Prolonged survival with systemic chemotherapy in an advanced malignant mesothelioma: A case report.

Peritoneal mesotheliomas are very rare tumors. Their prognosis is poor, average survival does not exceed 1 year after peritoneal cytoreduction. Systemic chemotherapy is considered to have no proven value in the management of peritoneal mesotheliomas. Objective responses with systemic chemotherapy are very rare. We report here a case of an advanced peritoneal mesothelioma which achieved an unexpected partial response with chemotherapy, allowing the patient to have a right colectomy. The patient was referred to a specialized center on HIPEC, but taking in account the long awaiting interval, the HIPEC was judged to be inefficient and then the poursuit of 6 cycles of systemic chemotherapy was decided. The patient is still alive without any symptom and with a good performance status at 59 months after diagnosis. Throughout our case, we provide an encouraging evidence of the role of initial systemic chemotherapy in the downstaging of initially unresectable primary malignant mesothelioma and in the improvement of overall survival.

Gastric diverticula as a diagnostic and therapeutic challenge: Case report and review of literature.

INTRODUCTION: Gastric diverticula are a rare condition characterized by a pouch protruding from the gastric wall. It is commonly asymptomatic and managed without surgery. Gastric diverticulotomy is indicated in the case of symptomatic or complicated diverticula. CASE: The authors report the case of a 67 year-old man presenting with heartburn and dyspepsia with no response to proton pump inhibitors. The patient was diagnosed with a gastric diverticula and a little hiatal hernia, which was subsequently successfully treated with a laparoscopic gastric diverticulectomy and Nissen fundoplication. CONCLUSION: Gastric Diverticula have to be evoked in the absence of response of Gastro Esophageal Reflux Disease to therapy or in atypical symptoms. Laparoscopic resection of GD can be safe with resolution of symptoms.

A Prospective Assessment of Adverse Events in 3 Digestive Surgery Departments From Central Tunisia.

OBJECTIVE: The aim of the study was to prospectively assess the incidence, the preventability, and the factors contributing to adverse events (AEs) in surgical departments of Tunisian hospitals. METHODS: A prospective longitudinal study evaluated the incidence of AEs in surgical departments of three university hospitals in central Tunisia. The study followed 1687 admitted patients until their discharge from the hospitals based on a standard two-stage method that first included staff interviews and review of medical records based on 18 criteria and later was followed by an expert review to confirm or reject the presence of an AE. RESULTS: The overall incidence of AEs was 18.1% (95% confidence interval = 16.26-19.94), with an incidence density of 21.6 events per 1000 patient-days. The most frequent AEs were those related to operative procedures (34.9%) and to hospital-acquired infections (30.3%).The multivariate analysis shows that the proportion of AEs increased significantly with intrinsic risk factors (odds ratio [OR] = 2.51, P < 0.001), extrinsic risk factors (OR = 1.38, P = 0.02), length of stay of greater than 7 days (OR = 2.27, P < 0.001), and unplanned admissions (OR = 2.59, P < 0.01). Overall, the major consequences of suffering an AE were that 90% had a prolonged hospital stay, 6% had a permanent disability, and 4% encountered death. More than 60% of the identified AEs were considered to be preventable. CONCLUSIONS: Surgical AEs have a significant impact on patient outcomes in terms of length of stay, disability, and mortality, and a considerable proportion of them are preventable. Prospective studies provide better insight regarding AEs under circumstances where hospital records are not optimal. Patient safety programs led by qualified health professionals can reduce patient harm in surgical departments of hospitals in most situations.

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.

Correlation between superficial and intra-operative specimens in diabetic foot infections: results of a cross-sectional Tunisian study.

