Chadli Dziri

Treatment of Hydatid Cyst of the Liver: Where Is the Evidence?

Treatment of hydatid cyst of the liver ranges from surgical intervention (conventional or laparoscopic approach) to percutaneous drainage and to medical therapy. The aim of this systematic review was to provide “evidence-based” answers to the following questions: Should chemotherapy be used alone or in association with surgery? What is the best surgical technique? When is the percutaneous aspiration injection and reaspiration technique (PAIR) indicated? An extensive electronic search of the relevant literature without limiting it to the English language was carried out using MEDLINE and the Cochrane Library. Key words used for the final search were “hydatid cyst,” “liver,” “treatment,” “meta analysis,” “randomized controlled trial,” “prospective study,” “retrospective study.” All relevant studies reporting the assessment of one modality of treatment or a comparison of two or several therapeutic methods to treat hydatid cyst of the liver and published in a peer-reviewed journal were considered for analysis. This systematic review allowed us to conclude that chemotherapy is not the ideal treatment for uncomplicated hydatid cysts of the liver when used alone (level II evidence, grade B recommendation). The level of evidence was too low to help decide between radical or conservative treatment (level IV evidence, grade C recommendation). Omentoplasty associated with radical or conservative treatment is efficient in preventing deep abscesses (level II evidence, grade A recommendation). The laparoscopic approach is safe (level IV evidence, grade C recommendation). Drug treatment associated with surgery (level II evidence, grade C recommendation) requires further studies. Percutaneous drainage associated with albendazole therapy is safe and efficient in selected patients (level II evidence, grade B recommendation). The level of evidence is low concerning treatment of complicated cysts.

Omentoplasty in the prevention of deep abdominal complications after surgery for hydatid disease of the liver: a multicenter, prospective, randomized trial

BACKGROUND Omentoplasty (OP) is thought to fill residual cavity, to assist healing of raw surfaces, and to promote resorption of serosal fluid and macrophagic migration in septic foci. Results published to date, whether retrospective or prospective, are not controlled and are discordant. STUDY DESIGN The authors investigated whether OP, either filling the residual cavity after unroofing, or covering the hepatic raw surface after pericystectomy, could reduce the rate or severity of deep abdominal complications (DAC) after surgical treatment of hydatid disease of the liver. Between January 1993 and December 1996, 115 consecutive patients (51 males and 64 females, mean age 42+/-16 years [range 10 to 80 years]) with previously unoperated uni- or multilocular hydatid disease of the liver, complicated or not, without other abdominal hydatid disease, were randomly allotted to OP (n = 58) or not (NO) (n = 57) after unroofing, total, or partial pericystectomy. Patients were divided into 2 strata according to the site of the cyst with respect to the diaphragm: a) posterosuperior segments II, VII, and VIII or b) anterior segments III, IV, V, and VI. Main outcomes measures included deep bleeding, hematoma, infection, or bile leakage. Subsidiary measures included wound complications, extraabdominal complications, duration of operation, and length of hospital stay. RESULTS Both groups were comparable regarding patient demographics, cyst characteristics, intraoperative procedures, search for bile leaks, and intraoperative transfusion requirements. On the other hand, more patients (86%) in NO had associated drainage of the abdominal cavity than in OP (64%) and the duration of operation was 9 minutes longer in OP, but neither of these differences was statistically significant. Less DAC occurred in OP (10%) than in NO (23%) (a posteriori gamma risk < 0.05) and fewer deep abdominal abscesses (0 versus 11%) (p < 0.03). Median duration of hospital stay, however, was similar. CONCLUSIONS OP decreases the rate of DAC and especially deep abdominal abscess after surgical treatment (unroofing or pericystectomy) for hydatid disease of the liver and should be recommended in this setting.Background: Omentoplasty (OP) is thought to fill residual cavity, to assist healing of raw surfaces, and to promote resorption of serosal fluid and macrophagic migration in septic foci. Results published to date, whether retrospective or prospective, are not controlled and are discordant. Study Design: The authors investigated whether OP, either filling the residual cavity after unroofing, or covering the hepatic raw surface after pericystectomy, could reduce the rate or severity of deep abdominal complications (DAC) after surgical treatment of hydatid disease of the liver. Between January 1993 and December 1996, 115 consecutive patients (51 males and 64 females, mean age 42 ± 16 years [range 10 to 80 years]) with previously unoperated uni- or multilocular hydatid disease of the liver, complicated or not, without other abdominal hydatid disease, were randomly allotted to OP (n = 58) or not (NO) (n = 57) after unroofing, total, or partial pericystectomy. Patients were divided into 2 strata according to the site of the cyst with respect to the diaphragm: a) posterosuperior segments II, VII, and VIII or b) anterior segments III, IV, V, and VI. Main outcomes measures included deep bleeding, hematoma, infection, or bile leakage. Subsidiary measures included wound complications, extraabdominal complications, duration of operation, and length of hospital stay. Results: Both groups were comparable regarding patient demographics, cyst characteristics, intraoperative procedures, search for bile leaks, and intraoperative transfusion requirements. On the other hand, more patients (86%) in NO had associated drainage of the abdominal cavity than in OP (64%) and the duration of operation was 9 minutes longer in OP, but neither of these differences was statistically significant. Less DAC occurred in OP (10%) than in NO (23%) (a posteriori gamma risk < 0.05) and fewer deep abdominal abscesses (0 versus 11%) (p < 0.03). Median duration of hospital stay, however, was similar. Conclusions: OP decreases the rate of DAC and especially deep abdominal abscess after surgical treatment (unroofing or pericystectomy) for hydatid disease of the liver and should be recommended in this setting.

