PLACE DE LA CHIRURGIE DANS LA PRISE EN CHARGE DE LA MALADIE DE CROHN ANO-PERINEALE

Introduction: The attack ano-perinéale during the disease of Crohn is relatively frequent, with difficult treatment. Materials and methods: A retrospective study, spread out over six years, 12 patient collages in the service of visceral and proctologic surgery II of the military hospital of instruction Mohamed V of Rabat, were taken charges some for localizations anoperinéales of  Crohn’s disease  . Results: Ano-perinéale was noted has 38 years an average age, dominated especially by the dents in 83% of the cases. The diagnosis was evoked in front of the presence of the épithélio-giganto-cellular granulome among all patients, and retained on the whole of the arguments clinical, endoscopic, histological and evolutionary. The surgical treatment was a fistulectomy or a fistulotomy associated with drainage in 10 cases and a double fissurectomy with anoplastie at two others. The average retreat was of 19.42mois. The cicatrization was considered to be good in 3 cases, slow in 3cas, an anal stenos moderate in a case and a relapse of fistula in a case. On the functional level, one noted a hypotonic in 5cas and an anal incontinence at a case. Discussion: The anoperinéal lesions of Crohn’s disease are frequent, often awkward, chronic, repeating, extensive, complex and of difficult treatment. The treatment of these lesions remains still discussed, partly because of the difficulties of evaluation related to their diversity and their complexity. Currently the contribution of the modern medical treatment made it possible to avoid any surgical aggression which is likely to involve or to worsen disorders of the continence except required. Conclusion: The medical treatment must be always prescribed in first intention. As for the surgical treatment, it should be considered only in the event of no active Crohn’s disease.Introduction : L’atteinte ano-perinéale au cours de la maladie de Crohn est relativement fréquente et de traitement difficile. Nous rapportons une étude rétrospective dont le but est de discuter la prise en charge thérapeutique medico-chirurgicale de ces lésions. Matériels et méthodes : Une étude rétrospective, entre le premier Janvier 2000 et le 31 Décembre 2005 avec un recul de 19 mois, faite d’une série de12 patients opérés pour maladie de Crohn ano-perinéale au sein de service de chirurgie viscérale et proctologique II de l’hôpital militaire d’instruction Mohamed V, Résultats : La maladie de Crohn ano-perinéale a été notée à un âge moyen de 38 ans avec une prédominance masculine, dominé surtout par les fistules dans 83% des cas. Le diagnostic a été évoqué en postopératoire, devant la présence du granulome épithélio-giganto-cellulaire chez tous les malades, et retenu, après un bilan complémentaire réalisé à distance, sur l’ensemble des arguments cliniques, endoscopiques, histologiques et évolutifs. Un bilan de la maladie crohnienne a été réalisés, les LAP, en rapport avec la maladie de Crohn, étaient isolées chez  8 patients et associée à des lésions intestinales méconnues chez 4 patients. Le traitement chirurgical a été une fistulectomie ou une fistulotomie associée à un drainage en séton(10cas) et une double fissurectomie avec anoplastie (2cas). Le recul moyen était de 19 mois. La cicatrisation a été jugée bonne dans 3 cas, lente dans 3cas, une sténose anale modérée a été notée dans un cas et une récidive de fistule dans un cas. Sur le plan fonctionnel, on a noté une hypotonie sphinctérienne dans 5cas et une incontinence anale chez un cas. Discussion : Les lésions anoperinéales de la maladie de Crohn sont fréquentes, souvent gênantes, chroniques, récidivantes, extensives, complexes et de traitement difficile. Le traitement de ces lésions reste encore controversé, en partie du fait des difficultés d’évaluation liées à leur diversité et à leur complexité. Actuellement l’apport du traitement médical moderne permet d’éviter toute agression chirurgicale qui risque d’entraîner ou d’aggraver des troubles de la continence sphinctérienne sauf nécessité. Conclusion : Le traitement médical doit être toujours prescrit en première intention. Quant au traitement chirurgical, il ne doit être envisagé qu’en cas l’absence de maladie de Crohn active

Current Opinion and Practice on Peritoneal Carcinomatosis Management: The North African Perspective.

