Median arcuate ligament syndrome (Dunbar syndrome): A diagnosis not to be underestimated

Medial arcuate ligament syndrome (MALS) is an anatomoclinical entity underestimated in most situations due to the lack of specific signs. However, the consequences can be disastrous if the diagnosis is not seriously considered and investigations are not fully undertaken to confirm this hypothesis. We report a case of Median Arcuate Ligament Syndrome in a young woman who presented to the Emergency Department with moderate postprandial pain. All investigations were carried out promptly, with no abnormalities, and the diagnosis was retained on the evidence of a well-performed and appropriately interpreted abdominal CT. This case illustrates a rare cause of epigastralgia simulating a surgical emergency. This condition should be considered when biological and often radiological investigations are inconclusive. The relative youth of the patient is often suggestive, but confirmation is based on a CT scan with injection of a well-technical contrast product, or angiography. Treatment is debatable between a conservative approach and surgery. Surgical approach is discussed depending on the degree of vascular stenosis and the impact on the digestive tract. However, the recurrence of symptoms may be a contributory factor in the therapeutic decision. The impact could be lethal depending on the degree of stenosis and consequently on the repercussions on the digestive tract. A multidisciplinary approach is required for its management.

Early laparoscopic cholecystectomy for acute cholecystitis: Does age matter?

AIM

Advances in laparoscopic surgery and perioperative care have improved the prognosis of operated patients, especially the oldest among them. This study aimed to assess the outcomes of early laparoscopic cholecystectomy for acute calculous cholecystitis in older adult patients.

METHODS

A retrospective analysis was carried out of 567 patients who underwent early laparoscopic cholecystectomy for acute calculous cholecystitis between January 2003 and July 2021. The outcomes of older adult patients (≥ 75 years) were compared with those of younger patients.

RESULTS

The older adult group had significantly more patients with an American Society of Anesthesiologists score ≥3 (37.5% vs 8.3%; P < 0.001) and more severe acute calculous cholecystitis (grade II; 82.8% vs 67%; P = 0.01). There were no significant differences regarding operative time (90 vs 80 min; P = 0.064), conversion rate (20.3% vs 13.5%; P = 0.144), and both intra- and postoperative morbidity, principally bile duct injuries (1.6% vs 0%; P = 0.113) and bile leakage (0% vs 1.2%; P = 1).

CONCLUSION

Early laparoscopic cholecystectomy could be proposed safely for older adult patients with mild and moderate acute cholecystitis. Geriatr Gerontol Int 2023; 23: 671-675.

Acute intestinal obstruction: What if it is instead colonic tuberculosis? What diagnostic and management dilemmas are there?

INTRODUCTION AND IMPORTANCE

Colonic tuberculosis is rare. Clinical, biologic endoscopic and radiological features are not unequivocal. A multitude of differential diagnoses interfere, including Crohn's disease and cancer.

CASE PRESENTATION

we present a case of a 48-year-old Tunisian female who complained from occlusive syndrome. For whom none of the various elements of the medical record, the clinical, endoscopic and radiological investigations had enabled a decision to be reached in favor of one diagnosis over the other. Several diagnoses were suggested, including Crohn's disease, neoplastic diseases and, ultimately, colonic tuberculosis, since our country was endemic for this pathology. The collegial decision of the medical staff involved in the management was to operate on the patient. Surgery was required with the intention to treat and mainly to provide histological proof of the disease. A right colectomy allowed histological examination and a diagnosis of colonic tuberculosis.

DISCUSSION

The diagnosis should be discussed in patient from endemic countries, who complain chronic abdominal pain, vesperal fever and weight loss for who endoscopy shows the presence of nodules or ulcers. The diagnosis is retained on the basis of pathological findings.

CONCLUSIONS

Because of a nonspecific clinical and endoscopic presentations, multiples biopsies even surgical resection are mandatory to rule out differential diagnosis and to confirm the diagnoses of colonic tuberculosis.

A case report of gastroduodenal artery pseudoaneurysm and giant pancreatic pseudocyst following acute pancreatitis revealed by obstructive jaundice

Acute necrotic pancreatitis is an emergency of evolution and is often unpredictable because of the potentially life-threatening complications it can cause. We report a unique case of a 56-year-old woman hospitalized for acute necrotic pancreatitis. The evolution of the latter was characterized by the occurrence of two very rare complications, of which the clinical presentations were atypical. The first complication was a gastroduodenal pseudoaneurysm compressing the main biliary tract and causing obstructive jaundice, which evolved well following percutaneous embolization. The second complication was a giant 20 cm pancreatic pseudocyst revealed by obstructive jaundice secondary to biliary compression, which progressed well following surgical treatment.

Gas spread following endoscopic sphincterotomy: Challenging diagnosis and management: A case reports

INTRODUCTION AND IMPORTANCE

Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum simultaneously are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP) that usually indicates free perforation to the peritoneal cavity or the retroperitoneal space.

CASE PRESENTATION

We report an unusual case of a subcutaneous emphysema, pneumomediastinum and pneumoperitoneum following an ERCP for removal of a common bile duct stone. There was no radiological evidence of peritoneal or retroperitoneal perforation.

CLINICAL DISCUSSION

This complication seems to be relative to duodenal perforation. However, hypotheses of transdiaphragmatic pressure effects and gas diffusion within the mucosa are discussed in the literature pneumomediastinum and pneumoperitoneum, must be recognized, because it is benign and needs exceptionally surgical or radiological intervention. Management of this adverse event depends on type of perforation and clinical presentation.

CONCLUSION

ERCP has facilitated innovative diagnosis and treatment of pancreatobiliary tract diseases. Nevertheless, some complications may occur such gas diffusion in the peritoneal cavity or the retroperitoneal space with or without perforation. Our case our case illustrates such incidents could be benign, self-limited and need no intervention.

Management of pheochromocytoma during pregnancy. A multidisciplinary challenge: A case reports

INTRODUCTION

Identification of pheochromocytoma during pregnancy is unusual. Lack of appropriate management may be responsible of high risk for both mother and fetus. The guarantee of a successful management of a pheochromocytoma during pregnancy is the establishment of an early diagnosis as well as the prevention of a hypertensive crisis during delivery and surgical treatment and without compromising the maternal-fetal prognosis.

CASE PRESENTATION

A 31-year-old female patient, without any notable pathological history, pregnant at 20 weeks of amenorrhea was diagnosed for a Menard's triad. The medical investigations had allowed to confirm the diagnosis of left secretory pheochromocytoma. The surgical indication was taken in concertation between surgeons, endocrinologists, gynecologists and anesthesiologists. The parturient had undergone an uneventful laparoscopic left adrenalectomy without incidents.

CASE DISCUSSION

Our case well illustrates that when the operative indication is posed, laparoscopic surgery can be performed safely during any trimester. However, it is legitimate to modulate the incisions according to gestational age and the height of the fundus. The involvement of all disciplines intervening in the management of the pregnant woman with pheochromocytoma is the guarantor of a favorable maternal-fetal prognosis.

CONCLUSION

A well-established diagnosis for pregnant women with severe secondary hypertension, multidisciplinary management, and safe laparoscopic approach are crucial to prevent perinatal morbidity and mortality.

Extensive small bowel necrosis due to congenital para duodenal hernia: A diagnostic and therapeutic challenge: Case Report

INTRODUCTION

A paraduodenal hernia is a rare variety of hernia, however it is the most usual type of internal hernias. Clinical presentation is nonspecific. The clinical presentation is variable: indeed, the patient can be completely asymptomatic or present with symptoms which severity is variable according to the mechanism. The most common cause is an acute intestinal occlusion that could progress even to ischemia and intestinal necrosis. Depending on the clinical presentation and the suspected diagnosis, computed tomography can be of considerable help in demonstrating a para duodenal hernia.

CASE PRESENTATION

We describe the case of a young man aged 18 years, who presented to the emergency unit with severe abdominal pain associated with incoercible vomiting. The surgical exploration had confirmed a para duodenal hernia responsible for an extensive necrosis of the small intestine allowing viable 90 cm only.

CASE DISCUSSION

Paraduodenal hernias are rare and their diagnosis is not always easy. Therefore, they should be considered especially in the case of an occlusive syndrome occurring in a young patient who has never been operated on. If no treatment is undertaken, the evolution is drastic and the mortality rate is significant.

CONCLUSION

Successful surgical management requires knowledge of the intra-abdominal peritoneal spaces and management of suggestive clinical situations in order to reduce postoperative morbidity and mortality resulting from delayed diagnosis and treatment.

Recurrent caecal volvulus in an adult: Should we practice coecopexy systematically at neonatal age for incomplete common mesentery? A case report

INTRODUCTION AND IMPORTANCE

Malrotation is usually revealed early in infancy and or later in childhood, even more unusually in adulthood. This disorder is treated through Ladd's procedure. Literature is limited on the long-term outcomes of this approach, especially into adulthood.

CASE PRESENTATION

We present a case of a 33 years male with a history of a laparotomy as a new born for a bowel obstruction secondary to malrotation, presenting with an obstruction and colonic volvulus. Laparotomy reveals a volvulus of the coecum secondary to a failure of the coecum to attach during surgery performed at neonatal age.

CLINICAL DISCUSSION

For a patient operated on during the neonatal period for intestinal malrotation, the examination for sub occlusive episodes should suggest a recurrence of malrotation such as coecal volvulus, and the possibility of technical malfunction during the previous procedure. This reflection leads us to consider the necessity of performing coecopexy systematically during the first surgery.

CONCLUSION

Ladd's technique is the surgical treatment of the incomplete common mesentery. The fixation of the coecum could be done in a systematic way to prevent a possible coecal volvulus which can be responsible for digestive necrosis and often even a fulminant evolution.

Early laparoscopic cholecystectomy for acute cholecystitis: should we operate beyond the first week?

BACKGROUND

The deadline for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is the subject of much debate. The aim of this study was to assess outcomes of ELC in patients with more than 7 days of symptoms.

METHODS

It is a retrospective analysis of 564 patients having undergone ELC for ACC between January 2003 and June 2021. Patients were divided into two groups according to the timing between the onset of symptoms and surgery: group 1 (G1), within the first 7 days of symptoms, and group 2 (G2) after day 7 of symptoms.

RESULTS

Apart from a longer operative time (G1 80 min vs. G2 90 min; p = 0.016), there were no significant differences regarding conversion rate (G1 14.5% vs. G2 13.2%; p = 0.748), both intra- and postoperative complications, mainly bile duct injuries (G1 0.2% vs. G2 0%; p = 1) and bile leakage (G1 1.2% vs. G2 0%; p = 1) and postoperative length of stay (G1 2 days [1-3] vs. G2 2 days [1-4]; p = 0.125).

CONCLUSION

Early laparoscopic cholecystectomy could be proposed for patients with acute calculous cholecystitis even beyond 7 days of symptoms.

