Predicting Intestinal Ischaemia in Patients with Adhesive Small Bowel Obstruction: A Simple Score.

BACKGROUND/AIMS: Intestinal ischaemia (II) is the most critical factor to determine in patients with adhesive small bowel obstruction (ASBO) because intestinal ischaemia could be reversible. The aim of this study was to create a clinicoradiological score to predict II in patients with ASBO. METHODS: We conducted a retrospective study including 124 patients with ASBO. Logistic regression analysis was used to identify 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 curves. RESULTS: Six independent predictive factors of II were identified: age, pain duration, body temperature, WBC, reduced wall enhancement and segmental mesenteric fluid at CT scan. According to the regression, coefficient points were assigned to each of the variables associated with II. The estimated rates of II were calculated for the total scores ranging from 0 to 24. The AUC of this clinicoradiological score was 0.92. A cut-off score of 6 was used for the low-probability group (the risk of II was 1.13%). A score ranging from 7 to 15 defined intermediate-probability group (the risk of II was 44%). A score ≥16 defined high-probability group (100% of patients in this group had II). CONCLUSIONS: We performed a score to predict the risk of intestinal II with a good accuracy (the AUC of our score exceeded 0.90). This score is reliable and reproducible, so it can help surgeon to prioritize patients with II for surgery because ischaemia could be reversible, avoiding thus intestinal necrosis.

Extra-gastrointestinal stromal tumor of the pancreas: A case report.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) represent the most common mesenchymal tumors of the gastrointestinal tract. In rare cases, these tumors do not develop in the gastrointestinal tract and are defined as extra-gastro-intestinal stromal tumors (EGISTs). Pancreatic EGIST is extremely rare. We reported a case of EGIST of the pancreas in a 53-year-old patient. PRESENTATION OF CASE: A 53-year-old man presented with chronic epigastralgia. An enhanced CT scan showed a solido-cystic tumor of the pancreatic body-tail. The patient underwent a laparotomy. Cytology fine needle aspiration did not find any tumor cells. Enucleation was performed. Histopathology and immunohistochemical examination confirmed the diagnosis of EGIST (CD117 +, Dog-1 +) with a high risk of malignancy. The patient received adjuvant therapy. There was no evidence of disease recurrence after 8 months of follow-up. CLINICAL DISCUSSION: We reported a rare case of a pancreatic EGIST. Enucleation was performed permitting to avoid distal pancreatectomy and thus decreasing morbidity rates. The clinical presentation is not specific and it depends on the location and the size of the tumor. CT scan shows hypervascular tumors with no regional lymph nodes metastasis but is not accurate in assessing diagnosis. Whenever possible, enucleation should be performed. This tumor should be considered in the differential diagnoses of pancreatic neoplasms. CONCLUSION: Pancreatic stromal tumor is extremely rare. There are no specific clinical and radiologic findings. A careful decision should be made after a discussion in a multidisciplinary coordination meeting. Surgical resection is the cornerstone of the treatment. Whenever possible, enucleation is sufficient.

Stump appendicitis, a rare but serious complication of appendectomy: A case report.

Stump appendicitis is a rare delayed post-appendectomy complication. This diagnosis must be considered in case of right iliac fossa pain in a patient with a history of appendicectomy.

C-reactive Protein Is the Best Biomarker to Predict Advanced Acute Cholecystitis and Conversion to Open Surgery. A Prospective Cohort Study of 556 Cases.

BACKGROUND: White blood cell levels (WBC) is the only biologic determinant criterion of the severity assessment of acute cholecystitis (AC) in the revised Tokyo Guidelines 2018 (TG18). The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WBC for the severity of AC, and the risk for conversion to open surgery and to determine their diagnostic cutoff levels. METHODS: This was a prospective cohort study. Over 3 years, 556 patients underwent laparoscopic cholecystectomy for AC. Patients were classified into two groups: 139 cases of advanced acute cholecystitis (AAC) (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 cases of non-advanced acute cholecystitis (NAAC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables (WBC, CRP, and neutrophil-to-lymphocyte ratio (NLR)) were statistically significant in predicting AAC and conversion to open surgery. RESULTS: On multivariable logistic regression analysis, male gender (OR = 0.4; p = 0.05), diabetes mellitus (OR = 7.8; p = 0.005), 3-4 ASA score (OR = 5.34; p = 0.037), body temperature (OR = 2.65; p = 0.014), and CRP (OR = 1.01; p = 0.0001) were associated independently with AAC. The value of the area under the curve (AUC) of the CRP (0.75) was higher than that of WBC (0.67) and NLR (0.62) for diagnosing AAC. CRP was the only predictive factor of conversion in multivariate analysis (OR = 1.008 [1.003-1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in terms of conversion. CONCLUSION: CRP is the best inflammatory marker predictive of AAC and of conversion to open surgery. We think that our results would support a multicenter-international study to confirm the findings, and if supported, CRP should be considered as a severity criterion of acute cholecystitis in the next revised version of the Guidelines of Tokyo.

