Retroportal lamina or mesopancreas? Lessons learned by anatomical and histological study of thirty three cadaveric dissections

OBJECTIVE AND BACKGROUND

Despite its importance in pancreatic head carcinoma, the retroportal lamina is still under studied, with only two anatomical cadaveric dissections in the English literature, with recent controversies about the concept of a mesopancreas.

METHODS

Resection of the mesopancreas was performed in 33 fresh cadavers. The pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated.

RESULTS

The retroportal lamina is roughly rectangular in shape. Its dimensions are: height 6.2 cm (5-8), 2.5 cm wide (1.5-4). It contains a right hepatic artery arising from the superior mesenteric artery in 13.3% of cases. Microscopic examination revealed areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatics and capillaries. However, fibrous sheath and fascia were not found around these structures.

CONCLUSION

A right hepatic artery arising from the superior mesenteric artery is a frequent anatomic variation. Surgeons must be aware of this to ensure the integrity of the hepatic artery blood supply in patients treated by pancreaticoduodenectomy. Despite controversy about the reality of the mesopancreas (postulated in analogy to the mesorectum), because of the absence of fibrous sheath or fascia, its complete removal in pancreatic head carcinoma is feasible by a subadventitial dissection of the superior mesenteric artery which can be considered as the real limit of the mesopancreas.

Time-dependent evolution of olive mill wastewater sludge organic and inorganic components and resident microbiota in multi-pond evaporation system

The physico-chemical and microbiological characterizations of olive mill wastewater sludge (OMWS) were investigated in five OMW evaporation ponds of the open-pond system in Sfax (Tunisia), during the olive oil production period in 2004. Time-dependent changes in both physico-chemical parameters and the microbiota were investigated. Mathematical models and principal component analysis (PCA) were used to establish the correlations between the studied parameters. During the effluent time-dependent changes in the ponds, the result of OMWS analysis showed an increase of sludge index (SI), ash content, total solids (TS), volatile solids (VS), ethyl acetate extractive (EAE) and total phosphorus (Total P), as well as microbial flora especially the yeasts and moulds. The SI, TS, VS and Total P changes with time fit a simple linear equation, while EAE, phenols and NH(4)(+) fit a second-degree polynomial model. The PCA analysis exhibited three correlated groups. The first group included temperature, ash content, evaporation, SI, TS, VS, Total P, EAE, yeasts and moulds. The second group was made by bacteria and moisture; and the third group by NH(4)(+), oil and phenol. Such modelling might be of help in the prediction of OMW changes in natural evaporation ponds.

Retrovesical hydatid disease: a clinical study of 27 cases

OBJECTIVES

We report our experience with 27 cases of retrovesical hydatid cysts (RVHC) and discuss the pathogenesis, diagnosis and treatment of this hydatid location.

MATERIALS AND METHODS

We retrospectively reviewed the clinical files of 27 patients with RVHC admitted to our institution from January 1984 to December 2000.

RESULTS

The predominant presenting symptom was burning micturition (13 cases). Physical examination revealed a pelvic mass in 17 patients. Preoperative diagnosis was based upon ultrasonography, intravenous pyelography, and serology tests. CT was performed in 10 patients. We noticed that RVHC can be subdivided into two categories: those that develop mainly in the peritoneal cavity (intraperitoneal type; 18 cases), and those that develop mainly in the confined pelvic cavity (subperitoneal type; 9 cases) and are more liable to induce ureteral compression and more difficult to approach surgically. One patient died before operation. Twenty-six patients were operated and had either a total (9 cases) or partial pericystectomy (17 cases). Four patients underwent closure of cystovesical fistulas. Two patients had ureteral reimplantation. Postoperatively, 1 patient died with septic shock and 1 was reoperated for peritonitis. Mean postoperative hospital stay was 8 days.

CONCLUSIONS

The preoperative diagnosis of RVHC is based mainly on ultrasonography. Open surgery is the treatment of choice.

The severity grading of acute cholecystitis following the Tokyo Guidelines is the most powerful predictive factor for conversion from laparoscopic cholecystectomy to open cholecystectomy

BACKGROUND

The relationship between the severity assessment of acute cholecystitis based on the Tokyo Guidelines and the risk for conversion from laparoscopic surgery to open surgery has been assessed in few previous reports, with conflicting results.

METHODS

A retrospective review of patients with acute cholecystitis within a single system from 2010 to 2013 was performed. The diagnosis and severity of acute cholecystitis were assigned by the Tokyo Guidelines 2013 (TG13). The primary outcome measure was conversion to open cholecystectomy.

