Right-sided acute diverticulitis in a North African country: Presentation and management in one surgical center.

PURPOSE: Right-sided diverticulitis is a rare entity in North Africa. Therefore, it is usually misdiagnosed, and the management of cecal diverticulitis is aggressive in most cases, whereas nowadays, most studies recommend a conservative approach with promising results. This study aims to describe the presentation, management, and outcomes of right-sided diverticulitis (RSD) and to present the experience of one surgical center in Tunisia. METHODS: This is a retrospective study including all patients presented with RSD, in the Department of Surgery "A" of the Charles Nicolle Hospital between 2007 and 2021. RESULTS: Forty patients were included in our study. The mean age was 42 years with a standard deviation of 14. The sex ratio was 1.1. Only 2 patients had chronic constipation. All patients presented right-sided abdominal pain, and only 3 patients had diarrhea. Twenty one patients were diagnosed during surgery. Fourteen patients were treated successfully by conservative management. An operative procedure was performed in 26 cases: 21 had a diverticulectomy (80%), two had an ileal resection (8%), and three had a right colectomy (11.5%). No postoperative events occurred with a short hospital stay (5 ± 3 days). Follow-up showed no recurrences. CONCLUSION: Right-sided diverticulitis has a lower incidence and complication rate compared to left-sided diverticulitis. Conservative treatment has demonstrated favorable outcomes in managing RSD, although the available evidence remains limited.

Siewert II esophagogastric junction adenocarcinoma: Still searching for the right treatment transabdominal or transthoracic surgical approaches?

INTRODUCTION: To date, the discussion is still ongoing whether the Siewert II adenocarcinoma of the esophagogastric junction (AEG) should be resected either by thoracoabdominal esophagectomy or gastrectomy with resection of the distal esophagus by transhiatal extension. The aim of our study was to compare the oncological and perioperative outcomes of the transthoracic approach (TTA) and the transabdominal approach (TAA). METHODS: Searches of electronic databases identifying studies from Cochrane, PubMed and Google Scholar were performed. Randomised and non-randomised studies comparing TTA and TAA approaches for surgical treatment of AEG Siewert type II were included. The Newcastle-Ottawa and Jada scales were used to evaluate methodological quality. The risk of bias was assessed using the Rob v2 and Robins-I tools. Meta-analyses were conducted for the outcomes. RESULTS: We included 17 trials (2 randomised controlled trials and 15 cohorts) involving 15297 patients. Longer three-year overall survival, five-year overall survival and R0 resection rates were observed in the TTA group. However, TTA had greater morbidity and pulmonary complications. CONCLUSION: Transthoracic approach appears to be preferable for selected Siewert II tumours. This may lead to higher survival rates and better R0 resection rate. Well-designed studies are needed to confirm the results of this systematic review.

Co-occurrence of blaNDM-1 and blaOXA-23 in carbapenemase-producing Acinetobacter baumannii belonging to high-risk lineages isolated from burn patients in Tunisia.

AIMS: Carbapenem-resistant Acinetobacter baumannii (CR-Ab) is an important cause of infections in burn patients. This study aimed to characterize the antimicrobial susceptibility pattern of CR-Ab isolated from burns in Burn Intensive Care Unit (BICU) of the Trauma and Burn Centre of Ben Arous, to determine the prevalence of ß-lactamase-encoding genes and to search eventual genetic relatedness of CR-Ab strains. METHODS AND RESULTS: From 15 December 2016 to 2 April 2017, all nonduplicated CR-Ab isolated in burn patients in the BICU were screened by simplex Polymerase Chain Reaction (PCR) for the class A, B, C, and D ß-lactamase genes. Sequencing was performed for NDM gene only. Genetic relatedness was determined by using pulsed field gel electrophoresis (PFGE) and by multilocus sequence typing. During the study period, 34 strains of CR-Ab were isolated in burns, mainly in blood culture (n = 14) and central vascular catheter (n = 10). CR-Ab strains were susceptible to colistin but resistant to amikacin (91%), ciprofloxacin (100%), rifampicin (97%), and trimethoprim-sulfamethoxazole (100%). All strains harbored blaOXA-51-like and blaOXA-23 genes, only or associated to blaGES (n = 26; 76%), blaADC (n = 20; 59%), blaPER-1 (n = 6; 18%) or/and blaNDM-1 (n = 3; 9%). PFGE identified 16 different clusters and revealed that most strains belonged to one major cluster A (n = 15; 44.1%). Among NDM-1 isolates, two were clonally related in PFGE and belonged to two single locus variant sequence type ST-6 and ST-85. CONCLUSIONS: This is the first description of clonally related NDM-1 and OXA-23-producing A. baumannii strains in the largest Tunisian BICU associated with two single locus variant sequence types ST6 and ST85.

