Standardized approach to the conservative surgery of hepatic cystic echinococcosis: A prospective study.

OBJECTIVE: Surgery is the mainstay of hepatic cystic echinococcosis (HCE). The conservative surgery of HCE carries a non-negligible risk of recurrence and significant morbidity, dominated by Deep Surgical Site Infections (DSSI). To address these issues, we have improved and standardized this technique, which could reduce complications and achieve better postoperative outcomes. PATIENTS AND METHODS: We conducted a prospective study from June 2017 to June 2022 involving of patient operated using a standardized open technique for uncomplicated HCE at Habib Bourguiba University Hospital, Sfax, Tunisia. The aim was to obtain results at least similar to radical management in terms of DSSI. Patients with large cystobiliary fistulas or patients with complicated cysts were excluded. RESULTS: Fifty patients with 106 cysts were operated using the standardized technique comprising of liver mobilization, intraoperative ultrasound, systematic methylene blue injection to detect cystobiliary fistulas and omentoplasty. The median age of the patients was 44(semi-interquartile range: 16) years. The main symptom described by the patient was pain in 43 cases (86%). An abnormal liver test was found in 20 cases (40%). On imaging studies, the cyst had a median size of 7.4(3.0) cm. Cyst of the hepatic dome accounted for 38 cases (35.8%) with most cysts being situated in the right hemi-liver. Visual inspection of the cavity and Methylene blue testing allowed for the discovery of 57 cysts (53.7%) that had cystobiliary fistulas that were sutured. Omentoplasty was performed in 77 cysts (72.6%). Postoperatively, only 2 cases (1.9%) developed a DSSI in the form of an external bile leak with resolved with conservative management. No case of recurrence was found after a median follow-up of 24 months. CONCLUSION: The standardized conservative surgical technique, in selected patients, shows promise in reducing DSSI rates and overall morbidity, and achieve as equally good result as radical management.

Cystic Echinococcosis of the Liver: Correlation Between Intra-Operative Ultrasound and Pre-Operative Imaging.

Background: Imaging plays an essential role in the management of hepatic hydatid cysts (HCE). The objective of our study was to determine the correlation between pre-operative ultrasound, computed tomography (CT), and intra-operative ultrasound (IOUS) in studying the characteristics and complications of HCE. Patients and Methods: This was a prospective, descriptive, and analytical study conducted in the General Surgery Department of Habib Bourguiba Hospital in Sfax. The study included patients with HCE who underwent conservative surgery between April 2017 and June 2022. Results: We enrolled 49 patients with 94 cysts. At the end of our study, IOUS allowed for better detection of HCE (98.8%) regardless of the number of cysts per patient. IOUS and CT were accurate in studying the location of cysts (κ = 1), whereas pre-operative abdominal ultrasound was less efficient (κ = 0.870). IOUS was the best examination for detecting exocysts (κ = 0.961), studying daughter cysts (κ = 0.823), and exploring vascular relations, but it was less effective (κ = 0.523) in detecting calcifications. Regarding classifications, ultrasound and CT had similar results. However, IOUS was most reliable in differentiating between CE3b and CE4 types (κ = 0.653). Ultrasound, CT, and IOUS were not sensitive in detecting latent HCE suppurations and cystobiliary fistulas. Conclusions: Performing IOUS is essential to prevent recurrences and reduce post-operative morbidity.

Predictive factors of occult cystobiliary fistulas during conservative treatment of hepatic hydatid cyst: a prospective study.

BACKGROUND: Occult cystobiliary fistula (CBF) is a common complication of hepatic hydatid cyst (HHC). It is often the cause of high morbidity of conservative treatment of HHC. This study aimed to determine the predictive factors of occult CBF to establish the indications for the investigation and treatment of these CBFs. METHODS: This was a prospective study that included all operated HHCs over a 3-year period. HHCs complicated with large CBFs were not included in the study. Systematic cholecystectomy and methylene blue test for all cysts were performed. RESULTS: A total of 46 patients operated on with 113 cysts were included in this study. The median cyst size was 6.7 cm (IQR, 1-38). A total of 114 CBFs were detected in 51 cysts (45.1%). The postoperative course was simple in 95.0% of cases. The specific morbidity rate was 2.7%. In a bivariate study, absence of mass and abdominal pain on palpation, hemoglobin level >11.55 g/dL, negative hydatid serology, cyst size, absence of calcifications, vascular compression, existence of a single cyst, and localization at segment VIII were predictive factors of occult CBF. At the end of the multivariate study, cyst size was determined to be the only predictive factor for occult CBF. A threshold of 3 cm was used. CONCLUSION: Cyst size is a major predictive factor for occult CBF.

