Impact of mental imagery on enhancing surgical skills learning in novice's surgeons: a pilot study.

OBJECTIVE: Mental imagery (MI) has long been used in learning in both fields of sports and arts. However, it is restrictively applied in surgical training according to the medical literature. Few studies have evaluated its' feasibility and usefulness. The aim of this study is to assess the impact of mental imagery on surgical skills learning among novice's surgeons. MATERIAL AND METHODS: In this pilot prospective randomized comparative study; we recruited 17 residents and interns of surgery education curriculum. They were all included in their first semester of the curricula. Two groups were randomly designed. Group (a) including "Mental Imagery" volunteers (n = 9) which benefited from a mental imagery rehearsal exercise prior to physical practice, while the control group (b) (n = 8) didn't underwent any MI process prior to surgery practice. Each participant of both groups was invited to perform an intestinal hand-sewn anastomosis on bovine intestine. Each procedure was evaluated and analyzed according to 14 qualitative criteria while each criterion was scored 0, 1 or 2 respectively assigned to the gesture was not acquired, gesture was performed with effort, or mastered gesture. The final score is 28 for those who master all 14 gestures. A non-parametric statistical comparison between the both studied groups was performed. RESULTS: Both groups of surgery students demonstrated equivalent age, sex ratio, laterality, and surgical experience. The mean overall score is significantly higher in the MI group (a) (17.78; SD = 2.42) compared to the control group (b) (10.63, SD = 2.85). However, advanced analysis of individual assessment items showed significant statistical difference between both groups only in 6 out of 14 assessed items. CONCLUSION: Indeed, mental imagery will not be able to substitute the traditional learning of surgery for novice surgeons; it is an important approach for improving the technical skills acquisition and shortening the physical learning.

[Cancer patient satisfaction survey in a Moroccan university hospital]. / Enquête de satisfaction des patients atteints de cancer dans un hôpital universitaire au Maroc.

OBJECTIVES: Assessment of patient satisfaction helps to guide hospital strategies concerning optimal patient management. The objective of this study was to evaluate the satisfaction of cancer patients hospitalised at Fez university hospital, to study the various components of satisfaction and to integrate the patient in quality of care improvement policies. METHODS: A prospective study was conducted in two voluntary wards of the hospital. An anonymous standardized questionnaire was administered to patients hospitalised for cancer surgery or treatment. RESULTS: 87.1% of patients reported that they were very satisfied with their hospitalisation, while 12.9% rated their stay as acceptable. 98.4% would recommend the hospital to their relatives. In contrast, 67.2% of patients surveyed considered that the cost of their stay was too expensive. CONCLUSION: The majority of items were declared as "Very satisfactory" by the patients. They represent a challenge to be maintained in the future: ward reception, comfortable accommodation, the behaviour and availability of staff, the doctor-patient relationship, respect for patient, the explanations provided concerning the health problem and treatment, psychological support and pain management. For items reported to be less satisfactory, recommendations should be implemented concerning the admissions office, administrative formalities on admission, the information provided at the time of discharge, quality of meals, development of nursing skills and dietary advice.

An inflammatory myofibroblastic tumor of the ampulla of Vater, an exceptional location: a case report.

Introduction and importance: Inflammatory myofibroblastic tumors constitute a group of mesenchymal tumors associated with inflammatory infiltration. They occur mainly in young patients. It is classified by the World Health Organization as a borderline neoplasm. They are observed in many organs, particularly the lungs. Digestive localization is rare, and localization into the ampulla of Vater has been reported once. Case presentation: We report the case of a 39-year-old patient who was admitted for cholestatic jaundice with right hypochondrium pain. Computed tomography and magnetic resonance imaging revealed a tumor at the biliopancreatic junction. A cephalic duodenopancreatectomy was performed, and a histological examination of the surgical specimen revealed an inflammatory myofibroblastic tumor of the ampulla of Vater. The postoperative evolution was without any complications. Clinical discussion: This is the second case of localization of an inflammatory myofibroblastic tumor in Vater's ampulla. The therapeutic approach is the complete excision of these inflammatory tumors, thus reducing the risk of local recurrence. In the literature, all cases of incomplete excision have resulted in recurrences. Conclusion: Inflammatory myofibroblastic tumors are rare. The diagnosis was based on histopathological findings and confirmed using immunohistochemical techniques.

Dermatofibrosarcoma protuberans of the anterior abdominal wall: case report and literature review.

