BACKGROUND:Laparoscopic surgery with three-dimensional (3D) vision has recently been introduced, allowing enhanced visualization and improved suturing capabilities. However, its clinical impact has not been widely studied, particularly in laparoscopic pancreatoduodenectomy (LPD), where visualization and suturing are critical. In this study, we compared outcomes between 2D and 3D LPD. METHODS:In our center, the first 2D-LPD was performed in 2011, and 3D-LPD was introduced in 2019. To assess the impact of 3D vision while minimizing bias related to the learning curve, we compared two consecutive four-year periods before and after the implementation of 3D vision: a first period with 2D-LPD (2015-2018) and a second period with 3D-LPD (2019-2022). There were no major modifications in surgical technique between the two periods. Operative and postoperative outcomes were compared between 2D and 3D LPD, both before and after propensity score matching. A generalized linear mixed model (GLMM) was associated to account for the time-effect. RESULTS:During the study period, 162 LPDs were performed, including 79 with 2D-LPD and 83 with 3D-LPD. There was no significant difference in baseline clinical characteristics, except for ampullary tumors, which were more frequently operated on in the 2D-LPD group (16 % vs. 4.8 %; p = 0.016). Operative data and pancreatic characteristics were similar between groups. However, 3D-LPD was associated with a lower conversion rate (0 % vs. 6 %; p = 0.026) and a lower transfusion rate (0 % vs. 6 %; p = 0.027). After propensity score matching (2D-LPD: n = 39; 3D-LPD: n = 83), outcomes remained significantly better with 3D-LPD, with fewer grade C postoperative pancreatic fistulas (10 % vs. 2 %; p = 0.038) and lower readmission rates (10 % vs. 0 %; p = 0.009), while median hospital stay was similar between groups (14 vs. 15 days; p = 0.699). CONCLUSION:This study shows that 3D-LPD, compared to 2D-LPD, is associated with a lower incidence of grade C postoperative pancreatic fistula and readmission. Given its availability and cost-effectiveness compared to robotic surgery, 3D-LPD should be promoted.

INTRODUCTION:Injuries caused by terrorism attacks are one of the urgent problems of the society and the health system. In this work, we aimed to assess the injury severity score (ISS) and trauma injury severity score (TRISS) in Tunisian military combatants injured during terrorism attacks. MATERIALS AND METHODS:A total of 153 victims of terrorism admitted to the Military Hospital of Tunis between January 2012 and January 2017 were included. Among them, 107 survived and 46 died (43 victims died at the terrorist attack scene and 3 died in the hospital). All dead patients were autopsied. Injury severity scores and TRISSs were then calculated by 2 professors in the anesthesia-resuscitation department, and the agreement level was assessed using the Bland and Altman curve. RESULTS:We obtained a strong agreement between the 2 experts when assessing the TRISS and ISS. Using the Bland and Altman curve, an agreement between the 2 experts was obtained between 0 to 40 and 60 to 75 for the ISS and between 0 to 25 and 75 to 100 for the TRISS. Moreover, we detected a high level of ISS and TRISS, especially in deceased victims compared to survivors (P <.001). To predict mortality, we revealed by the receiver operating characteristic curve high sensitivity and specificity (more than 90%) before day 28 of hospital stay as well as for ISS and TRISS. Regarding the mechanism of injury, patients injured by gunshot have higher ISSs and TRISSs than those injured by explosion (P < .001). CONCLUSIONS:Injury severity scores and TRISSs showed a high reliability to predict the mortality rate in Tunisian victims of terrorism.

Background. COVID-19 is the major cause of serious acute respiratory complications, leading to strong perturbation of cytokine release and high levels of interleukin-6. In this work, we assessed the efficacy and safety of Tocilizumab in Tunisian patients with severe COVID-19. Materials and Methods. We enrolled in this retrospective study 255 critically ill patients in the intensive care unit of the military hospital of Tunis. These patients were categorized into a standard group (n = 148) and a Tocilizumab group (n = 107). Medical records were gathered and analyzed between September, 2020 and September, 2021. Results. No significant difference was detected in clinical and biological parameters at admission between the two studied groups. Interestingly, we revealed here a significant improvement in respiratory parameters as well as biological findings such as hemoglobin (p=0.001), platelets (p=0.005), CRP (p=0.0001), fibrinogen (p=0.0001), and creatinine (p=0.002). Regarding the Simplified Acute Physiology Score II and 28-day mortality, we showed a significant decrease of these two parameters following 48 hr of drug administration (p=0.0001, respectively). No significant difference between the two groups regarding complications except the renal failure and the need for renal replacement therapy, which are higher in the standard group as compared to patients treated with Tocilizumab (p=0.02; p=0.0001, respectively). Conclusions. Treatment with TCZ seems to be safe and effective in reducing the mortality rate in severe COVID-19 patients.