Viability predictive factors of the daughter vesicles in hepatic cystic echinococcosis.

INTRODUCTION: Management of cystic echinococcosis (CE) requires knowledge of certain aspects related to the survival of Echinococcus granulosus. The viability of daughter vesicles (DV) is a determining factor in guiding therapeutic indications, particularly for transiently active Cysts type CE3b. PURPOSE: To determine the predictive factors of DV viability and its impact on the therapeutic management of CE3b type. MATERIALS AND METHODS: This is a prospective pilot study with an analytical aim on patients with cystic echinococcosis of the liver type CE2 and CE3b, operated in the General Surgery Department of Habib-Bourguiba Academic Hospital, Sfax-Tunisia for 22 months from March 2018 until December 2019. The unit of the study is the DV. A parasitological study of the DV was done in the parasitology laboratory. RESULTS: During the study period, 27 (40.9%) of 66 operated CE Disease from 21 patients containing 248 DV were explored. The median viability of DV protoscoleces was 16.7%. In bivariate analysis, factors for viability of DV protoscoleces were: fever, acute cholangitis, hyperbilirubinemia, left liver location, rock water and bilious echinococcal fluid (EF), cyst size ≥ 43 mm, Intracystic pressure ≥ 35 mmHg, DV size ≥ 6.5 mm, volume, number of DV/cyst ≥ 5, and opaque wall (p < 0.05). Predictive factors for the Non-viability of DV were: CE3b type, purulent EF, gelatinous EF. In multivariate analysis, only CE2 type, cyst size ≥ 43 mm, number of DV/cyst ≥ 5 and DV size ≥ 6.5 mm were factors significantly associated with the viability of DV protoscoleces. CONCLUSION: CE3b cysts without the criteria of viability of DV protoscoleces may become candidates for the 'Wait-and-Watch' procedure.

Primary cystic echinococcosis of the peritoneum: a case report.

BACKGROUND: Peritoneal cystic echinococcosis happens usually after traumatic rupture or after surgical treatment. Primary peritoneal cystic echinococcosis is a very rare case that constitutes a diagnostic and therapeutic challenge. CASE REPORT: A 30-year-old Tunisian man was admitted for hypogastric pain since 4 months. He has a 10 cm hypogastric mass. Biological-tests were normal. A computed tomography Scan showed a cystic mass on the pelvis measuring 13 × 17 cm without echinococcosis cyst in the liver. The patient was operated and we found a cystic mass of 17 cm located on the Douglas cul-de-sac that suggest a pelvic hydatid cyst. We have performed an aspiration of the cyst confirms the diagnosis followed by injection of hypertonic solution, extarction of the germinal layer and a maximal reduction of the pericyst. The postoperative course was uneventful. CONCLUSION: Trough our case, we try to focus on the diagnosis and therapeutic options of this rare entity that we should think of in front of a patient with isolated peritoneal cyst especially in endemic country.

McGrath® versus Macintosh laryngoscopes on hemodynamic response to intubation in elderly patients: a randomized clinical trial.