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BackgroundLaparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe.MethodsA systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference.ResultsA total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI.ConclusionsBecause BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Prevention of deep abdominal complications with omentoplasty on the raw surface after hepatic resection

BACKGROUND Several methods have been suggested to treat the hepatic raw surface after resection. Among these, omentoplasty (OP) has been employed occasionally but there are no clinical studies that clearly demonstrate its usefulness. METHODS Of 172 randomized patients undergoing hepatic resection between January 1991 and December 1994, 5 were withdrawn for protocol violation, leaving 167 who were randomly allotted to undergo OP (n = 87) on the hepatic raw surface or not (NO; n = 80). This procedure was performed for malignant tumor in 125 cases, benign tumor in 33, and for other causes in 15. Six patients had more than two types of lesions, and 32 patients had associated cirrhosis. Sixty-five major and 102 minor hepatic resections were performed. The main outcome measures studied were the number of patients with deep abdominal complications (DAC; deep bleeding or hematoma, deep infection, with or without pus discharge through drains, bile leakage), as well as repeat operations and postoperative death. Patients were divided into two strata according to the site of the lesion with respect to the diaphragm: (1) in contact (posterosuperior segments II, VII and VIII) or (2) not in contact (anterior segments III, IV, V, and VI). RESULTS Both groups were comparable as regards patient demographics, intraoperative procedures, intraoperative search for bile leaks and intraoperative transfusion requirements. Fewer patients had DAC in OP (n = 11) than in NO (n = 15) (difference not significant). Ten patients (6%) required repeat operations: 4 in OP without immediate mortality and 6 in NO, 3 followed by death. One further patient in OP required repeat operation after discharge and died. Four patients died in OP and 7 in NO, 1 and 4 of DAC, respectively (not significant). Deep abdominal complications were significantly associated with major hepatic resection (P <0.05) whereas postoperative death was significantly correlated with cirrhosis (P <0.05). CONCLUSIONS OP on the raw surface after hepatic resection lowers the rate of all complications related to DAC (except biliary leaks) and their severity (repeat operations and death) but not significantly so. OP is not recommended as a routine measure to complete elective hepatic resections.

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.

