Umbrella review of the efficacy of perioperative immunonutrition in visceral surgery.

INTRODUCTION: Immunonutrition (IN) is used in major visceral surgery to reduce postoperative complications. This umbrella review (review of reviews) collects and analyses data on the efficacy of perioperative IN. METHODS: The review was conducted in accordance with PRISMA 2020 guidelines. Inclusion criteria were meta-analyses comparing IN with normal diet or isocaloric isonitrogenous feeding. The primary outcome was infectious complications. Secondary outcomes were overall morbidity, hospital length of stay and mortality. Methodological quality was evaluated using AMSTAR-2. Overlap and certainty of evidence (GRADE) were assessed. RESULTS: Twenty meta-analyses (MAs) were included in the umbrella review: eleven on various abdominal surgeries (one MA was considered twice) and eight on pancreatic, oesophageal, hepatic, or colorectal surgeries. Overall, IN was associated with significantly fewer postoperative infectious complications (OR 0.60 [0.54-0.65], random effect model) but with substantial heterogeneity (I2 = 64%), and less postoperative morbidity (OR 0.78 [0.74-0.81], I2 = 30.3%). Excluding three MAs with heterogeneity did not alter the results. The overlap between the MAs was slight, with a corrected covered area of 0.13. There was no significant difference in the timing of IN (preoperative, postoperative or perioperative). CONCLUSION: This umbrella review confirms the beneficial effect of IN in visceral surgery. Some practical questions remain unanswered: optimal timing of IN, in which surgical speciality it is best used, and its utility in enhanced recovery programmes. REGISTRATION IN PROSPERO: CRD42021255177.

Omentoplasty decreases deep organ space surgical site infection compared with external tube drainage after conservative surgery for hepatic cystic echinococcosis: Meta-analysis with a meta-regression.

INTRODUCTION: The rate of deep organ space/surgical site infection after conservative surgery for hepatic cystic echinococcosis (HCE) ranges from 12% to 26% with a post-operative mortality rate between 0% and 7.5%. This systematic review with meta-analysis aimed to investigate whether omentoplasty (OP) following conservative surgery for HCE leads to decreased rates of morbidity and mortality compared to external tube drainage ETD. PATIENTS AND METHODS: We identified 4540 articles through database searching. After verifying the inclusion and exclusion criteria, we retained eight studies for final analysis: two randomized controlled trials (RCT), one prospective comparative study and five retrospective comparative studies. The main outcome measure was organ space/surgical site (OS/SS) morbidity that was limited to "deep organ space/surgical site infection (Deep OS/SSI) with or without re-operation". RESULTS: The eight studies reported results for deep OS/SSI (6/374 (OP) and 60/403 (ETD), respectively). There were statistically significantly less deep OS/SSI with OP (vs. ETD) OR=0.17 95%CI [0.05, 0.62] (P=0.007). A random-effect meta-regression, including the eight studies, showed an interaction in favor of OP. There were also statistically significant less biliary leakage±fistula and overall morbidity in OP compared to ETD. On the other hand, no statistically significant difference was found concerning deep bleeding, mortality and recurrence between these two groups. CONCLUSION: This meta-analysis with a meta-regression showed that there were statistically significant less deep OS/SSI, biliary leakage±fistula and overall morbidity in OP compared to ETD.

Acute celiac trunk thrombosis revealed by biliary peritonitis.

Acute thrombosis of the celiac trunk is a very uncommon condition, which is a life-threatening emergency. The clinical presentation is highly variable depending on the extent of the ischemic territory. We report a case of biliary peritonitis related to an acute thrombosis of the celiac trunk. This case highlights the role of abdominal computed tomography in the diagnosis of acute upper abdominal pain.

Supra-vesical hernia presenting as intestinal obstruction.

Supra-vesical hernia is a rare form of internal hernia. It often presents as bowel obstruction. Diagnosis is increasingly established pre-operatively because of the broader application of computed tomography in cases of intestinal obstruction.