Usefulness of Laparoscopy in Gangrenous Cholecystitis.

BACKGROUND: Gangrenous cholecystitis (GC) is a rare and severe condition requiring immediate cholecystectomy. The aim of this study was to compare outcomes of laparoscopic cholecystectomy with open cholecystectomy in patients with GC. MATERIALS AND METHODS: The records of 278 patients with GC who underwent cholecystectomy, for acute cholecystitis were compared with those of 531 patients with nongangrenous cholecystitis. In patients with GC, the outcomes of laparoscopic cholecystectomy were also compared with the outcomes of open cholecystectomy. RESULTS: Multivariate analysis demonstrated an independent association of diabetes mellitus, temperature, muscle rigidity on examination, white cell blood count, gallbladder wall thickening, gallbladder wall interruption, detection of pericholecystic exudate on ultrasonography, with the development of acute GC. The rate of conversions in the GC group was higher than in nongangrenous cholecystitis group. In patients with GC morbidity did not differ between patients operated using laparoscopic technique or open technique. Total and postoperative hospital stays were shorter in patients operated using laparoscopic technique. CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in patients with GC. Although the conversion rate to open surgery was elevated, the number of other complications was comparable to open surgery. Laparoscopic cholecystectomy significantly reduced total hospital stays and medical costs.

Should acute cholecystitis be operated in the 24 h following symptom onset? A retrospective cohort study.

BACKGROUND: Early laparoscopic cholecystectomy is the gold standard for management of acute cholecystitis (AC). Nevertheless, the definition used for early phase remained unclear. We aimed to compare the clinical outcome and cost of immediate (patients undergoing laparoscopic cholecystectomy within 24 h following symptom onset) versus early laparoscopic cholecystectomy (patients managed 25-72 h following symptom onset) for acute cholecystitis. METHODS: A retrospective analysis was performed. The outcomes of 143 patients undergoing laparoscopic cholecystectomy within 24 h (ICG) were compared to 350 patients managed 25-72 h following symptom onset (ECG) for acute cholecystitis. RESULTS: There were significantly more diabetic patients in the early laparoscopic group (ECG). All other characteristics were comparable (demographic, clinical, biologic and ultrasonographic characteristics) between the two groups. The rate of conversion to open surgery was significantly higher in the ECG. Overall postoperative morbidity and specific morbidity did not differ significantly between the groups. Total hospital stay was longer in the ECG. Direct medical costs were higher in the ECG. CONCLUSIONS: Laparoscopic cholecystectomy, for acute cholecystitis, during the first 24 h of onset of symptoms, significantly reduced conversion to open surgery and total hospital stay without increasing postoperative complications.

Histopathologic characteristics and short-term outcomes of colorectal cancer in young Tunisian patients: one center's experience.

INTRODUCTION: Colorectal carcinoma (CRC) is generally a disease of persons older than 40 years. Concerning younger patients, controversies still exist regarding features and prognosis of CRC. We performed this study to characterise CRC in young patients (≤ 40 years) as well as to evaluate short-term outcome in comparison with older patients (>40 years) with CRC. METHODS: Clinical and histopathological parameters of 40 patients aged 40 years or less were compared with 240 patients aged more than 40 years. RESULTS: In young patients, the minority suffered from hereditary cancer syndromes (0.4%). Furthermore, up to 87% of young patients denied any cancers in their families. Compared with older patients, young patients had more mucinous adenocarcinomas (32.5% vs. 11.5%; p=0.02), more venous invasion (p=0.021), more perineural invasion (p=0.028). For grading (p=0.42), lymphatic invasion (p=0.17) and tumor sites (p=0.46), no significant differences between young and older patients were found. Young patients had less post operative morbidity (p=0.039), less post operative mortality (0.029). Young and older patients had the same overall 1-year survival rates (p=0.24), and the same cancer-related 1-year survival rates (p=0.1). CONCLUSION: Tunisian patients present with colorectal cancer at a more advanced stage of the disease at younger ages compared to developed countries. The early detection of CRC followed by a sufficient oncologic treatment is crucial regardless of age. It is mandatory for all patients with suspicious symptoms to undergo early adequate diagnoses.