Introduction: laryngoscopy and tracheal intubation induce catecholaminergic release. Our study aimed to evaluate the hemodynamic impact of orotracheal intubation by McGrath® compared to the Macintosh laryngoscope in the elderly. Methods: we conducted a prospective randomized clinical trial that included elderly patients proposed for a scheduled surgery under general anesthesia with orotracheal intubation and divided into 2 groups: patients who were intubated using the McGrath® (group V) and patients who were intubated using the Macintosh direct laryngoscope (group M). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MAP), were recorded before induction of anesthesia (baseline), and at 1 min, 3 min, and 5 min after intubation. Our outcomes were the increase of SBP (∆ SBP), MAP (∆ MAP), and HR (∆ HR) between the two groups, during the 5 minutes following the start of the orotracheal intubation, intubation time and the incidence of its related complications. Results: sixty patients were included and randomized into 2 groups of 30. The average age of our sample was 70±6 years with a sex ratio of 1.22. Most of the patients were operated on for orthopedic, urologic, or abdominal surgery. There were no statistically significant differences between the two groups in terms of demographic characteristics and the duration of anesthesia (p> 0.05). The intubation time was significantly increased in group M (p≤0.001). There was a significant difference in SBP, MAP, and HR values at 1 min after orotracheal intubation compared with the baseline values in Group V(P<0,05) and Group M (p < 0.05). There was a significant increase in the first minute after tracheal intubation in terms of SBP (151±42 vs 134.5±26 mmHg, p=0.012), MAP (114±4 vs 102±17 mmHg, p=0.015), DBP (89±32 vs 84±16 mmHg, p=0.01), and HR (99.5±10 vs 94.5±2 b/min, p=0.008) when group M was compared to group V. The ∆SBP was significantly different between group M (∆SBP = 36.2±23.5mmHg) and group V (∆SBP= 30.77±21.6mmHg) (p = 0.005). There were 4 ventricular arrhythmias in group M versus zero in group V (p <0.0001). The postoperative sore throat was significantly decreased in group M vs V (p=0.036). Conclusion: the McGrath® videolaryngoscope decreased the hemodynamic fluctuations due to endotracheal intubation in elderly patients.

[The effect of intraperitoneal administration of dexamethasone on postoperative analgesia after laparoscopic cholecystectomy: a prospective randomized controlled double-blind study]. / Intérêt de la déxaméthasone en intrapéritonéale dans l'analgésie post cholécystectomie laparoscopique: étude prospective contrôlée randomisée en double aveugle.

Introduction: the effect of intravenous corticosteroids on postoperative pain has been well demonstrated; however, few studies have focused on the efficacy of intraperitoneal corticosteroid use after laparoscopic surgery. The purpose of this study was to evaluate the effect of intraperitoneal administration of dexamethasone on postoperative analgesia after laparoscopic cholecystectomy. Methods: we conducted a prospective, randomised, double-blind, controlled study, including patients scheduled for laparoscopic cholecystectomy and randomised into two groups: the group D (receiving 16 ml: 12 ml saline and 4 ml solution containing 16mg dexamethasone) and the group T (receiving 16 ml saline). The primary endpoint was: Visual Analogue Scale (VAS) for abdominal pain during the first 24 hours after surgery. The secondary endpoints were the incidence of shoulder pain, time to first request for analgesia, the consumption of morphine in the post-intervention surveillance room (PACU), the consumption of non-opioid analgesics and the incidence of nausea and vomiting during the first 24 hours after surgery as well as the presence of complications. Results: sixty patients were included in the study and divided into two groups of 30. Demographic parameters, duration of surgical and anesthesia procedures, as well as intraoperative fentanyl consumption were comparable between the two groups. Abdominal pain VAS values (p≤0.001), the incidence of shoulder pain (p<0.001), opioid and analgesic consumption (p<0.001) and the incidence of nausea (p=0.002) and vomiting (p=0.012) during the first 24 hours after surgery were significantly lower in group D. No complications related to dexamethasone administration were noted. Conclusion: intraperitoneal dexamethasone reduces postoperative pain after laparoscopic cholecystectomy.

Laparoscopic repair of the broad ligament hernia: A case report.