On March 13, 2021, Tunisia started a widespread immunization program against SARS-CoV-2 utilizing different vaccinations that had been given emergency approval. Herein, we followed prospectively a cohort of participant who received COVID-19 vaccine (Pfizer BioNTech and Sputnik-Gameleya V). The goal of this follow-up was to define the humoral and cellular immunological profile after immunization by assessing neutralizing antibodies and IFN- γ release. 26 vaccinated health care workers by Pfizer BioNTech (n=12) and Sputnik-Gameleya V (n=14) were enrolled from June to December 2021 in Military hospital of Tunis. All consenting participants were sampled for peripheral blood after three weeks of vaccination. The humoral response was investigated by the titer of anti-SARS-CoV-2 immunoglobulin G (IgG) antibodies to S1 protein. The CD4 and CD8 T cell responses were evaluated by the QuantiFERON® SARS-CoV-2 (Qiagen® Basel, Switzerland). Regardless the type of vaccine, the assessment of humoral and cellular response following vaccination showed a strong involvement of the later with expression of IFN-γ as compared to antibodies secretion. Moreover, we showed that people with past SARS-CoV-2 infection developed high levels of antibodies than those who are not previously infected. However, no significant difference was detected concerning interferon gamma (IFN-γ) expression by CD4 and CD8 T cells in health care worker (HCW) previously infection or not with COVID-19 infection. Analysis of immune response according to the type of vaccine, we found that Pfizer BioNTech induced high level of humoral response (91.66%) followed by Sputnik-Gameleya V (64.28%). However, adenovirus vaccine gave a better cellular response (57.14%) than mRNA vaccine (41.66%). Regarding the immune response following vaccine doses, we revealed a significant increase of neutralizing antibodies and IFN-γ release by T cells in patients fully vaccinated as compared to those who have received just one vaccine. Collectively, our data revealed a similar immune response between Pfizer BioNTech and Sputnik-Gameleya V vaccine with a slight increase of humoral response by mRNA vaccine and cellular response by adenovirus vaccine. It's evident that past SARS-CoV-2 infection was a factor that contributed to the vaccination's increased immunogenicity. However, the administration of full doses of vaccines (Pfizer BioNTech or Sputnik-Gameleya V) induces better humoral and cellular responses detectable even more than three months following vaccination.

Background:Immune response plays a crucial role in virus clearance during COVID-19 infection and underpins vaccine efficacy. Herein, we aimed to assess the immune response during COVID-19 infection and following SARS-CoV-2 vaccination.Methods:In this retrospective study, 94 confirmed COVID-19 patients admitted to the intensive care unit were categorized into unvaccinated patients (n = 50), including 33 deceased and 17 discharged patients, and vaccinated group (n = 44) with 26 deceased and 18 discharged patients. Records of patients with severe COVID-19 admitted to the ICU between March, 2021 and March, 2022 were gathered and analyzed.Result:The assessment of immune cell counts revealed a large rise of neutrophils associated to decrease number of lymphocytes in patients with COVID-19 infection. In dead patients, we detected a significant correlation between neutrophils and inflammatory parameters such as IL-6 and CRP. Moreover, analysis of immune cell count following vaccination did not reveal any significant difference. However, the most substantial result, herein, detected is the decrease level of IL-6 in vaccinated patients as compared to unvaccinated. The reduce level of IL-6 following vaccination is observed in discharged patients as compared to deceased. Regarding the level of mortality after vaccination, we showed that all patients who received the first dose were died (46.1%, n = 12) as compared to those who have received two doses (34.6%, n = 9) and the third dose of vaccine (19.23%, n = 3) (p=0.0018). Strikingly, studying the inflammatory parameters after each vaccine dose, we revealed a significant decrease of IL-6 level after the booster dose (third dose), especially in vaccinated discharged patients.Conclusions:Neutrophils combined with IL-6 and CRP can be very useful markers to predict disease severity in patients admitted to ICU. The decrease level of IL-6 in vaccinated group pointed out the impact of vaccination to prevent inflammatory cytokine release.

