Early laparoscopic cholecystectomy in severely comorbid patients with acute cholecystitis: results of a monocentric study.

Aim: The aim is to evaluate laparoscopic cholecystectomy safety based on American Society of Anesthesiologists score for acute cholecystitis in patients with comorbidities. Patients & methods: This is retrospective study of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2003 and 2021. According to their respective ASA-score, patients were divided into group 1: ASA1-2 and group 2: ASA3-4. Results: We collected 578 patients. Even though the gangrenous forms were more frequent and the operative time was longer in group 2, laparoscopic cholecystectomy seems safe and effective. We didn't observe any differences in terms of intraoperative incidents, open conversion rate, or postoperative complications compared with other patients. Conclusion: ASA3-4 patients with acute cholecystitis don't face elevated risks of complications or mortality during laparoscopic cholecystectomy.

This study, involving 578 patients with acute cholecystitis, assessed the safety of early laparoscopic cholecystectomy based on their health scores. Despite longer operative times and more gangrenous forms in higher-scored patients, laparoscopic cholecystectomy was found to be safe and effective. No significant differences in complications or mortality were observed compared with lower-scored patients. In conclusion, early laparoscopic cholecystectomy is considered a safe option for patients with higher health scores facing acute cholecystitis.

Study assessed laparoscopic cholecystectomy safety in high-risk patients with acute cholecystitis based on ASA scores. Despite longer operative times, it's a safe and effective option. #CholecystectomySafety.

Median arcuate ligament syndrome (Dunbar syndrome): A diagnosis not to be underestimated.

Medial arcuate ligament syndrome (MALS) is an anatomoclinical entity underestimated in most situations due to the lack of specific signs. However, the consequences can be disastrous if the diagnosis is not seriously considered and investigations are not fully undertaken to confirm this hypothesis. We report a case of Median Arcuate Ligament Syndrome in a young woman who presented to the Emergency Department with moderate postprandial pain. All investigations were carried out promptly, with no abnormalities, and the diagnosis was retained on the evidence of a well-performed and appropriately interpreted abdominal CT. This case illustrates a rare cause of epigastralgia simulating a surgical emergency. This condition should be considered when biological and often radiological investigations are inconclusive. The relative youth of the patient is often suggestive, but confirmation is based on a CT scan with injection of a well-technical contrast product, or angiography. Treatment is debatable between a conservative approach and surgery. Surgical approach is discussed depending on the degree of vascular stenosis and the impact on the digestive tract. However, the recurrence of symptoms may be a contributory factor in the therapeutic decision. The impact could be lethal depending on the degree of stenosis and consequently on the repercussions on the digestive tract. A multidisciplinary approach is required for its management.

A case report of gastroduodenal artery pseudoaneurysm and giant pancreatic pseudocyst following acute pancreatitis revealed by obstructive jaundice.

Acute necrotic pancreatitis is an emergency of evolution and is often unpredictable because of the potentially life-threatening complications it can cause. We report a unique case of a 56-year-old woman hospitalized for acute necrotic pancreatitis. The evolution of the latter was characterized by the occurrence of two very rare complications, of which the clinical presentations were atypical. The first complication was a gastroduodenal pseudoaneurysm compressing the main biliary tract and causing obstructive jaundice, which evolved well following percutaneous embolization. The second complication was a giant 20 cm pancreatic pseudocyst revealed by obstructive jaundice secondary to biliary compression, which progressed well following surgical treatment.

Acute intestinal obstruction: What if it is instead colonic tuberculosis? What diagnostic and management dilemmas are there?

INTRODUCTION AND IMPORTANCE: Colonic tuberculosis is rare. Clinical, biologic endoscopic and radiological features are not unequivocal. A multitude of differential diagnoses interfere, including Crohn's disease and cancer. CASE PRESENTATION: we present a case of a 48-year-old Tunisian female who complained from occlusive syndrome. For whom none of the various elements of the medical record, the clinical, endoscopic and radiological investigations had enabled a decision to be reached in favor of one diagnosis over the other. Several diagnoses were suggested, including Crohn's disease, neoplastic diseases and, ultimately, colonic tuberculosis, since our country was endemic for this pathology. The collegial decision of the medical staff involved in the management was to operate on the patient. Surgery was required with the intention to treat and mainly to provide histological proof of the disease. A right colectomy allowed histological examination and a diagnosis of colonic tuberculosis. DISCUSSION: The diagnosis should be discussed in patient from endemic countries, who complain chronic abdominal pain, vesperal fever and weight loss for who endoscopy shows the presence of nodules or ulcers. The diagnosis is retained on the basis of pathological findings. CONCLUSIONS: Because of a nonspecific clinical and endoscopic presentations, multiples biopsies even surgical resection are mandatory to rule out differential diagnosis and to confirm the diagnoses of colonic tuberculosis.