Outbreak caused by pandrug-resistant blaOXA-69/blaOXA-23/blaGES harboring Acinetobacter baumannii ST2 in an intensive care unit.

Acinetobacter baumannii has emerged as a main nosocomial pathogen exhibiting high rates of resistance to clinically relevant antibiotics. Six pandrug-resistant A. baumannii (PDR-A. baumannii) were recovered from three patients in a Tunisian Intensive Care Unit (ICU) between 10th and 16th of May 2018 resulting in one fatal case and raising the possibility of an outbreak. On 18th of May environmental screening of ICU surfaces was carried out. On 22nd of May a fourth patient was infected with PDR-A. baumannii and died. A second investigation was carried out for environmental screening and PDR-A. baumannii was isolated from the respirator. Antimicrobial susceptibility testing was performed according to EUCAST (2019) guidelines. MIC of colistin was determined by broth microdilution method. PCR was used to detect 14 beta-lactamases/carbapenemases and mcr (mcr-1 to mcr-5) genes. The genetic relatedness of PDR-A. baumannii isolates was determined by PFGE and MLST. Seven PDR-A. baumannii isolates were recovered from four patients, one MDR strain from wash basin, a PDR strain from hand sanitizer bottle and another PDR strain from respirator. All PDR-A. baumannii (n = 9) harbored blaOXA-69 gene and none carried mcr. Moreover, seven carried blaGES and blaOXA-23 genes. PFGE identified four pulsotypes (A, B, C, and D) with the pulsotype A gathering seven PDR-A. baumannii isolates: six from three patients and one from hygiene sample. MLST revealed that all PDR-A. baumannii isolates of pulsotype A belonged to the pandemic clone ST2. Systematic screening of MDR and PDR-A. baumannii is highly recommended to limit dissemination of such strains in ICUs.

Prevalence of carbapenemases among Gram-negative bacteria in Tunisia: first report of KPC-2 producing Acinetobacter baumannii.

INTRODUCTION: The rapid evolution of the antibacterial resistance problem worldwide, including the Mediterranean countries, constitutes a real threat to public health. This study aims to characterize carbapenemase encoding genes among Gram-negative bacteria collected from some Tunisian hospitals. METHODOLOGY: Twenty-two clinical carbapenem-resistant Gram-negative bacteria were recovered, and identified by the matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) method. Antibiotic resistance was tested by disk diffusion method on Muller-Hinton Agar. The minimum inhibitory concentration (MIC) for imipenem was revealed by the E-test method. Carbapenemase encoding genes were screened by polymerase chain reaction (PCR). Genetic relatedness was performed by the pulsed field gel electrophoresis (PFGE) method. RESULTS: Our isolates, identified as K. pneumoniae (n = 7), P. mirabilis (n = 1), A. baumannii (n = 13), and P. aeruginosa (n = 1), presented high MIC values for imipenem. Enterobacerales were resistant to carbapenems due to OXA-48 production. Only, four K. pneumoniae harbored the blaNDM-1 gene. VIM-2 production was detected in P. aeruginosa. However, OXA-23 production was observed in A. baumannii isolates, one of which co-produced the KPC-2 enzyme that was identified for the first time in Tunisia in this species. A high genetic diversity was demonstrated by pulsed-field gel electrophoresis in K. pneumoniae and A. baumannii after XbaI and ApaI digestion respectively. CONCLUSIONS: Our findings highlight the spread of various unrelated clones of carbapenemase-producers in some Tunisian hospitals as well as the spread of several carbapenemase types.

