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.

Segmental branching pattern of the left portal vein: Anatomical characteristics and clinical implications.

The existing knowledge on anatomy of segmental branches of left portal vein (LPV) is limited. This study aims to describe the surgical anatomy and variations of LPV and its segmental branching pattern. Forty fresh cadaveric liver dissections were performed. The dissection of LPV was carried out from its emergence at the level of the portal vein bifurcation to its segmental branches penetrating the left hemiliver. LPV characteristics, the number, and situation of its segmental branches were recorded. LPV comprises two portions: a 28 ± 6.7 mm-long transverse portion (TPLPV) and a 34.9 ± 4.4 mm-long umbilical portion (UPLPV). Mean number of LPV branches to segments I, II, III, and IV was 2 ± 1 (1-6), 2 ± 1 (1-4), 2 ± 1 (1-5), and 8 ± 2 (4-14), respectively. A single large vein supplied segment II in 90% of the cases. Segment III constantly had one vein arising from the left horn of UPLPV with mean diameter of 5.9 ± 1.6 mm. Most of the veins to segment IV took origin from the right horn of UPLPV with a mean number of 5 ± 2 (2-8). Segmental veins arising from UPLPV and TPLPV and supplying segment IV were present in 90 and 45% of the cases respectively. Segmental veins arising from LPV are often multiple and variable in position. Detailed knowledge of these veins is mandatory in order successfully perform anatomical liver resections or monosegment graft harvest for pediatric liver transplantation. Clin. Anat. 31: 1122-1128, 2017. © 2017 Wiley Periodicals, Inc.

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.

Pre-existing renal lesions revealed after renal trauma, Difficulties in diagnosis and accountability: About 14 cases.

OBJECTIVE: Pre-existing renal lesions (PERL) may interfere with the patho-physiology of trauma, alter the radiographic imaging and influence the therapeutic approach. The aims of this study were to record the PERL found incidentally during blunt renal trauma, to specify the place for effective conservative management and to determin the estimated partial permanent disability (PPD). PATIENTS AND METHODS: The medical records of 14 patients with PERL and blunt renal trauma were reviewed. In each patient, pre-existing renal abnormalities, clinical symptoms, CT scan study findings, associated injuries, therapeutic approach, the accountability criteria and the estimated PPD were recorded. RESULTS: There were 11 men and 3 women with a mean age of 35,6 years (range 19-66 years). Renal trauma was due to a traffic accident in 8 patients. Renal damage appeared to be disproportionate to the severity of the trauma (minor trauma). They had a lower rate of associated trauma to other abdominal organs (four patients only). Urinary stones were present in 5 patients, pelvi-ureteric junction obstruction in 3, horseshoe kidny in 3, ectopic kidney in 2 and upper urinary tract carcinoma in one case. Early nephrectomy was required in three cases for hemodynamic instability. Ureteral stenting was indicated in 3 cases. Six patients were operated later because of their underlying renal pathology. A conservative treatment was possible only in 7 of cases. The PPD related to renal trauma varide from 0 to 13% in all cases. CONCLUSION: PERL may complicate a negligible renal trauma while in some cases they may be of vital importance for the patient's final outcome. The imaging findings are crucial but may be confusing. The therapeutic approach is, to a large extent, dependent on the type of PERL and the severity of damage, and is often conservative in the hemo-dynamically stable patient. Accountability link may be difficult to establish and the PPD depends on the PERL and the renal injuries severity. FUNDING: We have no involvement with funding in this case. Ethical approval: Not required Conflicts of interest: None.

Anatomical variations of renal venous vascularisation. A study of 71 three-dimensional kidney endocasts.