Colonic schwannoma: A case of unusual presentation and outcome

Background: Schwannomas are mesenchymal tumors arising from neural sheath cells and whose diagnosis is based on immunohistochemistery. The digestive and especially colonic location of this tumor is rare. Commonly described in elderly patient, their malignancy is unusual. Case report: We report the case of a 23-year-old girl, with learning disability, operated in emergency for acute peritonitis. Peroperatively, we discovered a peritonitis secondary to a bulky perforated cecal tumor. We performed a right colectomy and an ileostomy. The posterior margin of the resection was macroscopically involved. The diagnosis of colonic schwannoma was confirmed with immunopathological examination of the surgical specimen. Surgical exploration 4 months later and morphological investigations during 2 years showed stability of the tumoral residue in the right iliac fossa. However, we noticed, on CT scanning control 2 years postoperatively, the appearance of a mesenteric recurrence. Exploratory laparotomy confirmed the unresectability of this mesenteric mass and showed the presence of multiple parietal nodules whose biopsies revealed their neurofibromatous nature. The 4 year follow-up of the patient didn’t reveal any complication rather than need to right nephrostomy due to ureter compression by the primary tumoral residue. Discussion: Colonic schwannoma is a rare disease, commonly described in uncomplicated stages. The learning disability of our patient had favorized the absence of declared symptoms and promoted the evolution of the cecal swhannoma until its perforation. This complication was not described before. Local recurrence has been also rarely reported in the literature. Association with neurofibroma may be hereditary in a context of neurofibromatosis or sporadic. Conclusion: Colonic schwannoma may have polymorphic presentation mimicking malignant tumor in such cases. Not treated in time, it can lead to severe complications, such as tumoral perforation. Surgical resection remains the mainstay treatment. The slow evolutionary genius of schwannoma, even when incompletely resected by necessity, confirms its good prognosis.

East-central Tunisian patients with colorectal adenocarcinoma: a comparative study of the clinicopathological features between patients under 50 years of age and older patients

INTRODUCTION

Colorectal cancer is a major public health problem. In younger patients, its incidence continues to rise and its prognosis appears to be worse. Its treatment is based on curative surgery associated with neo-adjuvant and adjuvant therapies.

AIM

To describe the clinical and pathological characteristics of colorectal cancers in young patients.

METHODS

In this monocentric cohort study, we retrospectively analyzed the clinicopathological features in colorectal cancer patients who underwent treatment from 2002 to 2014. Data of younger (group A, ≤50years) vs older (group B, >50years) patients were compared.

RESULTS

Two hundred and sixty-six patients met inclusion and non-inclusion criteria. The younger and older groups consisted respectively of 25.2% and 74.8% of patients. Both groups were comparable regarding the symptom presentation and duration. Synchronous tumors were more frequent amongst the group A (10.7% vs 1.0%, p = 0.024). Preoperative staging showed a higher frequency of tumors classified as advanced stage (stages III and IV) in the group A (p = 0.001). The patients of group A were diagnosed with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas (13.4% vs 3.5%, p = 0.005), the mucinous character was also more frequent in the group A (28.4%). According to the pTNM (tumor, nodes and metastases) classification, tumors were more advanced in the group A than in group B (80.6% vs 48.7%, p <0.001).

CONCLUSION

This study revealed that colorectal adenocarcinomas in the younger patients, compared to the older ones, were more aggressive with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas, more often mucin production and more advanced tumors.

Anatomic variations of the extrahepatic biliary tree. A monocentric study and review of the literature

INTRODUCTION

The study of the anatomy of the extra hepatic bile ducts has demonstrated the existence of a significant number of variants which can be explained by hepato-biliary embryology. A good knowledge of this anatomy is essential for the interpretation of radiological examinations, and for a good practice of hepato-biliary and pancreatic surgery. Several imaging methods are used to study the anatomy of the bile ducts, including classical cholangiography, which is still practiced and very useful.

AIM

To study the modal anatomy (the most frequent) and the anatomical variants of the extrahepatic bile ducts through the interpretation of postoperative cholangiograms and to examine their implication on the surgical practice.

METHODS

This is a monocentric, retrospective observational study. It concerned any patient who underwent hepato-biliary or pancreatic surgery at the Department of General and Digestive Surgery of Farhat Hached University Hospital of Sousse between 2007 and 2016, and who received postoperative cholangiography. A data form was fulfilled for each patient.