Is There a Role for Mechanical and Oral Antibiotic Bowel Preparation for Patients Undergoing Minimally Invasive Colorectal Surgery? A Systematic Review and Meta-analysis.

INTRODUCTION: To date, all meta-analyses on oral antibiotic prophylaxis (OA) and mechanical bowel preparation (MBP) in colorectal surgery have included results of both open and minimally invasive approaches. Mixing both procedures may lead to false conclusions. The aim of the study was to assess the available evidence of mechanical and oral antibiotic bowel preparation in reducing the incidence of surgical site infection (SSI) and other complications following minimally invasive elective colorectal surgery. METHODS: We searched PubMed, Science Direct, Google Scholar and Cochrane Library from 2000 to May 1, 2022. Comparative randomized and non-randomized studies were included. We reviewed the use of oral OA, MBP and combinations of these treatments. The methodological quality of the included studies was assessed using the Rob v2 and Robins-I tools. RESULTS: We included 18 studies (7 randomized controlled trials and 11 cohort studies). Meta-analysis of the included studies showed that the combination of MBP + OA was associated with a significant reduction in SSI, AL and overall morbidity compared with the other options no preparation, MBP only and OA only.  CONCLUSION: Adding OA with MBP has a positive impact in reducing the incidence of SSI, AL and overall morbidity after minimally invasive colorectal surgery. Therefore, the combination of OA and MBP should be encouraged in this selected group of patients undergoing minimally invasive surgery.

Caudal-to-Cranial Approach for Right Colectomy with Complete Mesocolic Excision in Colon Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: A newly emerging approach "caudal to cranial" with complete mesenteric excision (CME) has recently been proposed for right colectomy in patients with right colon cancer. To date, only a few studies about this approach have appeared. Our study aims to investigate the safety and efficacy of this new technique. METHODS: A systematic review of the literature was conducted to evaluate the evidence regarding short- and long-term outcomes after the caudal-to-cranial approach (CCA). Methodological Index for Non-Randomized Studies was used to evaluate methodological quality. The risk of bias was assessed using Robvis tool. Meta-analyses have been conducted for the outcomes of studies comparing CCA with other techniques. RESULTS: We found six studies from 2017 to 2021 with a total of 594 patients. The postoperative complications and oncological outcomes were acceptable. Two studies comparing CCA to medial-to-lateral approach were included in the meta-analysis. No differences were found between the techniques regarding to operative time, length of hospital stay, overall morbidity, and number of lymph nodes. CONCLUSION: Although the interpretation of our findings may be restrained by methodological limitations, risk of bias, and the absence of well-designed randomized controlled trials, CCA with CME in right-sided colon cancer may be a feasible and safe procedure.

Giant retroperitoneal lymphangioma in a 70-year-old male: a case report.

Lymphangiomas are relatively rare benign congenital tumors of the lymphatic system. They are usually discovered during childhood and typically occur in the neck and axillary regions. Retroperitoneal lymphangiomas are a rare occurrence and represent 1% of all cases. Here, we presented a 70-year-old male who presented with abdominal discomfort and chronic constipation in the last three years. A computerized tomography scan showed a giant abdominal hypodense cystic mass measuring 195 x 145 mm, which laminates the abdominal aorta, the left iliac vessels, and the left ureter. The patient underwent surgical exploration. Due to the giant cystic volume, it was carefully opened, aspirated, and removed. The histopathological examination showed a retroperitoneal lymphangioma. In conclusion, giant retroperitoneal lymphangioma in an adult is a rare occurrence. The primary treatment is complete surgical excision. Histopathological examination is essential for diagnosis confirmation.

Spontaneous gas gangrene of the lower limb in a patient with rectal cancer: A fatal diagnostic pitfall.

Spontaneous gas gangrene of lower limb is rare. It may complicate digestive cancer or neutropenia. We report a case of spontaneous gas gangrene of the lower limb complicating a rectal cancer, initially diagnosed as deep vein thrombosis. The diagnostic delay was fatal.

An intermittent outbreak of Burkholderia cepacia contaminating hematopoietic stem cells resulting in infusate-related blood stream infections.