BACKGROUND: A better understanding of the anatomy of the renal vein and its relationship with the arterial and excretory systems can prevent intra operative complications. METHODS: Three-dimensional endocasts of intrarenal vessels and renal collecting systems were obtained from fresh cadavers, by injecting a polyester resin coloured with different pigments. A total of 71 endocasts were studied: 37 right kidneys and 34 left kidneys. RESULTS: Renal vein was unique in 88% of cases and double in 11% of cases. It was formed in 52% of cases by 3 trunks. Intrarenal veins anastomosed together to form 2 levels of arcades in 28% of cases and 3 levels in 71% of cases. The venous drainage of the upper pole was provided by two anterior and posterior plexus in 38% of cases, and by a single anterior plexus in 61% of cases. In 22% of cases, the venous drainage of the lower pole was provided by both an anterior and a posterior plexus, and in 77% of cases, there was only an anterior plexus. Renal artery was posterior to the vein in 66% of cases. It was anterior to the vein in 29% of cases, and located directly above it in 4% of cases. In 60% of cases, we noted a close relationship between the anterior surface of the ureteropelvic junction and the lower branch of the renal vein. CONCLUSION: Venous vascularisation of the kidney appears to be variable and its relationship with the arterial and the excretory systems may be complex.

Hydatid cyst of the ilium: A case report.

INTRODUCTION AND IMPORTANCE: Hydatid cyst is a common parasitic disease in endemic countries. It frequently occurs in the liver and lungs. Ilium involvement is extremely rare. We report the case of a 47-year-old man presenting with a hydatid cyst of the left ilium. CASE PRESENTATION: A rural 47-year-old patient, presented with pelvic pain and limping on walking for six months. He had a pericystectomy 10 years prior for a hydatid cyst of the left liver. A pelvic computed tomography scan showed an osteolytic remodeling of the left iliac wing associated with a large multiloculated cystic mass fusing along the left ilium. The patient had partial cystectomy and curettage of the ilium. The postoperative course was uneventful. CLINICAL DISCUSSION: Hydatid cysts of the bone are exceptional but aggressive due to the absence of a pericyst limiting the extension of the lesions. We report a rare case of a patient presenting with a hydatid cyst of the ilium. The prognosis is poor even in patients who undergo extensive surgical treatment. CONCLUSION: Early and adequate management can improve the prognosis. We highlight the importance of conservative treatment consisting of partial cystectomy with curettage of the bone to avoid morbidity related to radical surgery.

Leiomyoma of the esophagus: A case report and review of the literature.

INTRODUCTION: Benign tumors represent less than 1% of esophageal neoplasms. Esophageal leiomyoma is a very rare tumor that arises from mesenchymal tissue. We present here a case of leiomyoma of the esophagus which was revealed by dysphagia and vomiting that was treated by surgical enucleation. PRESENTATION OF CASE: This report illustrates the case of a female who presented with dysphagia and vomiting. Imageology demonstrated an esophageal mass which was treated with surgical enucleation. Histopathology confirmed the diagnosis of leiomyoma. CLINICAL DISCUSSION: Benign esophageal tumors are rare. Leiomyoma commonly presents as a single lesion in the middle or lower third of the esophagus. Leiomyomas located in the proximal and middle third of the esophagus can be operated on by right thoracotomy. Surgical treatment varies from enucleation to esophageal resection depending on the size and location of the mass. In our case, the tumor was enucleated by a right posterolateral thoracotomy. CONCLUSION: Esophageal leiomyoma is a benign and generally asymptomatic tumor. Surgery is the pillar of treatment. Enucleation should be performed whenever possible to avoid esophagectomy and thus decrease morbidity and mortality.

Acute Gangrenous Cholecystitis: Proposal of a Score and Comparison with Previous Published Scores.

BACKGROUND: Gangrenous cholecystitis (GC) is a particularly severe form of acute cholecystitis (AC) and is associated with an increased risk of postoperative morbidity and mortality. Recent reports show that surgeons are remarkably unsuccessful in diagnosing GC. METHODS: We conducted a retrospective study involving 587 patients with AC. Logistic regression analysis was used to identify independent predictive factors of GC. 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 population. We validated 2 previously published scoring models. RESULTS: Six independent predictive factors of GC were identified: [3-]4 ASA score, temperature, duration of symptoms, WBC, male gender, and pericholecystic fluid. A predictive score of GC was established based on these independent predictive factors. Sensitivity was 81.4%; specificity was 70%. The AUC of this clinicoradiological score was 0.83. The AUC of our score was higher than that of the first published score (the AUC was 0.75 in the original report and 0.78 in the validation model using our dataset) and that of the second published score (the AUC was 0.77 in the original report and 0.72 in the validation model using our dataset). CONCLUSIONS: The AUC of our score exceeded 0.80, indicating that this score can help in diagnosing patients with GC, and thus in prioritizing these patients for surgery or choosing the adapted technique of drainage in critically ill patients.