The status of peritoneal surface malignancy (PSM) management in North Africa is undetermined. The aim of this study was to assess and compare current practice and knowledge regarding PSM and examine satisfaction with available treatment options and need for alternative therapies in North Africa. This is a qualitative study involving specialists participating in PSM management in North Africa. The survey analyzed demographic characteristics and current knowledge and opinions regarding PSM management in different institutions. We also looked at goals and priorities, satisfaction with treatment modalities and heated intraperitoneal chemotherapy (HIPEC) usefulness according to specialty, country, years of experience, and activity sector. One-hundred and three participants responded to the survey (response rate of 57%), including oncologists and surgeons. 59.2% of respondents had more than 10 years experience and 45.6% treated 20-50 PSM cases annually. Participants satisfaction with PSM treatment modalities was mild for gastric cancer (3/10 [IQR 2-3]) and moderate for colorectal (5/10 [IQR 3-5]), ovarian (5/10 [IQR 3-5]), and pseudomyxoma peritonei (5/10 [IQR 3-5]) type of malignancies. Good quality of life and symptom relief were rated as main priorities for treatment and the need for new treatment modalities was rated 9/10 [IQR 8-9]. The perceived usefulness of systemic chemotherapy in first intention was described as high by 42.7 and 39.8% of respondents for PSM of colorectal and gastric origins, while HIPEC was described as highly useful for ovarian (49.5%) and PMP (73.8) malignancies. The management of PSM in the North African region has distinct differences in knowledge, treatments availability and priorities. Disparities are also noted according to specialty, country, years of expertise, and activity sector. The creation of referral structures and PSM networks could be a step forward to standardized PSM management in the region

L’évolution fatale d’une thrombose de la veine porte

La thrombose du système portal est rare et ses étiologies sont multiples. Nous rapportons le cas d’un jeune patient de 26 ans, sans antécédents pathologiques particuliers admis pour douleurs abdominales diffuses d’installation brutale. Le diagnostic de la thrombose porte a été établi par le scanner abdominal sans mise en évidence d’un foyer infectieux intra-abdominal. Le bilan biologique a mis en évidence une hyperleucocytose mais la procalcitonine était négative. Le traitement anticoagulant a été démarré le jour de l’admission et le patient est décédé le jour même.  

Treatment adherence and BMI reduction are key predictors of HbA1c one year after diagnosis of childhood Type 2 Diabetes in UK

Background/Objective: Type 2 Diabetes (T2DM) is increasing in childhood especially among females and South-Asians. Our objective was to report outcomes from a national cohort of children and adolescents with T2DM 1 year following diagnosis. Methods: Clinician reported, 1-year follow-up of a cohort of children (<17 years) diagnosed with T2DM reported through the British Paediatric Surveillance Unit (BPSU) (April 2015-April 2016). Results: One hundred (94%) of 106 baseline cases were available for review. Of these, five were lost to follow up and one had a revised diagnosis. Mean age at follow up was 15.3 years. Median BMI standard deviation scores (SDS) was 2.81 with a decrease of 0.13 SDS over a year. HbA1c <48 mmol/mol (UK target) was achieved in 38.8%. logHbA1c was predicted by clinician reported compliance and attendance concerns (β = 0.12, P = <0.0001) and change in body mass index (BMI) SDS at 1-year (β = 0.13, P=0.007). In over 50%, clinicians reported issues with compliance and attendance. Mean clinic attendance was 75%. Metformin was the most frequently used treatment at baseline (77%) and follow-up (87%). Microalbuminuria prevalence at 1-year was 16.4% compared to 4.2% at baseline and was associated with a higher HbA1c compared to those without microalbuminuria (60 vs 49 mmol/mol, P = 0.03). Conclusions: Adherence to treatment and a reduction in BMI appear key to better outcomes a year after T2DM diagnosis. Retention and clinic attendance are concerning. The prevalence of microalbuminuria has increased 4-fold in the year following diagnosis and was associated with higher HbA1c

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks