Comparison between signet-ring cell carcinoma and non-signet-ring cell carcinoma of the stomach: clinicopathological parameters, epidemiological data, outcome, and prognosis-a cohort study of 123 patients from a non-endemic country.

BACKGROUND: Signet-ring cell carcinoma of the stomach (SRCC) is a particular gastric cancer entity. Its incidence is increasing. Its diagnosis is pathological; it corresponds to adenocarcinoma with a majority of signet-ring cells component (> 50%). These histological features give it its aggressiveness characteristics. This has repercussions on the prognostic level and implications for the alternatives of therapy, especially since some authors suggest a potential chemoresistance. This survey aimed to identify the epidemiological, pathological, therapeutic, and prognostic characteristics of SRCC as a separate disease entity. METHODS: This was a retrospective study of 123 patients admitted for gastric adenocarcinoma to Habib Thameur Hospital in Tunis over 11 years from January 2006 to December 2016. A comparative study was performed between 2 groups: the SRCC group with 62 patients and the non-SRCC (non-signet-ring cell carcinoma of the stomach) with 61 patients. RESULTS: The prevalence of SRCC in our series was 50%. SRCC affected significantly younger patients (55 vs 62 years; p = 0.004). The infiltrative character was more common in SRCC tumors (30.6 vs 14.8%; p = 0.060), whereas the budding character was more often noted in non-SRCC tumors (78.7 vs 58.1%; p = 0.039). There was no significant difference in tumor localization between both groups. Linitis plastica was noted in 14 patients with SRCC against a single patient with non-SRCC (p = 0.001). The tumor size was more important in the non-SRCC group (6.84 vs 6.39 cm; p = 0.551). Peritoneal carcinomatosis was noted in 4.3% of cases in the SRCC group versus 2.2% of cases in the NSRCC group (p = 0.570). Total gastrectomy was more often performed in the SRCC group (87 vs 56%; p = 0.001). Resection was more often curative in the non-SRCC group (84.4 vs 78.3%; p = 0.063). Postoperative chemotherapy was more commonly indicated in the SRCC group (67.4 vs 53.3%; p = 0.339). Tumor recurrence was more common in the non-SRCC group (35.7 vs 32%; p = 0.776). The most common type of recurrence was peritoneal carcinomatosis in the SRCC group (62.5%) and hepatic metastasis in the non-SRCC group (60%; p = 0.096). The overall 5-year survival in the SRCC group was lower than in the non-SRCC group, with no statistically significant difference (47.1 vs 51.5%; p = 0.715). The overall survival was more important for SRCC in early cancer (100 vs 80%; p = 0.408), whereas it was higher for non-SRCC in advanced cancer (48.1 vs 41.9%; p = 0.635). CONCLUSION: Apart from its epidemiological and pathological features, SRCC seems to have a worse prognosis. Indeed, it is diagnosed at a more advanced stage and has a worse prognosis in advanced cancer than non-SRCC. It is therefore to be considered as a particular entity of gastric adenocarcinoma requiring a specific therapeutic protocol where the place of chemotherapy remains to be more investigated.

Ambulatory hernia repair: a study of 1294 patients in a single institution.

Introduction: ambulatory surgery is continuously expanding in global reach because of its several advantages. This study aimed to describe the experience of our department in outpatient hernia surgery, evaluate its feasibility and safety, and determine the predictive factors for failure of this surgery. Methods: we conducted a monocentric retrospective cohort study on patients who had ambulatory groin hernia repair (GHR) and ventral hernia repair (VHR) in the general surgery department of the Habib Thameur Hospital in Tunis between January 1st, 2008 and December 31st, 2016. Clinicodemographic characteristics and outcomes were compared between the successful discharge and discharge failure groups. A p-value of ≤ 0.05 was considered significant. Results: we collected data from the record of 1294 patients. One thousand and twenty patients had groin hernia repair (GHR). The failure rate of ambulatory management of GHR was 3.7%: 31 patients (3.0%) had unplanned admission (UA) and 7 patients (0.7%) had unplanned rehospitalization (UR). The morbidity rate was 2.4% while the mortality rate was 0%. On multivariate analysis, we did not identify any independent predictor of discharge failure in the GHR group. Two hundred and seventy-four patients underwent ventral hernia repair (VHR). The failure rate of ambulatory management of VHR was 5.5%: 11 patients (4.0%) had UA and 4 patients (1.5%) had UR. The morbidity rate was 3.6% and the mortality rate was zero. On multivariate analysis, we did not identify any variable predicting discharge failure. Conclusion: our study data suggest that ambulatory hernia surgery is feasible and safe in well-selected patients. The development of this practice would allow for better management of eligible patients and would offer many economic and organizational advantages to healthcare structures.

Surgical management of splenic artery aneurysm.

INTRODUCTION: Splenic artery aneurysms are a rare arterial disease. They are considered as the most common visceral artery aneurysms and found mostly in multiparous women and patients with portal hypertension. CASE PRESENTATION: We present a case of an unruptured SAA of the hilum in a 58-year-old woman, with vague abdominal pain, treated by open splenectomy. DISCUSSION: Splenic artery aneurysms are often difficult to diagnose due to their vague or asymptomatic forms. However, they present a high risk of rupture that may cause fatal hemorrhage and death. Symptomatic artery aneurysms or SAA, larger than 20 mm and aneurysms in pregnant or in women of childbearing age are indications for surgery because of the increased risk of rupture in these patients' groups. As known generally, the treatment of SAA has been surgical ligation of the splenic artery, ligation of the aneurysm or aneurysmectomy with or without splenectomy, depending on the aneurysm location. There are other percutaneous interventional procedures. CONCLUSION: A multidisciplinary discussion is an important step in choosing the optimal treatment for visceral aneurysms. Surgical approaches should take place especially in cases where splenic perfusion is seriously threatened.

What remains to surgeons in the management of abdominal tuberculosis? A 10 years experience in an endemic area.

BACKGROUND: Tuberculosis (TB) is a common endemic disease in Tunisia. Abdominal location is rare. Early diagnosis of abdominal TB remains difficult due to its non-specific clinical presentations. The aim of our study is to highlight the characteristics of the different presentations, to characterize tools contributing to a positive preoperative diagnosis, and finally to assess the role of surgery in the management of this entity. MATERIALS AND METHODS: A retrospective review from 2005 to 2015 identified 90 cases of confirmed abdominal TB managed in the Department of General Surgery of the Habib Thameur Hospital. The diagnosis was established by histopathology examination for all cases. This study was approved by the ethical committee. RESULTS: The mean age of the patient was 44.13 years with a sex ratio (M/F) of 0.34. We collected 56 cases of peritoneal TB, 12 cases of abdominal lymph node TB, 10 cases of intestinal TB, four cases of hepatic TB, and two cases of gallbladder's TB. For six patients, an association of many localizations was noted. The diagnosis was suspected on clinical, biological, and morphological arguments, but the confirmation was always made by surgical exploration and pathological examination of removed specimens. Surgical management was urgent in complicated cases (13.3%). Laparoscopy was performed in 71 cases (78.9%). Laparoscopic features of peritoneal TB were specific and always confirmed by histological examination. CONCLUSION: Despite the wide range of examination available for the preoperative exploration of abdominal TB, diagnosis is usually late and difficult. TB is a medical condition. However, surgical exploration is frequently needed in the management.

[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.

[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.