RESULTS

During the period of study, 493 patients were operated by laparoscopy for acute cholecystitis. Laparoscopic cholecystectomy was intraoperatively converted to open surgery in 56 cases (11.4%). The multivariate analysis showed that the risk factors for conversion to open surgery included male gender (OR: 2.15; IC_95% [1.18-3.9]), diabetes (OR: 2.22; IC_95% [1.13-4.33]), total bilirubin levels (OR: 1.02; IC_95% [1-1.05]), and the TG13 severity classification (OR: 4.44; IC_95% [2.25-8.75]).

CONCLUSIONS

The independent risk factors for conversion to open surgery included male sex, diabetes mellitus, total bilirubin level, and TG13 grade. TG13 grade was found to be the most powerful predictive factor for conversion as it had the highest OR.

Combination of ballistic lithotripsy and transurethral prostatectomy in bladder stones with benign prostatic hyperplasia: report of 120 cases

PURPOSE

We report our experience with the combination of ballistic lithotripsy (BL) and transurethral resection of the prostate (TURP) in 120 patients with benign prostatic hyperplasia (BPH) and bladder stone(s).

PATIENTS AND METHODS

The mean stone size, appreciated by measuring the greatest diameter, was 18.5 mm (range 10-80 mm). The mean prostate volume was 35.4 cc (26-62 cc). All procedures were monitored under direct endoscopic control with a videocamera.

RESULTS

Lithotripsy and evacuation of fragments was performed in an average time of 27.5 minutes (10-80 minutes). The only intraoperative complication was mild hematuria in 38 patients (32%), which did not affect vision for TURP. The mean resection time was 42 minutes (range 15-65 minutes). Four patients experienced mild postoperative bleeding, and one patient had clot retention. The mean hospital stay was 1.2 days (range 1-4 days).

CONCLUSIONS

Combined BL and TURP is effective, safe, and economical.

Polyphenolic compounds progress during olive mill wastewater sludge and poultry manure co-composting, and humic substances building (Southeastern Tunisia)

In Mediterranean areas, olive mill wastes pose a major environmental problem owing to their important production and their high polyphenolic compounds and organic acids concentrations. In this work, the evolution of polyphenolic compounds was studied during co-composting of olive mill wastewater sludge and poultry manure, based on qualitative (G-50 sephadex) and quantitative (Folin-Ciocalteu), as well as high pressure liquid chromatography analyses. Results showed a significant polyphenolic content decrease of 99% and a noticeable transformation of low to high molecular weight fraction during the compost maturation period. During this step, polyphenols disappearance suggested their assimilation by thermophilic bacteria as a carbon and energy source, and contributed to humic substances synthesis. Polyphenolic compounds, identified initially by high pressure liquid chromatography, disappeared by composting and only traces of caffeic, coumaric and ferulic acids were detected in the compost. In the soil, the produced compost application improved the chemical and physico-chemical soil properties, mainly fertilising elements such as calcium, magnesium, nitrogen, potassium and phosphorus. Consequently, a higher potato production was harvested in comparison with manure amendment.

Meckel's diverticulum: an exceptional cause of vesicoenteric fistula: case report and literature review

Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract. It can cause complications in the form of ulceration, hemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae as noted in six previously reported cases. 66-year-old woman was presented with an enterovesical fistula. Exploratory laparotomy revealed a vesico-diverticular fistula resulting from a perforated Meckel′s diverticulum. Pathologic examination revealed that the diverticulum did not contain ectopic gastric or pancreatic tissue. The patient underwent a diverticulectomy and had an uneventful postoperative course. Unlike four of the six previously reported cases, our patient had no coexisting bowel or bladder disease occurring with her vesico-diverticular fistula. Conclusion: This is only the third reported case of a vesico-diverticular fistula resulting from a perforated Meckel′s diverticulum that did not contain ectopic tissue.

Digital necrosis and lupus-like syndrome preceding ovarian carcinoma

Since 1967, about 40 cases of digital necrosis associated with neoplasia have been reported. We report a new case of digital necrosis associated with an ovarian carcinoma and with a lupus-like syndrome. Immunologic cross-reactivity to tumoral antigen could explain the lupus-like syndrome.

Appendiceal GIST: report of an exceptional case and review of the literature

Gastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only eight cases has been described in the literature, most of which have been of the benign type. We report a new case of an appendiceal GIST in a 75-year-old man. The tumor was discovered when the patient presented with acute appendiceacal peritonitis. Preoperative diagnosis of appendiceal GIST was rarely done as tumors were usually associated with appendicitis-like symptoms.

Bioconversion of wastes from the olive oil and confectionary industries: spectroscopic study of humic acids

Structural changes in humic acids extracted from composted mixtures of sesame bark with the paste of olive mill wastewater or exhausted olive cake, were investigated using FTIR spectroscopy and solid state 13C CP/MAS techniques. The C/N ratio and organic matter degradation decreased significantly after 6 months of composting. The FTIR spectra of humic acids content showed an increase in the aromatic compounds content and a degradation of aliphatic chains. During composting, nuclear magnetic resonance 13C spectral analyses confirmed that aromatic groups exhibited a slight increase while the aliphatic groups decreased and disappeared at the end of the composting process. These results showed that during composting, aliphatic chains were preferentially oxidized, while aromatic macromolecules were bio converted into highly functionalized compounds.

