Pancreaticojejunostomy vs. pancreaticogastrostomy following pancreaticoduodenectomy: results of comparative study

AIM

Several techniques have been proposed for reconstructing pancreatico-digestive continuity, which the first goal is reducing the rate of pancreatic leakage after pancreaticoduodenectomy. Only a limited number studies have been carried out. Our objective is to compare the results of pancreaticojejunostomy versus pancreaticogastrostomy following pancreaticoduodenectomy.

METHODS

This is a retrospective and comparative study about 80 patients who underwent pancreaticoduodenectomy. These patients were divided into two groups: pancreaticojejunostomy (group PJ) and pancreaticogastrostomy (group PG).

RESULTS

The PJ group included 39 patients, while 41 patients were included in the PG group. There were no differences between the two groups concerning: patients' demographics, risk factors, indication, mean duration of surgery, texture of pancreatic tissue, need for intraoperative blood transfusion and postoperative prophylactic octreotide. Overall, the mortality postoperative rate was 7.5% (N.=6), the incidence of surgical complications was 50% (51.3% in PJ, 48.8% in PG; P=0.823, not significant). Pancreatic fistula was the most frequent complication, occurring in 17.5% of patients (25.6% in PJ and 9.8% in PG; P=0.062, almost significant). 7.7% of patients who underwent PJ and 14.6% of patients who underwent PG required a second surgical intervention (P=0.326, not significant). There were no differences between the two groups PG and PJ concerning: Postoperative hemorrhage (P=0.63), biliary fistula (P=0.09), acute pancreatitis (P=0.95), delayed gastric emptying (P=0.33). The mean postoperative hospitalisation period stay was similar in both groups (P=0.63)

CONCLUSION

There were not any significant differences between the two groups in the overall postoperative complication rate, the incidence of postoperative haemorrhage, biliary fistula, acute pancreatitis, and delayed.

[Complicated sigmoid tumor: perforated amebiasis]

Amoeboma is an inflammatory mass of the colon. It can be an inaugural symptom and thus pose the problem of differential diagnosis with colon cancer. The purpose of this report is to describe the case of a 43-year-old patient who presented with acute abdomen. Physical examination revealed a perforated circumferential mass in the sigmoid colon. Based on a presumptive diagnosis of colonic cancer complicated by perforation, segmental colectomy was performed. Histological examination of the surgical specimen demonstrated colonic amoeboma. The patient was treated using metronidazole. Although rare, amoeboma must be considered in differential diagnosis of cancer of any colonic mass.

Abdominal metastasis of a parosteal osteosarcoma of the femur: an unusual cause of large-bowel obstruction

BACKGROUND

Parosteal osteosarcoma is a rare, well-differentiated, predominantly fibro-osseous variant of osteosarcoma. It is regarded as a distinct form of osteosarcoma with better prognosis than conventional osteosarcoma.

AIM

We report an unusual case of abdominal mass recurrence of parosteal osteosarcoma of the left distal femur treated eight years previously with wide resection, hip disarticulation and chemotherapy, which presented as an acute abdomen: we discuss the clinical outcomes of this rare entity.

CASE PRESENTATION

We present a 54-year-old patient with low-grade parosteal osteosarcoma of the left distal femur. Left total hip disarticulation was indicated after several local relapses of the tumour following extensive resection and chemotherapy. Eight years later, he presented with an acute large bowel obstruction secondary to a compression of the large bowel by an abdominal mass. Abdominal computed tomography showed a large abdominal calcified mass with dilated large bowel loops. During laparotomy, the mass was unresectable. So, the patient underwent emergent colostomy of diversion. Biopsy of the lesion yielded grade III parosteal osteosarcoma material. The patient received adjuvant chemotherapy, but the response was poor: six months later, the patient presented with a peristomal mass and two pulmonary metastases.

CONCLUSION

Abdominal recurrence of parosteal osteosarcoma of the distal femur eight years after definitive surgery is rare. This case emphasises the importance of the long-term follow-up of patients with parosteal osteosarcoma.

