Omentopexy versus no omentopexy in sleeve gastrectomy: an updated systematic review and meta-analysis.

Laparoscopic sleeve gastrectomy with omentopexy (O-LSG) has been compared to laparoscopic sleeve gastrectomy with no-omentopexy (NO-LSG) in terms of postoperative outcomes and one-year anthropometric results. This systematic review with meta-analysis aimed to compare the utility of omentopexy in sleeve gastrectomy. We performed a systematic review with meta-analysis according to PRISMA 2020 and AMSTAR 2 guidelines. We included studies that systematically searched electronic databases and compared the O-LSG with the NO-LSG conducted through 1st March 2023. The bibliographic research yielded 13 eligible studies. These studies included 5514 patients. The O-LSG is associated with lower leakage (OR = 0.22; 95% CI [0.08, 0.55], p = 0.001), bleeding (OR = 0.33; 95% CI [0.19, 0.57], p < 0.0001), vomiting (OR = 0.50; 95% CI [0.28, 0.89], p = 0.02), twist (OR = 0.09; 95% CI [0.02, 0.39], p = 0.001), and shorter hospital stay (MD = - 0.33; 95% CI [- 0.61, - 0.05], p = 0.02) compared with NO-LSG. The O-LSG is associated with longer operative time (MD = 8.15; 95% CI [3.65, 12.64], p = 0.0004) than the NO-LSG. There were no differences between the two groups in terms of postoperative GERD (OR = 0.53; 95% CI [0.27, 1.02], p = 0.06), readmission (OR = 0.60; 95% CI [0.27, 1.37], p = 0.23), and one-year total weight loss (MD = 2.06; 95% CI [- 1.53, 5.65], p = 0.26). In the subgroup analysis including only RCTs, postoperative GERD was lower in the O-LSG (OR = 0.26; 95% CI [0.11, 0.63], p = 0.003). Our systematic review and meta-analysis concluded that omentopexy in sleeve gastrectomy is feasible and safe It reduced leakage, bleeding, and twist. It probably increased the operative time. It may reduce vomiting, GERD, and hospital stay. We don't know if it led to an additional readmission rate or one-year total weight loss.Registration The protocol was registered in PROSPERO with the ID CRD42022336790.

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.

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.

Ordinal disciplinary responsibility of the certifying physician.

NTRODUCTION: Writing medical certificates is part of the doctor's daily practice. AIM: To analyze the complaints related to medical certificates filed to the Regional Council of the Order of Doctors (RCOD) of Tunis and to identify the predictive factors of disciplinary sanctions. METHODS: We collected the complaints filed to the RCOD of Tunis between 01/01/2017 and 31/12/2017, in relation to a problem with the establishment and/or the issuance of medical certificates by registered certifying doctors at RCOD, Tunis. RESULTS: We collected 32 complaints, the reason for which was a certificate of convenience in 88% of cases, a drafting error in 9% of cases and a fee problem in 3% of cases. The decision of the RCOD was a closing of the file in 56% of cases, a call to order in 28% of cases and a temporary ban on practicing medicine in 16% of cases.The multivariate analysis with logistic regression identified one independent predictor of a call to order or a sanction from the RCOD, namely the fact that the doctor did not bring the file of the patient(s) having been the subject of the complaint, at the time of his invitation to RCOD Tunis (p=0.037, OR=22.66). CONCLUSION: The doctor must always keep a medical form or a patient file, which will allow him to justify himself in the event of a complaint against him, for the reason of a certificate of convenience.

Quality assessment of rectal cancer surgery: How are we doing?

INTRODUCTION: Surgery remains a cornerstone in the treatment of rectal cancer. Optimal surgical resection implies respect for carcinologic principles. The best way to evaluate a good quality of resection requires certainly an exhaustive evaluation of the surgical specimen by the surgeon and the pathologist. AIM: To assess the quality of resected rectal cancers. METHODS: This study included patients operated on for rectal malignant epithelial tumors, between January 1st, 2015 and December 31st, 2020, in the general surgery department B at Charles Nicolle's Hospital in Tunis. Data relevant to the pathologic examination were recorded. We performed a descriptive study and an analytic bivariate study comparing the two groups "number of lymph nodes harvested less than 12" versus "number of lymph nodes harvested higher than or equal to 12". RESULTS: Neoadjuvant therapy was performed in 39 patients (79%). Anterior resection (AR) was performed in 43 patients (43%) and abdominoperineal resection (APR) was performed in 11 patients (20%). There were no invaded margins. The mean distal surgical margin was 3±1.4 cm. Mesorectum was complete in 38 surgical specimens (70%). The median number of lymph nodes harvested was 14. Resection was considered R0 in 47 patients (87%). In bivariate analysis, there was no difference between the "number of harvested lymph nodes <12" and the "number of harvested lymph nodes ≥ 12"groups for the variables: laparotomy, laparoscopic approach, conversion to laparotomy and chemoradiotherapy. CONCLUSION: Quality of surgical resection of rectal cancer in our department was in accordance with recommendations.