Surgery for Colorectal Cancer in Elderly Patients: How Could We Improve Early Outcomes ?

BACKGROUND

Age is one of the causes behind the undertreatment of elderly colorectal cancer patients. The increase of mortality among elderly colorectal cancer (CRC) patients is due to competing causes of death occurring in the early post operative period. The purpose of this study was to evaluate the risk factors for post operative mortality and morbidity among elderly CRC patients.

MATERIALS AND METHODS

A retrospective descriptive chart review was performed on consecutive patients older than 70 y with CRC. We have collected data of 124 patients who were admitted from January 2001 to January 2010. Demographic characteristics, operative and postoperative informations were retrospectively analysed.

RESULTS

Early postoperative morbidity, operation related to morbidity and mortality were observed in 44 (35.5%), 9 (7.3%) and 20 (16.1%) cases, respectively. No other factors but ASA score (p = 0.002 and 0.005 in univariate and multivariate analyses, respectively) and emergency operations (p<0.001 and 10(-3) in univariate and multivariate analyses, respectively), were found to be risk factors of mortality. The results of multivariate analyses indicated that anaemia (p=0.021) and rectal cancer (p=0.015) had significant impact on the risk of anastomotic leakage. On the other hand, diabetes mellitus and rectal cancer were indicators that correlated with the width of hospitalization.

CONCLUSION

Elderly CRC patients should no longer be undertreated only because of their age. They should be exposed to more aggressive management than they are currently receiving. Careful preoperative evaluation, followed by medical optimization and planning of perioperative care could improve outcomes of colorectal surgery for elderly patients.

Clinico-Pathological Caracteristics, Therapeutic Features and Post-operative Course of Colorectal Cancer in Elderly Patients

STATEMENT OF PROBLEM

Colorectal cancer is predominantly a disease of elderly people and is a major cause of morbidity and mortality in the elderly population. The geriatric colorectal population is a very heterogeneous group, including patients with excellent health status and others with comorbid conditions, functional dependency, and limited life expectancy. On the other hand, the effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved post-operative life expectancy or at least one that is not diminished by the surgery.

MATERIALS AND METHODS

This work is a descriptive study of a retrospective cohort, based on administrative databases, of all patients with colorectal cancer diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, stage of cancer, type of treatment received, post-operative complications and cause of post-operative death. We compared differences between an elderly group (Group A) (age >75 years) and a group of patients below 75 years (Group B).

RESULTS

We found that elderly patients with colorectal cancer were more likely to be operated in emergent conditions, had more non-specific complications and more post-operative mortality than patients below 75 years. On the other hand, tumours stages, tumours characteristics and post-operative specific morbidity have been proved to be similar, both in Group A and Group B patients.

CONCLUSION

These results suggest that surgery is feasible and can be safe for patients above 75 years, but it needs much more evaluation of comorbidities, pre- and post-operative intensive care to avoid post-operative non-specific complications.

Gallstone ileus: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Gallstone ileus (GI) is defined as the occlusion of the intestinal lumen due to the impaction of one or more gallstones. The optimal management of GI is not consensual. We report a rare case of GI with a successful surgical treatment for a 65 year-old-female.

CASE PRESENTATION

A 65 year-old-woman, presented with biliary colic pain and vomiting for three days. On examination, she had a distended tympanic abdomen. A computed tomography scan revealed signs of small bowel obstruction due to a jejunal gallstone. She had pneumobilia due to a cholecysto-duodenal fistula. We performed a midline laparotomy. We found a dilated and ischemic jejunum with false membranes regarding the migrated gallstone. We performed a jejunal resection with primary anastomosis. We performed cholecystectomy and closed the cholecysto-duodenal fistula at the same operative time. The postoperative course was uneventful.

CLINICAL DISCUSSION

We reported successful surgical treatment for GI. It was a one-step procedure. GI is a rare situation. Due to their restricted lumen, the terminal ileum and the ileocaecal valve are where GI occurs most commonly. GI appears usually in elderly patients with comorbidities. The clinical presentation is not specific. CT scan evokes the diagnosis with high specificity. The surgical management of GI is not consensual. In our case, we performed bowel resection due to the presence of an ischemic intestine.

CONCLUSION

GI is a rare situation. It appears usually in elderly patients with comorbidities. The clinical presentation is not specific. The surgical management of GI is not consensual.