OBJECTIVE: To determine the correlation between superficial, and intra-operative specimens in diabetic foot infections (DFIs). METHODS: We conducted a cross-sectional study in patients with DFIs hospitalized in a Tunisian teaching hospital. Superficial specimens were collected for all patients, and intra-operative specimens were collected in operated patients. The specimens were processed using standard microbiology techniques. Antimicrobial susceptibility testing was carried out according to the protocol established by the European Committee on Anti-microbial Susceptibility Testing. Intra-operative and superficial specimens were considered correlated if they isolated the same microorganism(s), or if they were both negative. RESULTS: One hundred twelve patients, 81 males and 31 females, mean age 56 years, were included. Superficial samples were positive in 77% of cases, and isolated 126 microorganisms. Among the positive samples, 71% were monomicrobial. The most frequently isolated microorganisms were Enterobacteriaceae (53%), followed by streptococci (21%) and Staphylococcus aureus (17%). Nine microorganisms (7%) were multi-drug resistant. Intra-operative samples were positive in 93% of cases. Superficial specimens were correlated to intra-operative specimens in 67% of cases. Initial antibiotic therapy was appropriate in 70% of cases. The lower-extremity amputation and the mortality rates were 41% and 1%, respectively. CONCLUSION: In our study, DFIs were most frequently caused by Enterobacteriaceae and superficial specimens were correlated to intra-operative specimens in only two thirds of cases. Clinicians should emphasize on the systematic practice of intraoperative specimens in all patients with DFIs treated surgically, while well-performed superficial specimens could be useful for prescribing appropriate antibiotic therapy in other patients.

Acute appendicitis complicating pregnancy: a 33 case series, diagnosis and management, features, maternal and neonatal outcomes.

The occurrence of acute appendicitis during pregnancy may pose diagnostic and therapeutic difficulties. In fact pregnancy can make the clinical diagnosis delicate and the use of morphological examinations is still subject to controversy. The debates concerning the ideal surgical approach during pregnancy continue. On the other hand, in some cases the occurrence of acute appendicitis, especially in its complicated form, which is frequent in pregnant women, exposes to obstetrical complications and an increased risk of premature delivery We aims to describe the clinical and management features of acute appendicitis in pregnant women and the maternal and neonatal outcomes and carry out a review of the literature on this topic. It is a retrospective analysis of a series of 33 cases of appendicitis in pregnant women who were diagnosed and managed, in collaboration between the departments of General and digestive surgery, Gynecology and Obstetrics and Anaesthesia at Farhat Hached Universitary Hospital Sousse Tunisia between January 2005 and December 2015. The average age of the patients was 29 (20-40). Fourteen patients were in the first trimester, twelve in the 2nd and seven in the third trimester. The main symptom was pain in the right iliac fossa. The mean delay between consultation and surgery was 2.7 days. Twenty five patients had a preoperative ultrasound. Eight of the 33 pregnant patients presented complicated appendicitis with localized or generalized peritonitis. Thirty patients underwent laparotomic appendectomy: 28 with a Mc Burney incision and 2 with a midline incision and only three patients underwent laparoscopy. Preventive tocolysis was given to 14 patients, maternal mortality was null. Twenty four pregnancies were followed until delivery: one case of premature birth and one case of preterm labor were observed. Pregnancy makes it difficult to diagnose appendicitis, which explains the high rate of complicated acute appendicitis in our series. An early treatment improves maternal and fetal outcome.

Unusual complication of seroma after ventral hernia mesh repair: Digestive perforation by tacks. A case report.

Intraperitoneal meshes are actually widely used in ventral hernia repair. They can reduce operative time, parietal prejudice and postoperative pain. One of the most well-known complications of intraperitoneal mesh is seroma, but it usually subsides without any therapeutic problems. These meshes can be fixed by tackers, suture or glue. Few complications related to the fixation technique are known. We report the case of a patient who underwent a laparoscopic mesh repair for incisional hernia. He developed an infected bulky seroma for which he had to undergo medical treatment and percutanous drainage in order to avoid the mesh removal. The evolution seemed to be favorable until the occurrence of an unusual and unexpected complication: a digestive fistula of the small bowel in the seroma cavity via a tack adhering to the intestines. The possibility of digestive lesions by a tack is reported by some cases reports. It seems most often to be related to a technical problem. In our case, this adhesion seems to be secondary to the pressure exerted by the seroma. The complicated seroma can be conservatively treated to save the mesh. However the delay before deciding to remove the mesh when using tackers for its fixation may be shortened.