Dermatofibrosarcoma protuberans (DFSP) is a rare and slowly growing cutaneous tumor with high risk of local invasion and recurrence. Here, we report a case of a DFSP of the anterior abdominal wall diagnosed in a 45-year-old woman. The clinical examination showed an indurated well-limited oval mass localized in the supra-umbilical level and measuring 5 cm by 3 cm. The histological finding of skin biopsy was consistent with the diagnosis of DFSP. A wide local excision was performed while respecting minimum safety margins of 3 cm. The primary closure was possible after advancing the subcutaneous adjacent tissue. The histological examination of the surgical specimen confirmed the DFSP diagnosis and determined safe microscopic margins. After 4 years of regular follow-up, no locoregional or distant recurrence was observed. We discuss through this case the diagnosis difficulties and the particularities of the abdominal wall localization.

Analysis of Molecular Pretreated Tumor Profiles as Predictive Biomarkers of Therapeutic Response and Survival Outcomes after Neoadjuvant Therapy for Rectal Cancer in Moroccan Population.

Pathologic features depending on tumor response to preoperative chemoradiotherapy are important to determine the outcomes in patients with rectal cancer. Evaluating the potential predictive roles of biomarker expression and their prognostic impact is a promising challenge. We reported here the immunohistochemical staining of a panel marker of mismatch repair protein (MMR), Ki67, HER-2, and p53. Additionally, identification of somatic mutations of KRAS, NRAS, and BRAF genes were performed by direct sequencing and pyrosequencing in pretreated biopsy tissues from 57 patients diagnosed for rectal cancer. Clinical features and pathological criteria for postneoadjuvant treatment surgical resection specimen's data were collected. Immunohistochemical expression and mutational status were correlated with therapeutic response, overall survival, and disease progression. The mean age of patients was 56 years. Seven (12.3%) out of 57 patients had a complete therapeutic response. Our analysis showed that when using complete therapeutic response (Dworak 4) and incomplete therapeutic response (Dworak 3, 2, and 1) as grouping factor, high p53 expression at the pretreatment biopsy was significantly associated to an incomplete response (p = 0.002). For 20 and 2 out of 57, KRAS and NRAS mutations were detected, respectively. The majority of these mutations affected codon 12. KRAS mutations detected at codon 146 (A146T, A146V) was associated with the appearance of recurrence and distant metastasis (p = 0.019). A high expression of HER-2 corresponding to score 3+ was observed in 3 pretreatment biopsy specimens. This class was significantly associated with a short relapse-free survival (p = 0.002). Furthermore, the high expression of Ki67 was moderately correlated with an older age (p = 0.016, r = 0.319). In addition, this shows that high p53 expression in the pretreatment biopsy was associated with an incomplete response in surgical resection specimens after neoadjuvant treatment, and a HER-2 score 3+ can be a predictive factor of distant metastasis and local recurrence. Larger, prospective, and more studies are needed.

Acute cecal volvulus: A diagnostic and therapeutic challenge in emergency: A case report.

INTRODUCTION: Cecal volvulus is an uncommon cause of intestinal obstruction due to an axial twist of the caecum, ascending colon and terminal ileum around the mesenteric pedicle. It is responsible for 1%-1.5 of all intestinal obstructions in adult. The clinical signs may be highly variables and can be responsible of delays in diagnostic and treatment. The delay in diagnosis leads to intestinal necrosis or perforation. The mortality ranges from 10 to 40% depending on the presence of a viable or gangrenous intestine. PRESENTATION OF CASE: A 64 year old woman admitted the emergency department for acute bowel obstruction. Clinical examination found typically acute bowel obstruction signs. Plain radiography showed dilated gas-filled segment of the colon in the left side of abdomen and volvulus of cecum was suspected. Enhanced abdominal CT scan confirmed the diagnosis. Emergency exploratory laparotomy was performed and confirmed the cecal volvulus. A manual untwisting of volvulus and a Caecopexy were performed. The patient subsequently recovered uneventfully and was discharged on postoperative day 3. DISCUSSION: The management of cecal volvulus requires prompt (emergency) diagnosis and prompt surgical intervention. Any delay in diagnosis may lead to intestinal necrosis or perforation and worsening the prognosis in patients who are generally elderly. Several authors reported a high mortality rate of cecal volvulus due to delay to diagnosis and surgical intervention. CONCLUSION: The low incidence of this condition needs a high index of suspicion and emergency surgical management. Despite significant progress in medical imaging, the preoperative diagnosis of cecal volvulus is very difficult. As a result, the treatment is often delayed.

[Total small bowel volvulus complicating common incomplete mesentery, an exceptional complication in adults: about a case]. / Volvulus total du grêle sur mésentère commun incomplet, une complication exceptionnelle chez l'adulte: à propos d'un cas.

