Early laparoscopic cholecystectomy for acute cholecystitis: should we operate beyond the first week?

BACKGROUND: The deadline for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is the subject of much debate. The aim of this study was to assess outcomes of ELC in patients with more than 7 days of symptoms. METHODS: It is a retrospective analysis of 564 patients having undergone ELC for ACC between January 2003 and June 2021. Patients were divided into two groups according to the timing between the onset of symptoms and surgery: group 1 (G1), within the first 7 days of symptoms, and group 2 (G2) after day 7 of symptoms. RESULTS: Apart from a longer operative time (G1 80 min vs. G2 90 min; p = 0.016), there were no significant differences regarding conversion rate (G1 14.5% vs. G2 13.2%; p = 0.748), both intra- and postoperative complications, mainly bile duct injuries (G1 0.2% vs. G2 0%; p = 1) and bile leakage (G1 1.2% vs. G2 0%; p = 1) and postoperative length of stay (G1 2 days [1-3] vs. G2 2 days [1-4]; p = 0.125). CONCLUSION: Early laparoscopic cholecystectomy could be proposed for patients with acute calculous cholecystitis even beyond 7 days of symptoms.

Gastric Adenocarcinomas in Central Tunisia: Evolution Specificities through Two Decades and Relation with Helicobacter pylori.

INTRODUCTION: In developed countries, authors have reported variations over time in the seat and histological type of gastric adenocarcinomas, which were explained by Helicobacter pylori infection (HPI) incidence changes. In North-African countries and the Arabic world, epidemiological changes in gastric adenocarcinomas are still unknown. Our study aims to explore and to describe those changes in central Tunisia. MATERIALS AND METHODS: This is a retrospective observational and descriptive study including 876 cases based on the National Central Tunisian Register of Cancers over a period of 21 years. Two groups were formed and compared (group A: 337 patients from 1995 to 2005; group B: 539 patients from 2006 to 2015). RESULTS: HPI decreased from 32.6% in group A to 11.2% in group B (p < 0.05). Signet ring cell carcinomas increased in 2 decades from 14% in group A to 36% in group B (p < 0.05). Proximal cancers were 16.61% in group A and increased to 19.66% in group B (p = 0.3). Total gastrectomy rate was 10.4% in group A versus 23.2% in group B (p < 0.05). CONCLUSION: This study has shown a significant increase of signet ring cell carcinomas with a simultaneous decrease in HPI in the last decade in central Tunisia.

Observance of the practice of digital rectal examination. Survey of general practitioners in East-central Tunisia.

INTRODUCTION: Digital rectal examination (DRE) is a simple gesture, used for diagnosis of several diseases. However, some general practitioners (GPs) are practicing it less and less often. AIM: To estimate the rate of unrealized DRE and to analyze the factors preventing threir achievement. METHODS: This is a prospective observational study conducted among 105 GPs practicing in Sousse. We used a pre-established pre-tested and self-administered questionnaire. RESULTS: We identified 551 DRE that were indicated but unrealized. There was a significant influence between the non-realization of DRE on the one hand, and on the other hand: the lack of experience; the closeness of the specialist; the lack of training and the lack of conviction of the importance of this examination. Embarrassment during the realization of the DRE was felt in 69.3% of cases. Factors associated with this embarrassment were: female practitioner; the young age of the practitioner; the rural practice and the nature of internship placements. CONCLUSION: Although it is a simple and inexpensive gesture, the DRE remains neglected by many physicians. Several factors appear to influence the achievement of the DRE. Ongoing continuing medical education seems necessary, especially as we found a lack of belief in the importance of this examination.

Giant staghorn common bile duct calculus.

Background - Stones in common bile duct are defined as 'large' if they are more than 15 mm in size. There are very few reports which describe a giant stone measuring 5 cm or more and exceptionally a staghorn calculus in the common bile duct. Purpose - The purpose is to report a new rare case of giant staghorn gallstone and discuss the diagnostic approach and therapeutic possibilities. Case report - We report a case of a giant staghorn common bile duct calculus in a 65-year-old patient. Its removal required 2 operations and an endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy. Conclusion - Lithiasis of the common bile duct is considered to be a benign, but may sometimes be complicated and time-consuming. Staghorn calculi are very rare in the biliary tract. We found only two published reports of staghorn common bile duct calculi.