RESULTS

Out of a total population of 293 patients, we identified 158 patients (53.9%) with anatomic variants of the extrahepatic bile ducts. The common bile duct was modally implanted in the second duodenum in 96.2% of cholangiographies and in the genu inferius in 3.8% of cases. The main pancreatic duct had a V-shaped implantation in 87.1% of cholangiograms, a U-shaped implantation in 4.2% of cases and a Y-shaped implantation in 7.1% of cases. The common bile duct had a modal aspect in 71.3% of cholangiograms, with 28.7% of anatomic variants, organized in 4 models. The cystic duct had a modal presentation in 80.9% of cases, and we recorded 6 other branching models (19.1% of cases). No significant difference was observed between the presence of anatomic variants on the one hand, and age, sex, conversion rate, intraoperative incidents, postoperative complications, postoperative hospital stay and overall hospital stay on the other hand.

CONCLUSION

Conventional cholangiography constitutes a more or less precise tool for detecting these anatomic variants and is therefore very useful in the practice of hepato-biliary surgery even after the advent of new techniques in this field. However, it also requires a more extensive and in-depth knowledge of these anatomic variants, which nevertheless remain quite frequent, and represent a source of surgical difficulties.

Pancreatic metastases and first reported gallbladder metastasis from phyllodes tumor of the breast

Distant metastases from breast phyllodes tumor (PT) are very rare. They usually occur in lung and bones. We report a case of a 51-year-old woman who was hospitalized in the digestive surgical department for atypical epigastric pain. Her medical history started 2 years ago when she underwent a curative left mastectomy for a malignant PT of the breast. Radical surgery was indicated to her resectable pancreatic tumor diagnosed on computed tomography. Histological exam confirmed that it was pancreatic metastases of her breast PT. Adjuvant chemotherapy was indicated. Three months after the surgery, the patient developed gallbladder and brain metastases. She died 5 weeks later. With this case, we enrich the literature with another example of pancreatic metastasis from PT and we report, for the first time, gallbladder metastasis. The very high aggressiveness of this tumor suggests that markers of tumor malignancy need to be sought after by subsequent studies.

Gastric diverticula as a diagnostic and therapeutic challenge: Case report and review of literature

INTRODUCTION

Gastric diverticula are a rare condition characterized by a pouch protruding from the gastric wall. It is commonly asymptomatic and managed without surgery. Gastric diverticulotomy is indicated in the case of symptomatic or complicated diverticula.

CASE

The authors report the case of a 67 year-old man presenting with heartburn and dyspepsia with no response to proton pump inhibitors. The patient was diagnosed with a gastric diverticula and a little hiatal hernia, which was subsequently successfully treated with a laparoscopic gastric diverticulectomy and Nissen fundoplication.

CONCLUSION

Gastric Diverticula have to be evoked in the absence of response of Gastro Esophageal Reflux Disease to therapy or in atypical symptoms. Laparoscopic resection of GD can be safe with resolution of symptoms.

Risk factors of conversion in laparoscopic cholecystectomies for lithiasic acute cholecystitis. Results of a monocentric study and review of the literature

INTRODUCTION

Nowadays, laparoscopic cholecystectomy has become the gold standard in the management of lithiasic acute cholecystitis. However, the rate of conversion to laparotomy remains considerable, greater than that of uncomplicated lithiasis. Some factors, related to the patient, the disease or the surgeon, are associated with a high risk of conversion.

AIM

To identify the factors associated with a significant risk of conversion in laparoscopic cholecystectomy for acute cholecystitis.

METHODS

Between January 2011 and December 2015, all patients operated on for acute cholecystitis at the Department of General and Digestive Surgery of Farhat Hached University Hospital of Sousse - Tunisia were divided into two groups: A for the laparoscopic approach and B for conversion. We compared the two groups.

RESULTS

The conversion rate was 21.9% (43 patients). At the end of this work, we found that the conversion rate was significantly increased for males (p = 0.044), ulcerative disease (p = 0.004), smokers (p = 0.007), ASA score = II (p = 0.005), abdominal guarding (p = 0.001), fever (p = 0.001), perivesicular effusion on ultrasound (p = 0.041), ultrasound Murphy's sign (p = 0.023), delayed cholecystectomy (p = 0.038), perivascular adhesions (p <10-3) and gangrenous cholecystitis (p = 0.009).