Total small bowel volvulus complicating common incomplete mesentery is an arrest of rotation of the primary intestinal loop at 180°. The root of the mesentery is very short and the whole small intestine is located on the superior mesenteric artery axis. Patients are at very high risk of small bowel volvulus and enteromesenteric infarction. Acute volvulus requires emergency surgery; imaging must not delay surgery. Surgery is based on the untwisting of the volvulus (counterclockwise) after the assessment of intestinal viability. The intestine placed in the complete common mesentery position: the cœcum is situated in the right iliac region. We report the case of a 60-year old patient admitted with total small bowel volvulus on an incomplete common mesentery who underwent emergency surgery with favorable postoperative outcome.

Implication of Microsatellite Instability Pathway in Outcome of Colon Cancer in Moroccan Population.

BACKGROUND: Tumors with microsatellite instability (MSI tumors) have distinct clinicopathological features. However, the relation between these tumor subtypes and survival in colon cancer remains controversial. The aim of this study was to evaluate the overall survival (OS) in patients with MSI phenotype, in FES population. METHODS: The expression of MMR proteins was evaluated by immunohistochemistry for 330 patients. BRAF, KRAS, and NRAS mutations were examined by Sanger sequencing and pyrosequencing methods. The association of MSI status with a patient's survival was assessed by the Kaplan-Meier method and log-rank test. RESULTS: The mean age was 54.6 years (range of 19-90 years). The MSI status was found in 11.2% of our population. MSI tumors were significantly associated with male gender, younger patients, stage I-II, right localization, and a lower rate of lymph node and distant metastasis. The OS tends to be longer in MSI tumors than MSS tumors (109.71 versus 74.08), with a difference close to significance (P = 0.05). CONCLUSION: Our study demonstrates that MSI tumors have a particular clinicopathological features. The results of survival analysis indicate that the MSI status was not predictive of improved overall survival in our context with a lower statistical significance (P = 0.05) after multivariate analysis.

[Abdominal gunshot wounds: experiences in the Emergency Department at the Hassan II University Hospital in Fes, Morocco]. / Plaies abdominales par arme à feu: expériences des urgences CHU Hassan II, Fès, Maroc.

We report the case of a young couple, a 30-year old man and his 21-year old wife victim, after a family conflict, of shotgun shooting. Shotgun is allowed in Morocco during the game hunting season. Surgical exploration of both patients showed multiple lesions of the digestive tract as well vascular wound on the man's femoral artery causing hemorrhagic shock. The study of gunshot wounds is based on resulting tissues lesions which vary as a function of the different shooting parameters. The impact, the path and the found projectile allow detect the type of weapons and the shooting conditions. Gunshot injuries may be very different. They depend on: the weapon in question, the trajectory of the projectile in relation to the hit body, the shooting distance and, especially, the characteristics of the projectile. Contused wounds are most common, with very specific features. They are caused by a criminal act, a suicidal act or an accidental act.

[Left paraduodenal hernia: a rare cause of bowel obstruction]. / Hernie paraduodénale gauche: une cause rare d'occlusion intestinale.

We here report two cases of acute bowel obstruction. Emergency intervention showed left obstructive paraduodenal hernia causing volvulus with necrosis of the incarcerated intestinal loops in one patient who underwent one-time anastomosis resection and suffering but viable small bowel in the second patient treated by incarcerated intestinal loop reduction and obturation of the orifice of the hernial canal. We here highlight the diagnostic and therapeutic features of this rare condition.

[Volvulus of the cecum: a rare cause of intestinal occlusion: about two cases]. / Volvulus du cæcum: une cause rare d'occlusion intestinale: à propos de deux cas.

The cecum is the second part of the colon that is most commonly affected by the volvulus after sigmoid colon and before left corner and the transverse colon. This condition occurs in patients with abnormally mobile cecum. Volvulus is characterized by torsion or tilt. Clinically, it appears as bowel obstruction due to acute strangulation. Abdominal x-ray without treatment and abdominal CT scan are the radiological procedures of choice in the diagnosis of volvulus of the cecum. Treatment is based on emergency surgical excision of the cecum and of the terminal ileum. We report two cases of patients with volvulus of the cecum admitted to the emergency department with acute intestinal obstruction. In both patients, the diagnosis was confirmed by abdomino-pelvic CT scan and the treatment was based on ileocolic resection with immediate restoration of the intestinal continuity. The postoperative course was uneventful.

Fournier gangrene: rare complication of rectal cancer.

Fournier's Gangrene is a rare complication of rectal cancer. Its discovery is often delayed. It's incidence is about 0.3/100,000 populations in Western countries. We report a patient with peritoneal perforation of rectal cancer revealed by scrotal and perineal necrotizing fasciitis.

