Reliability testing of a modified MISTELS score using a low-cost trainer box.

BACKGROUND: Training programs such as the fundamentals of laparoscopic surgery (FLS) that are based on simulation are being currently used in several western countries. FLS allows skill acquisition and evaluation of competency in laparoscopic surgery. On the practical side, evaluation is determined by the MISTELS metrics (MISTELS is the acronym for the McGill inanimate system for training and evaluation of laparoscopic skills). This training program may be modified so that it can be implemented in countries with limited resources using a low-cost trainer box. Would the use of a low-cost trainer box alter the reliability of the MISTELS score? OBJECTIVE OF STUDY: The aim of the study was to evaluate the reliability of a modified MISTELS using a low-cost trainer box. METHODS: It was a prospective study carried out at Habib Thameur hospital in Tunis (Tunisia), between April 2016 and August 2016. The study involved residents from different surgical specialties in the departments of general surgery and paediatric surgery of the hospital during 2015 and 2016. This study assessed the reliability of a modified MISTELS system (Only three tasks were performed out of the five tasks used in the original MISTELS system). Evaluation was based on Cronbach's alpha and intraclass correlation coefficients (ICC). A low-cost trainer box was designed and constructed. The residents included in the study performed three series of three tasks using this trainer box. The first series was scored by two trained raters to evaluate inter-rater reliability. The two-other series were successively performed to evaluate test-retest reliability. RESULTS: The internal consistency, assessed by Cronbach's alpha, was at 0.929 which is an acceptable score. As for inter-rater and test-retest reliabilities that were assessed by ICCs, they yielded excellent scores that were at 1 and 0.95 (95% CI, 0.891-0.978) respectively. CONCLUSIONS: The reliability of a modified MISTELS is not altered by the use of a low-cost trainer box. The score of the modified MISTELS is a reliable score for evaluating technical skills of surgical residents using a low-cost trainer box.

Gastric leiomyosarcoma and diagnostic pitfalls: a case report.

BACKGROUND: Since the advent of immunohistochemistry for the diagnosis of stromal tumours, the incidence of leiomyosarcomas has significantly decreased. Nowadays, gastric leiomyosarcoma is an exceptionally rare tumour. We report the second case in the English literature of gastric leiomyosarcoma revealed with massive bleeding and hemodynamic instability and diagnostic pitfalls that we encountered. CASE PRESENTATION: A 63-year-old woman, with 2 years' history of dizziness and weakness probably related to an anaemic syndrome, presented to the emergency room with hematemesis, melena and hemodynamic instability. On examination, she had conjunctival pallor with reduced general condition, blood pressure of 90/45 mmHg and a pulse between 110 and 120 beats per minute. On digital rectal examination, she had melena. Laboratory blood tests revealed a haemoglobin level at 38 g/L. The patient was admitted to the intensive care department. After initial resuscitation, transfusion and intravenous Omeprazole continuous infusion, her condition was stabilized. She underwent upper gastrointestinal endoscopy showing a tumour of the cardia, protruding in the lumen with mucosal ulceration and clots in the stomach. Biopsies were taken. Histological examination showed interlacing bundles of spindle cells, ill-defined cell borders, elongated hyperchromatic nuclei with marked pleomorphism and paranuclear vacuolization. Immunohistochemistry showed positivity for Vimentine, a strong and diffuse immunoreactivity for smooth muscle actin (SMA). Immunoreactivities for KIT and DOG1 were doubtful. Computed tomography scan revealed a seven-cm tumour of the cardia, without adenopathy or liver metastasis. The patient underwent laparotomy. A total gastrectomy was performed without lymphadenectomy. Post-operative course was uneventful. Histological examination of the tumour specimen found the same features as preoperative biopsies with negative margins. We solicited a second opinion of an expert in a reference centre for sarcomas in France, who confirmed the diagnosis of a high grade gastric leiomyosarcoma. CONCLUSION: Gastric leiomyosarcoma is a rare tumour. Diagnosis is based on histological examination with immunohistochemistry, which could be sometimes confusing like in our case. The validation of a pathological expert is recommended.

[First experience with outpatient laparoscopic cholecystectomy in Tunisia]. / Cholécystectomie laparoscopique ambulatoire: première expérience en Tunisie.