Management of pheochromocytoma during pregnancy. A multidisciplinary challenge: A case reports.

INTRODUCTION: Identification of pheochromocytoma during pregnancy is unusual. Lack of appropriate management may be responsible of high risk for both mother and fetus. The guarantee of a successful management of a pheochromocytoma during pregnancy is the establishment of an early diagnosis as well as the prevention of a hypertensive crisis during delivery and surgical treatment and without compromising the maternal-fetal prognosis. CASE PRESENTATION: A 31-year-old female patient, without any notable pathological history, pregnant at 20 weeks of amenorrhea was diagnosed for a Menard's triad. The medical investigations had allowed to confirm the diagnosis of left secretory pheochromocytoma. The surgical indication was taken in concertation between surgeons, endocrinologists, gynecologists and anesthesiologists. The parturient had undergone an uneventful laparoscopic left adrenalectomy without incidents. CASE DISCUSSION: Our case well illustrates that when the operative indication is posed, laparoscopic surgery can be performed safely during any trimester. However, it is legitimate to modulate the incisions according to gestational age and the height of the fundus. The involvement of all disciplines intervening in the management of the pregnant woman with pheochromocytoma is the guarantor of a favorable maternal-fetal prognosis. CONCLUSION: A well-established diagnosis for pregnant women with severe secondary hypertension, multidisciplinary management, and safe laparoscopic approach are crucial to prevent perinatal morbidity and mortality.

Gas spread following endoscopic sphincterotomy: Challenging diagnosis and management: A case reports.

INTRODUCTION AND IMPORTANCE: Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum simultaneously are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP) that usually indicates free perforation to the peritoneal cavity or the retroperitoneal space. CASE PRESENTATION: We report an unusual case of a subcutaneous emphysema, pneumomediastinum and pneumoperitoneum following an ERCP for removal of a common bile duct stone. There was no radiological evidence of peritoneal or retroperitoneal perforation. CLINICAL DISCUSSION: This complication seems to be relative to duodenal perforation. However, hypotheses of transdiaphragmatic pressure effects and gas diffusion within the mucosa are discussed in the literature pneumomediastinum and pneumoperitoneum, must be recognized, because it is benign and needs exceptionally surgical or radiological intervention. Management of this adverse event depends on type of perforation and clinical presentation. CONCLUSION: ERCP has facilitated innovative diagnosis and treatment of pancreatobiliary tract diseases. Nevertheless, some complications may occur such gas diffusion in the peritoneal cavity or the retroperitoneal space with or without perforation. Our case our case illustrates such incidents could be benign, self-limited and need no intervention.

Early laparoscopic cholecystectomy for acute cholecystitis: Does age matter?

AIM: Advances in laparoscopic surgery and perioperative care have improved the prognosis of operated patients, especially the oldest among them. This study aimed to assess the outcomes of early laparoscopic cholecystectomy for acute calculous cholecystitis in older adult patients. METHODS: A retrospective analysis was carried out of 567 patients who underwent early laparoscopic cholecystectomy for acute calculous cholecystitis between January 2003 and July 2021. The outcomes of older adult patients (≥ 75 years) were compared with those of younger patients. RESULTS: The older adult group had significantly more patients with an American Society of Anesthesiologists score ≥3 (37.5% vs 8.3%; P < 0.001) and more severe acute calculous cholecystitis (grade II; 82.8% vs 67%; P = 0.01). There were no significant differences regarding operative time (90 vs 80 min; P = 0.064), conversion rate (20.3% vs 13.5%; P = 0.144), and both intra- and postoperative morbidity, principally bile duct injuries (1.6% vs 0%; P = 0.113) and bile leakage (0% vs 1.2%; P = 1). CONCLUSION: Early laparoscopic cholecystectomy could be proposed safely for older adult patients with mild and moderate acute cholecystitis. Geriatr Gerontol Int 2023; 23: 671-675.

Recurrent caecal volvulus in an adult: Should we practice coecopexy systematically at neonatal age for incomplete common mesentery? A case report.

INTRODUCTION AND IMPORTANCE: Malrotation is usually revealed early in infancy and or later in childhood, even more unusually in adulthood. This disorder is treated through Ladd's procedure. Literature is limited on the long-term outcomes of this approach, especially into adulthood. CASE PRESENTATION: We present a case of a 33 years male with a history of a laparotomy as a new born for a bowel obstruction secondary to malrotation, presenting with an obstruction and colonic volvulus. Laparotomy reveals a volvulus of the coecum secondary to a failure of the coecum to attach during surgery performed at neonatal age. CLINICAL DISCUSSION: For a patient operated on during the neonatal period for intestinal malrotation, the examination for sub occlusive episodes should suggest a recurrence of malrotation such as coecal volvulus, and the possibility of technical malfunction during the previous procedure. This reflection leads us to consider the necessity of performing coecopexy systematically during the first surgery. CONCLUSION: Ladd's technique is the surgical treatment of the incomplete common mesentery. The fixation of the coecum could be done in a systematic way to prevent a possible coecal volvulus which can be responsible for digestive necrosis and often even a fulminant evolution.

