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.

Prevalence and risk factors of pressure ulcers in a Tunisian hospital.

BACKGROUND: the aim of thisstudywas to investigate the prevalence of pressure ulcers in hospitalized patients at the Charles Nicolle Hospital in Tunis, measure the risk of their occurrence, analyzepreventive and curative measuresundertaken and evaluatefactorspredisposing to pressure ulcers. METHODS: A one-day survey was performed in all hospitalized patients. Emergency services, neonatology and pediatrics were excluded. The Braden scale was used to measure the patient's risk for the development of pressure ulcers. Analysis of risk factors was performed using SPSS version 19 software. RESULTS: A total of 473 patients was included. The mean age was 52.26 years. Nearly 10% of patients had a moderate or a high risk of developing pressure ulcers with a Braden score less than 18. The prevalence of patients with pressure ulcers was 5.3% with a prevalence of 4.7% of nosocomial pressure ulcer. There was no significant difference in prevalence between medical and surgical services. The prevalence was relatively more important in intensive care and general surgery. The most frequent sites were sacrum and heels. Stages 3 (46.4%) and 2 (37.5%) were the mainly stages descriped. Evaluation of management of bedsores formed revealed that half was treated with modern wound dressings. Statistical analysis revealed that a Braden score <18 is correlated with pressure ulcers ( 96% of patients with bedsores. Patients transferred from other services, patients recently operated or those with probably inadequate diet seem to be more at risk of developing pressure ulcers. In contrast, age and sex were not identified as significant risk factors. CONCLUSION: pressure ulcer remains a significant problem in hospital.  This problem is preventable when applying adequate prevention but its management requires a multidisciplinary approach.

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.

Primary aorto-enteric fistula in a 52-year-old man.

BACKGROUND: Aorto/ilio enteric Fistula (AEF) is defined as a communication between the aorta or iliac artery and any adjacent segment of the bowel. It may be primary or secondary. The former occurs in patients with intestinal or vascular disease and mostly complicates abdominal aortic aneurysm (AAA), whereas secondary aorto-enteric fistula is a dreadful complication of aortic reconstruction with vascular prosthesis. THE AIM of this study is to report this case of unusual presentation of PAEF as a rare cause of low enteric bleeding and discuss the path physiology, etiology, diagnosis and management of this entity. CASE: The authors report a case of 52-year-old man who presented with acute rectal bleeding. Esophago-gastro-duodenoscopy and colonoscopy were non diagnostic. Because of persistence of bleeding and hemodynamic instability, patient underwent urgent laparotomy. At surgery, diagnosis of primary aorto enteric fistula (PAEF) was made between the right iliac artery and the sigmoid complicating an iliac pseudo aneurysm. Direct repair of the vascular and digestive defects and sigmoidostomy were performed. The patient died two hours after surgery of cardiac arrest. CONCLUSION: AEF is a rare but a life threatening cause of GI bleeding. A delay in identification, as in our observation, may partly explain the high morality and morbidity.

Ileal angiodysplasia presentation as a bowel obstruction: A case report.

INTRODUCTION: Angiodysplasia is a common vascular abnormality of the gastrointestinal tract, found in the elderly and most frequently revealed by gastrointestinal bleeding. We report an original case of ileal angiodysplasia in an 83-year-old woman presenting as a bowel obstruction. CASE PRESENTATION: An 83-year-old woman with a medical history of chronic untreated anemia, presented with cardinal symptoms of bowel obstruction. Computed tomography revealed diffuse ileal wall thickening with multiple zones of stenosis, which were aggravated by an ileal perforation and associated with vascular abnormalities compatible with angiodysplasia. Surgery confirmed the imaging findings. A large resection importing one meter of ileum was performed. The pathology report of the resected specimen revealed ischemic lesions of ileum associated with ileal angiodysplasia. The postoperative period was marked by an acute dehydration in the patient who died 3 weeks after surgery. DISCUSSION: Angiodysplastic lesions develop with aging due to chronic low-grade intermittent obstruction of submucosal veins. These lesions are the result of increased contractility at the level of muscularis propria, leading to congestion of the capillaries and failure of pre-capillary sphincters, resulting in the formation of small arteriovenous collaterals. The acquired arteriovenous malformation consisting of multiple shunts with rapid blood flow may result in inadequate oxygenation of a segment of the intestine and lead to ischemia and eventually wall thickening, stenosis and even perforation of the small bowel. CONCLUSION: Angiodysplasia should be kept in the back of one's mind as one of the causes of acute abdomen and bowel obstruction, especially in elderly people suffering from occult gastrointestinal bleeding.

[Perineal gangrene: clinical and therapeutic features and prognostic analysis of 35 cases]. / Etude clinique et thérapeutique et analyse pronostique des gangrènes du périnée: a propos de 35 cas.

STUDY OBJECTIVE: The objective of this retrospective study of 35 cases of perineal gangrene was to describe their clinical and therapeutic features and to analyze the prognostic factors of mortality. METHODS: From 1997 to 2004, 35 cases (25 men and 10 women, mean age=50.3 years) with perineal gangrene were treated in the "A" surgical department of Charles Nicole Hospital (Tunisia) with a combination of intensive care, antibiotic therapy, extensive excision and drainage, repeated if necessary and colostomy. RESULTS: The mortality rate was 17.1%. The mean duration of hospitalization was 15.3 (range: 2-64) days. One patient had anal incontinence as sequelae. The colostomy in two patients was closed at the 9(th) and the 13(th) month. Statistical analysis showed that the extent of cellulitis, presence of myonecrosis, occurrence of septic shock need for postoperative mechanical ventilation, and IGSII and FGSIS severity scores differed significantly between patients who survived and those who died. CONCLUSION: Perineal gangrene is still a very severe disease. The initial anatomic lesions, the IGSII and FGSIS severity scores and postoperative complications are the main prognostic factors of mortality.