Early versus delayed laparoscopic cholecystectomy for lithiasic acute cholecystitis during emergency admissions. Results of a monocentric experience and review of the literature.

BACKGROUND: It is established that the standard treatment for lithiasic acute cholecystitis is the laparoscopic cholecystectomie. However, the question of the timing of cholecystectomy remains controversial. AIM: To compare early laparoscopic cholecystectomies (within 72 hours of symptom onset) and delayed laparoscopic cholecystectomies (beyond 72 hours) for lithiasic acute cholecystitis in terms of intra-operative difficulties and post-operative complications. METHODS: The patients operated on for acute cholecystitis, between January 2007 and December 2012, were included in a retrospective study. They were divided into two groups based on whether surgery was performed before (group A) or after (group B) 72 hours after the onset of symptoms. We conducted a comparison between the two groups. RESULTS: The two groups were comparable in terms of background, clinico-biological presentation, and radiological findings. The average time of surgery was 111.6 hours after symptom onset.  Duration of surgery was significantly longer for group B (97 minutes versus 82.17 minutes, p = 0.003). There was more conversion in group B than in group A, without significant difference (20% versus 11.6%, p = 0.14). There were no deaths in our series. Specific post-operative complications were comparable between the two groups (wound infection: 3 (B) versus 1 (A), biliary fistula: 8 (B) versus 0 (A), p = Non significant). The post-operative hospital stay was significantly longer in group B (3.34 days versus 1.84, p <10-3). CONCLUSION: In case of early laparoscopic cholecystectomy, the conversion rate and post-operative morbidity are comparable to the delayed treatment of acute cholecystitis. But the early surgery can reduce the cost of care, the duration of surgery and the hospital stay. Key-words : Lithiasic acute cholecystitis ; Laparoscopic cholecystectomy.

Upper digestive stenosis due to a hydatid cyst of the liver.

UNLABELLED: The complications of the hydatid cyst of the liver are dominated by infection and rupture. The compression of adjacent organs (mainly the inferior vena cava, the portal vein and the bile ducts) can be seen, when the cyst is located in the dome, in the hilum or within the hepatic parenchyma. Upper digestive stenosis by compression of the duodenum by the hydatid cyst is an exceptional complication. CASE REPORT: A 63 year-old patient had, for two months, upper digestive stenosis associated with a sensation of weight in the right hypochondrium. Digestive endoscopy showed an extrinsic compression of the second portion of the duodenum. Biopsies were negative. Abdominal CT showed up a hydatid cyst in the segment VI of the liver, adhering to the duodenum, with an exo-vesiculation compressing it. The patient was operated on: There was a hydatid cyst of the right lateral sector compressing the duodenum. A partial intralamellar pericystectomy was performed. CONCLUSION: Hydatid cyst of the liver, a parasitic disease described as benign, may give mechanical complications related to compression of adjacent organs (especially the bile ducts and veins). Compression of the digestive tract is exceptional. This is due to the proximity of the cyst to the duodenum and the thickness of the cyst wall.

Ansa pancreatica: an anatomic variation and a rare cause of acute pancreatitis.

INTRODUCTION: The ansa pancreatica is a rare anatomic variation of the pancreatic ducts. It is a communication between the main pancreatic duct (Wirsung) and the accessory pancreatic duct (Santorini). Recently, the ansa pancreatica has been considered as a predisposing factor in patients with idiopathic acute pancreatitis. CASE REPORT: \We report a case of non-alcoholic and non-biliary acute pancreatitis, in a 53-year-old patient. An ansa pancreatica was discovered in a post-operative cholangiography. CONCLUSION: A pancreatic duct variation, as the ansa pancreatica, can be diagnosed during a severe acute pancreatitis. It is still not clear whether the presence of these two pathologies is a coincidence or if the ansa pancreatica is the cause of the acute pancreatitis. New studies are necessary to clarify these points.

