L. Ifrine

Thyroid Tuberculosis: Diagnosis and Treatment

Objective: It was the aim of this study to report clinical characteristics and treatment of thyroid tuberculosis (TT). Methods: During 16 years, 2,426 patients have been operated on the thyroid in the surgical department ‘A’ in Ibn Sina Hospital, Rabat, Morocco. Anatomopathological results of the removed thyroid were analyzed for evidence of tuberculosis. Results: Eight cases of TT were diagnosed. Five patients had a goiter and 3 patients had an isolated nodule of the thyroid. In one case, fine-needle aspiration cytology gave the diagnosis of TT. This patient had a complete drainage of the abscess. In all other patients, the diagnosis was given after surgery. All patients received additional antituberculous drugs for 6 months, and follow-up was satisfactory. Conclusion: TT does not have any consistent symptoms. Fine-needle aspiration is the best method for diagnosis and can result in the avoidance of surgery.

Radical versus conservative surgical treatment of liver hydatid cysts.

The management of liver hydatid cysts is controversial. Surgery remains the basic treatment, and can be divided into radical and conservative approaches. The purpose of this study was to compare the results of radical and conservative surgery in the treatment of liver hydatid cysts.

Changing paradigms in the surgical management of cystic liver hydatidosis improve the postoperative outcomes

AIM OF THE STUDY Our aim was to propose and examine the outcomes of a comprehensive strategy for the management of cystic liver hydatidosis (CLH) based on extensive intraoperative assessments and optimal management of cystobiliary communications. BACKGROUND DATA Although operative intervention remains the preferred treatment for CLH, and the presence of a cystobiliary communication remains a well-established predictive factor for postoperative complications, no internationally accepted management strategy integrates the specific management of cystobiliary communication into the choice of surgical approach. METHODS Early postoperative outcomes were compared before (1990-2004; P1 group; n = 664) and after (2005-2013; P2 group; n = 156) the implementation of a CLH surgical management strategy for CLH in our overall group of patients in subgroups selected by risk factors (as determined by multivariate analysis), and in 2 propensity score-matched groups. RESULTS Specific complications related to the hepatic procedure (intraabdominal complications) were independently associated with the presence of ≥ 3 cysts (P = .013), a fibrotic pericyst (P = .005), a cystobiliary communication (P < .001), and the P1 treatment period (P = .002). Between P1 and P2 groups, the rate of specific complications decreased in the overall group of patients with CLH (18.3% vs 4.5%; P < .001). The rate also decreased in risk factor-based subgroups: patients with ≥ 3 cysts (31.0% vs 4.0%; P = .005), a fibrotic pericyst (23.1% vs 9.2%; P = .011), and a cystobiliary communication (33.0% vs 13.2%; P = .006). After propensity score matching among 123 well-balanced matched pairs of patients, the overall complication rate, specific hepatic surgery-related complication rate, and median duration of hospital stay decreased between the P1 and P2 groups: 23.6% vs 12.2% (P = .02), 21.1% vs 4.9% (P < .001), and 7 vs 5 days (P < .001), respectively. CONCLUSION Implementation of a CLH surgical management strategy based on specific intraoperative assessment and optimal management of cystobiliary communications improved early postoperative outcomes.

Acute abdominal compartment syndrome complicating a colonoscopic perforation: a case report

IntroductionA perforation occurring during colonoscopy is an extremely rare complication that may be difficult to diagnose. It can be responsible for acute abdominal compartment syndrome, a potentially lethal complex pathological state in which an acute increase in intra-abdominal pressure may provoke the failure of several organ systems.Case presentationWe report a case of acute abdominal compartment syndrome after perforation of the bowel during a colonoscopy in a 60-year-old North African man with rectal cancer, resulting in respiratory distress, cyanosis and cardiac arrest. Our patient was treated by needle decompression after the failure of cardiopulmonary resuscitation. An emergency laparotomy with anterior resection, including the perforated sigmoid colon, was then performed followed by immediate anastomosis. Our patient remains alive and free of disease three years later.ConclusionAcute abdominal compartment syndrome is a rare disease that may occasionally occur after a colonoscopic perforation. It should be kept in mind during colonoscopy, especially considering its simple salvage treatment.

Impact of seniority on operative time and short-term outcome in laparoscopic cholecystectomy: Experience of an academic Surgical Department in a developing country.

Introduction: Resident participation in laparoscopic cholecystectomy (LC) is one of the first steps of laparoscopic training. The impact of this training is not well-defined, especially in developing countries. However, this training is of critical importance to monitor surgical teaching programmes. Objective: The aim of this study was to determine the impact of seniority on operative time and short-term outcome of LC. DESIGNS AND SETTINGS: We performed a retrospective study of all consecutive laparoscopic cholecystectomies for gallbladder lithiasis performed over 2 academic years in an academic Surgical Department in Morocco. Participants: These operations were performed by junior residents (post-graduate year [PGY] 4–5) or senior residents (PGY 6), or attending surgeons assisted by junior residents, none of whom had any advanced training in laparoscopy. All data concerning demographics (American Society of Anesthesiologists, body mass index and indications), surgeons, operative time (from skin incision to closure), conversion rate and operative complications (Clavien–Dindo classification) were recorded and analysed. One-way analysis of variance, Students t-test and Chi-square tests were used as appropriate with statistical significance attributed to P < 0.05. Results: One hundred thirty-eight LC were performed. No differences were found on univariate analysis between groups in demographics or diagnosis category. The overall rate of operative complications or conversions and hospital stay were not significantly different between the three groups. However, mean operative time was significantly longer for junior residents (n = 27; 115 ± 24 min) compared to senior residents (n = 37; 77 ± 35 min) and attending surgeons (n = 66; 55 ± 17 min) (P < 0.001). Conclusion: LC performed by residents appears to be safe without a significant difference in complication rate; however, seniority influences operative time. This information supports early resident involvement in laparoscopic procedures and also the need to develop cost-effective laboratory training programmes.