Extensive small bowel necrosis due to congenital para duodenal hernia: A diagnostic and therapeutic challenge: Case Report.

INTRODUCTION: A paraduodenal hernia is a rare variety of hernia, however it is the most usual type of internal hernias. Clinical presentation is nonspecific. The clinical presentation is variable: indeed, the patient can be completely asymptomatic or present with symptoms which severity is variable according to the mechanism. The most common cause is an acute intestinal occlusion that could progress even to ischemia and intestinal necrosis. Depending on the clinical presentation and the suspected diagnosis, computed tomography can be of considerable help in demonstrating a para duodenal hernia. CASE PRESENTATION: We describe the case of a young man aged 18 years, who presented to the emergency unit with severe abdominal pain associated with incoercible vomiting. The surgical exploration had confirmed a para duodenal hernia responsible for an extensive necrosis of the small intestine allowing viable 90 cm only. CASE DISCUSSION: Paraduodenal hernias are rare and their diagnosis is not always easy. Therefore, they should be considered especially in the case of an occlusive syndrome occurring in a young patient who has never been operated on. If no treatment is undertaken, the evolution is drastic and the mortality rate is significant. CONCLUSION: Successful surgical management requires knowledge of the intra-abdominal peritoneal spaces and management of suggestive clinical situations in order to reduce postoperative morbidity and mortality resulting from delayed diagnosis and treatment.

Early laparoscopic cholecystectomy for acute cholecystitis: should we operate beyond the first week?

BACKGROUND: The deadline for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is the subject of much debate. The aim of this study was to assess outcomes of ELC in patients with more than 7 days of symptoms. METHODS: It is a retrospective analysis of 564 patients having undergone ELC for ACC between January 2003 and June 2021. Patients were divided into two groups according to the timing between the onset of symptoms and surgery: group 1 (G1), within the first 7 days of symptoms, and group 2 (G2) after day 7 of symptoms. RESULTS: Apart from a longer operative time (G1 80 min vs. G2 90 min; p = 0.016), there were no significant differences regarding conversion rate (G1 14.5% vs. G2 13.2%; p = 0.748), both intra- and postoperative complications, mainly bile duct injuries (G1 0.2% vs. G2 0%; p = 1) and bile leakage (G1 1.2% vs. G2 0%; p = 1) and postoperative length of stay (G1 2 days [1-3] vs. G2 2 days [1-4]; p = 0.125). CONCLUSION: Early laparoscopic cholecystectomy could be proposed for patients with acute calculous cholecystitis even beyond 7 days of symptoms.

East-central Tunisian patients with colorectal adenocarcinoma: a comparative study of the clinicopathological features between patients under 50 years of age and older patients.

INTRODUCTION: Colorectal cancer is a major public health problem. In younger patients, its incidence continues to rise and its prognosis appears to be worse. Its treatment is based on curative surgery associated with neo-adjuvant and adjuvant therapies. AIM: To describe the clinical and pathological characteristics of colorectal cancers in young patients. METHODS: In this monocentric cohort study, we retrospectively analyzed the clinicopathological features in colorectal cancer patients who underwent treatment from 2002 to 2014. Data of younger (group A, ≤50years) vs older (group B, >50years) patients were compared. RESULTS: Two hundred and sixty-six patients met inclusion and non-inclusion criteria. The younger and older groups consisted respectively of 25.2% and 74.8% of patients. Both groups were comparable regarding the symptom presentation and duration. Synchronous tumors were more frequent amongst the group A (10.7% vs 1.0%, p = 0.024). Preoperative staging showed a higher frequency of tumors classified as advanced stage (stages III and IV) in the group A (p = 0.001). The patients of group A were diagnosed with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas (13.4% vs 3.5%, p = 0.005), the mucinous character was also more frequent in the group A (28.4%). According to the pTNM (tumor, nodes and metastases) classification, tumors were more advanced in the group A than in group B (80.6% vs 48.7%, p <0.001). CONCLUSION: This study revealed that colorectal adenocarcinomas in the younger patients, compared to the older ones, were more aggressive with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas, more often mucin production and more advanced tumors.

Colonic schwannoma: A case of unusual presentation and outcome.