INTRODUCTION AND IMPORTANCE: Broad ligament hernia is a rare type of internal hernia caused by the protrusion of viscera through an abnormal defect on the broad ligament. The diagnosis is difficult and challenging. Usually, it requires an urgent laparotomy to avoid intestinal necrosis or even the death of the patient. CASE PRESENTATION: A 34-year-old woman, with no medical or surgical history, presented to our educational hospital with acute abdominal pain and recurrent vomiting for the last two days. After clinical and radiological investigations, the diagnosis of an internal hernia through the broad ligament was confirmed. An emergent laparoscopic repair was performed and the postoperative course was uneventful. CLINICAL DISCUSSION: We report a rare case of an internal hernia through the broad ligament and we describe the challenges associated with the preoperative diagnosis and therapeutic approach. The defect in the broad ligament may be unilateral or bilateral and congenital or acquired. There are no specific clinical and radiologic findings. Surgery remains the cornerstone of the treatment. CONCLUSION: Early diagnosis and rapid management of broad ligament hernia are necessary to prevent catastrophic sequelae. It is important to keep in mind that internal hernia like broad ligament hernia can occur in patients with no surgical history.

Spontaneous perforation of the common bile duct in adults presenting as biliary peritonitis: a case report and literature review.

Spontaneous perforation of the common bile duct (SPCBD) is an exceptional disease, especially in adults. The cause is often idiopathic once trauma and choledochal cyst are excluded. Early diagnosis is often difficult because of its often-misleading appearance. Case presentation: The authors report the case of a 54-year-old man, a known case of type 2 diabetes mellitus, who presented to our emergency department for acute abdominal pain that had evolved for 2 days. Clinical findings and investigations: On physical examination, the patient had a fever of up to 38.5°C, and the abdomen was distended and generally tight. The abdominal computerized tomography scan confirms the presence of free fluid. In addition, the thickness of the gallbladder wall had increased in contrast with a resolved gallbladder distention. Because exploration failed to demonstrate the cause of ascites, the authors performed a diagnostic paracentesis, which revealing ascites with a dark yellow-green color, which implied bile leakage.After initial resuscitation, an emergent exploratory laparotomy was performed. The authors found biliary peritonitis secondary to SPCBD. After peritoneal lavage, the perforation was repaired over a T-tube. The postoperative course was uneventful. Histological findings were consistent with ulcerous acalculous cholecystitis. The patient was disease-free after a 3-month follow-up. Discussion: SPCBD is an uncommon condition in adults, and it is rarely reported in the literature. The pathogenesis of this disease is not clear and may be related to single or multiple factors. Usually, this disease is diagnosed in the postmortem. Early diagnosis and optimal surgical treatment are challenging. Conclusion: This present case highlighted the preoperative diagnostic difficulties of the SPCBD. Emergent surgical management should be instituted in the shortest time possible to reduce the high mortality.

Emphysematous cystitis revealed by necrotizing fasciitis: An unusual presentation.

Emphysematous cystitis (EC) is a severe infection of the bladder that usually affects older women with diabetes mellitus. In rare situations, EC can lead to serious complications such as necrotizing fasciitis. We report the case of a 77-year-old woman who developed emphysematous cystitis complicated with rapidly progressive, gas-producing, necrotizing inflammation located on the right lower abdominal wall. The patient had aggressive drainage and debridement in order to control the extensive necrosis. To our knowledge, this is the third case report that describes a possible association between EC and NF requiring aggressive surgical intervention for both diseases.

Primary aortoduodenal fistula presenting as a rare cause of upper gastrointestinal bleeding.

Primary aortoduodenal fistula (ADF) is a serious life-threatening condition. Unlike secondary ADF which occurs in patients who had previous aortic prosthetic reconstruction, primary ADF is uncommon. Its diagnosis is often unsuspected until surgery or postmortem. We report a rare case of primary ADF presenting as massive gastrointestinal bleeding.

A rare case of small intestinal metastasis from lung cancer.

We report the case of a 61-year-old male patient who was admitted with abdominal pain, vomiting and constipation. He had a past medical history of epidermoid lung cancer .computed tomography revealed distended stomach with mural bowel thickening. It was peroperatively two small-bowel metastasis from lung cancer that we resect.

Acute post-traumatic dermoid peritonitis: A rare entity.

Rupture of ovarian dermoid-cyst is rare case. We report the case of a woman admitted for acute post-traumatic abdominal pain due to ruptured ovarian cyst. The patient was operated and we found a very abundant peritoneal effusion with left ovarian cyst which was broken. we performed a left adnexectomy.

Gastric trichobezoar: An uncommon cause of epigastric pain: A case report.

