Intestinal ischemia in patients with incarcerated groin hernia: proposal and validation of a score.

PURPOSE: Intestinal ischemia (II) is the most critical factor to determine in patients with incarcerated groin hernia (IGH) because II could be reversible, and it is considered as a "time sensitive condition." Although predictive factors of II were identified in several previous studies, preoperative diagnosis of II cannot be reliably made or excluded by any known parameter. The aims of this study were: to devise and to validate a clinic-biologic score, with a strong discriminatory power, for predicting the risk of II in patients with IGH. METHODS: We conducted a retrospective bicentric study including 335 patients with IGH. Logistic regression analysis was used to identify independent predictive factors of II. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic (ROC) curves. The scoring system was then prospectively validated on a second independent population of 45 patients admitted for IGH in the same departments (internal validation). RESULTS: Four independent predictive factors of II were identified: heart rate, duration of symptoms before admission, prothrombin, and neutrophil-to-lymphocyte ratio (NLR). A predictive score of II was established based on these independent predictive factors. Sensitivity was 94.50%; specificity was 92.70%. The AUC of this score was 0.97. The AUC was 0.96 when the score was applied on the second population of patients. CONCLUSIONS: We performed a score to predict the risk of intestinal II with a good accuracy (the AUC of our score was 0.97). This score is reliable and reproducible, so it can help a surgeon to prioritize patients with II for surgery (especially at this time of COVID-19 pandemic), because ischemia could be reversible, avoiding thus intestinal necrosis.

Laparoscopic Versus Open Complete Mesocolon Excision in Right Colon Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Laparoscopic complete mesocolon excision (LCME) for right colonic cancer improves oncological outcomes. This systematic review and meta-analysis aimed to compare intraoperative, postoperative, and oncological outcomes after LCME and open total mesocolon excision (OCME) for right-sided colonic cancers. METHODS: Literature searches of electronic databases and manual searches up to January 31, 2019, were performed. Random-effects meta-analysis model was used. Review Manager Version 5.3 was used for pooled estimates. RESULTS: After screening 1334 articles, 10 articles with a total of 2778 patients were eligible for inclusion. Compared to OCME, LCME improves results in terms of overall morbidity (OR = 1.48, 95% CI 1.21 to 1.80, p = 0.0001), blood loss (MD = 56.56, 95% CI 19.05 to 94.06, p = 0.003), hospital stay (MD = 2.18 day, 95% CI 0.54 to 3.83, p = 0.009), and local (OR = 2.12, 95% CI 1.09 to 4.12, p = 0.03) and distant recurrence (OR = 1.63, 95% CI 1.23-2.16, p = 0.0008). There was no significant difference regarding mortality, anastomosis leakage, number of harvested lymph nodes, and 3-year disease-free survival. Open approach was significantly better than laparoscopy in terms of operative time (MD = - 34.76 min, 95% CI - 46.01 to - 23.50, p < 0.00001) and chyle leakage (OR = 0.41, 95% CI 0.18 to 0.96, p = 0.04). CONCLUSIONS: This meta-analysis suggests that LCME in right colon cancer surgery is superior to OCME in terms of overall morbidity, blood loss, hospital stay, and local and distant recurrence with a moderate grade of recommendation due to the retrospective nature of the included studies.

Management of perforated duodenal peptic ulcer treated by suture.

BACKGROUND: Laparoscopic surgery has become the gold standard for many procedures owing to its advantages such as a shorter post-operative stay, a faster recovery and less postoperative pain. However, choosing laparoscopic approach in an emergency situationsuch as in the management of a perforated duodenal peptic ulcer is still debated because of the absence of significant benefits. This study aimed to assess the management of perforated duodenal peptic ulcer treated by suture. METHODS: It's a retrospective study enrolling 81 patients operated on for duodenal perforated peptic ulcer between June 1st, 2012 and December 31st, 2016 who underwent surgery in the surgical department B of Charles Nicolle's Hospital. RESULTS: Our retrospective study showed that laparoscopic approach had shorter post-operative duration (3 [1-5] versus 4 [1-16] days, respectively, p< 0.001), shorter mortality rate (3% versus 19%, p=0.032) and more uneventful post-operative course (97% versus 74%, p=0.004) comparing to the open approach. Patients who were not admitted in the intensive care unit during the first 48 hours had 9.901 more chance to be operated by laparoscopic approach. Patients who were operated on by a senior had 3.240 times more chance to be operated by laparoscopic approach. There was no predictive variable for conversion. Mortality rate was 11%. Age was the only predictive independent factor of mortality with a cut-off point of 47 years. CONCLUSIONS: Laparoscopic approach is routinely practised in the perforated duodenal ulcer. In our study, we showed that laparoscopic approach had less post-operative complications, a lower rate of mortality and a shorter post-operative duration comparing to the open approach. The main limitation of our study was non-randomization and lack of laparoscopic expertise. The decision for either open or laparoscopic approach was then dependent on senior surgeon's availability.