BACKGROUND: Schwannomas are mesenchymal tumors arising from neural sheath cells and whose diagnosis is based on immunohistochemistery. The digestive and especially colonic location of this tumor is rare. Commonly described in elderly patient, their malignancy is unusual. CASE REPORT: We report the case of a 23-year-old girl, with learning disability, operated in emergency for acute peritonitis. Peroperatively, we discovered a peritonitis secondary to a bulky perforated cecal tumor. We performed a right colectomy and an ileostomy. The posterior margin of the resection was macroscopically involved. The diagnosis of colonic schwannoma was confirmed with immunopathological examination of the surgical specimen. Surgical exploration 4 months later and morphological investigations during 2 years showed stability of the tumoral residue in the right iliac fossa. However, we noticed, on CT scanning control 2 years postoperatively, the appearance of a mesenteric recurrence. Exploratory laparotomy confirmed the unresectability of this mesenteric mass and showed the presence of multiple parietal nodules whose biopsies revealed their neurofibromatous nature. The 4 year follow-up of the patient didn't reveal any complication rather than need to right nephrostomy due to ureter compression by the primary tumoral residue. DISCUSSION: Colonic schwannoma is a rare disease, commonly described in uncomplicated stages. The learning disability of our patient had favorized the absence of declared symptoms and promoted the evolution of the cecal swhannoma until its perforation. This complication was not described before. Local recurrence has been also rarely reported in the literature. Association with neurofibroma may be hereditary in a context of neurofibromatosis or sporadic. CONCLUSION: Colonic schwannoma may have polymorphic presentation mimicking malignant tumor in such cases. Not treated in time, it can lead to severe complications, such as tumoral perforation. Surgical resection remains the mainstay treatment. The slow evolutionary genius of schwannoma, even when incompletely resected by necessity, confirms its good prognosis.

Anatomic variations of the extrahepatic biliary tree. A monocentric study and review of the literature.

INTRODUCTION: The study of the anatomy of the extra hepatic bile ducts has demonstrated the existence of a significant number of variants which can be explained by hepato-biliary embryology. A good knowledge of this anatomy is essential for the interpretation of radiological examinations, and for a good practice of hepato-biliary and pancreatic surgery. Several imaging methods are used to study the anatomy of the bile ducts, including classical cholangiography, which is still practiced and very useful. AIM: To study the modal anatomy (the most frequent) and the anatomical variants of the extrahepatic bile ducts through the interpretation of postoperative cholangiograms and to examine their implication on the surgical practice. METHODS: This is a monocentric, retrospective observational study. It concerned any patient who underwent hepato-biliary or pancreatic surgery at the Department of General and Digestive Surgery of Farhat Hached University Hospital of Sousse between 2007 and 2016, and who received postoperative cholangiography. A data form was fulfilled for each patient. RESULTS: Out of a total population of 293 patients, we identified 158 patients (53.9%) with anatomic variants of the extrahepatic bile ducts. The common bile duct was modally implanted in the second duodenum in 96.2% of cholangiographies and in the genu inferius in 3.8% of cases. The main pancreatic duct had a V-shaped implantation in 87.1% of cholangiograms, a U-shaped implantation in 4.2% of cases and a Y-shaped implantation in 7.1% of cases. The common bile duct had a modal aspect in 71.3% of cholangiograms, with 28.7% of anatomic variants, organized in 4 models. The cystic duct had a modal presentation in 80.9% of cases, and we recorded 6 other branching models (19.1% of cases). No significant difference was observed between the presence of anatomic variants on the one hand, and age, sex, conversion rate, intraoperative incidents, postoperative complications, postoperative hospital stay and overall hospital stay on the other hand. CONCLUSION: Conventional cholangiography constitutes a more or less precise tool for detecting these anatomic variants and is therefore very useful in the practice of hepato-biliary surgery even after the advent of new techniques in this field. However, it also requires a more extensive and in-depth knowledge of these anatomic variants, which nevertheless remain quite frequent, and represent a source of surgical difficulties.

Pancreatic metastases and first reported gallbladder metastasis from phyllodes tumor of the breast.

Distant metastases from breast phyllodes tumor (PT) are very rare. They usually occur in lung and bones. We report a case of a 51-year-old woman who was hospitalized in the digestive surgical department for atypical epigastric pain. Her medical history started 2 years ago when she underwent a curative left mastectomy for a malignant PT of the breast. Radical surgery was indicated to her resectable pancreatic tumor diagnosed on computed tomography. Histological exam confirmed that it was pancreatic metastases of her breast PT. Adjuvant chemotherapy was indicated. Three months after the surgery, the patient developed gallbladder and brain metastases. She died 5 weeks later. With this case, we enrich the literature with another example of pancreatic metastasis from PT and we report, for the first time, gallbladder metastasis. The very high aggressiveness of this tumor suggests that markers of tumor malignancy need to be sought after by subsequent studies.

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.

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.

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.

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.

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.