Early laparoscopic cholecystectomy for acute cholecystitis: Does age matter?

AIM: Advances in laparoscopic surgery and perioperative care have improved the prognosis of operated patients, especially the oldest among them. This study aimed to assess the outcomes of early laparoscopic cholecystectomy for acute calculous cholecystitis in older adult patients. METHODS: A retrospective analysis was carried out of 567 patients who underwent early laparoscopic cholecystectomy for acute calculous cholecystitis between January 2003 and July 2021. The outcomes of older adult patients (≥ 75 years) were compared with those of younger patients. RESULTS: The older adult group had significantly more patients with an American Society of Anesthesiologists score ≥3 (37.5% vs 8.3%; P < 0.001) and more severe acute calculous cholecystitis (grade II; 82.8% vs 67%; P = 0.01). There were no significant differences regarding operative time (90 vs 80 min; P = 0.064), conversion rate (20.3% vs 13.5%; P = 0.144), and both intra- and postoperative morbidity, principally bile duct injuries (1.6% vs 0%; P = 0.113) and bile leakage (0% vs 1.2%; P = 1). CONCLUSION: Early laparoscopic cholecystectomy could be proposed safely for older adult patients with mild and moderate acute cholecystitis. Geriatr Gerontol Int 2023; 23: 671-675.

An unusual etiology of acute intestinal occlusion: The swallowed missing dentures a case reports and literature review.

INTRODUCTION: Denture swallowing is an uncommon incident. However, it should be suspected in edentulous elderly patients who wear removable dentures which are poorly cared for and maintain. The existence of neuro-psychiatric disorders may contribute to the occurrence of this adverse event. CASE PRESENTATION: We report the case of an 85-years-old woman admitted to emergency with acute intestinal occlusion. The investigations concluded that the bowel was obstructed by a foreign body blocked in the terminal ileum. There was a high suspicion that his dental prosthesis had been swallowed. Removal of the dental prosthesis was achieved surgically after laparotomy. DISCUSSION: Foreign bodies in the esophagus could be responsible of a variety of symptoms, including dysphagia, airway obstruction and even perforation. In the gastrointestinal tract foreign bodies may be responsible of fewer specific symptoms, including abdominal pain, melena or perforation. The blockage will occur in anatomical strictures. At the most appropriate situations, removal should be performed through endoscopy, although in case of failure of procedure or complication, surgery will be unavoidable. CONCLUSION: Ingestion of a dental or other foreign object is a clinical condition that is more common in pediatric populations, but is very rare in healthy individuals. Denture swallowing is insidious in itself and may lead to a complicated course, if not properly managed. Although most of these can be conservative, careful monitoring is necessary to avoid such adverse event.

Acute intestinal obstruction: What if it is instead colonic tuberculosis? What diagnostic and management dilemmas are there?

INTRODUCTION AND IMPORTANCE: Colonic tuberculosis is rare. Clinical, biologic endoscopic and radiological features are not unequivocal. A multitude of differential diagnoses interfere, including Crohn's disease and cancer. CASE PRESENTATION: we present a case of a 48-year-old Tunisian female who complained from occlusive syndrome. For whom none of the various elements of the medical record, the clinical, endoscopic and radiological investigations had enabled a decision to be reached in favor of one diagnosis over the other. Several diagnoses were suggested, including Crohn's disease, neoplastic diseases and, ultimately, colonic tuberculosis, since our country was endemic for this pathology. The collegial decision of the medical staff involved in the management was to operate on the patient. Surgery was required with the intention to treat and mainly to provide histological proof of the disease. A right colectomy allowed histological examination and a diagnosis of colonic tuberculosis. DISCUSSION: The diagnosis should be discussed in patient from endemic countries, who complain chronic abdominal pain, vesperal fever and weight loss for who endoscopy shows the presence of nodules or ulcers. The diagnosis is retained on the basis of pathological findings. CONCLUSIONS: Because of a nonspecific clinical and endoscopic presentations, multiples biopsies even surgical resection are mandatory to rule out differential diagnosis and to confirm the diagnoses of colonic tuberculosis.