Microbial contamination of hematopoietic stem cells (HSC), used for autologous and allogenic transplantations, is rare but could cause serious blood stream infection in transplanted patients. These infections occur immediately, or later following the formation of biofilm on the catheter lumen. The present study describes an intermittent B. cepacia HSC contamination associated with nosocomial bacteremia: from October 2011 to April 2015, 17 B. cepacia strains were isolated in HSC bags (n = 14) and blood cultures (n = 3) in patients hospitalized in the National Bone Marrow Transplant Center. Two epidemiologic investigations in the National Blood Transfusion Center, allowing the isolation of three strains in hygiene samples, and four interventions in this institution were done. To identify the source of this contamination, a molecular investigation was done on 23 B. cepacia strains isolated in our center from 2007 to 2015. PFGE analysis revealed five clusters. The major cluster included 18 strains isolated from HSC bags (n = 14), blood culture (n = 1), and water cans and bath (n = 3). The second cluster (B) including only two and the remaining clusters (C, D, and E) contained single strains isolated before the epidemic period. These findings confirmed that the origin of the outbreak was the contaminated water used in the water bath during the thawing step of HSC bags. Based on this result, new sterile water was used for every defrosting, but HSC bags contamination persisted. In May 2015, the water bath was replaced with a dry bath and no B. cepacia strain was isolated from that date to April 2020.

Primary Echinococcus Hydatid Cyst of the Uterus: An Unusual Location.

Hydatidosis is a widespread anthropozoonosis. It can affect almost any part of the body, but it occurs most commonly in the liver (75%) and the lungs (15%). Its occurrence in female genital tract, especially the uterus, is very rare. Diagnosing hydatid disease at these unusual locations can be difficult. Hereby, we report two cases of primary hydatid cyst of the uterus. The first case is that of a 62-year-old woman, G7P5A2, who presented with an eight-month history of chronic pelvic pain. Clinical examination and radiological explorations revealed the presence of a uterine fibroid and a serous cystadenoma of the left ovary. She underwent a hysterectomy and a bilateral adnexectomy. Anatomopathological examination concluded that a serous cystadenoma of the left ovary was a calcified subserous hydatid cyst of the uterine fundus. The second case is that of a 69-year-old woman, G6P4A2, who consulted for chronic pelvic pain that had been evolving for 3 months. The clinical examination and radiological explorations doubted a hydatid cyst of the uterus, with a positive hydatid serology. She underwent a resection of the salient dome. The anatomopathological examination was in favor of a hydatid cyst of the uterus. Hydatid disease is endemic in Tunisia. The pelvic region is rarely affected with an incidence ranging from 0.3 to 0.9%, 80% of which involves the genitals. The uterus is more rarely affected than the ovaries. Most often, it is a contamination secondary to the intra-abdominal rupture of a hydatid cyst of the liver. However, primary uterine hydatid cysts have been reported. Surgery is the Gold Standard for the treatment of uterine hydatid cysts. Exploration of the abdominal cavity is essential in the search for other localizations, particularly hepatic. Postoperative medical treatment with Albendazole can be discussed. The ideal approach to deal with this public health concern is to emphasize the need for improved preventive measures. Modern imaging techniques have significantly improved the detection rates of hydatid cysts in atypical localizations. Indeed, the preoperative diagnosis of uterine hydatidosis requires a meticulous approach which is necessary to initiate an adequate treatment and thus guarantee a better management of the patient.

Can we predict mediastinal lymph nodes metastasis in esophagogastric junction cancer? Results of a systematic review and meta-analysis.

PURPOSE: The aim of this systematic review and meta-analysis was to define clinical indicator that predicts mediastinal lymph nodes metastasis (MLNM) in patients with Esophagogastric junction cancer (EGJC) to select patient population requiring esophagectomy. METHODS: A systematic and electronic search of several electronic databases was performed up to August 2020. Studies containing information on risk factors for MLNM in patients diagnosed with EJGC and who underwent curative surgery were included. RESULTS: Two predictors, including undifferentiated type (OR = 1.82, 95% CI = 1.07-3.10, p = 0.03) and esophageal invasion length (EIL) (OR = 10.95, 95% CI = 6.37-18.82, p < 0.00001) were identified as significant predictors for the risk of MLNM. CONCLUSION: Knowledge of the associations of these clinicopathological features with MLNM can be useful in determining operative strategy for EGJC.