Atypical form of peritoneal tuberculosis.

It was a 48-year-old woman with a right flank mass. On examination there was a hard and painful mass of the right side, centered by a fistula orifice with a diameter of 5 mm. Abdominal computed tomography showed an intraperitoneal tissue structure in relation to the parietal peritoneum in the left hypochondria. A scanno-guided biopsy was performed. Pathological examination revealed non-specific inflammatory lesions. The evolution was marked by the appearance of a purulent fistula in the puncture site. A biopsy of the margins of the fistulous orifice of the left hypochondria was performed. Pathological examination found a granular infiltrate with caseous necrosis confirming the diagnosis of tuberculosis. The patient was put under anti-tuberculosis treatment with a good clinical and radiological evolution.

Predictive factors for major amputation of lower limb in diabetic foot: about 430 patients.

BACKGROUND: Major amputation of the lower limb is defined by a leg or thigh amputation. The aim of our work was identifying predictive factors for lower limb major amputation in patients with diabetes admitted on for foot lesions through using an administrative data base. METHODS: It was a retrospective study ranging from June 1st, 2008 to December 31st, 2011, which included all the patients admitted on for an infected diabetic foot to the surgery unit B of Charles Nicolle hospital in Tunis. The main judgement criterion was the major amputation of the lower limb. We have done a descriptive and a comparative study, with univariate and multivariate analysis. RESULTS: We have enrolled 319 men and 111 women. The average age was 60.5 ± 12 years. Ninety five patients (24%) had a major amputation. Former inpatient, patient readmitted within one month post-operatively, stay in intensive care, admission in intensive care within 48hours after admission, age ≥ 65 years, presence of kidney problem, preoperative stay and length of intervention were identified as predictive factors of major amputation in the univariate analysis. Age was the only independent variable predictive for major amputation which appeared from the multivariate analysis (p=0.004).  The age cut-off ≥ 65 years has a specificity of 69 % and a sensitivity of 47% [p=0.004, OR=1.971, IC 95% : 1.239-3.132]. CONCLUSIONS: Age was the only independent predictive factor for major amputation of the lower limb in the diabetic foot with a threshold value higher or equal to 65 years. Patients aged more than 65 had 1.9 time more risk to undergo major amputation of the lower limb.

Prognostic factors in rectal cancer: where is the evidence?

BACKGROUND: In rectal cancer, the 5 years survival is about 53 % for all stages: it remains low in spite of the progress of diagnostic and therapeutic tools. The aim of this work was to provide evidence based answers to the following question: what are the pre, intra and post operative prognostic factors in rectal cancer? METHODS: We have carried out a search in the following data bases: Pubmed, Embase, Cochrane and Scopus. The key words used were: « rectal cancer ¼, « adenocarcinoma ¼, « overall survival ¼, « disease-free survival ¼, « prognosis ¼ and « evidence-based medicine ¼. The overall 5 years survival rate has been retained as primary outcome measure. Recurrence-free survival has been retained as secondary endpoint. Were included meta-analyses and systematic reviews of clinical trials dating back to less than six years. RESULTS:   We retrieved 270 publications, 27 articles only met the above-mentioned eligibility criteria and thereof have been retained in this work. A high operating volume, a specialized surgeon in colorectal surgery, a total mesorectal excision, an adjuvant chemotherapy given within no more than 8 weeks following the curative resection improve prognosis in rectal cancer with level I of evidence. Anastomotic leak and diabetes worsen prognosis in rectal cancer with level I of evidence. Margin of surgical resection must be RO to improve prognosis in rectal cancer with level I of evidence. CONCLUSION: The main prognostic factors found in literature which we should keep in mind are those on which surgeons can  act:  neoadjuvant treatment,  high operating volume of the surgeon,  high tie of the inferior mesenteric  artery,  mesorectal excision , RO resection,  improvement of the techniques of intersphincteric resection and techniques of anastomosis   and adjuvant chemotherapy within less than 8 weeks when appropriate.