A case of primary mesenteric synovial sarcoma: a challenging presentation.

BACKGROUND: Synovial sarcoma is an uncommon soft tissue malignancy that mainly occurs near tendon sheath and bone joints. Primary intra-abdominal location is exceedingly rare and characterized by non-specific clinical signs. CASE PRESENTATION: We report the case of a young female without medical history who presented with acute abdominopelvic pain. Ultrasound echography revealed a right mass measuring 7 cm in greater diameter cystic with solid areas, likely of ovarian origin. A coelioscopy with peritoneal biopsies was performed. Histological examination with immunohistochemistry concluded the diagnosis of GIST. The patient was referred to the surgery department and after laboratory routine analysis and computed tomography, the patient was proposed to surgical management. Per-operative findings revealed a mesenteric mass locally invading the greater omentum and the appendicular wall. Pathological examination with immunochemistry confirmed the diagnosis of mesenteric monophasic synovial sarcoma invading the appendicular wall with positive surgical margins. Chemotherapy was proposed with a good response. Our patient is free from disease 9 months later. CONCLUSIONS: We aimed through this case report to discuss mesenteric presentation monophasic SS, mimicking ovarian malignancy, emphasizing clinicopathological features and differential diagnoses.

A case report of gastroduodenal artery pseudoaneurysm and giant pancreatic pseudocyst following acute pancreatitis revealed by obstructive jaundice.

Acute necrotic pancreatitis is an emergency of evolution and is often unpredictable because of the potentially life-threatening complications it can cause. We report a unique case of a 56-year-old woman hospitalized for acute necrotic pancreatitis. The evolution of the latter was characterized by the occurrence of two very rare complications, of which the clinical presentations were atypical. The first complication was a gastroduodenal pseudoaneurysm compressing the main biliary tract and causing obstructive jaundice, which evolved well following percutaneous embolization. The second complication was a giant 20 cm pancreatic pseudocyst revealed by obstructive jaundice secondary to biliary compression, which progressed well following surgical treatment.

East-central Tunisian patients with colorectal adenocarcinoma: a comparative study of the clinicopathological features between patients under 50 years of age and older patients.

INTRODUCTION: Colorectal cancer is a major public health problem. In younger patients, its incidence continues to rise and its prognosis appears to be worse. Its treatment is based on curative surgery associated with neo-adjuvant and adjuvant therapies. AIM: To describe the clinical and pathological characteristics of colorectal cancers in young patients. METHODS: In this monocentric cohort study, we retrospectively analyzed the clinicopathological features in colorectal cancer patients who underwent treatment from 2002 to 2014. Data of younger (group A, ≤50years) vs older (group B, >50years) patients were compared. RESULTS: Two hundred and sixty-six patients met inclusion and non-inclusion criteria. The younger and older groups consisted respectively of 25.2% and 74.8% of patients. Both groups were comparable regarding the symptom presentation and duration. Synchronous tumors were more frequent amongst the group A (10.7% vs 1.0%, p = 0.024). Preoperative staging showed a higher frequency of tumors classified as advanced stage (stages III and IV) in the group A (p = 0.001). The patients of group A were diagnosed with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas (13.4% vs 3.5%, p = 0.005), the mucinous character was also more frequent in the group A (28.4%). According to the pTNM (tumor, nodes and metastases) classification, tumors were more advanced in the group A than in group B (80.6% vs 48.7%, p <0.001). CONCLUSION: This study revealed that colorectal adenocarcinomas in the younger patients, compared to the older ones, were more aggressive with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas, more often mucin production and more advanced tumors.

Anatomic variations of the extrahepatic biliary tree. A monocentric study and review of the literature.