High Carbapenem Resistance Caused by VIM and NDM Enzymes and OprD Alteration in Nonfermenter Bacteria Isolated from a Libyan Hospital.

Acinetobacter baumannii and Pseudomonas aeruginosa are among the most prevalent pathogens causing a wide range of serious infections in hospitalized patients and contaminating intensive care units and inanimate surfaces. The purpose of this study was to investigate the mechanism of carbapenem resistance in clinical and hospital environmental isolates of A. baumannii and P. aeruginosa recovered from a Libyan hospital. From a total of 82 Gram-negative bacteria, 8 isolates of A. baumannii and 3 isolates of P. aeruginosa exhibited resistance to imipenem with minimum inhibitory concentrations ranging from 16 to >32 µg/mL. Five isolates of A. baumannii harbored blaOXA-23 gene, from which three isolates were collected from patients and two from hospital environment. Only one isolate harbored blaNDM-1 gene, which was responsible for carbapenem resistance in A. baumannii. The OprD gene seems to be disturbed by an insertion sequence (IS) in two isolates and affected by polymorphism in one isolate. Pulsed-field gel electrophoresis results showed high genetic diversity among carbapenemase producing A. baumannii. This study highlights the dissemination of blaOXA-23 and blaNDM-1 genes in a Libyan setting. Therefore, infection prevention and control practices, antimicrobial stewardship initiatives, and antimicrobial resistance surveillance systems should be implemented to prevent the wide spread of antimicrobial resistance.

Surgical site infection in mesh repair for ventral hernia in contaminated field: A systematic review and meta-analysis.

BACKGROUND: Given the risk of surgical site infection (SSI), the use of mesh in contaminated ventral hernia repair (VHR) is not standardized and still a clinical dilemma. This meta-analysis aimed to assess whether mesh use increased the risk of SSI in patients following VHR in contaminated field. METHODS: We performed a systematic review of published literature. Studies comparing the mesh repair and anatomic repair, the use of mesh in different Center for Disease Control and Prevention (CDC) wound classes and mesh repair with synthetic mesh or other type of meshes to treat complicated and contaminated VHR were considered for analysis. The main outcome was SSI incidence. RESULTS: Six studies compared mesh and suture repairs. No significant difference in SSI incidence was observed between patients with complicated VHR in the mesh and suture repair groups.Five studies analyzed mesh repair in patients by field contamination level. There was no significant difference between the use of mesh in clean-contaminated, contaminated and dirty field versus clean wound class. Moreover, there was no significant difference between the use of mesh in clean-contaminated and contaminated cases.Four studies compared mesh repair technique with synthetic mesh or other type of meshes were included. The incidence of SSI was significantly lower in the synthetic mesh group. CONCLUSIONS: The use of mesh repair in the management of complicated VHR compared to suture repair is not associated with an increased incidence of SSI even in potentially contaminated fields.

Clonal spread of PER-1 and OXA-23 producing extensively drug resistant Acinetobacter baumannii during an outbreak in a burn intensive care unit in Tunisia.

Extensively drug resistant Acinetobacter baumannii (XDR-Ab), has emerged as an important pathogen in several outbreaks. The aim of our study was to investigate the eventual genetic relatedness of XDR-Ab strains recovered from burn patients and environment sites in the largest Tunisian Burn Intensive Care Unit (BICU) and to characterize ß-lactamase encoding genes in these strains. Between March 04th, 2019 and April 22nd, 2019 an outbreak of XDR-Ab was suspected. Environmental screening was done. All isolates were screened by simplex PCR for ß-lactamase genes. Genetic relatedness was determined by pulsed field gel electrophoresis (PFGE) of ApaI-digested total DNA. During the study period, 21 strains of A. baumannii were isolated in burn patients, mainly in blood culture (n = 7) and central vascular catheter (n = 6). All strains were susceptible to colistin but resistant to imipenem (n = 23), ciprofloxacin (n = 23), amikacin (n = 22), tigecyclin (n = 5) and rifampicin (n = 4). The blaOXA-51-like, blaOXA23, and blaADC genes were present in all strains. These resistance determinants were associated with blaPER-1 in 10 strains. The ISAba1 was inserted upstream of blaOXA-23 in all isolates. PFGE revealed two major clusters A (n = 11) and B (n = 5). This is the first description in Tunisia of clonally related PER-1 producing XDR-Ab in burn patients with probable environmental origin.