[Bacteriological profile and antibiotic treatment of postoperative peritonitis]. / PROFIL BACTERIOLOGIQUE ET ANTIBIOTHERAPIE DES PERIONITES POST OPERATOIRES.

During the postoperative peritonitis (PPO) the main stay of treatment is the choice of probabilistic antibiotictherapy, it is also the main prognostic factor The aim of our study was to identify anappropriate antibiotic protocol to the current ecology of our unit. It was a retrospective study including 102 patients over a period of 09 years from 1 January 2003 to 3O November 2011. All of them are supported for the treatments off postoperative peritonitis in surgical intensive care unit of a service of general surgery a university hospital Charles Nicolle of Tunis. All bacteriological data (germs and sensitivity), and the terms of therapeutic modality for the empirical antibiotic therapy were listed. The incidence of PPO was Q90%.The average age of our patients was 57 +/- 18 years. The sex ratio was 1.08. One hundred and seven (107) microorganisms were isolated from 72 samples (44 microbial mono, 28 multi microbial). The frequency of gram-positive cocci (GPC) was 16.82%, the Gram-negative bacilli (BGN) was 82.2%. The Enterobacteriaceae have proved particularity resistant. Thus, the ampicillin resistance was 87.14%, that the C3G was 33.80%, the Piperacillin to Tazobactam combination, was 36.5% and that the association Ticarcillin-clavulanic acid was 43.6%. For non-fermenting BGN, Pseudomonas aeruginosa was sensitive to ticarcillin in 80% of cases, to ceftazidime in 66.6% of cases, PiperacillinTazobactam--in 71.43% of cases, imipenem in 85 72% of cases, colimycin in 100% of cases and Amiklin in 71.43% of cases. For CGP, enterococci were resistant to ampicillin in 50% of cases and vancomycin in 0% of cases. The majority of patients received triple antibiotic therapy (59.8%) or combination therapy (34.3%). The main associations were: cefotaxime + Gentamycin + Metronidazole (35.2%), Amikacin Imipenem + + Metronidazole (12.7%), Imipenem + amikacin (9.8%), Piperacillin / Tazobactam + amikacin (9.8%) + amikacin and ertapenem (5.88%). Probabilitic antibiotic therapy was addapted in 69.4% of cases. The average duration of the prescribed antibiotic was 11 days +/- 6 days. The mortality rate was 39.2%, was 32.23 days. The isolated microorganisms are those of the intestinal flora which is generally changed and thus the bacteria are selected then are multidrug resistant. Prescribing antibiotics should consider probabilistic. Thus, Imipenem-Amiklin combination seems appropriate to our ecology. This empiric antibiotic therapy is secondarily adapted to the results of susceptibility testing to limit the selection of multi-resistant organisms.

[Postoperative peritonitis: pronostic factors of mortality]. / PERITONITES POST OPERATOIRES: FACTEURS PRONOSTIQUES DE MORTALITE.

The postoperative peritonitis (POP) remains formidable conditions due to a high mortality rate of between 20 and 80%. The purpose of this study is to identify risk factors for mortality. This study is a retrospective, descriptive analysis carried out over a period of 09 years (1/1/2003 - 30/11/2011) and interesting 102 patients supported for POP following general surgery. Achieved in department of General Surgery B Charles Nicolle hospital Tunis. The parameters measured included epidemiological data, data related to the Initial Surgical Intervention and reoperation for POP, terms of management and evolution. Bacteriological data were also seized. The incidence of POP was 0.90%. The average age of our patients was 58 +/- 19 years with a sex ratio of 1.08. Forty-seven percent of our patients belonged to the ASAII class. The initial operation was performed urgently in 49 patients (48%) with a majority belonging to the class II Altemeier (49.01%). Colorectal pathology (373%) and hepatobiliay (176%) were the most frequent reasons for the initial intervention. The frequency of clinical signs were fever (75.5%), hypothermia (6.9%), abdominal pain (725%), abdominal distension (46.1%), productive gastric aspiration (30.4%), abdominal defense (25.5%), externalizing the digestive fluid (25.5%), vomiting (19.6%), diarrhea (12.7%), tachycardia (569%), oliguria (42.2%), respiratory failure (40.2%), hypotension (35.3%), neuropsychiatric disorders ( 23.5%) and jaundice (69%). The treatment period was 2.95 +/- 3.16 days. The surgical recovery time was 78 days +/- 5.66. At the time of reoperation, the APACHE II score was 8.43 +/- 6.26 and 25.1 +/- MPI score 8.53. The POP was generalized in 52.9% of cases with purulent peritoneal fluid in 51% of cases. The most common cause was the dropping of the anastomosis (59.8%). Empirical antibiotic therapy was appropriate in 69.44 % of cases. The mortality rate was 39.2%. Multivariate analysis using multiple logistic regression identified the following factors as independent mortality factors: Age > or = 60 years (RR = 6.089), multiple organ failure (RR = 18.019), non-appropriate empiric antibiotic therapy (RR = 6.541), stercoral aspect of peritoneal fluid (RR 6.412). Despite a low frequency, the POP are burdened with a high mortality rate. The improved prognosis requires early diagnosis in order to allow a appropriate load medicosurgical support before the installation of multiorgan failure syndrome. Among the independent factors associated with mortality that we have identifed, the not adapted empiric antibiotic therapy is the main factor on which we can act.