INTRODUCTION: Laparoscopic cholecystectomy is the gold standard treatment for symptomatic gallstones. There is some debate as to whether it should be performed in outpatient surgery or in one-day surgery to improve patient safety. This study aimed to evaluate the impact of laparoscopic cholecystectomy performed in outpatient surgery versus one-day surgery on standards such as mortality, serious adverse events and quality of life. METHODS: We conducted a cross-sectional descriptive study in the Department of General Surgery at the Habib Thameur Hospital over the period May 2009-February 2010. We here report 67 cases of symptomatic vesical lithiasis treated with outpatient laparoscopic cholecystectomy (OLC). ASA III and IV patients, diabetic patients treated with sulfonamides or insulin, severely obese patients, patients over 65 years of age and under 18 years of age, patients with a history of major abdominal surgery, patients with suspected lithiasis of the common bile duct, acute cholecystitis or pancreatitis were excluded from the study. Patients had to reside within 50 km of the hospital and be accompanied by an adult to undergo OLC. RESULTS: Seventeen patients were included and then excluded from our study because of the perioperative detection of signs of acute cholecystitis or difficulties in dissection leading to subhepatic drainage using Redon catheter at the end of the intervention. Finally, our study included 50 patients, 7 men and 43 women; the average age was 48 years. Surgery was based on the most common procedures. After leaving the recovery room, patients were conducted in the outpatient sector where they received a liquid diet. The patients were examined before 7 o'clock in the evening and discharge was established on the basis of the possibility of establishing an oral analgesic treatment, patients tolerance to liquid diet, the lack of urinary disorder, patients acceptance for discharge and analgesic and anti-inflammatory treatment if needed. Thirty-nine patients (78%) were discharged from hospital and 11 were kept in hospital. Patients > 45 years of age, anesthesia duration > 70 minutes and post operative fatigue were identified as risk factors for unsuccessful discharge. No readmission was observed. Discharged patients were satisfied with the therapeutic protocol, resulting in excellent and good outcome in the majority of cases (94%). CONCLUSION: Outpatient laparoscopic cholecystectomy seems to be as safe as day surgery laparoscopic cholecystectomy having low rate of complications and of hospital readmissions in some selected patients and lower surgery costs.

Ascending Cholangitis secondary to migrated embolization coil of gastroduodenal artery pseudo-aneurysm a case report.

BACKGROUND: Gastroduodenalartery (GDA) pseudo-aneurysms are very rare. Their clinical importance lies in the eventuality of rupture, causing bleeding and ultimately exsanguination. CASE PRESENTATION: We report the case of a man, with prior history of biliary surgery, presenting with haemobilia secondary to a rupture of GDA pseudo-aneurysm eroding the main bile duct. The patient was treated with coil embolization. This technique is considered to be safe. However, on the long term, some complications may occur. In our case, the patient presented with cholangitis subsequent to coil migration in the lower bile duct. This situation was managed using endoscopic retrograde cholangiopancreatography (ERCP) allowing coil extraction with favorable evolution. CONCLUSIONS: GDA pseudo-aneurysms are very rare. Bleeding, secondary to the rupture of these lesions, is a serious complication that could lead to death. Diagnosis and treatment of ruptured GDA pseudo-aneurysms rely on angiography. This method is considered to be safe. Cholangitis secondary to coil migration in the main bile duct is exceedingly rare,but remains an eventuality that physicians should be cognizant of.

Detection of a new JCV strain of genotype A in a subpopulation of colorectal adenocarcinomas in Tunisia

The etiology of colorectal cancer (CRC) remains elusive in spite of major advances in knowledge of this disease and related risk factors. Several studies report the detection of human polyomavirus JC (JCV) in colorectal tumors and some suggest its association with CRC. Since many known human virus associations with cancer are linked to factors such as ethnic and geographical origin, it is interesting to search for the postulated association of JCV with CRC in different populations and regions. In this perspective, the present work was undertaken to assess the presence of JCV in CRC tumors in Tunisia. Fresh biopsies were obtained from both colorectal tumors and adjacent normal tissues of 47 CRC patients. Only tumors diagnosed as adenocarcinomas were included in the present study. Twenty patients with other gastroenterological disorders were taken as controls. DNA was extracted from fresh biopsies or formalin-fixed, paraffin-embedded tissue sections. A region of the viral T-Ag gene was amplified by PCR and the DNA amplicons were subjected to automated sequencing. JCV DNA was found in 22 (46%) of the adenocarcinomas but in none of the normal mucosa biopsies of either CRC or control patients. Sequence analysis indicated that the amplified DNA belonged to a new JCV variant of genotype A. The presence of JCV DNA was correlated with tumor location and grade. The data obtained suggest that JCV may be associated either with a subpopulation of colorectal tumors or with CRC in general, possibly through a hit and run mechanism.

[Spigelian hernias]. / Hernies de Spiegel.

Spigelian hernias represent 1-2% of all abdominal wall hernias. The pathogenesis often involves a dehiscence of the transverse and internal oblique muscle aponeurosis. The diagnosis is made by physical examination; but sometimes it is complicated by obesity. The risk of strangulation is important and can reach 30%. The abdominal CT scan is helpful in the description of hernia's topography and sometimes in diagnostic confirmation. The treatment is surgical. The rate of recurrence after direct closure is considerable. Synthetic mesh repair seems to be a more adequate alternative. The advent of laparoscopy has improved the management of these hernias.

