Feasibility and safety of laparoscopic adrenalectomy for large tumours.

OBJECTIVE: To verify the feasibility and safety of laparoscopic adrenalectomy for large tumours, as since it was described, the laparoscopic approach for adrenalectomy has become the 'gold standard' for small tumours and for large and non-malignant adrenal tumours many studies have reported acceptable results. PATIENTS AND METHODS: This is a retrospective study from a general surgery department from January 2006 to December 2013 including 45 patients (56 laparoscopic adrenalectomies). We divided patients into two groups according to tumour size: <5 or ⩾5 cm, we compared demographic data and peri- and postoperative outcomes. RESULTS: There was no statistical difference between the two groups for conversion rate (3.7% vs 11.7% P = 0.32), postoperative complications (14% vs 12%, P = 0.4), postoperative length of hospital stay (5 vs 6 days P = 0.43) or mortality (3.5% vs 0% P = 0.99). The only statistical difference was the operating time, at a mean (SD) 155 (60) vs 247 (71) min (P < 0.001). CONCLUSION: Laparoscopic adrenalectomy for large tumours needs more time but appears to be safe and feasible when performed by experienced surgeons.

Does primary surgical management of liver hydatid cyst influence recurrence?

BACKGROUND AND AIMS: Hydatid disease is still a major health problem in sheep-raising areas. Surgery remains the basic treatment for liver hydatid cyst (LHC). However, recurrences can occur after all therapies. Surgery for recurrence of LHC becomes technically more difficult with higher rate of morbidity and mortality. The aim of this study was to determine perfective factors associated to hepatic recurrence after LHC surgery and to propose and discuss postoperative follow-up schedules. METHODS: It is a retrospective cohort study of 672 patients with LHC treated at the surgery department "A" at Ibn Sina University Hospital, Rabat, Morocco, from January 1990 to December 2004. Recurrence rates have been analyzed by the Kaplan-Meier method for patients undergoing surgery. RESULTS: Fifty-six patients (8.5%) had LHC recurrence after surgery. There were 34 females (60.7%) and 22 males (39.3%). Median duration of recurrence's diagnosis was 24 months (interquartile range: 10-48 months). Recurrence's risk was 2.3% +/- 0.6% at 1 year and 9.1% +/- 1.3% at the 10th year. The history of LHC (hazard ratio, 2; 95% confidential interval, 1.13-3.59) and three cysts or more (hazard ratio, 3.8; 95% confidential interval, 2.07-6.98) was an independent risk factor for recurrence. CONCLUSION: We think that the surgeon's practice and experience are the most important to success the surgical treatment. It prevents complications and recurrences.

Predictive model of biliocystic communication in liver hydatid cysts using classification and regression tree analysis.

BACKGROUND: Incidence of liver hydatid cyst (LHC) rupture ranged 15%-40% of all cases and most of them concern the bile duct tree. Patients with biliocystic communication (BCC) had specific clinic and therapeutic aspect. The purpose of this study was to determine witch patients with LHC may develop BCC using classification and regression tree (CART) analysis METHODS: A retrospective study of 672 patients with liver hydatid cyst treated at the surgery department "A" at Ibn Sina University Hospital, Rabat Morocco. Four-teen risk factors for BCC occurrence were entered into CART analysis to build an algorithm that can predict at the best way the occurrence of BCC. RESULTS: Incidence of BCC was 24.5%. Subgroups with high risk were patients with jaundice and thick pericyst risk at 73.2% and patients with thick pericyst, with no jaundice 36.5 years and younger with no past history of LHC risk at 40.5%. Our developed CART model has sensitivity at 39.6%, specificity at 93.3%, positive predictive value at 65.6%, a negative predictive value at 82.6% and accuracy of good classification at 80.1%. Discriminating ability of the model was good 82%. CONCLUSION: we developed a simple classification tool to identify LHC patients with high risk BCC during a routine clinic visit (only on clinical history and examination followed by an ultrasonography). Predictive factors were based on pericyst aspect, jaundice, age, past history of liver hydatidosis and morphological Gharbi cyst aspect. We think that this classification can be useful with efficacy to direct patients at appropriated medical struct's.

[Surgical management of bilateral pheochromocytoma]. / La prise en charge chirurgicale du phéochromocytome bilatéral.