The effect of 8-weeks proprioceptive exercise program in postural sway and isokinetic strength of ankle sprains of Tunisian athletes.

OBJECTIVE: Our objective is to investigate the effects of proprioceptive exercises rehabilitation on isokinetic strength and postural balance in athletes with sprain ankle. MATERIALS AND METHODS: The ankles of 16 subjects were tested: eight in the functional instability (FI) group and eight non-injured (NI) subjects in the control group. Subjects were asked to take part in a testing session. The test order for the postural stability and isokinetic strength tests was randomized to avoid learning or fatigue effects. The testing session started with a 5-minute warm-up. Subjects were then instructed to perform several lower body flexibility exercises. The test procedure consisted in static assessments, where single-limb (right and left) stance postural stability was assessed. Three practice trials were allowed for each subject. The assessment quantifies postural sway velocity while the athlete stands calmly on one foot on the force plate, for each leg. They were asked to stand as still as possible for 30s, upper limbs along the body. The subjects were requested to maintain balance with eyes open and then with the eyes closed on the firm surface. The sway velocity (in degrees per second) is given for all trials. Subjects were allowed a 1-minute rest between tests. The regime of isokinetic evaluation of dorsi-plantar flexions is concentric, with three successive speeds: slow (30°/s, reps 5), average (60°/s, reps 10), and fast (120°/s, reps 15), according to the protocol established by European Group for the development and the isokinetic research and the procedural guidelines. Relative moment of strength and times of acceleration and deceleration were calculated for each set of isokinetic testing repetitions per body side, muscle group and testing speed. RESULTS: The results of tests-retest and between both groups (injured vs. healthy) show that after eight weeks of proprioceptive work, significant increase of maximal strength, decrease in times of acceleration and deceleration at the level of plantar flexors and better stability of the injured limb at slow and average (P<0.05). For the healthy limb, improvements varying from 1 to 39% were obtained between test and retest on all the variables. However, these variations were not statistically significant. CONCLUSION: Proprioceptive training exercises can effectively stabilize an unstable ankle above for muscular and postural control. However, 8 weeks does not assess whether we have achieved maximum effect. In addition, we do not know to what extent these effects will continue over time. It would be interesting to later re-evaluate the athletes for the effect of this treatment, which is based on a proprioceptive training program on a year or more.

ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy.