CONCLUSION

The conversion is sometimes badly perceived by the surgeon. However, it should in no way be considered a failure, but rather a change of strategy to ensure patient safety. Conversion should not be delayed, especially as risk factors have been identified.

Unusual complication of seroma after ventral hernia mesh repair: Digestive perforation by tacks. A case report

•

Complicated seromas are rare and can cause therapeutic problems.

•

The right timing for mesh removal is delicate to be detected.

•

Erosion of the small bowel by the tacks has been reported. It seems to be due to technical problems.

•

In our case the pressure exerted by the bulky seroma favored the fistulization of the small bowel.

•

This case suggests that the type of mesh fixation may influence the time of its removal.

Intraperitoneal meshes are actually widely used in ventral hernia repair. They can reduce operative time, parietal prejudice and postoperative pain.

One of the most well-known complications of intraperitoneal mesh is seroma, but it usually subsides without any therapeutic problems.

These meshes can be fixed by tackers, suture or glue. Few complications related to the fixation technique are known.

We report the case of a patient who underwent a laparoscopic mesh repair for incisional hernia. He developed an infected bulky seroma for which he had to undergo medical treatment and percutanous drainage in order to avoid the mesh removal. The evolution seemed to be favorable until the occurrence of an unusual and unexpected complication: a digestive fistula of the small bowel in the seroma cavity via a tack adhering to the intestines.

The possibility of digestive lesions by a tack is reported by some cases reports. It seems most often to be related to a technical problem. In our case, this adhesion seems to be secondary to the pressure exerted by the seroma. The complicated seroma can be conservatively treated to save the mesh. However the delay before deciding to remove the mesh when using tackers for its fixation may be shortened.

The effect of environmental factors on the incidence of perforated appendicitis

BACKGROUND

Acute appendicitis is the most common abdominal emergency. Its etiopathogenesis appears to be multifactorial. Several studies suggested a relationship between the development of acute appendicitis and some environmental factors. Air pollution predisposes some people to develop perforated appendicitis. However, data are relatively scarce and the results still controversial.

AIM

Determine the seasonal variation of acute appendicitis and study the association between perforated appendicitis and short-term exposure to climatic factors and to air pollutants.

METHODS

A cross-sectional study was conducted including patients hospitalized in the general surgery department of Farhat Hached University Hospital in Sousse for acute appendicitis between January 1st and December 31st, 2014. Climatic conditions were collected from the National Institute of Meteorology. Data on air pollution were given by the National Agency for the Protection of the Environment and obtained by the modeling of the atmospheric pollution. For statistical analysis, we used mean concentrations of each environmental factor corresponding to the day of hospital admission and lagged by the 7 previous days. These factors were compared between the group of patients with perforated appendicitis and patients with nonperforated appendicitis.

RESULTS

We collected 246 cases of acute appendicitis. Perforated appendicitis was reported in 15.2% of the cases. The incidence of acute appendicitis was higher during summer. Compared to nonperforated appendicitis, perforated appendicitis was significantly associated with the mean relative humidity of the 5 day lag (p = 0.046), rainfall of the 7 day lag (p = 0.043), and consultation delay (p <10-3). Furthermore, perforated appendicitis was significantly associated with the daily mean concentration of carbon dioxide (p = 0.042), the 2- day lag mean concentration of particulate matter less than 10 μ (PM10 ) (p = 0.016), and the 2-day lag mean concentration of ozone (p = 0.048). After multivariate statistical analysis, predictive factors for perforated appendicitis were the consultation delay (OR: 1.621, 95% CI [1.288 - 2.039]; p<10-3) and the 2 day lag mean concentration of PM10 (OR: 1.066, 95% CI [1.007- 1.130]; p = 0.029).

CONCLUSION

Short-term exposure to particulate matter was associated with perforated appendicitis. Further large-scale studies are needed to support this conclusion.