How to Teach Evidence-based Surgery

The objectives of teaching evidence-based surgery (EBS) are to inform and convince that EBS is a method of interrogation, reasoning, appraisal, and application of information to guide physicians in their decisions to best treat their patients. Asking the right, answerable questions, translating them into effective searches for the best evidence, critically appraising evidence for its validity and importance, and then integrating EBS with their patients’ values and preferences are daily chores for all surgeons. Teaching and learning EBS should be patient-centered, learner-centered, and active and interactive. The teacher should be a model for students to become an expert clinician who is able to match and take advantage of the clinical setting and circumstances to ask and to answer appropriate questions. The process is multistaged.Teaching EBS in small groups is ideal. However, it is time-consuming for the faculty and must be clearly and formally structured. As well, evidence-based medicine (EBM) courses must cater to local institutional needs, must receive broad support from the instructors and the providers of information (librarians and computer science faculty), use proven methodologies, and avoid scheduling conflicts. In agreement with others, we believe that the ideal moment to introduce the concepts of EBM into the curriculum of the medical student is early, during the first years of medical school. Afterward, it should be continued every year. When this is not the case, as in many countries, it becomes the province of the surgeon in teaching hospitals, whether they are at the university, are university-affiliated, or not, to fulfill this role.

Synchronous double cancer of the common bile duct.

Synchronous double cancer of the common bile duct is exceptional and only one reported case was found in the literature. We report a case in which the diagnosis of the double tumor was missed by computed tomography scan, magnetic resonance imaging, and endoscopic ultrasonography. The diagnosis of the distal tumor was made only during surgery. There was no communication in either the mucosal layer or the subepithelial layer between the 2 cancers without periductal lymphatic spread, thus suggesting that they are primary.

Surgeon-dependent predictive factors for mortality after elective colorectal resection and immediate anastomosis for cancer or nonacute diverticular disease: multivariable analysis of 2,605 patients.

BACKGROUND Multivariable analysis best identifies independent risk factors. STUDY DESIGN We conducted a prospective evaluation of 2,605 patients through univariate analysis followed by nonconditional multiple logistic regression analysis on 39 pre-, intra-, and postoperative factors, analyzed according to preoperative factors alone, preoperative and intraoperative factors together, and all 3 combined. The purpose was to identify surgeon-dependent independent risk factors for mortality after elective colorectal surgery, with immediate anastomosis for cancer and nonacute diverticular disease. RESULTS Overall mortality was 3.5%. Through multivariable analysis, five risk factors were found when preoperative data were analyzed alone. Four remained (age between 60 and 75 years, age greater than 75 years, male gender, and heart failure) and 4 new factors (palliative resection, total colectomy, respiratory failure, and surgeon-dependent fecal soiling [the only surgeon-dependent factor]) appeared when pre- and intraoperative factors were analyzed together. Of the latter, two remained stable when all three categories of risk factors were combined and analyzed (palliative resection and total colectomy), and the two others disappeared. Of the eight pre-, intra-, and postoperative factors combined, two new factors appeared: extrasurgical site (ESS) and surgeon-dependent, organ space surgical site (O/SSS) morbidity. CONCLUSIONS Every effort must be made to collect specific, surgeon-dependent (technical and clinical) data, along with administrative data, for multivariable analysis of risk factors. Classification into three periods (pre-, pre- and intraoperative together, and pre-, intra-, and postoperative combined) enables determination of relevant, surgeon-dependent risk factors (fecal soiling and postoperative morbidity) for which there are direct preventive actions.