Alkalin phosphatase is a predictive factor of unresecability in ampullary and periampullary tumors.

BACKGROUND: Patients with malignant obstructive jaundice should undergo surgery on the basis of results of preoperative imaging. However, about half of patients are found to be unsuitable forresection during surgical exploration. Our study aimed to determine the clinicobiologicalcharacteristics that predict the resecability of ampullary and periampullary tumors. METHODS: We retrospectively reviewed the medical records of 49 patients (45% men and 55% women) who had malignant obstructive jaundice collected in the Department B of generalsurgery, Charles Nicolle hospital between July 1, 2008 and December 31, 2013. Predictivevariables of unresecability in malignant obstructive jaundice were identified using univariate andmultivariate analysis. RESULTS: 49 patients were included in the study. The mean age was 66,3±12,9 years. Twenty patients underwent surgery. Radical resection was performed in 12 patients and surgical palliation by biliary bypass was performed in 8 patients. Twenty-nine patients unfit for surgery underwent endoscopic stenting and chemotherapy. At univariate analysis, age (p=0,016), body mass index (p=0,033), worse general health status (p=0,037), locally advanced disease (p<0,001), serum conjugated bilirubin level (p=0,055), and serum level alkaline phosphatase (ALP) (p=0,014) were associated with unresectableampullary and periampullary tumors. At multivariate analysis serum level ALP was identify as an independent factor of unresecability in malignant obstructive jaundice [OR=0,996; IC à 95% (0,992-1,000) ;p=0,048]. The area under the ROC curve was 0,745 (p=0,016). CONCLUSION: Serum level of ALP can predict resecability in malignant obstructive jaundice. Further studies are needed to identify other factors predicting resecability and prognosis of ampullary and periampullary tumors.

Predictive factors of failure and mortality after CT-Guided percutaneous drainage of infected pancreatic necrosis.

BACKGROUND: The traditional approach to the drainage of infected pancreatic necrosis (IPN) is open necrosectomy. As an alternative to open necrosectomy, percutaneous drainage is the first-line treatment of IPN. This study is aimed to identify predictive factor of failure after CT-guided percutaneous catheter drainage (PCD) of IPN. METHODS: Between June 1st 1988 and October 31th 2011, 26 patients with IPN were treated by PCD. The outcome measures were the failure of the PCD and/or death. A descriptive analysis was performed followed by a comparative analysis of alive versus deceased patients and success group versus failure group. Univariate and multivariate analysis were performed to determine predictive factors of failure after percutaneous drainage or death. RESULTS: The failure and mortality rates were respectively 38% and 34%. The size of catheter inferior to 10 French was the only variable associated with the percutaneous drainage failure (OR=27, CI95% [2.5-284.6], p=0.006]. The collection number on CT scan was associated with mortality (OR=2.2, IC95% [1-5.1], p=0.050). CONCLUSION: PCD with catheter size equal or greater than 10 French is efficient tool for the treatment of IPN. Collection number on CT scan is an independent predictive factor of mortality.

Treatment of inguinal hernia by lichtenstein technique: an open prospective study.

BACKGROUND: Treatment of inguinal hernia is still a challenge for the surgeon. The multitude of surgical techniques attests of the difficulty of choosing the best procedure. In the surgical B department of the Charles Nicolle Hospital we have chosen the Lichtenstein technique since 2008. The aim of this study was to evaluate the immediate and long-term results of this technique and to identify the predictive factors of recurrence. METHODS: This open prospective study included all patients who underwent an elective inguinal hernia repair in the surgical B department of the Charles Nicolle Hospital between June 1st 2008 and December 31st 2009. These patients were regularly followed for at least three years. Hernia's recurrence was the primary study endpoint. Postoperative pain, wound complications, urinary complications were secondary endpoints.  An univariate and multivariate analysis were performed to identify predictive factor of hernia recurrence. RESULTS: 256 men and eight women were involved in this study with a sex ratio to 32. The average age was 54 years, ranging from 18 to 85 years. we identified seven cases of recurrent hernia (2,6%) with a risk of recurrence at five years equal to 4.9%, 95%CI[4,5 - 5,3].Wound complications were present in 90 patients (34%), dominated by serums seen in 12.1% of cases. The scrotal edema was found in 32 patients (12%). Eight patients kept a postoperative pain after three years of follow-up (3%). The presence of coagulation disorders in pre-operative check-up ( OR 32.25, 95% CI [3.33- 333.3], p = 0.003) and the persistence of pain after one year of intervention ( OR 16.12,95% CI [2.68 -100], p = 0.01) were two predictive factors of hernia recurrence. CONCLUSION: The Lichtenstein technique remains the gold standard technique in the treatment of inguinal hernias by open surgery. It is a safe, simple, reproducible procedure with a low recurrence rate.