INTRODUCTION: The study of the anatomy of the extra hepatic bile ducts has demonstrated the existence of a significant number of variants which can be explained by hepato-biliary embryology. A good knowledge of this anatomy is essential for the interpretation of radiological examinations, and for a good practice of hepato-biliary and pancreatic surgery. Several imaging methods are used to study the anatomy of the bile ducts, including classical cholangiography, which is still practiced and very useful. AIM: To study the modal anatomy (the most frequent) and the anatomical variants of the extrahepatic bile ducts through the interpretation of postoperative cholangiograms and to examine their implication on the surgical practice. METHODS: This is a monocentric, retrospective observational study. It concerned any patient who underwent hepato-biliary or pancreatic surgery at the Department of General and Digestive Surgery of Farhat Hached University Hospital of Sousse between 2007 and 2016, and who received postoperative cholangiography. A data form was fulfilled for each patient. RESULTS: Out of a total population of 293 patients, we identified 158 patients (53.9%) with anatomic variants of the extrahepatic bile ducts. The common bile duct was modally implanted in the second duodenum in 96.2% of cholangiographies and in the genu inferius in 3.8% of cases. The main pancreatic duct had a V-shaped implantation in 87.1% of cholangiograms, a U-shaped implantation in 4.2% of cases and a Y-shaped implantation in 7.1% of cases. The common bile duct had a modal aspect in 71.3% of cholangiograms, with 28.7% of anatomic variants, organized in 4 models. The cystic duct had a modal presentation in 80.9% of cases, and we recorded 6 other branching models (19.1% of cases). No significant difference was observed between the presence of anatomic variants on the one hand, and age, sex, conversion rate, intraoperative incidents, postoperative complications, postoperative hospital stay and overall hospital stay on the other hand. CONCLUSION: Conventional cholangiography constitutes a more or less precise tool for detecting these anatomic variants and is therefore very useful in the practice of hepato-biliary surgery even after the advent of new techniques in this field. However, it also requires a more extensive and in-depth knowledge of these anatomic variants, which nevertheless remain quite frequent, and represent a source of surgical difficulties.

Anthropometric Characteristics of Tunisian Population in Comparison to the World.

BACKGROUND: Anthropometry is the one and only universally applicable, inexpensive and non-invasive method for studying the proportions of the human body. Anthropometric measurements reflect nutritional status and health, but can also be used to predict skills, health status and survival. It is therefore a reliable tool, but currently underused, to guide public health policies. AIM: Therefore, this study investigated anthropometric characters of Tunisian people and compared it with those of other nationalities. METHODS: 429 subjects have participated in this study (322 men and 107 women), aged between 20 and 85. Anthropometric measurements used in this study were body mass, body size, thigh circumference, lower limbs length and body mass index. RESULTS: With an average body size of 171 cm for men and 157 cm for women, Tunisians were close to neighboring countries. Nevertheless, with a body mass of 77.23 kg and 72.66 kg and a BMI of 26.48 and 29.18 respectively for men and women, Tunisia has the highest prevalence of obesity in the region, especially for women. Several anthropometric correlations have also been noticed such as relationships between thigh circumference, BMI, body mass, lower limbs length, and body size. CONCLUSION: Obesity is proving to be a public health problem for which effective strategies and measures are needed.

Duodenal duplication: a rare cause of abdominal pain in adults.

Duodenal duplication is an extremely rare congenital abnormality that occurs mostly in children. It represents only 2% to 12% of all gastrointestinal tract duplication. Its clinical presentation is highly variable and non-specific making the positive diagnosis very difficult. Imaging modalities can help to detect the lesions making the diagnosis more accurate before surgery. Here, we report a case of duodenal duplication revealed by chronic abdominal pain and treated by surgical resection in a 26-year-old man. Even in adults, it is necessary to evoke the diagnosis of duodenal duplication in patients with unexplained abdominal pain. Surgical resection remains the treatment of choice and endoscopic treatment is reserved for selected patients in whom surgery is difficult.

Metastatic renal clear cell carcinoma mimicking a gallbladder polyp: Case report and literature review.