Trichobezoars are foreign and indigestible materials in the gastrointestinal tract and are usually found in psychiatric females, who often deny eating their own hair, but also at situations of gastric dysmotility and prior gastric surgery. Although rare, gastric trichobezoar should not be forgotten as a differential diagnosis in females presenting with vague epigastric pain. Its treatment well in time will prevent complications.

Predictive factors of occult cystobiliary fistula after conservative surgical treatment of the hepatic hydatid cyst A retrospective study of 105 patients.

OBJECTIVES: The objective of our study was to determine the predictive factors of their occurrence during conservative surgical treatment of the hepatic hydatid cyst (HHC). PATIENTS AND METHODS: We carried out a retrospective review of patients who had undergone conservative surgical treatment of the HHC during 6 years. Univariate analyzes were used to determine the predictive factors of an occult cystobiliary fistula (CBF). RESULTS: This current study included 105 patients. Concerning the predictive factors of an CBF regardless of its pattern of evolution, we noted that the presence of fistula was statistically correlated with the a cyst size (bigger than 8.65 cm ; p = 0.003) and with advanced age (p=0.035). Interestingly enough, the correlation to a degenerated cyst (p=0.069) were of little significance. CONCLUSION: The size of the cyst greater than 8.65 cm and the advanced age are the risk factors of CBF according to our study. KEY WORDS: Biliary Fistula, Diagnosis, Echinococcosis, Hepatic, Prevention and control.

[Comparison between endoscopic stenting and colostomy in the management of obstructing cancer of the left colon: Literature review]. / Comparaison entre stent endoscopique et colostomie pour les cancers coliques gauches en occlusion : revue de la littérature.

INTRODUCTION: Colonic occlusion is the mode of discovery of 8 to 29% of colonic neoplasms. Our objective is to compare the placement of stent versus colostomy in the management of obstructing cancer of the left colon. MATERIAL AND METHODS: We have carried out a systematic search of literature from MEDLINE, EMBASE and Cochrane Library database to identify articles related to the comparison of stent versus colostomy published between 2000 and 2016. RESULTS: We have identified 6 studies. Only one study was prospective comparative. Three studies were for curative purposes. The total number of patients was 7205. In the "stent" group, there was a decrease in the average length of hospital stay compared to the "stoma" group and there was a decrease in cost with a statistically significant relationship. There was no difference between the two groups in terms of 4 hospital mortality and early morbidity. CONCLUSION: In case of neoplastic occlusion of the left colon, the choice between colostomy or colonic stent depends on the therapeutic strategy. Indeed, for curative strategy or administration of anti-angiogenics, it is recommended to practice a colostomy. However, for palliative treatment, colonic stenting is the treatment to follow.

Correlation of radiological findings with surgical findings in hepatic hydatid disease. A prospective study of 79 cases.

OBJECTIVES: The liver is the most frequent anatomic location of hydatid disease. Imaging modality nowadays are numerous and increasingly efficient. The objective of our study is to precise the correlation between Ultrasonography, computed tomography and intraoperative findings on the different characteristics of hepatic hydatid cyst. PATIENTS AND METHODS: We conducted a prospective study including all hepatic hydatid cyst operated in 2015. We evaluated statistically, by calculating the coefficient K or the intraclass correlation coefficient, the concordance between Ultrasonography, computed tomography (CT) and intraoperative findings on the different characteristics of hepatic hydatid cyst. RESULTS: In our study, we included 48 patients with 79 hepatic hydatid cysts. It was concluded that Ultrasonography performs better than CT in the study of type of cyst, pericyst, relationships with portal vein and main bile duct. While CT is better than echography in terms of number, localizations of cyst, relationship with the vena cava inferior, other localizations and the remaining liver, both examinations remain limited in the determination of pericyst characteristics and the identification of biliary fistula. CONCLUSION: Ultrasonography and CT cannot provide accurate data for the study of pericyst and biliary fistula, hence requiring prospective studies of the place of MRI and intraoperative echography in this domain. KEY WORDS: Diagnostic, Imaging, Echinococcosis, Hepatic, Intraoperative Care.