The COVID-19 pandemic caused havoc on the world, infecting more than 3.5 billion people and resulting in over 15 million deaths, and overwhelmed existing healthcare infrastructures around the world, as announced by the World Health Organization (WHO). We propose in this work an effective and low-cost strategy for collecting, pre-processing, and extracting meaningful information from different types of patient data that may be useful for statistics and training of Machine Learning (ML) models to respond to pandemics such as COVID-19. Information like medical history, clinical examination, para-clinical testing, and patient RGB videos are collected This achievement will enable further studies to train, test, and deploy on-device decentralized ML models to monitor patients at home.

The severity of COVID-19 is largely determined by the inflammatory response, a "Cytokine storm," that involves both pro-and anti-inflammatory cytokines. In the current study we investigated the balance of pro-and anti-inflammatory status as represented by the levels of IL-6/IL-10 in severe to critical COVID-19 patients. 66 confirmed COVID-19 patients admitted to the ICU were categorized into groups according to the mortality and respiratory failure. Data were collected retrospectively in ICU, including a peripheral immune cells and infection-related biomarker CRP. The measurements of cytokine levels were performed by Immulite analyzer for IL-6 and ELISA sandwich for IL-10. In addition, longitudinal measurement of IL-6 was performed during 5 days post admission. Longitudinal assays showed that IL-6 was sustained at a medium level within 5 days post admission in severe cases who survived or not requiring mechanical ventilation, whereas it was sustained at high levels throughout the disease course in either deceased cases or who developed respiratory failure. The ratio of IL-6/ lymphocytes was positively correlated with the risk of mortality, while IL-10/lymphocytes ratio could predict respiratory failure in ICU. IL-6/IL-10 profiling revealed that deceased patients have different magnitudes of both IL-6 and IL-10 cytokine release. Notably, excessive levels of IL-6 concomitant with high levels of IL-10 were more common in diseased COVID-19 patients. Taking into account the IL-6/IL-10 profiling may help clinicians to identify the right time of anti-inflammation treatment and select patients who will respond to anti-cytokine therapies and maintain an adequate inflammatory response for SARS-CoV-2 clearance.

The SARS CoV-2 pandemic is a global health threat with high morbidity and mortality (1 to 4%) rates. COVID-19 is correlated with important immune disorders, including a "cytokine storm". A new therapeutic approach using the immunomodulatory drug, Anti-IL6 (tocilizimub), has been proposed to regulate it. We report here the first Tunisian experience using tocilizimub in two severe cases of COVID-19 pneumonia. The diagnosis was confirmed by chest scan tomography. Biological parameters showed a high level of Interleukin-6 (IL-6) that increased significantly during hospitalization. The patients developed hypoxia, so they received intravenously 8 mg/kg body weight tocilizumab. There was a resultant decrease in the level of IL6, with clinically good evolution. Blocking the cytokine IL-6 axis is a promising therapy for patients developing COVID-19 pathology.

In our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results. Between 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (n = 43), second period (n = 43), and third period (n = 44). In the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%, p = 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%; p = 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%; p = 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%; p = 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%; p = 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270; p < 0.001) with less blood loss (300, 200, 125; p < 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%; p = 0.017), bleeding (28%, 21%, 14%; p = 0.26), Clavien-Dindo III–IV (40%, 33%, 16%; p = 0.013), re-interventions (19%, 14%, 9%; p = 0.43), and the hospital stay (26, 19, 18; p = 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%; p = 0.002) with more harvested lymph nodes in the third period (21,19, 25; p = 0.031) and higher R0 resection (70%, 79%, 84%; p = 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m2, and patients operated in the third period. This study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.

Background: The management of septic shock requires the administration of an alpha-adrenergic drug such as norepinephrine, after optimization of the patient’s preload, to maintain adequate mean arterial pressure. Nevertheless, with optimal macrocirculatory parameters, alterations of tissue perfusion can occur. This study aimed to investigate the effect of norepinephrine dosage on microcirculation parameters, studied by microdialysis, in patients with septic shock. Methods: We conducted a retrospective study. We included all patients aged over 16 years in septic shock. We studied three groups (levosimendan, dobutamine, and control group). We administrated norepinephrine before inclusion, at stable flow for more than an hour. We performed hemodynamic monitoring of macrocirculation by echocardiography. We analyzed microcirculation parameters (lactate, pyruvate, and lactate/pyruvate ratio) every six hours during the first three days, by muscle microdialysis (CMA 600, CMA microdialysis AB, Stockholm, Sweden). We studied correlations between microcirculation parameters and norepinephrine doses.Results: We included thirty patients in the study (ten patients in each group). Demographic characteristics and mortality were comparable across the three groups. In total, we analyzed 390 samples of interstitial muscle fluid. We did not find any correlation between norepinephrine doses and the lactate concentration in the muscle, as well as the ratio of lactate/ pyruvate concentration in the muscle (p > 0.05) for all groups. We found a weak inverse correlation between norepinephrine doses and muscle pyruvate levels (p < 0.05) for the dobutamine group and the control group and but not for the levosimendan group.Conclusions: Noradrenaline dose has little effect on microcirculation when administered for hemodynamic optimization, as recommended by the Surviving Sepsis Campaign.