Prognostic Nutritional Index score is useful to predict post-operative mortality and morbidity in gastric cancer.

Background - The Prognostic Nutritional Index (PNI) score is based on the level of lymphocytes and albuminemia. The aim of this study was to validate the pre-operative PNI score for predicting post-operative mortality and morbidity of patients operated on for gastric cancer. Methods - This retrospective study collected data from patients operated on for a gastric cancer at the surgical unit B of Charles Nicolle's hospital in Tunis between January 1st, 2008 and December 31, 2012. The main outcome measure was post-operative death within 30 days. The secondary outcome was post-operative morbidity (within 30 days). We have performed a descriptive analysis, a univariate and multivariate analysis with logistic regression and a ROC curve analysis. Results - 14 women and 26 men were enrolled, with a sex ratio of 1,85. The mean age was 63 ± 15. Post-operative mortality and morbidity rate were respectively 18% and 28%. The ROC curve allowed us to validate the PNI for predicting post-operative mortality in gastric cancer with a threshold level of 38 with sensitivity 100% and specificity 64%. PNI was also validated for post-operative morbidity with a threshold level of 38 with sensitivity 82% and specificity 66%. Conclusion - PNI was validated for predicting post-operative mortality and post-operative morbidity in gastric cancer.

Laparoscopic cholecystectomy decreases extra surgical site morbidity compared with open cholecystectomy: A propensity matched analysis.

BACKGROUND: The ideal way to show treatment effectiveness is through randomized controlled trials the 'gold standard' in evidence-based surgery. Indeed, not all surgical studies can be designed as randomized trials, sometimes for ethical and otherwise, for practical reasons. This article aimed to compare laparoscopic cholecystectomy to open cholecystectomy, according to data from an administrative database, managed by a propensity matched analysis. METHODS: Were included all patients with cholelithiasis admitted in Department B between June 1st, 2008 and December 31st, 2009. In this study, the propensity score represented the probability that a patient would be treated by a procedure based on variables that were known or suspected to influence group assignment and was developed using multivariable logistic regression used here to match patients who had laparoscopic cholecystectomy to a control patient who had open cholecystectomy. The main outcome measure was morbidity. This was expressed as the number of patients with 1 or more complications occurring during the hospital stay or within 30 days following discharge. RESULTS: According to intention to treat, 535 patients had a laparoscopic approach (LC group) and 60 patients had a traditional open approach (OC group) regarding associated cardiac disease, previous laparotomy or when choledocholithiasis was suspected, however intra operative cholangiography showed that there was no choledocolithiasis. According to the propensity score, 28 patients in OC were matched with 58 in LC. Comparison between OC and LC before and after propensity matched analysis showed that OC was associated with a higher rate of Extra Surgical Site morbidity (p= 0.010), a longer median duration of intervention, post-operative stay and overall hospital stay (p= 0. 0001). CONCLUSION: LC should be considered as first-line therapy to treat cholelithiasis surgically even if it becomes necessary to convert to OC because of intra operative findings.

Management of liver metastases from gastric carcinoma: where is the evidence?