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.

Recommandations of the Tunisian Association of Surgery for the practice of visceral surgery during COVID-19 pandemic.

The World Health Organization declared on March 11, 2020 that the COVID-19 epidemic has become a pandemic. In Tunisia, the Ministry of Health has recommended enhanced preventive hygiene measures to contain and limit the spread of the virus. Following the entry of Tunisia into phase 4 of the COVID-19 epidemic, the Tunisian Association of Surgery proposed recommendations related to surgical activity. Surgical emergencies must be treated urgently and without delay. Non-tumor pathologies which require surgery in an elective situation and for which the risk of aggravation or complication is considered low shoud be postponed. For digestive tumor pathology, and apart from complicated forms, neoadjuvant treatment is highly recommended in the context of multidisciplinary concertation staff.

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.

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.

Management of perforated duodenal peptic ulcer treated by suture.

BACKGROUND: Laparoscopic surgery has become the gold standard for many procedures owing to its advantages such as a shorter post-operative stay, a faster recovery and less postoperative pain. However, choosing laparoscopic approach in an emergency situationsuch as in the management of a perforated duodenal peptic ulcer is still debated because of the absence of significant benefits. This study aimed to assess the management of perforated duodenal peptic ulcer treated by suture. METHODS: It's a retrospective study enrolling 81 patients operated on for duodenal perforated peptic ulcer between June 1st, 2012 and December 31st, 2016 who underwent surgery in the surgical department B of Charles Nicolle's Hospital. RESULTS: Our retrospective study showed that laparoscopic approach had shorter post-operative duration (3 [1-5] versus 4 [1-16] days, respectively, p< 0.001), shorter mortality rate (3% versus 19%, p=0.032) and more uneventful post-operative course (97% versus 74%, p=0.004) comparing to the open approach. Patients who were not admitted in the intensive care unit during the first 48 hours had 9.901 more chance to be operated by laparoscopic approach. Patients who were operated on by a senior had 3.240 times more chance to be operated by laparoscopic approach. There was no predictive variable for conversion. Mortality rate was 11%. Age was the only predictive independent factor of mortality with a cut-off point of 47 years. CONCLUSIONS: Laparoscopic approach is routinely practised in the perforated duodenal ulcer. In our study, we showed that laparoscopic approach had less post-operative complications, a lower rate of mortality and a shorter post-operative duration comparing to the open approach. The main limitation of our study was non-randomization and lack of laparoscopic expertise. The decision for either open or laparoscopic approach was then dependent on senior surgeon's availability.

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.

Morbidity and mortality of infected diabetic foot managed in general surgical department.

