Cholécystectomie laparoscopique ambulatoire: première expérience en Tunisie

Introduction: La cholécystectomie laparoscopique est le gold standard de la prise en charge des calculs vésiculaires symptomatiques. Il existe une importante controverse quant au fait de savoir si elle devrait être pratiquée en chirurgie ambulatoire ou dans le cadre d'une chirurgie avec hospitalisation d'une nuit pour ce qui concerne la sécurité des patients. Le but du travail est d’évaluer l'impact de la cholécystectomie laparoscopique en chirurgie ambulatoire versus en chirurgie avec hospitalisation d'une nuit sur les critères de jugement axés sur le patient, tels que la mortalité, les graves événements indésirables et la qualité de vie. Méthodes: Il s’agit d’une étude transversale descriptive réalisée au sein du service de chirurgie générale de l’hôpital Habib Thameur, sur la période allant de Mai 2009 à Février 2010. Cette étude porte sur 67 malades porteurs d’une lithiase vésiculaire symptomatique ayant eu une cholécystectomie laparoscopique en ambulatoire (CLA). Étaient exclus de l’étude: les malades ASA III et IV, les diabétiques sous sulfamides ou sous insuline, les grands obèses, les malades de plus de 65 ans et moins de 18 ans, ceux avec un antécédent de chirurgie abdominale majeure, les malades suspects d’une lithiase de la voie biliaire principale, d’une cholécystite aiguë ou d’une pancréatite. Pour être traité par CLA, le malade devait résider à moins de 50 km de l’hôpital, et avoir la possibilité d’une présence adulte à ses côtés. Résultats: Dix-sept patients étaient inclus puis exclus de notre étude devant la découverte per opératoire de signes de cholécystite aigue ou devant des difficultés de dissection amenant le chirurgien à mettre un drain de Redon en sous hépatique en fin d’intervention. Finalement, 50 patients ont été retenus: 7 hommes et 43 femmes d’âge moyen de 48 ans. L’intervention se déroulait selon les modalités habituelles. A la sortie de la salle de réveil, le patient était dirigé en secteur ambulatoire où une alimentation liquide était autorisée. Le malade était revu avant 19 h et la sortie décidée si une analgésie orale était possible, si une alimentation liquide était tolérée, s’il n’existait aucun trouble de la diurèse, et si le patient acceptait un retour à domicile avec un traitement antalgique et anti-inflammatoire à la demande. Trente neuf patients (78%) ont quitté l’hôpital et 11 ont été gardés. L’âge > à 45 ans, la durée de l’anesthésie > à 70 minutes et la fatigue post opératoire ont été identifié comme facteur de risque de sorties ratées. Aucune réadmission n’a été observée. Les patients qui ont pu être mis sortants ont été satisfaits du protocole de prise en charge avec des réponses majoritairement de type excellent et bon (94%). Conclusion: La chirurgie ambulatoire semble tout aussi sûre que la chirurgie avec hospitalisation d'une nuit dans la cholécystectomie laparoscopique avec un faible taux de complication et de réadmission chez des malades sélectionnés, et avec une réduction du coût de l’intervention

Ultrasound Modality in the Evaluation and Management of Gallbladder Polyps

Gallbladder polyps (GBP) are defined as developed masses inside the wall of the gallbladder; most of them (90%) are nontumor lesions. Abdominal ultrasound is the main and the first line radiological modality for their diagnosis and their risk lamination. We conducted a 12 year retrospective study between 2009 and 2020, which included patients who had preoperative transabdominal ultrasonography showing gallbladder polyps and had undergone cholecystectomy, and for whom postoperative pathology results were available, as well as patients who had at least one polyp discovered on the histopathological exam and who were not determined preoperatively. A total of 70 patients were identified. Preoperative diagnosis of vesicular polyp by ultrasound was carried in 82.9% of patients. The number of ultrasounds performed per person was 1.2 ± 0.47. The polyps’ size in mm was on average 6.14 ± 2.6 with extremes between 3 and 13 mm. On anatomopathological examination, a polyp was objectified in 33.3% of cases. In our series, abdominal ultrasound had a low sensitivity at 36.4%. We aim to provide the accuracy of abdominal ultrasound for the diagnosis of GBP, as a low-cost modality, and to evaluate the concordance of preoperative ultrasound imaging with postoperative pathology