INTRODUCTION: Metastatic tumors to the gallbladder are uncommon. Metastases from renal cell carcinoma (RCC) to the gallbladder are exceptional. Frequencies of less than 0.6% reported in large autopsy reviews and few cases have been reported in the literature. PRESENTATION OF CASE: Herein we present a case of a 50-year-old man that developed four years after radical nephrectomy for RCC, a gallbladder metastasis, discovered incidentally on Computed Tomography (CT) scan. It was described as an intraluminal gallbladder polyp. Radiological features were very suggestive of primary gallbladder carcinoma, thus the patient had a laparoscopic cholecystectomy. The pathological examination of the surgical specimen concluded to a RCC metastasis. Immunochemistry with vimentin and pancytokeratin were supportive of this diagnosis. The clinical course was uneventful after 18 months period of follow up. DISCUSSION: At the time of presentation, almost one-third of the patients with RCC are metastatic. Metastases to the gallbladder are extremely rare. Clinical presentation and physical examination are unspecific. Radiological findings can raise information and orient the diagnosis although the difference between both diagnoses remains difficult. Usually, it is a pedunculated and not associated with gallstones with enhancement on CT scan. The treatment remains surgical with R0 cholecystectomy, and prognosis is mainly related to disease free interval and single site metastasis. CONCLUSION: We highlight here the challenge to make the difference between a primary gallbladder carcinoma and metastasis from RCC. Diagnosis is made on pathological examination and immunochemistry.

Risk factors of conversion in laparoscopic cholecystectomies for lithiasic acute cholecystitis. Results of a monocentric study and review of the literature.

INTRODUCTION: Nowadays, laparoscopic cholecystectomy has become the gold standard in the management of lithiasic acute cholecystitis. However, the rate of conversion to laparotomy remains considerable, greater than that of uncomplicated lithiasis. Some factors, related to the patient, the disease or the surgeon, are associated with a high risk of conversion. AIM: To identify the factors associated with a significant risk of conversion in laparoscopic cholecystectomy for acute cholecystitis. METHODS: Between January 2011 and December 2015, all patients operated on for acute cholecystitis at the Department of General and Digestive Surgery of Farhat Hached University Hospital of Sousse - Tunisia were divided into two groups: A for the laparoscopic approach and B for conversion. We compared the two groups. RESULTS: The conversion rate was 21.9% (43 patients). At the end of this work, we found that the conversion rate was significantly increased for males (p = 0.044), ulcerative disease (p = 0.004), smokers (p = 0.007), ASA score = II (p = 0.005), abdominal guarding (p = 0.001), fever (p = 0.001), perivesicular effusion on ultrasound (p = 0.041), ultrasound Murphy's sign (p = 0.023), delayed cholecystectomy (p = 0.038), perivascular adhesions (p <10-3) and gangrenous cholecystitis (p = 0.009). CONCLUSION: The conversion is sometimes badly perceived by the surgeon. However, it should in no way be considered a failure, but rather a change of strategy to ensure patient safety. Conversion should not be delayed, especially as risk factors have been identified.

Colonic intussusception caused by a sigmoidal lipoma: A case report.

INTRODUCTION: Intussusception is a relatively common condition seen in children. In comparison, adult intussusception is rare and is often secondary to inflammatory diseases, benign or malignant tumors and motility disorders. Being a benign cause, lipomas appear as a particularly rare gastrointestinal tumor. PRESENTATION OF CASE: We present a case of colo-colonic intussusception secondary to a sigmoidal lipoma, in a 40-year-old man. We describe the different aspects of diagnosis and management of this rare complication. DISCUSSION: Adult intussusception is the cause of symptomatic bowel obstruction in 1% of cases and its colo-colonic occurrence represents 17% of all intestinal intussusceptions. The case that we describe is particularly unique because apart from being an example of intussusception in adults, it occurred in the sigmoid colon and was not associated with a malignant lesion. The treatment of intussusception in adults is surgical resection because of the high incidence of underlying malignancy. Colonoscopy is a modality which allows direct visualization of the lipoma. However, intraluminal reduction via colonoscopy is not recommended. CONCLUSION: Colo-colonic intussusception is a very rare complication of lipoma. It is determined that the treatment is surgical due to the risk of malignancy.