Risk factors of postoperative pancreatic fistula (POPF) after laparoscopic distal pancreatectomy (LDP) are not well known and were studied, including the stapler cartridge size and drainage modality.

The aim of this study was to compare C5-C6 and C6-C7 level injections in ultrasound-guided interscalene catheter and to determine which level enhances the quality of analgesia after shoulder surgery. Study design: prospective, randomized, simple blinded. Sixty randomized patients scheduled for elective shoulder surgery (Latarjet technique) were divided into group C5-C6 (n = 29) and group C6-C7 (n = 31). Injection via interscalene catheter with 20 mL of bupivacaine 0.25 % administered preoperatively before surgery under general anesthesia and followed by 2 mL/h continuous infusion during 48 h with subcutaneous morphine as rescue analgesia. Patients were assessed in the recovery room, at 1, 3, 12, 24 and 48 h (at rest and movement) after surgery, for pain, sleep and overall satisfaction. All patients had excellent analgesic effects at rest all times. VAS at movement in group 1 was statistically lower than in group 2 at 24 h. Weakness was more marked in group 1 than in group 2 at 24 and 48 h. There were no differences in sleep quality, complications, and patient satisfaction. Injection below C6 level provided the same efficiency in analgesia after shoulder surgery as an injection cranial to C5 nerve root with less muscular weakness improving early postoperative physiotherapy.

Introduction: Mitochondrial dysfunction and consequent cellular energetic failure play a key role in the development of sepsis-related organs failure. Evidence suggests that the pleiotropic effects of levosimendan may positively affect cellular metabolism during septic shock. Objectives: To investigate changes in the concentration of glucose, lactate, pyruvate, and glycerol in the extracellular fluid of the skeletal muscle following levosimendan administration in patients with septic shock. Methods: The study was designed as a prospective, double-blind, controlled, clinical pilot trial and performed in a multidisciplinary intensive care unit. After achieving normovolemia and a mean arterial pressure of at least 65 mm Hg, 20 septic shock patients were randomized to receive either levosimendan 0.2 mu g/kg/min (n = 10), or dobutamine 5 mu g/kg/min as active comparator (n = 10). Interstitial tissue concentrations of lactate, pyruvate, glucose, and glycerol were obtained by using muscle microdialysis. All measurements, including data from right heart catheterization, were obtained at baseline and every 6 h for the following 72 h after randomization. The trial is registered with Clinicaltrials.gov, number NCT02963454. Results: Compared with dobutamine, levosimendan increased interstitial tissue pyruvate concentration (153.3 +/- 73 and 187.2 +/- 13.5 vs. 210.7 +/- 76.2 and 161 +/- 64.6; P< 0.05), and lactate clearance (55 vs. 10). Lactate/pyruvate ratio was lower in the levosimendan group at the end of study period (37.7 +/- 18.9 and 29.3 +/- 12.7 vs. 10.9 +/- 4.5 and 31.4 +/- 13.2; P< 0.05). Conclusion: Although we investigated a small number of patients, our preliminary results suggest that levosimendan may improve cellular metabolic alterations in patients with septic shock.