Primary hydatid cyst of the gallbladder: an unusual localization diagnosed by magnetic resonance imaging (MRI).

Hydatid disease is endemic in Tunisia and has been considered as one of the most common surgical pathology. Several localizations have been described, but hydatidosis of the liver is the most frequent clinical entity. Primary hydatid cyst of the gallbladder is very rare. We report in this observation a new case of primary hydatid cyst of the gallbladder diagnosed by Magnetic Resonance Imaging (MRI).

Giant gastric lipoma mimicking well-differentiated liposarcoma.

Gastric lipoma is a rare tumor, accounting for only 5% of gastrointestinal tract lipomas and less than 1% of all gastric tumors. Histological diagnosis is usually easy. However, the tumor may sometimes undergo significant inflammatory changes leading to a difficult differential diagnosis with well-differentiated liposarcoma. Authors report the case of a 51-year-old man, presenting with epigastralgia of recent onset. Physical exam was unremarkable. Endoscopy revealed a large, ulcerated, submucosal, and antral tumor. CT scan showed an antral mass with fat attenuation. The patient underwent a total gastrectomy. Macroscopic examination identified in the antral wall a 9-cm, well-circumscribed, nodular lesion, with a greasy cut surface. On histological examination, the tumor was composed of a mature adipocytes proliferation, showing significant variation in cell size, associated to some lipoblasts. Nuclei were sometimes large, irregular, neither with hyperchromasia nor mitosis. Diagnosis of a well-differentiated liposarcoma was suspected and molecular cytogenetic analyses showed neither MDM2 nor CDK4 gene amplification on fluorescent in situ hybridization. The diagnosis of lipoma was made. Twelve months after surgery, the patient is doing well. In conclusion, Differentiating benign from malignant fatty tumors is sometimes difficult in morphologic features. In these cases, cytogenetic procedures are the only means for an accurate diagnosis.

Giant gastric lipoma mimicking well-differentiated liposarcoma.

Authors report the case of a 51-year-old man, presenting with epigastralgia of recent onset. Physical exam was unremarkable. Endoscopy revealed a large, ulcerated, submucosal, antral tumor. CT scan reveals an antral mass with fat attenuation. The patient underwent a total gastrectomy. Macroscopic examination identified in the antral wall a 9-cm, well-circumscribed, nodular lesion, with a yellow, greasy cut surface. On histological examination, the tumor was composed of a mature adipocytes proliferation, showing significant variation in cell size, associated to some lipoblasts. Nuclei were sometimes large, slightly irregular, but without hyperchromasia nor mitosis. Diagnosis of a well-differentiated liposarcoma was suspected and molecular cytogenetic analyses showed no MDM2 nor CDK4 gene amplification on fluorescent in situ hybridization. The diagnosis of lipoma was made. Twelve months following surgery, the patient is doing well.

[Feasibility of laparoscopic treatment of duodenal ulcers: results of 160 cases]. / Traitement laparoscopique de l'ulcere duodenal faisabilite et resultats: a propos de 160 cas.

AIM: The objective of this study is to evaluate the feasibility, efficacy and safety of laparoscopic repair for perforated duodenal ulcer. METHODS: One hundred and sixty patients were treated by coelioscopic procedure for a perforated duodenal ulcer. The procedure consists on a suture of perforated ulcer associated with a peritoneal lavage. A medical treatment of Helicobacter pylori associated with an inhibitor of the protons pomp was conducted. RESULTS: The coelioscopic procedure permitted to confirm the diagnostic of perforated duodenal ulcer in all cases. A simple suture of the ulcer was done in 155 cases. The conversion was compulsory in 5 cases, because of difficulties of the peritoneal lavage in 2 cases, a bleeding associated with perforation of the ulcer in one case and associated stenosis in 2 cases. Mean duration was 90 min (extremes 50 - 120 min). Complications occur in 3,1%. They were post - operative peritonitis in 3 cases and duodenal fistulae in 2 cases. All patients were reviewed at 16 months. A recurrence, either clinical or endoscopic occurs in 4 cases because of no adhesion to medical treatment. CONCLUSION: Coelioscopic treatment of perforated duodenal ulcer is a safe and efficacy method. It permits to avoid potential septic and parietal complications of laparotomy. The actual efficacy of medical treatment mustn't allow place to the radical treatment of ulcerous illness.

[Common bile duct distomatosis managed by coelioscopic aproach. One case report]. / Distomatose de la voie Biliaire principale traitée par voie coelioscopique. A propos d'un cas.

Biliary distomatosis is caused by a parasitis of trematode family: the fascialo hepatica. It is a rare affection in Tunisia. The diagnostic is often done in the status phase. Adult parasite stay preferentially at biliary ducts, cause obstruction and cholangitis. The authors report a case of biliary treated successfully by laparoscopic procedure.