Reliability testing of a modified MISTELS score using a low-cost trainer box

Abstract Background Training programs such as the fundamentals of laparoscopic surgery (FLS) that are based on simulation are being currently used in several western countries. FLS allows skill acquisition and evaluation of competency in laparoscopic surgery. On the practical side, evaluation is determined by the MISTELS metrics (MISTELS is the acronym for the McGill inanimate system for training and evaluation of laparoscopic skills). This training program may be modified so that it can be implemented in countries with limited resources using a low-cost trainer box. Would the use of a low-cost trainer box alter the reliability of the MISTELS score? Objective of study The aim of the study was to evaluate the reliability of a modified MISTELS using a low-cost trainer box. Methods It was a prospective study carried out at Habib Thameur hospital in Tunis (Tunisia), between April 2016 and August 2016. The study involved residents from different surgical specialties in the departments of general surgery and paediatric surgery of the hospital during 2015 and 2016. This study assessed the reliability of a modified MISTELS system (Only three tasks were performed out of the five tasks used in the original MISTELS system). Evaluation was based on Cronbach’s alpha and intraclass correlation coefficients (ICC). A low-cost trainer box was designed and constructed. The residents included in the study performed three series of three tasks using this trainer box. The first series was scored by two trained raters to evaluate inter-rater reliability. The two-other series were successively performed to evaluate test-retest reliability. Results The internal consistency, assessed by Cronbach’s alpha, was at 0.929 which is an acceptable score. As for inter-rater and test-retest reliabilities that were assessed by ICCs, they yielded excellent scores that were at 1 and 0.95 (95% CI, 0.891–0.978) respectively. Conclusions The reliability of a modified MISTELS is not altered by the use of a low-cost trainer box. The score of the modified MISTELS is a reliable score for evaluating technical skills of surgical residents using a low-cost trainer box

Sporadic Burkitt lymphoma presenting with peritoneal lymphomatosis

Abstract Burkitt lymphoma (BL) is a highly aggressive non‐Hodgkin B‐cell lymphoma. It has a doubling time of 24 h. Fortunately, it is highly sensitive to aggressive chemotherapy. Sporadic BL often affects the mesenteric and retroperitoneal lymph nodes. Extra‐nodal involvement includes the ileocecal area, stomach, kidneys, gonads, and central nervous system. Peritoneal lymphomatosis is a rare presentation. We report a case of BL presenting with peritoneal lymphomatosis to emphasize the importance of early histological diagnosis of any peritoneal thickening

Gastric leiomyosarcoma and diagnostic pitfalls: a case report

Abstract Background Since the advent of immunohistochemistry for the diagnosis of stromal tumours, the incidence of leiomyosarcomas has significantly decreased. Nowadays, gastric leiomyosarcoma is an exceptionally rare tumour. We report the second case in the English literature of gastric leiomyosarcoma revealed with massive bleeding and hemodynamic instability and diagnostic pitfalls that we encountered. Case presentation A 63-year-old woman, with 2 years’ history of dizziness and weakness probably related to an anaemic syndrome, presented to the emergency room with hematemesis, melena and hemodynamic instability. On examination, she had conjunctival pallor with reduced general condition, blood pressure of 90/45 mmHg and a pulse between 110 and 120 beats per minute. On digital rectal examination, she had melena. Laboratory blood tests revealed a haemoglobin level at 38 g/L. The patient was admitted to the intensive care department. After initial resuscitation, transfusion and intravenous Omeprazole continuous infusion, her condition was stabilized. She underwent upper gastrointestinal endoscopy showing a tumour of the cardia, protruding in the lumen with mucosal ulceration and clots in the stomach. Biopsies were taken. Histological examination showed interlacing bundles of spindle cells, ill-defined cell borders, elongated hyperchromatic nuclei with marked pleomorphism and paranuclear vacuolization. Immunohistochemistry showed positivity for Vimentine, a strong and diffuse immunoreactivity for smooth muscle actin (SMA). Immunoreactivities for KIT and DOG1 were doubtful. Computed tomography scan revealed a seven-cm tumour of the cardia, without adenopathy or liver metastasis. The patient underwent laparotomy. A total gastrectomy was performed without lymphadenectomy. Post-operative course was uneventful. Histological examination of the tumour specimen found the same features as preoperative biopsies with negative margins. We solicited a second opinion of an expert in a reference centre for sarcomas in France, who confirmed the diagnosis of a high grade gastric leiomyosarcoma. Conclusion Gastric leiomyosarcoma is a rare tumour. Diagnosis is based on histological examination with immunohistochemistry, which could be sometimes confusing like in our case. The validation of a pathological expert is recommended