La dysfonction ventriculaire droite est fréquente chez les patients de réanimation. La société américaine d'échocardiographie recommande le TAPSE (Tricuspid annulus plane systolic excurtion) et de l'onde S′ (Tricuspid annulus plane peak systolic velocity) pour l'évaluation de la fonction systolique du VD en pratique quotidienne [1]. La réalisation de ces paramètres échocardiographiques habituels est souvent difficile dans le contexte de réanimation. L'objectif de notre travail était de tester la capacité de l'indice de clairance du ventricule droit (ICVD), un nouveau paramètre échocardiographique simple à mesurer, pour prédire la dysfonction systolique du ventricule droit chez les patients critiques. Trente-cinq patients admis en réanimation pour pathologies diverses et menés d'un cathéter veineux central dans le territoire cave supérieur ont été inclus. Le comité d'étique a jugé le consentement des patients facultatifs puisque la pratique d'ETT et d'ETO fait partie des standards de soins dans notre unité. Chez chaque patient deux opérateurs expérimentés en échocardiographie réalisent une ETT et une ETO. Le premier opérateur réalise une mesure du TAPSE et de l'onde S′. Le deuxième opérateur réalise une épreuve de contraste du VD en ETO en injectant 5 mL de produit de contraste échographique (microbulles) à travers le cathéter veineux central. Le temps (T) mis par les microbulles pour disparaître complètement de la surface du VD est noté. L'indice de clairance du VD (ICVD) est calculer à partir de T et de la fréquence cardiaque (FC): ICVD = 100 × T/FC. On a testé la corrélation entre ICVD, TAPSE et S′ par le test de Pearson. Des courbes ROC ont été construites pour tester la capacité de l'ICVD à prédire une dysfonction systolique du VD définie par un TAPSE < 16 mm ou une S′ < 10 cm/s. Nous avons trouvé une corrélation négative significative entre ICVD et TAPSE (r = −0.68, p < 0,0001). Nous avons également trouvé une corrélation négative significative entre ICVD et S′ (r = −0.66, p < 0,0001). Une valeur de l'ICVD supérieure à 21 permet de prédire un TAPSE altéré ou une S′ abaissée avec des sensibilités respectives de 85% et 92% et avec la même spécificité de 91%. Tableau: Fig. 1 diagramme du choix du seuil de ICVD (RVCI) pour prédire une S′ < 10 cm/s. L'indice de clairance du VD est un paramètre fiable pour évaluer la dysfonction systolique du VD en réanimation. Il offre par rapport aux paramètres classiques sa simplicité et sa facilité de mesure.

Comparer la qualité d’analgésie après chirurgie de l’épaule en fonction de la position de l’extrémité du cathéter interscalénique (C5–C6 ou C6–C7) mis sous échoguidage. Type d’étude : étude prospective, randomisée, en insu simple. Soixante patients programmés pour une chirurgie réglée de l’instabilité de l’épaule (technique de Latarjet) ont été divisés en groupe 1 : cathéter placé en C5–C6 (n=29) et groupe 2 : en C6–C7 (n=31). Une première injection de 20mL de bupivacaïne 0,25 % était réalisée en préopératoire ; elle était suivit d’une perfusion continue (2mL/h) pendant 48h. Les patients ont été évalués en salle de réveil, à 1, 3, 12, 24 et 48h (au repos et mouvement) sur la douleur, le sommeil et la satisfaction globale. Les scores de douleur étaient identiques dans les 2 groupes au repos. L’EVA au mouvement du groupe 1 était statistiquement plus faible que dans le groupe 2 uniquement à 24h. La faiblesse musculaire a été plus marquée dans le groupe 1 à 24 et 48h. Il n’y avait pas de différences concernant la qualité du sommeil et la satisfaction des patients. L’injection au-dessous de C6 a la même efficacité analgésique qu’une injection entre C5 et C6 après chirurgie de l’épaule mais avec une faiblesse musculaire moindre améliorant ainsi la rééducation postopératoire précoce.

To prevent hypotension during spinal anesthesia for caesarean section, we assessed IV ondansetron of invasive maternal hemodynamic and fetal gazometric parameters.

BACKGROUND:Hypotension is a common complication following spinal anesthesia for cesarean delivery. Techniques to prevent hypotension include preloading intravenous fluid.AIM:To compare the effect of two preloading regimens: 6% hydroxyethyl starch (HES) and 9‰ saline solution, to prevent hypotension after spinal anesthesia in cesarean delivery.METHODS:105 patients undergoing intrathecal anesthesia for elective cesarean delivery were randomized and allocated to receive a preload of 500 ml HES 130/0.4 (HES Group) or a preload of 1500 ml 9‰ saline solution (CR group). Blood pressure and heart rate were recorded at baseline and after spinal anesthesia (every minute for the first 10 min, every 3 min for the next 10 min, and then every 5 min for the last 20 min). The primary outcome was to compare the incidence of hypotension (defined as a 20% reduction in systolic arterial pressure from baseline) between the two preloading regimens. Vasopressor requirements (i.v. bolus of 6 mg ephedrine) were also compared.RESULTS:The incidence of hypotension was 87% in the CR group and 69% in the HES group (p= 0.028). Ephedrine requirement, incidence of nausea, and/or vomiting and neonatal outcome did not significantly differ between the two groups.CONCLUSION:The incidence of hypotension was lower after preloading of 500 mL of HES 130/0.4 than preloading with 1500 mL of 9‰ saline solution.