BACKGROUND: Several studies seem to indicate at least a 2-fold increase in bile duct injuries (BDI) since the inception of laparoscopic cholecystectomy. Moreover, injuries seem to be more proximal, seem to be revealed earlier, are expressed by leaks more often than by strictures, are repaired more frequently by nonspecialists (either during the index operation or soon after), and appear to be more often associated with loss of substance and ischemia. The plethora of prior classifications probably attests to the evolving clinical spectrum, the mounting wealth of ever-increasing diagnostic methods, and an acknowledgment of insufficiencies or lack of data in earlier classification reports. Previous attempts at uniformity remain incomplete. The purpose of this study was to devise a nominal classification, combining all existing classification items, taking into account the changing pattern of BDI. METHODS: Extensive bibliographic research, analysis of each category within the individual classifications combined into one uniform classification. RESULTS: Fifteen classifications were retained. All items were integrated into the European Association for Endoscopic Surgery (EAES) classification, using semantic connotations, grouped in three easy-to-remember categories, A (for anatomy), To (for time of), M (for mechanism): (1) the anatomic characteristics of the injury: NMBD for non-main bile duct or MBD for main bile duct (followed by a number 1-6, corresponding to the anatomic level on the MBD), followed by Oc (for occlusion) or D (division), P (partial) or C (complete), LS (loss of substance), VBI (vasculobiliary injury in general), and whenever known, the vessel; (2) time of detection: Ei (early intraoperative), Ep (early postoperative) or L (late); and (3) mechanism of injury: Me (mechanical) or ED (energy-driven). CONCLUSIONS: The EAES composite, all-inclusive, nominal classification ATOM (anatomic, time of detection, mechanism) should allow combination of all information on BDI, irrespective of the original classification used, and thus facilitate epidemiologic and comparative studies; indicate simple, appropriate preventive measures; and better guide therapeutic indications for iatrogenic BDI occurring during cholecystectomy.

[Ileocolic intussusception from metastatic renal cell carcinoma]. / Localisation iléale d'un carcinome à cellules rénales révélée par une invagination iléo-cæcale.

The lung, the liver, the bone tissue and the brain are the most frequent sites for renal cell carcinoma metastasis. Small bowel metastasis from renal cell carcinoma is rare, with only few cases published. We report the case of ileal metastasis from operated kidney cancer revealed by ileocolic intussusception and causing intestinal obstruction in a 32-year-old woman.

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe. METHODS: A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference. RESULTS: A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI. CONCLUSIONS: Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Validation of the Lacaine-Huguier predictive score for choledocholithiasis: prospective study of 380 patients.

UNLABELLED: The aim of this study was to validate the Lacaine-Huguier score for the prediction of asymptomatic choledocholithiasis. METHODS: The study enrolled patients over age 18 with symptomatic chronic or acute calculous cholecystitis. Patients already known to have common bile duct stones (CBDS), as evidenced by symptomatic presentation with acute cholangitis or acute gallstone pancreatitis, were not included. We compared the group of patients with a score less than 3.5 versus those with a score greater or equal to 3.5; we also compared the group of patients who underwent intraoperative cholangiography (IOC) with those who did not undergo IOC. The negative predictive value of the Lacaine-Huguier score was calculated. RESULTS: We note that 308 women and 72 men were consecutively enrolled between February 2008 to March 2009; the average age was 51±16.4 years. The score was less than 3.5 in 154 patients (40.5%). IOC was only performed in 135 of the 226 patients with a score greater or equal to 3.5; reasons for this included a very narrow cystic duct in 67 cases, preoperative miscalculation of the score in nine cases, a technical problem in eight cases, an unspecified reason in four cases, contraindication due to pregnancy in two cases, and intraoperative difficulties in one case. CBDS were detected by IOC in 18 cases. Performance of IOC lengthened the median operative time by 20 minutes. The median follow-up was 8 months (range: 0-30 months). Eleven patients were lost to follow-up (2.9%), six of these had a score less than 3.5. Two patients had residual common bile duct (CBD) stones, one of whom had a score less than 3.5. The negative predictive value was 99.4% (95% confidence interval (CI 95%)=[98-100%]). The risk of leaving a stone in the CBD was 0.6%. When data was analyzed according to the worst case scenario, the negative predictive value became 95.5% (CI 95%=[92-99%]) with a risk of residual CBDS of 4.5%. CONCLUSION: This study confirmed the validity of the Lacaine-Huguier score. When the score is less than 3.5, the surgeon can refrain from performing IOC with a risk of asymptomatic residual CBDS ranging from 0.6% to 4.5%.