Predictive factors of bowel necrosis in patients with incarcerated femoral hernia

PURPOSE

Intestinal necrosis is a frequent complication in patients with incarcerated femoral hernias (IFH). Knowing the low incidence of IFH, few series with large samples studied predictive factors of intestinal necrosis. The main objectives of our study were to determine the predictive preoperative factors of intestinal necrosis in patients with IFH and to compare its morbidity with that related to incarcerate inguinal hernias (IIH).

METHODS

We conducted a retrospective observational cohort study in which we included patients with incarcerated groin hernias (IGH). This is a single-center study between January 2004 and December 2021. Patients were divided into two groups: group A (admitted for IFH) and group B (admitted for IIH). Intestinal necrosis was confirmed intraoperatively.

RESULTS

383 patients with IGH were included in the study: 91 patients had IFH (23.76%) and 282 patients had IIH (76.24%). In patients with IFH, the median age was 67 years. We had 60 females (66%) and 31 males (34%). Bowel ischemia was present in 29 patients (32%). Bowel necrosis was present in 14 patients (16%). We identified three independent variables predicting bowel necrosis in patients with IFH: Duration from symptoms to surgery, NLR (Neutrophil to Lymphocyte ratio), and urea. Bowel ischemia and bowel necrosis were significantly higher in patients with IFH compared to those with IIH.

CONCLUSIONS

In summary, we found that duration from symptoms to surgery, NLR, and urea were significantly predictive of intestinal necrosis in patients with IFH.

Spontaneous rupture of an infected pseudocyst of the pancreas: A case report

INTRODUCTION AND IMPORTANCE

A pancreatic pseudocyst is a known complication of acute and chronic pancreatitis. A pseudocyst rupture into the abdomen causes peritonitis, which can be fatal if surgical treatment is delayed. Here in we report the case of a 46-year-old woman presenting with a pancreatic pseudocyst doubly complicated with infection and rupture causing sepsis shock.

CASE PRESENTATION

A 46 year-old-woman, with a history of chronic pancreatitis four years prior complicated with a pancreatic pseudocyst of 3 cm, presented to our emergency department with clinical signs of generalized peritonitis. After a brief resuscitation, we performed a midline laparotomy. It showed purulent peritonitis due to a rupture of an infected pseudocyst of the pancreas. We performed an abundant peritoneal toilet with drainage. The patient was discharged after 25 days. In the one month follow-up, there were no unfavourable outcomes.

CLINICAL DISCUSSION

In presence of ruptured and infected pancreatic pseudocyst, surgical treatment should be performed as soon as possible after brief resuscitation. Laparotomy is the gold standard treatment. The main objective of surgical treatment is to perform abundant peritoneal toilet with large external drainage. In our case, the pancreatic pseudocyst didn't communicate with the Wirsung duct allowing us to withdraw the drainage. Otherwise, the drainage should be retained longer to treat the pancreatic leakage.

CONCLUSION

Rupture and infection of pancreatic pseudocysts is a rare situation. Diagnosis is assessed via computed tomography scan. Emergency laparotomy should be performed timely to make the peritoneal toilet and drain the pancreatic pseudocyst.

Primary small bowel volvulus: A case report and literature review

Background

Small bowel volvulus (SBV) is an aberrant rotation of the small bowel segment along the axis of its mesentery.

Secondary SBV is the most frequent situation. Postoperative adhesions represent the main cause. On the other hand, primary SBV is an extremely rare situation. There are no predisposing anatomical abnormalities.

Herein, we present a case of a 73-year-old-patient, with no surgical history, presenting primary SBV.

Case presentation

A 73-year-old-patient presented to the emergency department with a one-day history of acute abdominal pain and vomiting. He had no medical comorbidities and no previous abdominal surgery.

On examination, he was agitated and afebrile.

Urgent computed tomography (CT) scan showed dilated small bowel loops with a “whirl sign”.

A laparotomy was performed. It revealed a 320° SBV of the distal jejunum and the proximal ileum. The small bowel was ischemic. There were no congenital malformations, no adhesions, and no internal hernia.

We performed a detorsion of the small bowel. It regained good vitality. To avoid recurrence, we performed enteropexy of the terminal ileum, and the caecum to widen the mesenteric base.

We noted no recurrence of the pathology after three months of follow-up.

Conclusion

Primary SBV is an extremely rare situation. Physiopathology is still misunderstood. The clinical presentation is not specific. Diagnosis can be evoked by CT scan but can only be confirmed intraoperatively. The surgical treatment should be performed timely. Different techniques have been described to avoid recurrence. None of those techniques is consensual.

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Primary small bowel obstruction is an extremely rare situation.

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The physiopathology is still unclear.

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The diagnosis is difficult due to the non-specificity of the symptoms.

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The surgical treatment should be performed timely.

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Enteropexy is an option to avoid recurrence but it's not consensual.