Predicting Intestinal Ischaemia in Patients with Adhesive Small Bowel Obstruction: A Simple Score.

BACKGROUND/AIMS: Intestinal ischaemia (II) is the most critical factor to determine in patients with adhesive small bowel obstruction (ASBO) because intestinal ischaemia could be reversible. The aim of this study was to create a clinicoradiological score to predict II in patients with ASBO. METHODS: We conducted a retrospective study including 124 patients with ASBO. Logistic regression analysis was used to identify 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 curves. RESULTS: Six independent predictive factors of II were identified: age, pain duration, body temperature, WBC, reduced wall enhancement and segmental mesenteric fluid at CT scan. According to the regression, coefficient points were assigned to each of the variables associated with II. The estimated rates of II were calculated for the total scores ranging from 0 to 24. The AUC of this clinicoradiological score was 0.92. A cut-off score of 6 was used for the low-probability group (the risk of II was 1.13%). A score ranging from 7 to 15 defined intermediate-probability group (the risk of II was 44%). A score ≥16 defined high-probability group (100% of patients in this group had II). CONCLUSIONS: We performed a score to predict the risk of intestinal II with a good accuracy (the AUC of our score exceeded 0.90). This score is reliable and reproducible, so it can help surgeon to prioritize patients with II for surgery because ischaemia could be reversible, avoiding thus intestinal necrosis.

The surgical management of a hypogastric dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon skin tumor with intermediate grade of malignancy. Wide surgical resection with disease-free margin offers an excellent probability of cure. These large excisions cause large skin defect that can be difficult to cover. Through this case report we describe a surgically treated DFSP that was covered by a Mc Gregor flap; which despite its seniority is still relevant and continues to serve plastic surgery.

Could the Tokyo guidelines on the management of acute cholecystitis be adopted in developing countries? Experience of one center.

PURPOSE: The Tokyo guidelines for diagnostic criteria and severity assessment of acute cholecystitis (AC), published in 2007, recommend early laparoscopic cholecystectomy (ELC) be done as soon as possible after the onset of symptoms. We conducted this study to analyze the changes in the therapeutic strategy for AC in a surgical center in Tunisia after the Tokyo guidelines were published. METHODS: Between January, 2005 and January, 2013, 649 patients underwent cholecystectomy for AC at the Department of Surgery, Mohamed Tahar Maamouri Hospital in Nabeul, Tunisia. The study period was subdivided into before (n = 192) and after (n = 457) the publication of the Tokyo guidelines, that is, prior to and including 2007, and from 2008 onward, respectively. We reviewed patient records retrospectively to collect demographic data, biochemical data, radiological findings, and postoperative outcomes. All these factors were compared between the groups. RESULTS: The duration of symptoms before surgery was significantly longer before 2008 (p = 0.018). ELC was significantly more frequent after 2008 (p = 0.001). Laparoscopic surgery was converted to open surgery in 16.1 % of patients before 2008 vs. 7.8 % of patients after 2008 (p = 0.02). There were no significant differences in bile duct injury or postoperative complications between the groups. The length of preoperative, postoperative, and total hospital stay was longer before 2008. CONCLUSIONS: ELC is a safe and effective therapeutic strategy for AC. The Tokyo guidelines resulted in a significant increase in the number of ELCs being performed and significantly reduced preoperative and total hospital stay without increasing intra- and postoperative complications. Importantly, ELC reduced medical costs, which is crucial for a country with limited resources, such as Tunisia.

Surgery for Colorectal Cancer in Elderly Patients: How Could We Improve Early Outcomes ?

BACKGROUND: Age is one of the causes behind the undertreatment of elderly colorectal cancer patients. The increase of mortality among elderly colorectal cancer (CRC) patients is due to competing causes of death occurring in the early post operative period. The purpose of this study was to evaluate the risk factors for post operative mortality and morbidity among elderly CRC patients. MATERIALS AND METHODS: A retrospective descriptive chart review was performed on consecutive patients older than 70 y with CRC. We have collected data of 124 patients who were admitted from January 2001 to January 2010. Demographic characteristics, operative and postoperative informations were retrospectively analysed. RESULTS: Early postoperative morbidity, operation related to morbidity and mortality were observed in 44 (35.5%), 9 (7.3%) and 20 (16.1%) cases, respectively. No other factors but ASA score (p = 0.002 and 0.005 in univariate and multivariate analyses, respectively) and emergency operations (p<0.001 and 10(-3) in univariate and multivariate analyses, respectively), were found to be risk factors of mortality. The results of multivariate analyses indicated that anaemia (p=0.021) and rectal cancer (p=0.015) had significant impact on the risk of anastomotic leakage. On the other hand, diabetes mellitus and rectal cancer were indicators that correlated with the width of hospitalization. CONCLUSION: Elderly CRC patients should no longer be undertreated only because of their age. They should be exposed to more aggressive management than they are currently receiving. Careful preoperative evaluation, followed by medical optimization and planning of perioperative care could improve outcomes of colorectal surgery for elderly patients.

Clinico-Pathological Caracteristics, Therapeutic Features and Post-operative Course of Colorectal Cancer in Elderly Patients.

STATEMENT OF PROBLEM: Colorectal cancer is predominantly a disease of elderly people and is a major cause of morbidity and mortality in the elderly population. The geriatric colorectal population is a very heterogeneous group, including patients with excellent health status and others with comorbid conditions, functional dependency, and limited life expectancy. On the other hand, the effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved post-operative life expectancy or at least one that is not diminished by the surgery. MATERIALS AND METHODS: This work is a descriptive study of a retrospective cohort, based on administrative databases, of all patients with colorectal cancer diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, stage of cancer, type of treatment received, post-operative complications and cause of post-operative death. We compared differences between an elderly group (Group A) (age >75 years) and a group of patients below 75 years (Group B). RESULTS: We found that elderly patients with colorectal cancer were more likely to be operated in emergent conditions, had more non-specific complications and more post-operative mortality than patients below 75 years. On the other hand, tumours stages, tumours characteristics and post-operative specific morbidity have been proved to be similar, both in Group A and Group B patients. CONCLUSION: These results suggest that surgery is feasible and can be safe for patients above 75 years, but it needs much more evaluation of comorbidities, pre- and post-operative intensive care to avoid post-operative non-specific complications.

Appendiceal GIST: report of an exceptional case and review of the literature.

Gastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only eight cases has been described in the literature, most of which have been of the benign type. We report a new case of an appendiceal GIST in a 75-year-old man. The tumor was discovered when the patient presented with acute appendiceacal peritonitis. Preoperative diagnosis of appendiceal GIST was rarely done as tumors were usually associated with appendicitis-like symptoms.

Retroportal lamina or mesopancreas? Lessons learned by anatomical and histological study of thirty three cadaveric dissections.

OBJECTIVE AND BACKGROUND: Despite its importance in pancreatic head carcinoma, the retroportal lamina is still under studied, with only two anatomical cadaveric dissections in the English literature, with recent controversies about the concept of a mesopancreas. METHODS: Resection of the mesopancreas was performed in 33 fresh cadavers. The pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated. RESULTS: The retroportal lamina is roughly rectangular in shape. Its dimensions are: height 6.2 cm (5-8), 2.5 cm wide (1.5-4). It contains a right hepatic artery arising from the superior mesenteric artery in 13.3% of cases. Microscopic examination revealed areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatics and capillaries. However, fibrous sheath and fascia were not found around these structures. CONCLUSION: A right hepatic artery arising from the superior mesenteric artery is a frequent anatomic variation. Surgeons must be aware of this to ensure the integrity of the hepatic artery blood supply in patients treated by pancreaticoduodenectomy. Despite controversy about the reality of the mesopancreas (postulated in analogy to the mesorectum), because of the absence of fibrous sheath or fascia, its complete removal in pancreatic head carcinoma is feasible by a subadventitial dissection of the superior mesenteric artery which can be considered as the real limit of the mesopancreas.

Meckel's diverticulum: an exceptional cause of vesicoenteric fistula: case report and literature review.

UNLABELLED: Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract. It can cause complications in the form of ulceration, hemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae as noted in six previously reported cases. 66-year-old woman was presented with an enterovesical fistula. Exploratory laparotomy revealed a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum. Pathologic examination revealed that the diverticulum did not contain ectopic gastric or pancreatic tissue. The patient underwent a diverticulectomy and had an uneventful postoperative course. Unlike four of the six previously reported cases, our patient had no coexisting bowel or bladder disease occurring with her vesico-diverticular fistula. CONCLUSION: This is only the third reported case of a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum that did not contain ectopic tissue.

Huge desmoid tumor of the anterior abdominal wall mimicking an intraabdominal mass in a postpartum woman: a case report.

Desmoid tumors are benign neoplasms that most often arise from muscle aponeurosis and have been associated with both trauma and pregnancy. The etiology of desmoids has not been determined. We report the case of anterior abdominal wall desmoid tumor in a female patient with previous history of cesarean section. Preoperative ultrasound and computed tomography demonstrated a large mass mimicking a large hematoma or an intraabdominal mass. The tumor was removed by wide excision with safe margins. The abdominal wall defect was reconstructed with polypropylene mesh. Subsequent histology revealed a desmoid tumor. Desmoid tumors in females are often associated with pregnancy or occur post-partum. The reasons behind this association are unclear. The most common sites are in the abdominal muscles.

Histopathologic characteristics and short-term outcomes of colorectal cancer in young Tunisian patients: one center's experience.

INTRODUCTION: Colorectal carcinoma (CRC) is generally a disease of persons older than 40 years. Concerning younger patients, controversies still exist regarding features and prognosis of CRC. We performed this study to characterise CRC in young patients (≤ 40 years) as well as to evaluate short-term outcome in comparison with older patients (>40 years) with CRC. METHODS: Clinical and histopathological parameters of 40 patients aged 40 years or less were compared with 240 patients aged more than 40 years. RESULTS: In young patients, the minority suffered from hereditary cancer syndromes (0.4%). Furthermore, up to 87% of young patients denied any cancers in their families. Compared with older patients, young patients had more mucinous adenocarcinomas (32.5% vs. 11.5%; p=0.02), more venous invasion (p=0.021), more perineural invasion (p=0.028). For grading (p=0.42), lymphatic invasion (p=0.17) and tumor sites (p=0.46), no significant differences between young and older patients were found. Young patients had less post operative morbidity (p=0.039), less post operative mortality (0.029). Young and older patients had the same overall 1-year survival rates (p=0.24), and the same cancer-related 1-year survival rates (p=0.1). CONCLUSION: Tunisian patients present with colorectal cancer at a more advanced stage of the disease at younger ages compared to developed countries. The early detection of CRC followed by a sufficient oncologic treatment is crucial regardless of age. It is mandatory for all patients with suspicious symptoms to undergo early adequate diagnoses.

Inflammatory myofibroblastic tumor of the lung: a benign lesion with aggressive behavior.

Inflammatory myofibroblastic tumor is a rare solid tumor that most often affects children and young adults. They present as myofibroblastic cell proliferations accompanied by inflammatory cells made up mostly of plasma cells. Although benign, the tumor may be very aggressive locally. In this report we describe a 22-year-old woman with primary invasive myofibroblastic tumor of the left lower lobe leading to a left pneumonectomy.

Management of penetrating cardiac injuries in the Department of surgery, Mohamed Thahar Maamouri Hospital, Tunisia: report of 19 cases.

The goal of this paper is to discuss how to ameliorate the management of penetrating cardiac injuries in general surgery department. An algorithm for the initial assessment of penetrating injuries in cardiac box, based on our own experience, is presented. This was a retrospective study of 19 patients undergoing thoracotomy for penetrating cardiac injuries, managed in the department of general surgery of Nabeul-Tunisia, between 1994 and 2010. The mean age of patients was 25 years old. Sex ratio was 8,5. All patients had cardiac injury resulting from stab wounds inside of the pericardium. 42% of them were critically unstable, 21% had cardiac tamponnade. All these patients were quickly transferred to the operating room without any other investigations. 37% of patients were hemodynamically stable and underwent additional investigations. The management of penetrating cardiac injuries is possible in a general surgery department, but it requires a rapid prehospital transfer, a yet thorough physical examination along with efficient surgical management, all done in minimal time.

A wandering spleen presenting as a hypogastric mass: case report.

Wandering spleen is a rare condition characterized by the absence or underdevelopment of one or all of the ligaments that hold the spleen in its normal position in the left upper quadrant of the abdomen. It is an uncommon clinical entity that mainly affects children. Among adults it most frequently affects women of reproductive age, in whom acquired laxity of the splenic ligaments is usually the cause. Patients with a wandering spleen may be asymptomatic, present with a movable mass in the abdomen, or have chronic or intermittent abdominal pain because of partial torsion and spontaneous detorsion of the spleen. A 26-year-old woman was admitted to our hospital with vomiting and abdominal pain. Abdominal examination revealed a large ovoid hypogastric mass. A CT scan showed a wandering spleen in the hypogastric region. Exploratory laparotomy revealed an ischemic spleen. A total splenectomy was performed.