[Primary hydatid cyst of the psoas muscle: description of 9 cases in Tunisia and review of the literature]

The psoas muscle is an uncommon location for hydatid cyst accounting for only 1 to 3% of cases. The purpose of this report is to describe the epidemiologic, clinical, paraclinical, and therapeutic features of primary hydatid cyst of the psoas muscle. A retrospective study conducted in Surgery Department A at the Rabta Hospital in Tunisia compiled a total of 9 cases of primary hydatid cyst of the psoas muscle treated between 1980 and 2006. There were 6 men and 3 women with a mean age of 42.8 years. Symptomatology was nonspecific with pain in 6 cases. Discovery was coincidental in two cases. Clinical examination detected a mass in the presents of an abdominal mass in 7 cases. Radiologic findings (ultrasound and/or CT scan) confirmed diagnosis in 8 cases. In one case a mistaken diagnosis of psoas muscle abscess was made in a patient with an infected hydatid cyst. Serological tests were performed in 4 cases and were positive in 3. All patients underwent surgical treatment. The extraperitoneal approach (Leriche) was used in 7 cases and the transperitoneal approach via median laparotomy in 2. In all cases the surgical procedure consisted of partial cystectomy leaving a part of the pericystic against neurovascular structures. There was no operative mortality. The only postoperative complication was urinary infection in one patient. Mean follow-up was 2.5 years. One local recurrence was observed 4 years after surgical treatment and required reoperation.

A report of 15 cases of small-bowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties

Phytobezoars are a rare cause of acute bowel obstruction. The purpose of this work was to identify the predisposing factors and diagnostic difficulties of this rare entity.

MATERIAL AND METHODS

This was a retrospective study including all cases of small-bowel obstruction secondary to phytobezoars observed between April 2001 and August 2007. The diagnosis of bezoars was established by surgical exploration or by computed tomography (CT).

RESULTS

During the study period, 375 patients were hospitalized at our institution with a diagnosis of bowel obstruction that, in 15 (4%) cases, was secondary to phytobezoars. The average patient age was 55 years, with a gender ratio of 1.7, favoring men. The predisposing factors were gastroduodenal surgery for peptic ulcer in nine patients, and excessive consumption of prickly pears (cactus figs) in 12. The diagnosis was established by CT scans in three patients, who were successfully treated with gastric aspiration, thereby avoiding surgery. Laparotomy was performed in 12 patients to allow digital fragmentation of the bezoar, which was then washed into the colon. There were no postoperative deaths and morbidity was about 13%.

CONCLUSION

An abdominal CT scan should be obtained for patients with small-bowel obstruction. This examination offers a precise diagnosis of bezoars, reducing the number of unnecessary surgical procedures, and helping to guide the approach if surgery is needed.

A report of 15 cases of small-bowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties

Phytobezoars are a rare cause of acute bowel obstruction. The purpose of this work was to identify the predisposing factors and diagnostic difficulties of this rare entity.

MATERIAL AND METHODS

This was a retrospective study including all cases of small-bowel obstruction secondary to phytobezoars observed between April 2001 and August 2007. The diagnosis of bezoars was established by surgical exploration or by computed tomography (CT).

RESULTS

During the study period, 375 patients were hospitalized at our institution with a diagnosis of bowel obstruction that, in 15 (4%) cases, was secondary to phytobezoars. The average patient age was 55 years, with a gender ratio of 1.7, favoring men. The predisposing factors were gastroduodenal surgery for peptic ulcer in nine patients, and excessive consumption of prickly pears (cactus figs) in 12. The diagnosis was established by CT scans in three patients, who were successfully treated with gastric aspiration, thereby avoiding surgery. Laparotomy was performed in 12 patients to allow digital fragmentation of the bezoar, which was then washed into the colon. There were no postoperative deaths and morbidity was about 13%.

CONCLUSION

An abdominal CT scan should be obtained for patients with small-bowel obstruction. This examination offers a precise diagnosis of bezoars, reducing the number of unnecessary surgical procedures, and helping to guide the approach if surgery is needed.

[Primary hydatid cyst of the pancreas: Diagnosis and surgical procedures. Report of three cases]

The pancreas is an uncommon site of a hydatid cyst, even in countries where echinococcal disease is endemic. We report three cases of primary hydatid cysts of the pancreas revealed by abdominal pain. The diagnosis was based on ultrasound and CT-scan, which showed a cystic mass in the tail of the pancreas in the two first cases. In the third case, the diagnosis was determined preoperatively and a pancreatic fistula was found in the head of the pancreas during peroperative cholangiography. The echinococcal immunological test (Elisa) was positive in all cases. Surgical treatment included resection of the prominent lump in two patients and a cystogastric anastomosis in the third. Based on these three cases and a study of the literature, the difficulties of diagnosing this rare disease and the surgical procedures are discussed.

[Radiologic diagnosis of enterosalpingeal fistula complicating Crohn's disease]

Enterosalpingeal fistula is a rare complication of Crohn's disease which is rarely diagnosed preoperatively. We describe a new case of this complication suspected by CT scan and confirmed by hysterosalpingogram and contrast from the ileum. This case is about a 50-year-old woman suffering from ileal Crohn's disease diagnosed two years previously and actually complicated by stenosis and entero-salpingeal fistula. The treatment consisted on resection of the ileocaecal region with salpingectomy. Postoperative course was uneventful.