What should surgeons know about evidence-based surgery

The practice of medicine has long been an empiric enterprise. In 1996, Sackett et al. [1] immortalized a new concept they called evidence-based medicine (EBM). They defined it as ‘‘the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients.’’ The history of EBM, chronologically detailed through its evolution in this review, tells us that the concept has been on surgeons minds for years but has come to fruition in the electronic age. Traditionally, the practice of surgery has been based on understanding the pathophysiology of a disease process, the introduction of new procedures, and the evaluation of results of treatment as reported in case series. As we all recognize the value of discoveries announced in the medical journals, we also recognize that every year the medical literature doubles in size. How can the surgeon of today cope with this wealth of knowledge now available? Critical appraisal is a core component of EBM. The challenge for the surgeon today is to know how to search the best evidence relevant for his or her clinical practice. The electronic age has helped the surgeon in this endeavor enormously as can be easily seen by the increasing number of ‘‘hits’’ seen on MEDLINE with the keywords ‘‘evidence-based medicine.’’ However, correct appraisal of the results—the only way to accept or refute the wealth of information found in the literature—is possible only when the surgeon, with the necessary background in biostatistics [2], is equipped with the knowledge and skills to interpret the statistical data critically and accurately. Once accepted, the surgeon must then ‘‘integrate’’ this information with the specific questions that were asked. A surgeon should be able to recognize the differences between means and medians and normal and nonnormal data distributions, as well as be able to define a risk ratio, absolute risk, odds ratio, and relative risk. A surgeon should also know the meaning of type I and type II errors, how to interpret a p value, and understand survival curves and confounding variables. In this symposium, our goal was to complete the knowledge and provide insight to the general surgeon concerning the skills necessary to interpret data critically and accurately, holding his or her attention long enough to realize that this information is important and cannot continue to be ignored. Also, we did not want to provoke a retreat to the Stone Age of surgery: This is ‘‘evidencebased surgery’’ for surgeons ‘‘without tears.’’ We voluntarily inserted three specific articles related, respectively, to confidence intervals, the number needed to treat (or harm), and sample size computations. The confidence interval is useful for quantifying the uncertainty in estimates of a clinically relevant quantity. More informative than results presented with just p values, confidence intervals avoid misinterpretation of nonsignificant results of small studies. More and more leading journals require them. A surgeon should be able to distinguish between clinical and statistical significance. Statistical significance involves calculating a p value; clinical significance, on the other hand, relies on a new parameter, the ‘‘number needed to treat,’’ which not only tells us whether a treatment works but how well it works. Sample size calculations are necessary to give the results of a trial its ‘‘power’’: It is dependent on the two types of error: Type I error means concluding—erroneously—that there is a difference between study groups when, in reality, there is no difference (false-positive result), whereas type II error entails concluding—erroneously—that there is no difference between the study groups when, in reality, a difference exists (false-negative result). Too many surgeons are ill-prepared to understand these parameters on which the appropriate sample size is based. Another aim of this symposium was to help surgeons analyze an article, appraise a prognostic study, determine the effectiveness of treatment or a diagnostic test, and to interpret the results of metaanalysis and systematic reviews, allowing him or her to be able to apply the evidence gleaned from rigorously designed studies to individual patients. Analyzing the literature requires a rigorous approach: a prepared checklist applied to each article is essential for correct appraisal. Relevant answers should be provided for each section of any article, including why the study was done and its aims in the introduction, a sufficient number of patients, valid and reliable measurement parameters, clinically relevant outcome and irreproachable statistics in the methods, proper description of basic data, consistent numerical results, proper measurement and presentation of statistical significance in the results, and finally how the results compare with those of previously published data, and how thy apply to daily practice. As well, critical appraisal of a Correspondence to: Chadli Dziri, M.D., e-mail: chadli.dziri@planet.tn World J. Surg. 29, 545–546 (2005) DOI: 10.1007/s00268-005-7909-7

Synthesis and evaluation of analgesic, behavioral effects and chronic toxicity of the new 3,5-diaminopyrazole and its precursor the thiocyanoacetamide

This study aimed to explore the analgesic, antioxidant, behavioral and toxicological effects of 3,5-diaminopyrazole and thiocyanoacetamide. Caffeine was used as reference drug whose effects are known after oral treatment with an efficient dose (10mg/kg/day) for 30days. The preliminary bioassays indicated that both compounds at this dose have strong antioxidant capacities and present highly analgesic effects. The behavioral study showed an activation of the rat memory by thiocyanoacetamide. This molecule caused a phobia state to open areas in the elevated plus maze and specifically agoraphobia in the open field with a lack in the development of the exploratory capacity. 3,5-Diaminopyrazole caused memory troubles in rats that forgot the pathway to the exit from the maze, and induced an anxiety state revealed by immobility in closed arms of the elevated plus maze. All these observations were compared to the treatment by the known analgesic, caffeine, which increased the state of vigilance of the rats and developed their exploratory capacity. The chronic treatment with the investigated compounds showed no sign of toxicity with the absence of effect on the body and organ weights, blood count, kidney and liver function and histology. 3,5-Diaminopyrazole and thiocyanoacetamide have potent antioxidant and analgesic activities that are higher than caffeine with a safety profile. The chronic treatment by thiocyanoacetamide activated the memory and caused an emotional state of agoraphobia, but 3,5-diaminopyrazole caused a memory impairment and an emotional state of anxiety. Thus, the present study warrants further investigations involving these novel molecules for a possible development of new strong analgesic and antioxidant drugs which have an effect on the memory capacity.