AIM: the aim of this retrospective study was to assess our experience in surgical management of bilateral pheochromocytoma (BP) and to report diagnosis methods and therapeutic results of a series of 10 patients treated in "surgical clinique A" department. METHODS: from 1986 to 2005, we studied all cases of histological confirmed BP in their clinical, biochemical and radiological aspects. We analyzed all of therapeutic attitudes suggested and their results. RESULTS: Ten patients underwent adrenalectomy for BP: 6 men and 4 women with age average of 37.1 (13-60). Eight of them were synchronous BP versus two metachronous ones. Eight patients were symptomatic. One of them had a Von Hippel Lindeau syndrome and 2 others had a familial form of BP. For the two asymptomatic cases: the first one was an incidentaloma and the second one was discovered in a MEN IIb screening. As a primary biochemical diagnostic measure, the determination of the excretion rate of cathecholamine in the 24h urine was high among 6 patients. The ultrasonic imaging and CT scanning were done to localize the tumor site. The surgical treatment consisted in a bilateral adrenalectomy in one phase for 5 patients and in two phases for the 5 others (one double laparoscopy). An enucleating of a pancreatic nodule was an associated act practiced on a patient. Perioperative incidents were related in heart rythme dysfunctions, crises of hypertension among 6 patients and a cardiac arrest rehabilitated. In postoperative phase we assess a death case of sepsis chock, an acute adrenal insufficiency, an acute pancreatitis and a liver metastasis one year after the adrenalectomy. All patients were under hydrocortisone (30 mg) for life. CONCLUSION: Bilateral adrenalectomy is the basic treatment of a BP. A familial screening must be systematically carried out. Laparoscopic adrenalectomy has good results.

[Isolated tuberculosis of pancreas and peripancreatic lymph nodes: diagnostic challenge]. / Tuberculose isolée du pancréas et des ganglions péripancréatiques: challenge diagnostique.

BACKGROUND: Isolated tuberculosis of pancreas and peripancreatic lymph nodes is very rare and difficult to recognise. It may mimic pseudocyst, cystic tumor or carcinoma of pancreas and lead to unuseful and potentially morbid surgery. AIM: We report 3 cases diagnosed in peropeative and postoperative situations. CASES: Thirty four-year-old and 50-year-old women presented with obstructive jaundice. Abdominal CT scan showed resectable head of pancreas tumour. In first patient, peroperative biopsies suggested tuberculosis and resection was avoided. The second patient underwent Whipple procedure. Third case was a 48-year-old alcoholic man who presented with recent history of painful mass of left hypochondre. Cystic tumor of pancreas tail and pseudocyst were suggested in CT scan. En bloc resection of tumor, pancreas tail and spleen was performed. The three patients had antitubercular therapy after histological confirmation of pancreatic tuberculosis. Follow-up is respectively 3 years, 5 months and 2 years free of recurrence. CONCLUSION: Radio or echoendoscopical fine needle punction can contribute to the diagnosis. Surgery remains the main treatment of complications (fistulas, bleedings, obstructions) and the last diagnosis option. Tuberculous origin of an isolated pancreatic mass may be suspected in young people and immunocompromised especially in endemic areas.

Predictive factors of deep abdominal complications after operation for hydatid cyst of the liver: 15 years of experience with 672 patients.

BACKGROUND: Operations are the mainstay of liver hydatid cyst (LHC) treatment. Operations are still associated with high morbidity and mortality because of specific postoperative complications (bile leaks, bilomas, deep bleeding, and deep suppurations) and deep abdominal complications (DAC). The aim of this study was to identify the predictive factors of DAC after LHC operation. STUDY DESIGN: We conducted a retrospective study of 672 patients with LHC treated at the Surgery Department "A" at Ibn Sina University Hospital, Rabat, Morocco. Specific morbidity (DAC) and 30 variables were assessed. Univariate and multivariate logistic regression were performed to identify predictive factors for DAC. An associated risk scoring system was developed. RESULTS: Six hundred sixty-four patients underwent operations. Mortality rate was 0.8% (n = 5) and DAC rate was 18.4% (n = 121). Five independent predictive factors of DAC after LHC operation were retained, ie, presence of cyst preoperative complications (odds ratio [OR] = 3.10; 95% CI, 1.85 to 5.17), 3 or more cysts in the liver (OR = 2.55; 95% CI, 1.42 to 4.59), thick pericyst (OR = 2.59; 95% CI, 1.27 to 5.29), biliary fistula (OR = 2.27; 95% CI, 1.38 to 3.72), and capitonnage alone as residual cavity management (OR = 2.23; 95% CI, 1.12 to 4.44). Multivariate model showed a good fit. Discriminating ability of the model was fair. In theoretical risk, scores ranged from 0 to 5. When the score was 2 or more, sensitivity of the scoring model was 80.3%, specificity was 58.5%, positive predictive value was 30.3%, and negative predictive value was 93%. CONCLUSIONS: Identification of these five factors will allow more appropriate therapeutic care after LHC operation.