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.

Contribution of microRNA-149, microRNA-146a, and microRNA-196a2 SNPs in colorectal cancer risk and clinicopathological features in Tunisia.

BACKGROUND AND AIM: Colorectal cancer (CRC) is a worldwide leading cause of mortality. Genetic studies have associated single nucleotide polymorphisms in genes encoding microRNAs with CRC risk but results are mostly inconclusive across variable ethnicities. In this study, we investigated the association of hsa-mir-149 rs2292832 C/T, hsa-mir-146a rs2910164 G/C and hsa-mir-196a2 rs11614913 C/T and explored their roles in clinicopathological features of CRC progression in an Eastern Tunisian cohort. SUBJECTS AND METHODS: Three hundred thirteen subjects were enrolled in our retrospective study including 152 CRC cases and 161 controls. Genotyping was assayed by RFLP-PCR (Restriction Fragment Length Polymorphism-Polymerase Chain Reaction) method. SPSS v.18.0, R and SNP Stats online software performed statistical analysis. RESULTS: Significantly higher hsa-mir-149C/T rs2292832 minor allele frequency was associated with increased risk of CRC [p = .03; OR = 1.54 (1.08-2.19)]. In addition, significant crude associations of hsa-mir-149C/T rs2292832 polymorphism were detected under codominant, dominant and additive models of inheritance. After adjusting for covariates and performing FDR correction, these associations did not remain. No associations were detected for hsa-mir-146a G/C rs2910164 and hsa-mir-196a2 C/T rs11614913. When performing stratified analysis of clinicopathological features according to genotypes, a significant association (p = .004) was found between hsa-mir-146a G/C rs2910164 and tumour differentiation grade. Regression analysis according to CRC progression features had demonstrated a trend toward significance in overdominant model of inheritance for hsa-mir-149C/T rs2292832 with a protective effect [p = .05; OR = 0.51 (0.26-1.02)]. CONCLUSION: Hsa-mir-149C/T rs2292832 and hsa-mir-146a G/C rs2910164 may influence CRC risk in an ethnicity-dependent manner by interfering with CRC progression parameters in Tunisian cohort.

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.

Partial spontaneous anal expulsion of the right colon lipoma: An exceptional diagnostic circumstance.

INTRODUCTION: Lipomas are most common benign tumors of the colon. They are asymptomatic and fortuitously discovered on a morphological examination. Rarely, they cause complications such as acute intussusception. In this article, we reported an exceptional discovery mode of right colon lipoma. CASE PRESENTATION: A 54-year-old woman has consulted for acute abdominal pain relieved by the anus emission of a fat ball that she brought back with her. Abdominal computed tomography scan showed the remaining part of a lipoma developed in her right colon. Laparoscopic right colonic resection was performed. DISCUSSION: Colic lipomas are usually asymptomatic and surgical indication in these cases is debated, but it is indicated whenever complications occur such as acute intestinal intussusception. In this case, discovery mode was not considered as a complication because lipoma evacuation could have been complete. Radiological explorations and colonoscopy could evaluate the lesional state. When surgery is decided, intersecting therapeutic strategy of a short colonic resection guided by a colonization during colonoscopy should be considered. CONCLUSION: The spontaneous expulsion of a colonic lipoma is very rare. Our observation showed that this expulsion may be partial. +The changes that the lipoma undergoes can evoke a malignant cause. a supplement to take care of this eventuality is necessary.

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.

Spontaneous intraperitoneal rupture of hepatic hydatid cyst: a rare cause of ascites.

