Necrotizing fasciitis of the thigh: An unexpected route to discover an infected colonic cancer.

Introduction: Necrotizing fasciitis (NF) is a rare but potentially fatal soft tissue infection characterized by its aggressive nature. This case report highlights a unique and atypical presentation of NF associated with colorectal cancer. Case presentation: A 76-year-old male with no significant medical history presented with left knee pain and rapidly progressing septic shock. Clinical examination revealed skin necrosis, inflammation, and swelling in the left thigh and inguinal region. Laboratory investigations showed leukocytosis and elevated C-reactive protein levels. Computed tomography angiography revealed fluid and gas tracking along fascial planes in the left thigh. Surgical intervention revealed NF in the thigh and abdominal wall, with the underlying cause being a perforated sigmoid colon cancer. Conclusion: Recognizing the polymorphic clinical manifestations of NF and its potential association with underlying abdominal pathology can aid in early diagnosis and improve patient outcomes. This report serves as a reminder of the life-threatening nature of NF and the necessity for rapid and comprehensive management.

Intestinal ischemia in patients with incarcerated groin hernia: proposal and validation of a score.

PURPOSE: Intestinal ischemia (II) is the most critical factor to determine in patients with incarcerated groin hernia (IGH) because II could be reversible, and it is considered as a "time sensitive condition." Although predictive factors of II were identified in several previous studies, preoperative diagnosis of II cannot be reliably made or excluded by any known parameter. The aims of this study were: to devise and to validate a clinic-biologic score, with a strong discriminatory power, for predicting the risk of II in patients with IGH. METHODS: We conducted a retrospective bicentric study including 335 patients with IGH. Logistic regression analysis was used to identify independent predictive factors of II. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic (ROC) curves. The scoring system was then prospectively validated on a second independent population of 45 patients admitted for IGH in the same departments (internal validation). RESULTS: Four independent predictive factors of II were identified: heart rate, duration of symptoms before admission, prothrombin, and neutrophil-to-lymphocyte ratio (NLR). A predictive score of II was established based on these independent predictive factors. Sensitivity was 94.50%; specificity was 92.70%. The AUC of this score was 0.97. The AUC was 0.96 when the score was applied on the second population of patients. CONCLUSIONS: We performed a score to predict the risk of intestinal II with a good accuracy (the AUC of our score was 0.97). This score is reliable and reproducible, so it can help a surgeon to prioritize patients with II for surgery (especially at this time of COVID-19 pandemic), because ischemia could be reversible, avoiding thus intestinal necrosis.

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.

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.

Daughter cyst sign in liver hydatid cyst.

Daughter cyst sign is one of the most characteristic imaging findings of liver hydatid cysts. It is schematically divided into two types according to the daughter cyst localization in regard to the hydatid cyst wall: endogenous daughter cysts and exogenous daughter cysts. The endogenous daughter cyst is presented by a small cyst that protrudes into the lumen of the cystic mass. The exogenous daughter cysts are enclosed in the laminated layer then gradually pushed outwards giving the hydatid a bumpy appearance that distorts the classic circular radiological image. Imaging findings could detect these daughter cysts and dictate some additional precautions during surgical procedures. This surgery is associated with a high recurrence rate essentially in case of exogenous daughter cysts. However, if we detect many exogenous daughter cysts, a radical treatment should be favored otherwise the post-operative recurrence will be certain.

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.

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.

Alkalin phosphatase is a predictive factor of unresecability in ampullary and periampullary tumors.

BACKGROUND: Patients with malignant obstructive jaundice should undergo surgery on the basis of results of preoperative imaging. However, about half of patients are found to be unsuitable forresection during surgical exploration. Our study aimed to determine the clinicobiologicalcharacteristics that predict the resecability of ampullary and periampullary tumors. METHODS: We retrospectively reviewed the medical records of 49 patients (45% men and 55% women) who had malignant obstructive jaundice collected in the Department B of generalsurgery, Charles Nicolle hospital between July 1, 2008 and December 31, 2013. Predictivevariables of unresecability in malignant obstructive jaundice were identified using univariate andmultivariate analysis. RESULTS: 49 patients were included in the study. The mean age was 66,3±12,9 years. Twenty patients underwent surgery. Radical resection was performed in 12 patients and surgical palliation by biliary bypass was performed in 8 patients. Twenty-nine patients unfit for surgery underwent endoscopic stenting and chemotherapy. At univariate analysis, age (p=0,016), body mass index (p=0,033), worse general health status (p=0,037), locally advanced disease (p<0,001), serum conjugated bilirubin level (p=0,055), and serum level alkaline phosphatase (ALP) (p=0,014) were associated with unresectableampullary and periampullary tumors. At multivariate analysis serum level ALP was identify as an independent factor of unresecability in malignant obstructive jaundice [OR=0,996; IC à 95% (0,992-1,000) ;p=0,048]. The area under the ROC curve was 0,745 (p=0,016). CONCLUSION: Serum level of ALP can predict resecability in malignant obstructive jaundice. Further studies are needed to identify other factors predicting resecability and prognosis of ampullary and periampullary tumors.