C-reactive Protein Is the Best Biomarker to Predict Advanced Acute Cholecystitis and Conversion to Open Surgery. A Prospective Cohort Study of 556 Cases.

BACKGROUND: White blood cell levels (WBC) is the only biologic determinant criterion of the severity assessment of acute cholecystitis (AC) in the revised Tokyo Guidelines 2018 (TG18). The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WBC for the severity of AC, and the risk for conversion to open surgery and to determine their diagnostic cutoff levels. METHODS: This was a prospective cohort study. Over 3 years, 556 patients underwent laparoscopic cholecystectomy for AC. Patients were classified into two groups: 139 cases of advanced acute cholecystitis (AAC) (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 cases of non-advanced acute cholecystitis (NAAC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables (WBC, CRP, and neutrophil-to-lymphocyte ratio (NLR)) were statistically significant in predicting AAC and conversion to open surgery. RESULTS: On multivariable logistic regression analysis, male gender (OR = 0.4; p = 0.05), diabetes mellitus (OR = 7.8; p = 0.005), 3-4 ASA score (OR = 5.34; p = 0.037), body temperature (OR = 2.65; p = 0.014), and CRP (OR = 1.01; p = 0.0001) were associated independently with AAC. The value of the area under the curve (AUC) of the CRP (0.75) was higher than that of WBC (0.67) and NLR (0.62) for diagnosing AAC. CRP was the only predictive factor of conversion in multivariate analysis (OR = 1.008 [1.003-1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in terms of conversion. CONCLUSION: CRP is the best inflammatory marker predictive of AAC and of conversion to open surgery. We think that our results would support a multicenter-international study to confirm the findings, and if supported, CRP should be considered as a severity criterion of acute cholecystitis in the next revised version of the Guidelines of Tokyo.

Should acute cholecystitis be operated in the 24 h following symptom onset? A retrospective cohort study.

BACKGROUND: Early laparoscopic cholecystectomy is the gold standard for management of acute cholecystitis (AC). Nevertheless, the definition used for early phase remained unclear. We aimed to compare the clinical outcome and cost of immediate (patients undergoing laparoscopic cholecystectomy within 24 h following symptom onset) versus early laparoscopic cholecystectomy (patients managed 25-72 h following symptom onset) for acute cholecystitis. METHODS: A retrospective analysis was performed. The outcomes of 143 patients undergoing laparoscopic cholecystectomy within 24 h (ICG) were compared to 350 patients managed 25-72 h following symptom onset (ECG) for acute cholecystitis. RESULTS: There were significantly more diabetic patients in the early laparoscopic group (ECG). All other characteristics were comparable (demographic, clinical, biologic and ultrasonographic characteristics) between the two groups. The rate of conversion to open surgery was significantly higher in the ECG. Overall postoperative morbidity and specific morbidity did not differ significantly between the groups. Total hospital stay was longer in the ECG. Direct medical costs were higher in the ECG. CONCLUSIONS: Laparoscopic cholecystectomy, for acute cholecystitis, during the first 24 h of onset of symptoms, significantly reduced conversion to open surgery and total hospital stay without increasing postoperative complications.

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.

[True aneurysm of the common hepatic artery: a case report]. / Anévrysme vrai de l'artère hépatique commune: a propos d'une observation.

We report a case of hepatic artery aneurysm suggested by the appearance of epigastric mass. The diagnosis was confirmed by doppler sonography and helical CT. Surgical excision of the aneurysm without vascular reconstruction was carried out.

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.

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.

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.

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.