[Unopened colostomy in colorectal surgery: a renewal interest?]

INTRODUCTION

Anastomotic leak or disruption is a grave complication of colorectal surgery. Protection of an at-risk anastomosis by an upstream open diverting colostomy (OC) reduces this gravity. An unopened upstream loop colostomy is a surgical alternative which may diminish the unpleasant consequences of an open colostomy while maintaining the option of diversion in case of need. The aim of this study is to report the results of this approach and to define its indications.

MATERIAL AND METHODS

[corrected] We report a retrospective series of 34 cases of unopened diverting loop colostomy to protect an at-risk colorectal anastomosis. Indications for this procedure were stool-laden bowel (59%), low serum albumin (11.5%), local inflammation (11.5%), and very low placed anastomosis (17.5%).

RESULTS

The loop colostomy was eventually opened after surgery in six cases because of anastomotic leakage diagnosed clinically and/or detected by water soluble contrast opacification which was performed routinely on the sixth post-operative day. In all six cases, there was no need for an urgent surgical intervention. In 28 cases, the anastomosis healed without complication and the exteriorized loop was returned to the abdominal cavity seven days after the initial surgery. This was a short, simple procedure with an average operating time of ten minutes. Average hospital stay after returning the unopened colostomy to the abdomen was two days.

CONCLUSION

Unopened loop colostomy offers the advantages of protection of a colorectal anastomosis without proper morbidity or mortality, shorter hospitalization, and improved psychological comfort for the patient. It's principal indication is to minimize the risks related to leakage from an at-risk colorectal anastomosis.

[Subcutaneous hydatid cyst. Case report of an exceptional location]

Primary subcutaneous cyst hydatid disease is an exceptional entity. We report a new case involving a 70-year-old woman hospitalized for a subcutaneous mass in the hypogastric area with no local inflammatory signs. Radiological examination was consistent with a partially calcified subcutaneous cyst in the hypogastric area. Complete surgical resection of the mass was performed with uneventful postoperative recovery. Histopathological examination of the surgical specimen demonstrated multivesicular hydatid cyst.

[A previously unreported late complication of Finney strictureplasty]

We report the case of a 23 year old woman, treated for Crohn's disease for 11 years. She was operated on for multiple obstructing jejuno-ileal strictures using strictureplasty technique. Nine stricturoplasties of Heineke-Mikulicz type and one Finney type were performed without immediate postoperative complication. The patient received Imurel(R) and remained in remission for 15 months. Peritonitis due to a perforation of the Finney strictureplasty required re-operation; an ileostomy was performed. Such a late complication of a strictureplasty has not previously been reported in the literature. Although this complication was severe, the indication for this procedure in the surgical management of Crohn's complications should not be modified.

[Subcutaneous rupture of hydatid cyst of liver: dealing with a rare observation]

Hydatid cyst of liver is a parasitosis of endemic proportions in Tunisia. The purpose of this report is to describe a case involving subcutaneous rupture of a hydatid cyst of liver in a 41-year-old patient. Diagnosis was established by ultrasonography and CT-scan. The patient underwent surgical treatment and recovered uneventfully. Subcutaneous rupture remains an uncommon complication. This is only the second case reported in the literature up to now.

Tumeur intracanalaire papillaire mucineuse du pancréas dégénérée et fistulisée dans l'estomac, le duodénum, et le côlon

We report a case of intraductal papillary mucinous tumor of the pancreas (IPMT) degenerated and fistulized into the stomach, the duodenum and the colon. Diagnoses of malignancy and fistulization were proven preoperatively. Pancreaticoduodenectomy extended to the body was performed. Pathological examination revealed a malignant IPMT with an invasive component. Of the 3 fistulizations tracts, both gastric and duodenal ones were malignant. To our knowledge, this is the first reported case of IPMT with colonic fistulization. Twelve months later, the patient is alive without signs of recurrence.

[Gastric amyloidosis mimicking malignancy. A case report]

Amyloidosis is an abnormal extracellular deposition of insoluble proteins, which is associated with an involvement of the gastrointestinal tract in 50 to 70% of cases. In primary amyloidosis (light chain amyloidosis), localized gastric involvement is a rare finding which can mimic malignancy. We report the case of a 56-year-old man, admitted with upper digestive outlet obstruction. Linitis plastica with lymph node involvement was suspected by gastroscopy, barium meal and endoscopic ultrasonography but was not confirmed by gastric biopsies. The patient was treated with total gastrectomy with lymph node dissection. Pathological examination demonstrated gastric and lymph nodes amyloidosis and no malignant tumor was found. The patient died 9 months later from cardiac failure due to amyloidosis.