BACKGROUND: Foot ulcers are diabetes-related complications which occur in 10%-25% in diabetic patients. They are an important cause of morbidity and mortality in diabetes. This retrospective study aimed to assess, using an administrative database, the morbidity and the mortality risk of infected diabetic ulcers. METHODS: It's a retrospective study enrolling 644 patients operated on for a diabetic foot between January 1st, 2012 and December 31st, 2016 in the surgical department B of Charles Nicolle's Hospital. Logistic regression identified independent predictive factors of major amputation, morbidity and mortality. RESULTS: This retrospective study showed that "Cardiac failure" (OR=5.00, 95%CI [1.08  23.25], p=0.039), "Admission in the ICU in the first 48h" (OR=12.76, 95%CI [4.92  33.33], p<0.001) and "Major amputation" (OR=6.40, 95%CI [2.41  16.94], p<0.001) were considered as independent predictive factors of mortality. As concerns morbidity, Cardiac failure (OR=0.163, 95%CI [0.055  0.479], p=0.001) and organ failure at admission (OR=0.017, 95%CI [0.004  0.066], p=0.017) were predictive factors of admission in the ICU during the first 48 hours. Besides, advanced age (OR=1.033, 95%CI [1.014  1.052], p=0.001), Pre-operative stay (OR=1.093, 95%CI [1.039  1.151], p=0.001) and admission in the ICU during the first 48 hours (OR=0.142, 95%CI [0.071  0.285], p<0.001) were predictive factors of major amputation. Moreover, Cardiac failure (OR=0.517, 95%CI [0.298  0.896], p=0.019), admission in the ICU during the first 48 hours (OR=0.176, 95%CI [0.088  0.354], p<0.001)  and Pre-operative stay (OR=1.083, 95%CI [1.033  1.134], p=0.001) were predictive variables of complicated post-operative course. Admission in the ICU during the first 48h (OR=0.140, 95%CI [0.48  0.405], p<0.001), major amputation (OR=0.170, 95%CI [0.76  0.379], p<0.001), and number of ICU stays (OR=3.341, 95%CI [1.558  7.164], p=0.002) were predictive factors of medical complications. Preoperative stay (OR=1.091, 95%CI [1.038  1.147], p=0.001) was predictive of reintervention. CONCLUSIONS: Our retrospective study assessed that mortality rate was inferior when the patient didn't have amputation, no post-operative complications and no reintervention. The main limitation of our study was the retrospective design.

Diaphragmatic hydatid disease: a diagnostic challenge for the radiologist.

Primitive hydatid disease of diaphragm is very rare. The preoperative diagnosis of this hydatid location represents a challenge for the radiologist. We reported a case of primitive hydatid cyst of the diaphragm not associated with other hydatid localizations which was diagnosed preoperatively. A 70 year-old woman with no previous medical history, complained of abdominal pain in the right upper quadrant for 7 months. The physical exam and the laboratory tests were unremarkable. Abdominal ultrasound showed multiloculated cystic lesion which appeared to be located in the hepatic dome suggestive of hydatid cyst of the liver.  However, computed tomography showed findings but in favour of the diaphragmatic origin of the cyst which was confirmed peroperatively. Since the exploration of cysts lying between the thorax and the abdomen is difficult by ultrasound, computed tomography with multiplanar reconstruction appears to be indispensable in the preoperative assessment of hydatid cysts in contact with the diaphragm.

Pseudo papillary and solid tumor of the pancreas: a rare tumor and a difficult diagnosis.

The pseudopapillary and solid tumor of the pancreas is a rare disease that accounts for 2% of pancreatic tumors. It affects mainly young, female adults. The clinical features are not specific, hence the diagnostic difficulty and the importance of imaging. The diagnosis is based on pathological examination coupled with immunohistochemistry. The aim of our work was to report the difficulty of the diagnostic procedure in a patient with a pancreatic cystic tumor.

Prevalence and risk factors of pressure ulcers in a Tunisian hospital.

BACKGROUND: the aim of thisstudywas to investigate the prevalence of pressure ulcers in hospitalized patients at the Charles Nicolle Hospital in Tunis, measure the risk of their occurrence, analyzepreventive and curative measuresundertaken and evaluatefactorspredisposing to pressure ulcers. METHODS: A one-day survey was performed in all hospitalized patients. Emergency services, neonatology and pediatrics were excluded. The Braden scale was used to measure the patient's risk for the development of pressure ulcers. Analysis of risk factors was performed using SPSS version 19 software. RESULTS: A total of 473 patients was included. The mean age was 52.26 years. Nearly 10% of patients had a moderate or a high risk of developing pressure ulcers with a Braden score less than 18. The prevalence of patients with pressure ulcers was 5.3% with a prevalence of 4.7% of nosocomial pressure ulcer. There was no significant difference in prevalence between medical and surgical services. The prevalence was relatively more important in intensive care and general surgery. The most frequent sites were sacrum and heels. Stages 3 (46.4%) and 2 (37.5%) were the mainly stages descriped. Evaluation of management of bedsores formed revealed that half was treated with modern wound dressings. Statistical analysis revealed that a Braden score <18 is correlated with pressure ulcers ( 96% of patients with bedsores. Patients transferred from other services, patients recently operated or those with probably inadequate diet seem to be more at risk of developing pressure ulcers. In contrast, age and sex were not identified as significant risk factors. CONCLUSION: pressure ulcer remains a significant problem in hospital.  This problem is preventable when applying adequate prevention but its management requires a multidisciplinary approach.