KEY WORDS

Air pollution, Appendicitis, perforated appendicitis, Climateparticulate matter.

Observance of the practice of digital rectal examination. Survey of general practitioners in East-central Tunisia

INTRODUCTION

Digital rectal examination (DRE) is a simple gesture, used for diagnosis of several diseases. However, some general practitioners (GPs) are practicing it less and less often.

AIM

To estimate the rate of unrealized DRE and to analyze the factors preventing threir achievement.

METHODS

This is a prospective observational study conducted among 105 GPs practicing in Sousse. We used a pre-established pre-tested and self-administered questionnaire.

RESULTS

We identified 551 DRE that were indicated but unrealized. There was a significant influence between the non-realization of DRE on the one hand, and on the other hand: the lack of experience; the closeness of the specialist; the lack of training and the lack of conviction of the importance of this examination. Embarrassment during the realization of the DRE was felt in 69.3% of cases. Factors associated with this embarrassment were: female practitioner; the young age of the practitioner; the rural practice and the nature of internship placements.

CONCLUSION

Although it is a simple and inexpensive gesture, the DRE remains neglected by many physicians. Several factors appear to influence the achievement of the DRE. Ongoing continuing medical education seems necessary, especially as we found a lack of belief in the importance of this examination.

Early versus delayed laparoscopic cholecystectomy for lithiasic acute cholecystitis during emergency admissions. Results of a monocentric experience and review of the literature

BACKGROUND

It is established that the standard treatment for lithiasic acute cholecystitis is the laparoscopic cholecystectomie. However, the question of the timing of cholecystectomy remains controversial.

AIM

To compare early laparoscopic cholecystectomies (within 72 hours of symptom onset) and delayed laparoscopic cholecystectomies (beyond 72 hours) for lithiasic acute cholecystitis in terms of intra-operative difficulties and post-operative complications.

METHODS

The patients operated on for acute cholecystitis, between January 2007 and December 2012, were included in a retrospective study. They were divided into two groups based on whether surgery was performed before (group A) or after (group B) 72 hours after the onset of symptoms. We conducted a comparison between the two groups.

RESULTS

The two groups were comparable in terms of background, clinico-biological presentation, and radiological findings. The average time of surgery was 111.6 hours after symptom onset.  Duration of surgery was significantly longer for group B (97 minutes versus 82.17 minutes, p = 0.003). There was more conversion in group B than in group A, without significant difference (20% versus 11.6%, p = 0.14). There were no deaths in our series. Specific post-operative complications were comparable between the two groups (wound infection: 3 (B) versus 1 (A), biliary fistula: 8 (B) versus 0 (A), p = Non significant). The post-operative hospital stay was significantly longer in group B (3.34 days versus 1.84, p <10-3).

CONCLUSION

In case of early laparoscopic cholecystectomy, the conversion rate and post-operative morbidity are comparable to the delayed treatment of acute cholecystitis. But the early surgery can reduce the cost of care, the duration of surgery and the hospital stay. Key-words : Lithiasic acute cholecystitis ; Laparoscopic cholecystectomy.

Giant staghorn common bile duct calculus

Background - Stones in common bile duct are defined as 'large' if they are more than 15 mm in size. There are very few reports which describe a giant stone measuring 5 cm or more and exceptionally a staghorn calculus in the common bile duct. Purpose - The purpose is to report a new rare case of giant staghorn gallstone and discuss the diagnostic approach and therapeutic possibilities. Case report - We report a case of a giant staghorn common bile duct calculus in a 65-year-old patient. Its removal required 2 operations and an endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy. Conclusion - Lithiasis of the common bile duct is considered to be a benign, but may sometimes be complicated and time-consuming. Staghorn calculi are very rare in the biliary tract. We found only two published reports of staghorn common bile duct calculi.

Upper digestive stenosis due to a hydatid cyst of the liver

The complications of the hydatid cyst of the liver are dominated by infection and rupture. The compression of adjacent organs (mainly the inferior vena cava, the portal vein and the bile ducts) can be seen, when the cyst is located in the dome, in the hilum or within the hepatic parenchyma. Upper digestive stenosis by compression of the duodenum by the hydatid cyst is an exceptional complication.

