Managing Complicated Diverticular Disease in 2014

Complicated diverticular disease refers to patients who present with abscess, peritonitis, bleeding, fistula, or bowel obstruction. Management paradigms for these complications have changed enormously in the last 20 years. Surgical options include primary resection with or without anastomosis, exteriorisation of the perforation as the site of diversion, and more and more in recent years, simple lavage and drainage. The different classifications, the indications and techniques of interventional radiology, and endoscopy, as well as other minimally invasive or traditional surgical treatment of these complications are covered in this review

Teaching clinical reasoning among undergraduate medical students: A crossover randomized trial

Background & Objective: Many clinical reasoning teaching techniques have been reported in the literature. The authors focused on 2 teaching techniques of clinical reasoning, the technique Summarize, Narrow, Analyze, Probe the preceptor, Plan, Self-selected topic (SNAPPS) and the Clinical Reasoning Technique (CRT), and compared their efficiency to improve the clinical reasoning competencies of third-year undergraduate medical students. Materials & Methods: The authors performed a prospective randomized, controlled, non-blinded crossover trial including year-3 undergraduate medical students. Judgment criteria consisted of the scores attributed to a test assessing the cognitive competencies of the participants which was a structured summary performed by the students after each session. Besides, a satisfaction Likert-scale questionnaire was fulfilled by the students. Statistical analysis was performed using SPSS software (version 20.0). Results: Seventy-two students were included with a mean age of 21.03 (SD:2,30) years. The mean scores of the students allocated to the CRT arm reached 4.62 (SD:2.93)versus 4.99 (SD:2.93) for the SNAPPS arm. No significant statistical difference was observed between the mean scores according to the method used. The analysis of the satisfaction questionnaire revealed that 75% of the students preferred CRT because of the collaborative work performed. Conclusion: This study highlights the need for varying techniques to improve the critical reasoning skills of medical students. Besides, it pointed out students' preference for collaborative approaches illustrating socio-constructivist theories of learning

Rectal stromal tumor with an exceptional liver and bone metastatic locations

Gastrointestinal stromal tumours (GIST) are rare mesenchymal tumours which represent 1% to 3% of gastrointestinal neoplasm. Rectal location of GIST is extremely rare reaching 5% of GIST and only 0.1% of rectal tumours. They usually metastases to the liver (65%) and exceptionally to the bone (3%). We reported a case of rectal stromal tumour with an exceptional metastasis located in the rib. A 40-year-old man who presented with pelvic pain, associated with rectal syndrome, rectal bleeding and subocclusive episodes. Physical examination objectified a tough, budding rectal mass, with a smooth wall, localized 3cm above of anal margin. A Thoraco-abdominal computed tomography showed a large heterogeneous tissue mass, taking the whole pelvis, coming from the right-side wall of the rectum of 17.3 x 14cm. It was associated with liver and bone secondary locations. Biopsies confirmed the secondary locations of an intermediate risk GIST. Immunohistochemical study showed an overexpression of c-kit protein (CD117) and Dog1. Imatinib was prescribed to reduce the tumour size. Stromal metastatic rectal tumours in bone level are extremely rare conditions. The diagnosis is confirmed by histological examination with immune histochemical analysis. The prognosis remains poor in metastatic forms but it has been improved since the introduction of Imatinib

Radical surgery decreases overall morbidity and recurrence compared with conservative surgery for liver cystic echinococcosis: systematic review with meta-analysis

Background: This systematic review with meta-analysis aimed to investigate whether radical surgery (RS) for liver cystic echinococcosis (LCE) is superior to conservative surgery (CS) to decrease morbidity, mortality and recurrence. Methods: MEDLINE, Embase, the Cochrane Library, Scopus, INIST, Ovid, Science Direct, Google Scholar, Springer link, clinical key, and web of science were searched up to April 13th, 2018. Adults of either sex operated on for symptomatic but non-complicated LCE were included. The quality of studies was assessed using the Jadad scoring system or the Methodological Index for Non-Randomized Studies index when appropriate. Meta-analyses were performed with a Mantel-Hansel method for random-effects. Results: One randomized controlled trial, one retrospective comparative study using propensity-matching analysis for comparison and 14 retrospective comparative studies were included (3,771 patients). This meta-analysis showed that there were statistically significantly fewer biliary leakage +/- fistula [odds ratio (OR) =0.35; 95% CI, 0.21-0.60, P=0.00001], overall morbidity: (OR =0.49; 95% CI, 0.40-0.59, P=0.00001), and recurrence: (OR =0.17; 95% CI, 0.11-0.26; P<0.00001) in RS compared to CS. Conclusions: This meta-analysis showed that there were statistically significantly fewer biliary leakage +/- fistula, overall morbidity and recurrence in RS compared to CS. In the absence of large-scale RCTs, this meta-analysis suggests that RS is superior to CS in treating hydatid disease of the liver

Prevalence of and Risk Factors for Morbidity After Elective Left Colectomy Cancer vs Noncomplicated Diverticular Disease

Hypothesis: Independent risk factors for postoperative morbidity after colectomy are most likely linked to disease characteristics. Design: Retrospective analysis. Setting: Twenty-eight centers of the French Federation for Surgical Research. Patients: In total, 1721 patients (1230 with colon cancer [CC] and 491 with diverticular disease [DD]) from a databank of 7 prospective, multisite, randomized trials on colorectal resection. Intervention: Elective left colectomy via laparotomy. Main Outcome Measures: Preoperative and intraoperative risk factors for postoperative morbidity. Results: Overall postoperative morbidity was higher in CC than in DD (32.4% vs 30.3%) but the difference was not statistically significant (P=.40). Two independent risk factors for morbidity in CC were antecedent heart failure (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.42-6.32) (P=.003) and bothersome intraluminal fecal matter (2.08; 1.42-3.06) (P=.001). Three independent risk factors for morbidity in DD were at least 10% weight loss (OR, 2.06; 95% CI, 1.25-3.40) (P=.004), body mass index (calculated as weight in kilograms divided by height in meters squared) exceeding 30 (2.05; 1.15-3.66) (P=.02), and left hemicolectomy (vs left segmental colectomy) (2.01; 1.19-3.40) (P=.009). Conclusions: Patients undergoing elective left colectomy for CC or for DD constitute 2 distinct populations with completely different risk factors for morbidity, which should be addressed differently. Improving colonic cleanliness (by antiseptic enema) may reduce morbidity in CC. In DD, morbidity may be reduced by appropriate preoperative nutritive support (by immunonutrition), even in patients with obesity, and by preference of left segmental colectomy over left hemicolectomy. By decreasing morbidity, mortality should be lowered as well, especially when reoperation becomes necessary