complicated appendicular hydatid cyst mimicking an appendiceal mucocele.

Retaining the etiology of a cystic lesion in the right iliac fossa can be difficult. Appendicular hydatid cyst is a very uncommon cause of a such lesion. In some cases, diagnosis is not obvious. It can radiologically mimic an appendix mucocele, a complicated ovarian cyst, an appendicular lymphangioma or an abscess. Our case highlights the difficulties encountered in this kind of situation and despite the contribution of imaging. We present a case of a 75 years-old woman presented with a right lower quadrant continuous pain. Abdominal CT-scan revealed a multilocular cystic and hydro-aeric mass. The diagnosis of an appendiceal mucocele complicated with gelatinous peritonitis was suspected. An open debulking surgery with right hemicolectomy was performed. The pathological exam has concluded to an infected appendicular hydatid cyst with thick calcified walls. The aim of this work is to report a case of an appendicular hydatid cyst that has imitated an appendicular mucocele to discuss the importance of differential diagnostic reflections and the appropriate treatment.

Mini-Invasive management of concomitant gallstones and common bile duct stones : where is the evidence ( Review article).

BACKGROUND: The ideal mini-invasive management of common bile duct stones (CBDS) with concomitant gallbladder stones is debatable. This article aims to review the management of this condition during the last decade using the mini-invasive approach. METHODS: A database research in Medline, Embase, Cochrane and Google Scholar during the period between January 2009 to December 2018 was performed. The keywords used were «ERCP¼, «common bile duct exploration¼, «endoscopic sphincterotomy¼, «laparoscopic surgery¼, «laparoscopic cholecystectomy¼, «choledocholithiasis¼, «common bile duct stones¼ «meta-analysis¼ and «randomized clinical trials¼. RESULTS: There were 14 studies comparing mini-invasive procedures. There were nine meta-analysis, three reviews articles and two randomized clinical trials. We concluded to the absence of difference between the group laparoscopic cholecystectomy (LC) with a laparoscopic exploration of CBD (LECBD) and LC with endoscopic retrograde cholangiopancreatography (ERCP) in terms of mortality, morbidity, stones extraction success rate and duration of hospital stay. LC + ERCP is superior in terms of conversion and treatment cost. Concerning LC with a preoperative ERCP versus LC with postoperative ERCP, based on the literature data, no conclusions could be drawn. Concerning LC with LECBD versus LC with preoperative ERCP, we conclude to the absence of difference in terms of mortality, morbidity and conversion rate. Given the discordance of the results, in terms of successful extraction rate of stones, operating time and duration of hospital stay we cannot conclude to the superiority of one technique. Concerning LC with LECBD versus LC with postoperative ERCP, we conclude the absence of difference in terms of mortality, morbidity, the success rate of stones extraction, duration of hospital stays and conversion rate. Concerning LC with intraoperative ERCP versus LC with preoperative ERCP, we concluded to the absence of difference in terms of mortality, morbidity and rate of success stones extraction. The LC + intraoperative ERCP was superior in terms of hospital stay duration and conversion rate. Concerning one-stage versus two-stage treatment, we concluded to the absence of difference in terms of mortality, morbidity, the success rate of stone extraction, the conversion rate and the duration of hospital stay. CONCLUSIONS: One-stage or two-stages procedures are feasible and safe with equivalent efficacy. Surgeons must be aware of the different difficulties of these procedures and should be judicious in their use of different techniques.

Predictive factors for major amputation of lower limb in diabetic foot: about 430 patients.

BACKGROUND: Major amputation of the lower limb is defined by a leg or thigh amputation. The aim of our work was identifying predictive factors for lower limb major amputation in patients with diabetes admitted on for foot lesions through using an administrative data base. METHODS: It was a retrospective study ranging from June 1st, 2008 to December 31st, 2011, which included all the patients admitted on for an infected diabetic foot to the surgery unit B of Charles Nicolle hospital in Tunis. The main judgement criterion was the major amputation of the lower limb. We have done a descriptive and a comparative study, with univariate and multivariate analysis. RESULTS: We have enrolled 319 men and 111 women. The average age was 60.5 ± 12 years. Ninety five patients (24%) had a major amputation. Former inpatient, patient readmitted within one month post-operatively, stay in intensive care, admission in intensive care within 48hours after admission, age ≥ 65 years, presence of kidney problem, preoperative stay and length of intervention were identified as predictive factors of major amputation in the univariate analysis. Age was the only independent variable predictive for major amputation which appeared from the multivariate analysis (p=0.004).  The age cut-off ≥ 65 years has a specificity of 69 % and a sensitivity of 47% [p=0.004, OR=1.971, IC 95% : 1.239-3.132]. CONCLUSIONS: Age was the only independent predictive factor for major amputation of the lower limb in the diabetic foot with a threshold value higher or equal to 65 years. Patients aged more than 65 had 1.9 time more risk to undergo major amputation of the lower limb.

Atypical form of peritoneal tuberculosis.

It was a 48-year-old woman with a right flank mass. On examination there was a hard and painful mass of the right side, centered by a fistula orifice with a diameter of 5 mm. Abdominal computed tomography showed an intraperitoneal tissue structure in relation to the parietal peritoneum in the left hypochondria. A scanno-guided biopsy was performed. Pathological examination revealed non-specific inflammatory lesions. The evolution was marked by the appearance of a purulent fistula in the puncture site. A biopsy of the margins of the fistulous orifice of the left hypochondria was performed. Pathological examination found a granular infiltrate with caseous necrosis confirming the diagnosis of tuberculosis. The patient was put under anti-tuberculosis treatment with a good clinical and radiological evolution.