A randomised clinical trial to compare octyl cyanoacrylate with absorbable monofilament sutures for the closure of laparoscopic cholecystectomy port incisions.

Tissue adhesives have gained increasing use as a possible method of wound closure. We compared the use of 2-octyl cyanoacrylate (OCA) or subcuticular suture in incisions sutures for the closure of laparoscopic cholecystectomy port incisions. A prospective randomised controlled trial was performed. Patients were randomised to have closure of laparoscopic port sites using either OCA or sutures. Patients were reviewed at 24 hours and returned for follow-up 1 week and 1 month after postoperatively. At these times, different wound characteristics were documented: Two tools were used to measure the cosmetic result using Hollander wound evaluation scale (HWES) and the patient and observer scar assessment scale (POSAS). A total of 70 patients, 35 in each group were enrolled. The wounds were closed significantly faster in the OCA group (mean 229.16 [±43.7] seconds versus 258.82 [±51.7] seconds, P = .01). Statistically significant difference in favour of using OCA was found for dehiscence (17.1% versus none in the suture group, P = .025) after 1 week. However, no difference was found for wound dehiscence after 1 month. OCA and suture groups did not differ significantly on patient satisfaction. There were no differences in the percentage of wounds achieving optimal scores on the HWES (suture 85.7% versus OCA 74.2%, P = .169). Nerveless, wound evolution was judged to be significantly better in the OCA group using POSAS. Patients' median POSAS was 9.45 (6-11) and 11.43 (10-13) in the OCA and suture groups, respectively (P = .005), and surgeon's median POSAS was 9.42 (6-11) and 11.48 (10-13) in the OCA and suture groups, respectively (P = .006). N-butyl-cyanoacrylate tissue adhesive is an acceptable technique for the closure of laparoscopic wounds with less operative time, and cosmetic results are comparable to suturing.

Intussusception through an ileostomy: A case report and literature review.

INTRODUCTION: Intussusception through an ileostomy is one of the rarest complications of stomas. In this study we report a case and a brief update of the literature to focus on the clinical level of this pathology and the therapeutic attitudes. PRESENTATION OF CASE: a 44-year-old man who underwent a small bowel resection with double stoma for tuberculosis peritonitis presented with stomatal prolapse. On examination of the stoma, small bowel mucosa appeared to have evident rather than serosa. The patient had an elective reduction of the proximal stoma under anesthesia. CONCLUSION: A review of the literature shows that Intussusception through an ileostomy can occur at any time after the first surgery. The cause is still unclear. Urgent conservative surgical management based on manual reduction should be preferred.

Thymoquinone attenuates lead-induced nephropathy in rats.

Kidney hazards from lead (Pb) exposure are one of the fastest growing areas of concern in toxicology today. The thymoquinone (TQ) renoprotective effect against Pb-induced nephropathy has not previously been studied. Therefore, adult male Wistar rats were treated with Pb (2000 ppm of Pb acetate in drinking water) and/or TQ (5 mg/kg/day,  per os). All treatments were applied for 5 weeks. The results indicated that Pb exposure produced metal deposition, histopathological changes, functional impairment (significant elevation in plasma urea, uric acid, and creatinine levels), total antioxidant status decrease, and lipid peroxidation stimulation in the kidneys. Interestingly, TQ supplementation remarkably improved the Pb-induced renal adverse effects without significantly reducing the tissue metal accumulation. In conclusion, our data indicate for the first time a protective effect of TQ against Pb-induced nephropathy, most likely through an antioxidant mechanism. On this basis, TQ deserves more consideration and further examination as a potential therapeutic option.