BACKGROUND: Liver metastases of gastric carcinoma are often the synonym of advanced neoplastic disease which has long justified the indication of palliative chemotherapy. However, inspired by the good results of the management of liver metastases of colorectal cancers,several surgeons have focused on the treatment of liver metastases of gastric carcinoma. The different therapeutic modalities used are surgery, radiofrequency ablation, hepatic arterial infusion and palliative gastrectomy. AIMS: To provide evidence based answer to the following questions regarding liver metastases from gastric carcinoma: 1. What is the indication of surgery? 2. Does radiofrequency ablation useful? 3. What is the contribution of the hepatic arterial infusion? 4. Is there any benefit to palliative gastrectomy? METHODS: A literature search on PubMed database over the period from January 1990 to December 2011 was conducted using as key words "gastric cancer" and "liver metastases". RESULTS: Surgery of a single liver metastasis smaller than 5 cm and not associated with another metastatic site offers better results in terms of 5-year survival rate than palliative chemotherapy. Intra hepatic arterial chemotherapy offers an alternative to surgery in inoperable patients and can be proposed as neo adjuvant treatment to surgery. The interest of radiofrequency ablation and palliative gastrectomy remains unproven. CONCLUSION: Surgery is a good indication for single liver metastasis of gastric carcinoma less than 5 cm and not associated with another extra hepatic metastasis.

Paraduodenal hernia: An exceptional cause of acute bowel obstruction.

Internal hernias represent only 0.2%-0.9% of all causes of bowel obstruction. A 59-year-old patient presented urgently with small bowel obstruction. Laparotomy revealed a left paraduodenal hernia with most of the small bowel herniating through a space between the inferior mesenteric vein and duodenojejunal junction.

Quality assessment of rectal cancer surgery: How are we doing?

INTRODUCTION: Surgery remains a cornerstone in the treatment of rectal cancer. Optimal surgical resection implies respect for carcinologic principles. The best way to evaluate a good quality of resection requires certainly an exhaustive evaluation of the surgical specimen by the surgeon and the pathologist. AIM: To assess the quality of resected rectal cancers. METHODS: This study included patients operated on for rectal malignant epithelial tumors, between January 1st, 2015 and December 31st, 2020, in the general surgery department B at Charles Nicolle's Hospital in Tunis. Data relevant to the pathologic examination were recorded. We performed a descriptive study and an analytic bivariate study comparing the two groups "number of lymph nodes harvested less than 12" versus "number of lymph nodes harvested higher than or equal to 12". RESULTS: Neoadjuvant therapy was performed in 39 patients (79%). Anterior resection (AR) was performed in 43 patients (43%) and abdominoperineal resection (APR) was performed in 11 patients (20%). There were no invaded margins. The mean distal surgical margin was 3±1.4 cm. Mesorectum was complete in 38 surgical specimens (70%). The median number of lymph nodes harvested was 14. Resection was considered R0 in 47 patients (87%). In bivariate analysis, there was no difference between the "number of harvested lymph nodes <12" and the "number of harvested lymph nodes ≥ 12"groups for the variables: laparotomy, laparoscopic approach, conversion to laparotomy and chemoradiotherapy. CONCLUSION: Quality of surgical resection of rectal cancer in our department was in accordance with recommendations.

Biosimilar versus branded enoxaparin to prevent postoperative venous thromboembolism after surgery for digestive tract cancer: Randomized trial.

Cancer and/or major surgery are two factors that predispose to post-operative thrombosis. The annual incidence of venous thromboembolic disease (VTED) in cancer patients was estimated at 0.5%-20%. Surgery increases the risk of VTED by 29% in the absence of thromboprophylaxis. Enoxaparin is a low molecular weight heparin that is safe and effective. Branded Enoxaparin and biosimilar Enoxaparin are two enoxaparin treatments. This study aimed to compare Branded Enoxaparin with biosimilar Enoxaparin in patients operated on for digestive cancer regarding the prevention of postoperative thrombosis event, to compare the tolerance of the two treatments and to identify independent predictive factors of thromboembolic incident. A randomized controlled trial conducted in a single-centre, surgical department B of Charles Nicolle Hospital, over a 5-year period from October 12th, 2015, to July 08th, 2020. We included all patients over 18 who had cancer of the digestive tract newly diagnosed, operable and whatever its nature, site, or stage, operated on in emergency or elective surgery. The primary endpoint was any asymptomatic thromboembolic event, demonstrated by systematic US Doppler of the lower limbs on postoperative day 7 to day 10. The sonographer was unaware of the prescribed treatment (Branded Enoxaparin [BE] or biosimilar Enoxaparin [BSE]). Of one hundred sixty-eight enrolled patients, six patients (4.1%) had subclinical venous thrombosis. Among those who had subclinical thrombosis, four patients (5.6%) were in the Branded Enoxaparin group and two patients (2.7%) in the Biosimilar Enoxaparin group without statistically significant difference (p = 0.435). Analysis of the difference in means using Student's t test demonstrated the equivalence of the two treatments. Our study allowed us to conclude that there was no statistically significant difference between Branded Enoxaparin and Biosimilar Enoxaparin regarding the occurrence of thromboembolic accidents postoperatively. BE and BSE are equivalent. Trial registration. Trial registration: The trial was registered on CLINICALTRIALS.GOV under the number NCT02444572.