[Laparoscopic cholecystectomy in a patient with situs inversus]

Laparoscopic cholecystectomy is the standard approach to manage symptomatic gallbladder stones. However, only twelve patients with total situs invertus have been previously reported in the literature. We report a new case of a 58-year-old patient hospitalized for acute pain of the left hypochondrium with fever. The diagnosis of acute cholecystitis with situs inversus totalis was made following clinical examination and radiological investigations. Laparoscopic cholecystectomy was subsequently performed through a modification of the technique to adapt to the mirror image anatomy.

Spontaneous false aneurysm of the gastroduodenal artery in a hemophilic patient ruptured into the duodenum: case report

Pseudoaneurysms of the splanchnic arteries are rare causes of gastrointestinal bleeding. We report a case of a spontaneous gastroduodenal artery false aneurysm ruptured into the duodenum in a patient with hemophilia. The diagnosis was confirmed by spiral computed tomography and magnetic resonance angiography. The patient died from massive gastrointestinal bleeding.

[Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas. A case report]

Undifferentiated carcinoma with osteoclast-like giant cells is a rare pancreatic neoplasm, with a possible cystic pattern, includes an adenocarcinoma component and giant cell mimicking osteoclastic bone tumor. We report the case of a 72-year woman admitted for jaundice and epigastric pain. Abdominal ultrasound and computed tomography scan revealed a 6 x 5 cm cystic and solid tumor of the pancreatic head with both bile duct and pancreatic duct dilatation. A pancreaticoduodenectomy was performed and pathologic examination revealed an undifferentiated carcinoma with osteoclast-like giant cells of the pancreatic head. The patient was alive and disease-free with a 18-month follow-up.

[Primary hydatid cyst of adrenal gland. Report of two cases]

Primary hydatid cyst of adrenal gland is still an exceptional localization. The adrenal gland is an uncommon site even in our country in which echinococcal disease is endemic. We report two cases of primary hydatid cyst of adrenal gland presented with isolated abdominal pain. The diagnosis was based on CT-scan, which showed a cystic mass of respectively the right and left adrenal gland with a calcified wall. The echinococcal immunologic test (Elisa) was positive in one case. The surgical treatment consisted on a total resection of the cyst, without rupture of the cystic wall and preserving the gland. The diagnosis was confirmed on the macroscopic examination of the resected pieces. In the first case the cyst was multilocular filled with daughter cysts and in the second case the cyst was unilocular filled with hydatid membrane and clear fluid. In the two cases, the postoperative course was uneventful. No recurrence had occurred respectively after 24 months and 36 months of follow up.

[Encapsulating peritonitis disclosing primary melanoma of the small intestine: a case report]

Encapsulating peritonitis is a chronic peritonitis leading to the constitution of the thick white nacred fibrosis membrane. It is a rare affection. Its physiopathology is poorly elucidated. Diagnosis is usually at operation. We report an unpublished case of a 36-year-old patient, admitted for an abdominal mass. The different investigations demonstrated small bowel tumor with entrapped ileal and jejunal loops within a capsule. Diagnosis was made at the time of operation by discovering an encapsulating peritonitis caused by a primary malignant melanoma of the small bowel, which is an exceptional affection.

Kyste lymphoépithélial inhabituel du pancréas. À propos d'un cas

Lymphoepithelial cyst of the pancreas is a benign and rare pathology. Its histogenesis is still unknown. The diagnosis is difficult to establish before surgery. We report a new case of a 20-year-old woman admitted for abdominal pain and vomiting. Radiologic investigations described a multilocular cystic tumor of the tail of the pancreas. The patient underwent a left pancreatectomy with splenectomy. Histologic investigations revealed pancreatic cysts lined by squamous epithelium surrounded by dense lymphoid tissue. The diagnosis of lymphoepithelial cyst of the pancreas was done.

[Pancreatic cystadenocarcinoma revealed by an acute pancreatitis and exploratory surgery. A rare case report]

Cystadenocarcinoma of the pancreas is a rare malignant tumor. It may appear as a typical pseudocyst on ultrasonography or CT scan. It is exceptionally revealed by an acute pancreatitis. Authors report a new case of cystadenocarcinoma of pancreas misinterpreted as pancreatic pseudocyst complicating acute pancreatitis. The diagnosis was established at laparotomy by discovering a locally advanced tumor of pancreatic tail with hepatic and peritoneal carcinosis metastasis.

[Diaphragmatic bronchogenic cyst: a rare case report]

Retroperitoneal bronchogenic cysts are rare and those located in the diaphragm are exceptional. We describe an additional case of bronchogenic cyst of the left crus of diaphragm. Diagnosis of a diaphragmatic lesion was confirmed during laparotomy and complete resection was successful. Final diagnosis was done on pathology.