Primary omental gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) represent the majority of primary non-epithelial neoplasms of the digestive tract, most frequently expressing the KIT protein detected by immunohistochemical staining for the CD117 antigen. Extragastrointestinal stromal tumors (EGISTs), neoplasms with immunohistological features overlapping those of GISTs, are found in the abdomen outside of the gastrointestinal tract with no connection to the gastric or intestinal wall. The present report presents the clinical, macroscopic and immunohistological features of an EGIST arising in the greater omentum of a 63-year-old woman, and discusses the clinical behavior and prognostic factors of such lesions in comparison to their gastrointestinal counterparts.

Parathyroid incidentaloma. Literature review about three case reports.

BACKGROUND Parathyroid incidentaloma is not a well-known entity. The aim of this study was to show its incidence and to discuss its management. METHODS This was a prospective study analyzing cases of enlarged parathyroid glands discovered during thyroid surgery. The records of patients with parathyroid incidentaloma were reviewed. We also reviewed all cases of primary hyperparathyroidism (HPTPs) operated during the same period for comparison. RESULTS Three cases of enlarged parathyroid were found. No clinical or biochemical features led us to suspect hyperparathyroidism before surgery, but a macroscopically enlarged parathyroid gland was discovered during the dissection and was removed in all three patients. CONCLUSIONS Enlarged parathyroid glands discovered at the time of surgery may represent an early pathological stage responsible for overt primary hyperparathyroidism. In absence of major risk for recurrent nerve palsy, we recommend removal of any enlarged parathyroid discovered during neck surgery in order to avoid the risks of future surgical procedures, preserving in the same time at least one normal parathyroid gland.

Aspects diagnostiques et thérapeutiques des tumeurs stromales digestives

RésuméIntroductionLes tumeurs stromales (GIST pour gastrointestinal stromal tumors) sont les tumeurs conjonctives les plus fréquentes du tube digestif. Elles s’intègrent désormais dans un cadre nosologique précis défini par la positivité au CD117 en immunohistochimie. Nous rapportons et analysons une série de 17 GIST opérées à la Clinique chirurgicale « A » (Rabat, Maroc) entre mars 1999 et mars 2005.Matériel et méthodesNous avons inclus rétrospectivement les GIST confirmées à l’examen histologique ayant comporté obligatoirement une étude immunohistochimique. Les données démographiques, cliniques, histologiques et thérapeutiques des patients ont été analysées.RésultatsNous avons colligé 17 cas de GIST, 8 hommes et 9 femmes. L’âge moyen était de 57 ans (extrêmes: 20–75 ans). Les localisations tumorales étaient l’estomac (n = 12) et l’intestin grêle (n = 3) puis l’œsophage (n = 1) et le rectum (n = 1). Chez 16 patients, le traitement à visée curative a consisté en une résection chirurgicale de première intention, adaptée à la localisation tumorale, sans curage ganglionnaire systématique, avec une métastasectomie hépatique dans un cas. La tumeur a été jugée inextirpable à l’exploration chirurgicale chez une patiente. La résection tumorale a été réalisée par voie cœlioscopique dans un cas. La mortalité opératoire était nulle. Les suites opératoires immédiates étaient simples à l’exception d’une éviscération libre traitée au onzième jour postopératoire. Le délai moyen de suivi était de 9 mois (extrêmes : 1–40 mois). Huit patients étaient vivants sans récidive. Une patiente ayant développé, après 8 mois des métastases hépatiques et péritonéales a été traitée par imatinib avec une régression des lésions. Un patient en récidive locale (œsophage) est décédé après 17 mois de survie globale. Sept patients ont été perdus de vue dont un ayant développé des métastases hépatiques.ConclusionLe potentiel évolutif de ces tumeurs reste difficile à évaluer, faute de critères histopronostiques fiables. Le devenir au long cours de nos patients opérés pour GIST doit faire l’objet d’une évaluation rapprochée et régulière en vue d’un dépistage précoce des récidives et pour établir dans un cadre prospectif les facteurs prédictifs de récidive. La chirurgie large et complète reste, dans les régions du monde où l’imatinib ne peut être distribué, la seule arme thérapeutique efficace.SummaryGastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the digestive tract, now defined by the immunohistochemical expression of CD117. We report 17 cases of GIST operated between March 1999 and March 2005 in The Clinique chirurgicale « A » of Rabat (Morocco).Methodswe have retrospectively included GIST confirmed by histopathological and immunohistochemical examination. Demographic, clinical, pathological and treatment data were analysed.Resultsseventeen patients with GIST were operated: 8 men and 9 women. The mean age was 57 years (20–75). Tumours were located in the stomach (n = 12), small intestine (n = 3), oesophagus (n = 1) and rectum (n = 1). Sixteen patients underwent a curative resection adapted to the location, without systematic lymphadenectomy. A patient underwent a hepatic metastasectomy. Resection was not possible in one patient. The mean follow-up was 9 months (1–40). Eight patients were living without recurrence. A patient who had developed liver and peritoneum metastasis was treated by imatinib with good result. A patient operated for oesophagus GIST developed a local recurrence and died 17 months after operation. Seven patients were not followed up, one with liver metastasis.ConclusionGIST evolution is hard to predict. Close follow-up of our patients would help us to identify and treat recurrence earlier and determine local patterns of tumour recurrence. Complete and wide surgical resection remains the only efficient treatment in regions where imatinib is not available.