[Assessment of care quality in department of general surgery : usefulness of administrative database]. / Evaluation de la qualité des soins dans un service de chirurgie générale Utilité d'une base de données administrative .

BACKGROUND: Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting informations in the field of descriptive and analytic epidemiology with less cost. AIM: To assess the usefulness of administrative database for quality of care and research. METHODS: It was a prospective study concerning 4690 hospitalisations in Department B of General Surgery of hôpital Charles Nicolle during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a pronostic study with a univariate and multivariate analysis was performed. RÉSULTATS : Our study showed the usefulness of an administrative database in assessing the quality of care, it allowed us to determine postoperative mortality rate (2.7%), deep morbidity (2.5%), parietal morbidity (1.2%), medical complications (6%), nosocomial infections (3.6%) and re intervention (2.7%), with independent predictive factors of these events. To reduce the incidence of these events we should reduce length of pre-operative stay, prevent intra operative accidents, avoid intra operative bleeding in order to reduce intra operative transfusions and avoid as far as possible the stay in ICU Independent predictors of post trauma death are multiple trauma [OR: 6.14, 95% (from 1.68 to 16.94), p = 0.002], a traumatized patient in distress on arrival [OR: 8.74, 95% (3.59 -27.77), p = 0.000] and overall medical complications [OR: 13.18, 95% (from 4.01 to 31.25), p=0.000]. The ISS is a good discriminative indice to assess the severity and life-threatening risk. CONCLUSION: Administrative databases provide information on the efficiency of care, it helps to realise observational studies on large samples representative of the population at low cost. They are very useful in the research, despite the lack of clinical data.

[Spinal anesthesia versus general anesthesia for inguinal hernia repair: propensity score analysis]. / Anesthésie locorégionale versus Anesthésie générale pour la Hernie Inguinale : Analyse par le score de propension.

BACKGROUND: Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting information's in the field of descriptive and analytic epidemiology with less cost. AIM: To compare spinal to general anesthesia for inguinal hernia repair concerning a population extracted from administrative database after propensity matched analysis. METHODS: Prospective study concerning 4690 hospitalizations in Department B of General Surgery of Charles Nicolle hospital during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a comparison between spinal and general anesthesia according propensity matched analysis were performed. Résultats: 595 inguinal hernias were operated on. Mean age was 55±15.We mentioned a male predominance: 326 men (84.2%) and 61 women (15.8%). 137 patients had previous medical diseases(35.4%). 47(12.1%) patients were operated on in emergent situation on the other hand 340(87.9%) had elective surgery.264(68.2%) were ASA I, 110(28.4%) ASA II, 13(3.4%) ASA III. Post operative course were uneventful in 96.1% (372) and complicated in 11 patients (2.9%).Four deaths were observed (1%). Comparison before and after propensity matched analysis showed a statistical difference regarding postoperative stay and all hospital stay in favor of spinal anesthesia (p=0.007). CONCLUSION: Postoperative stay is significantly shorter in the group of spinal anesthesia (p=0.007). A randomized clinical trial comparing spinal anesthesia to general anesthesia is needed.