[Hydatid cyst of the psoas muscle]. / Kyste hydatique du muscle psoas.

While hydatid cysts may occur in any area of the body, isolated muscular localizations are rare. Only some thirty-odd such cases have been reported. The authors report the case of a 38-year-old man who consulted for isolated abdominal pain in the left iliac region. Radiographic study showed a simple hydatid cyst of the left psoas muscle. The cyst was removed by extraperitoneal transverse laparotomy. Crural nerve palsy occurred but regressed after 2 months and had not recurred after 24 months. Ultrasonography is the preferred method for detecting muscular hydatid cysts. No other diagnostic tool is needed. Surgical treatment remains best. We recommend the unroofing technique over pericystectomy. Other cyst localizations must be sought before any therapeutic decision, since they determine the initial surgical management and allow consideration of other therapeutic methods to be combined with surgery.

[Intraperitoneal perforation of hepatic hydatid cyst]. / Rupture intrapéritonéale du kyste hydatique du foie.

The incidence of the rupture of hydatid cyst of the liver is about 15 to 40% of the cases. In 2 to 7% of the cases the cyst can perforate into the peritoneum. The occurrence of a sclerosing peritonitis secondary to the rupture of the hydatid cyst of the liver was described, to our knowledge, only once. We report the observation of a 43 year-old woman in whom the diagnostis of peritoneal rupture of a liver hydatid cyst was made after 3 months. The patient was treated by albendazole (10 mg/kg/d). Two months after the beginning of this treatment, the patient was operated. A sclerosing peritonitis was discovered. The parasitologic studies of the different specimens were negative. The surgical treatment consisted of a good washing with H2O2 of the fibrous hull of the sclerosing peritonitis and drainage without any dissection. The evolution was satisfactory with albendazole treatment for 14 months. Currently, she is in good health without recurrence and without any abnormalities with a 2 years follow-up. We think that albendazole in the treatment of the hydatid disease is very effective in condition to give a continuous treatment for a long time. The occurrence of a sclerosing peritonitis is fortunately an exceptional situation whose surgical management is very delicate.

[Digestive actinomycosis: three cases and review]. / Actinomycose digestive. Trois cas et revue de la littérature.

Actinomycosis is a chronic suppurative disease. It is caused by an anaerobic bacterium, generally Actinomyces israelii. Cervical and thoracic localizations are most frequent. Digestive actinomycosis is rare and can simulate cancer leading to resection. We report 3 cases of surgical abdominal actinomycosis. Localization was colic in 2 cases and hepatic in 1 case. The diagnosis of actinomycosis was made after resection in the 3 cases. The evolution was favourable under medical treatment. These observations illustrate the difficulty of diagnosing this rare and unrecognised disease which can be cured by long term penicillin therapy.

[Leiomyosarcoma of the inferior vena cava: diagnostic problem and treatment]. / Le léiomyosarcome de la veine cave inférieure: problème diagnostique et traitement.

The authors report the case of a 42-year-old woman in whom a tumour of the inferior vena cava was discovered intraoperatively. Histological examination of the specimen confirmed the diagnosis of leiomyosarcoma. Malignant tumours of the inferior vena cava are very rare and about 95% of these tumours are leiomyosarcomas. These tumours are diagnosed preoperatively in only 10% of cases. CT and MRI allow a precise staging assessment. Radical surgery and a combination of radiotherapy-chemotherapy constitute optimal treatment for leiomyosarcoma of the inferior vena cava, ensuring long survival, but recurrences are frequent.