BACKGROUND: Hydatid disease is endemic in certain areas of the world and it is located mostly in the liver. Intraperitoneal rupture is rare. Rupture may result from trauma or may occur spontaneously from increased pressure of the cystic fluid. Ruptured hydatid cyst is a rare cause of ascites, but should be considered in the differential diagnosis, especially in endemic areas. The diagnosis of ruptured hydatid cyst should be prompt because it requires emergency intervention. CASE PRESENTATION: The present case refers to a 62 year old Tunisian male admitted in our institution for diffuse abdominal distension. Physical examination was unremarkable except for the presence of ascites. Abdominal ultrasonography showed a large amount of fluid into the peritoneal cavity associated with many intraperitoneal cysts with a scalloping on the liver. It showed also a heterogeneous cystic lesion of the segment II of the liver. Abdominal computed tomography (CT) revealed in addition a fat infiltration and a thickening of the peritoneum. Thus intraperitoneal hydatid cyst rupture was suspected and emergency laparotomy was performed. A yellow serous fluid , containing many daughter vesicles disseminated through the peritoneal cavity was noted. A mass consistent with a hydatid cyst was noted at segment II of the liver with a tear on the inferior surface. Thus, intraperitoneal rupture of hepatic hydatid cyst was diagnosed. CONCLUSION: The rupture of hydatid cyst into the peritoneal cavity is rare but presents a challenge for the radiologist and the surgeon. This condition is included in the differential diagnosis of ascites in endemic areas.

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.

[Quality of life in patients with colo-rectal cancers at a Tunisian hospital center. A case control study of a population unhurt by cancer]. / Qualite de vie des patients traites pour cancers colo-rectaux au Centre Tunisien. Etude cas témoin avec une population indemne de cancer.

UNLABELLED: The aim of our study is to value the quality of life (QOL) in patients with colo-rectal cancers in the region of tunisian center and to compare it to the QOL in a healthy population unhurt of cancer. METHODS: Our population is made by 80 patients treated for coloractal cancers. The population witness includes 80 healthy individuals unhurt of cancers. The assessment of the QOL in patients is achieved with the specific colo-rectal cancer questionnaire: the FACT-C. The comparison of the QOL in the 2 populations is made by the general questionnaire of quality of life of Spitzer. RESULTS: The QOL in patients is good in 55% of cases, average in 44% of cases and bad in 11% of cases. The QOL is better in case of favourable socioeconomic conditions (p < 0,05), colic localization (p < 0.015), absence of metastases (p< 0.05), not mutilating surgery (p < 0.01) especially the absence of stoma (p < 0.001) and the restoring of the continuity (p < 0.002), absence of pain (p < 0.0001), absence of current treatment (p < 0.01). The comparison of the different domains of QOL between the 2 groups (patients and healthy) finds a better QOL in healthy group, in all domains except for the relational ship domain witch turned to be comparable for the 2 samples.

[Predictive factors of recurrence after surgery in severe attacks of hemorrhagic ulcerative proctocolitis]. / Facteurs prédictifs de recours à la chirurgie dans la rectocolite ulcéro hémorragique en poussée grave.

AIM: The purpose of our study was to determine clinical, biological or endoscopic factors that predict surgery after a glucocortico steroid treatment failure in severe attacks of ulcerative colitis. METHODS: Sixty one patients were analyzed. A therapeutic response for glucocorticosteroid was defined as the absence of resort to surgery within the first 30 days after hospitalization. Predictive factors were assessed using univariate and multivariate analysis. RESULTS: Fifteen patients (24.6%) had a medical response. In univariate analysis, predictive factors of surgery were: male sex, tobacco, number of colitis attacks in case history, temperature over 38 degrees C, erythrocyte sedimentation rate over 30 mm, systolic blood pressure below 11, deep and wide ulcers. During the course, bowel movements/day over 7, pulse over 90/mn, temperature over 38 degrees C on day 3 after treatment initiation as well as passage of blood on day 5 were identified as predictors of surgery. In multivariate analysis, bowel movements over 7/day on day 3 of hospitalization was independently predicted a surgery. CONCLUSION: Bowel movements/day over 7 on day 3 of hospitalization was the only independently predictive factor of surgery after glucortico steroid treatment failure