[Parietal abscess revealing a lost gallstone 8 years after laparoscopic cholecystectomy]. / Abcès pariétal fistulisé révèlant des calculs oubliés huit ans après une cholécystectomie laparoscopique.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for symptomatic gall stone disease. The perforation of the gallbladder happens in 40% of cases. Stones spilled remain there in 20% of cases in view of their number and location. These lost stones can cause adhesions, abscess, peritonitis, digestive fistula or else cutaneous fistula. AIM: to report a new observation of a cutaneous fistula resulting from a gallstone lost during laparoscopic cholecystectomy, eight year later. CASE: A 57-year-old women, underwent 8 years ago laparoscopic cholecystectomy for acute cholecystitis. A cholecystectomy was performed without incidence and with uneventful post-operative course. She was admitted to hospital again for an inflammatory painful swelling of the right renal fossa which had been developing for one week without any fever or transit disorder. The abdominal C.T. scan performed revealed a subcutaneous collection of 8 CM. She underwent an excision of the collection with drainage of pus and numerous small stones. She was diagnosed with lost gallstone complicated with cutaneous fistula. The control C.T. scan made 3 months later showed a small collection at the level of the right parieto-colic gutter. She was operated on again, laparoscopy excision of the fistulous tract was performed without showing stones. Healing was achieved two months later. She re-presented 3 months later for a swelling of the old scar which fistulized spontaneously with pus leaking. The abdominal CT scan was normal. She underwent an excision of a collection wish containing a large stone of two centimetres. The patient was regularly seen afterwards at the outpatients' department. She was feeling well 18 months later. CONCLUSION: A lost gallstone can cause serious complications. Spillage of gallstones should be avoided. When does occur, every effort should be made to withdraw spilled gallstones and especially to mention the event in the post-operative report.

[Laparascopic cholecystectomy on a previously operated abdomen]. / Les choléystectomies sous coelioscopie sur abdomen cicatriciel.

BACKGROUND: Laparoscopic cholecystectomy is the "gold standard" reference treatment of gall bladder stones. Laparoscopy is still contra-indicated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. AIM: This study aimed to assess outcomes of laparoscopic cholecystectomy on a scarred abdomen. METHODS: We have carried out a retrospective study on a number of consecutive patients operated between the first januar 2000 and 31 december 2006, who underwent laparoscopic cholecystectomy with previous abdominal surgery (one or several) during this period, laparoscopic cholecystectomy was performed on 2281 patients, including 233 patients who had at least one abdominal scar (10%). We have noted on the records of these patients all the data relating to the epidemiological, clinical and therapeutical aspects. We have worked out a descriptive analysis of the series and we have thus studied the rate of operative and post-operative complications, the rate of conversion, the duration of the operation and the duration of post-operative stay. Then we have compared two groups of patients, those with an upper abdominal surgery: group 1 (G1) and those with lower abdominal surgery: group 2 (G2). RESULTS: The groups consist of 200 women and 33 men aged on average 13.8 +/- 49.6 years. The indication for cholecystectomy was a symptomatic cholelithiasis in 78% of cases (n = 181), an acute cholecystitis in 22% of cases. The adhesions were believed numerous or very numerous in only 46 patients (20%). Four patients had interventional adverse events: a small intestine injury, a choledoch injury, a gastric injury and a least known colic injury. The rate of open conversion was 2.1%. Post-operative complication was 2.1%. The evolution was satisfactory in all cases. Mean operating time was 50 minutes (15-230). Mean post operative stay was one day (1-29 days). When comparing the above mentioned two groups of patients (G1: 45 patients and G 2: 188 patients), we can conclude that the first group (G1) is made up of more male patients aged over 60 years (p < 10-3). It also appears that the existence of an upper umbilical scar is correlated to a greater number of adhesions (p < 10-3), an increased risk of operative complications (p = 0.01), a greater conversion rate (p < 10-4), a prolonged operating time (p < 10-3) and a longer stay (p = 0.017). On the other hand, post-operative complications was similar in group 1 and 2. CONCLUSION: Previous abdominal operations, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a higher rate of adhesions, an increased risk of operative complications, a greater conversion rate, a prolonged operating time and longer stay.

Adreno-cortical oncocytoma: a case report.

BACKGROUND: Adrenal oncocytoma is a very rare lesion, non functioning and benignin most cases. Only 46 cases have been reported in the medical literature. AIM: This study aimed to report a new case of adrenal oncocytic tumor with uncertain malignant potential. CASE: A 72 year-old- man, consulted for renal fossa pain. Ultrasonography and omputed tomography scan revealed a large mass in the right adrenal gland with extension to the right kidney. A right adrenalectomy and nephrectomy was performed. The diagnosis of adrenal oncocytoma with malignant potential was confirmed by pathology. Patient had a well recovery and left hospital on the fifth day post operatively. He was followed up for 8 months, no tumor recurrence detected. CONCLUSION: Adreno cortical oncocytoma is a rare tumor. The majority of reported cases had good prognosis.