Left paraduodenal hernia: A rare cause of acute abdomen.

Paraduodenal hernia is a rare congenital anomaly that arises from an error of rotation of the midgut. The duodenum and the small intestine become trapped in a sac which is lined by the peritoneum, behind the mesentery of the colon, either to the right or left of the midline. It is therfore a rare and potentially life-threatening condition that can cause intestinal obstruction progressing to strangulation and perforation. We report a case of a 55-year-old patient presenting a left paraduodenal hernia diagnosed intraoperatively after being operated on in the emergency setting for acute abdomen. The small bowel was twisted upon its mesentery and was entrapped in a large left paraduodenal space. Fortunately, once the bowel was reduced from the paraduodenal space, the blood flow was reestablished and the small bowel resumed a proper functioning. The mouth of the sac was obliterated by suture opposition to the posterior wall. The patient's subsequent hospital course was uneventful, and he was discharged in satisfactory condition 4 days postoperatively.

Stromal tumor of the lesser omentum : a case report.

Gastrointestinal stromal tumors (GISTs) represent the majority of primary non-epithelial neoplasms of the digestive tract, most frequently expressing the KIT protein detected by immunohistochemical staining for the CD117 antigen. Extragastrointestinal stromal tumors (EGISTs), neoplasms with immunohistological features overlapping those of GISTs, are found in the abdomen outside of the gastrointestinal tract with no connection to the gastric or intestinal wall. We report the clinical, macroscopic and immunohistological features of an EGIST arising in the lesser omentum of a 58-year-old woman. This is a very rare location of intra abdominal stromal tumors.

Primary perivascular epithelioid cell tumor of the liver: new case report and literature review.

Perivascular epithelioid cell tumors (PEComas) encompass a group of rare mesenchymal neoplasms, which typically have a perivascular location with dual melanocytic and muscular differentiation. They are found in a variety of localizations, though lesions in the liver are exceedingly rare. Because of their rarity, the clinical, radiological and histological features of these tumors have yet to be established. This is why, it seems appropriate to report the observation of this rare hepatic tumor with a literary review including others published cases, assessing through it, clinicopathologic and radiologic features of all reported cases as well as their follow-up whenever possible. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1967094999126169.

A rare cause of intestinal obstruction: ileosigmoid knot.

Intestinal obstruction is common surgical emergency; ileosigmoid knot is a rare cause of intestinal obstruction (a loop ileum and sigmoid colon twisted around each other in a knot). We recorded a three cases in HASSAN II hospital in the last 3 years.

[Resectability evaluation in pancreatic cancer]. / Cancer du pancréas : bilan de résécabilité

Accurate staging of pancreatic cancer is essential in order to select patients, which are candidates for curative resection. Multidetector computed tomography is the best imaging for determination of pancreatic cancer loco regional and distal resectability. Endoscopic ultra sonography has complementary role in small tumours. It can guide regional lymph node puncture for accurate staging. Magnetic resonance with MR angiography can be helpful in determining vascular respectability of pancreatic cancer. The use of laparoscopy with laparoscopic ultrasound has been increased last years in order to avoid unnecessary laparotomy. Positron emission tomography may be useful tool for diagnosing occult metastatic disease. It is still in evaluation.

Anorectal avulsion: an exceptional rectal trauma.

Anorectal avulsion is an exceptional rectal trauma in which the anus and sphincter no longer join the perineum and are pulled upward. As a result, they ventrally follow levator ani muscles. We present a rare case of a 29-years old patient who was admitted in a pelvic trauma context; presenting a complete complex anorectal avulsion. The treatment included a primary repair of the rectum and a diverting colostomy so as to prevent sepsis. Closure of the protective sigmoidostomy was performed seven months after the accident and the evolution was marked by an anal stenosis requiring iterative dilatations.

Recurrent desmoid tumor of the abdominal wall.

Desmoid tumors most often occur in abdominal wall. Their tendency to recur lead to repeated operations which can make the abdominal wall reconstruction difficult. We report a 28-year-old female history. The patient was referred to our hospital for a recurrent desmoid tumor of the abdominal wall. The tumor was totally removed. The reconstruction was successful and the patient recovery was uneventful. Radical surgery still the mainstay of the desmoid tumors treatement. In abdominal wall location, the reconstruction can be a real challenge. Many procedures are discussed in literature. We used a double layer mesh covered by a fascial bepedicled flap. Taking into account their unpredictable behaviour and treatment complications, recurrent abdominal desmoid tumors can be managed simply and efficiently.