CASE REPORT

A 63 year-old patient had, for two months, upper digestive stenosis associated with a sensation of weight in the right hypochondrium. Digestive endoscopy showed an extrinsic compression of the second portion of the duodenum. Biopsies were negative. Abdominal CT showed up a hydatid cyst in the segment VI of the liver, adhering to the duodenum, with an exo-vesiculation compressing it. The patient was operated on: There was a hydatid cyst of the right lateral sector compressing the duodenum. A partial intralamellar pericystectomy was performed.

CONCLUSION

Hydatid cyst of the liver, a parasitic disease described as benign, may give mechanical complications related to compression of adjacent organs (especially the bile ducts and veins). Compression of the digestive tract is exceptional. This is due to the proximity of the cyst to the duodenum and the thickness of the cyst wall.

Ansa pancreatica: an anatomic variation and a rare cause of acute pancreatitis

INTRODUCTION

The ansa pancreatica is a rare anatomic variation of the pancreatic ducts. It is a communication between the main pancreatic duct (Wirsung) and the accessory pancreatic duct (Santorini). Recently, the ansa pancreatica has been considered as a predisposing factor in patients with idiopathic acute pancreatitis.

CASE REPORT

\We report a case of non-alcoholic and non-biliary acute pancreatitis, in a 53-year-old patient. An ansa pancreatica was discovered in a post-operative cholangiography.

CONCLUSION

A pancreatic duct variation, as the ansa pancreatica, can be diagnosed during a severe acute pancreatitis. It is still not clear whether the presence of these two pathologies is a coincidence or if the ansa pancreatica is the cause of the acute pancreatitis. New studies are necessary to clarify these points.

[Stromal tumors of the digestive tract: three small bowel localisation]

BACKGROUND

Stromal tumors of the digestive tract are undifferenciated connective tissue tumors, identified as stemming of "pace-maker" cells of Cajal related to the immunohistochimical characterization of the phenotype.

AIM

Report three new cases

CASE REPORT

We report three observations of the small bowel stromal tumors reveal by anemia in one case and mass formation in two cases. The aim of this study was to discuss the anatomo-clinical, prognosis and management of these tumors.

[Port site recurrence after laparoscopic cholecystectomy]

BACKGROUND

Gallbladder cancer diagnosis is usually at a later stage. Only 1% of gallbladder cancers are discovered fortuitously at infra-clinic stage when histological exam of cholecystectomy specimen. Laparoscopic cholecystectomy was realised for gallbladder lithiasis or polyps. Port site metastasis after laparoscopy was reported. The aim of our study is to report our series of port site metastasis complicating gallbladder cancer discovered fortuitously after laparoscopic cholecystectomy.

METHODS

From 1 January 1994 to 31 December 2004, 2562 laparoscopic cholecystectomy was carried out. Ten gallbladder cancers were diagnosed than the incidence was 0.39%.

RESULTS

Gallbladder cancer diagnosis was carried out by histology in 8 cases, and when port site metastasis in two cases whereas histological exam of cholecystectomy specimen was negative. Recurrence of gallbladder cancer was in port site in 4 cases. The mean rate survival of patients with port site metastases was 19 months.

[Epidemiologic profile of gastric carcinoma: study of 140 cases]

The authors make a retrospective study of a series of 140 patients aged 59 years in average, followed up from 1995 to 2002 for adenocarcinoma of the stomach. Surgical resection was performed in 79 percent of the patients with total gastrectomy in 15.4%, partial gastrectomy in 50.6%. Resection was considered as curative in 66%. Lymph node metastases were present in 42, 9 percent of the patients. Margins of resection were involved in 24, 5% of the specimens. The mean survival rate was 26.5 months, 13 months and 5 months after curative resection, palliative resection and without resection.