Burkitt Lymphoma Mimicking an Acute Appendicitis in a 17 Years Old Boy: a Case Report

Burkitt lymphoma belongs to the B cell non-Hodgkin tumors and is known as the fastest growing human tumor. It is mostly seen in children and young adults. Typically for this type of lymphoma is the chromosomal translocation that leads to a deregulated expression of the c-myc oncogene. Our case report describes a 17 year old patient who presents with atypical right lower quadrant pain. He underwent an explorative laparoscopy and a Burkitt lymphoma was discovered. Subsequently several imaging studies were performed to stage the disease. Intensive systemic chemotherapy is the choice of treatment. Surgery can have a role in early stages and acute complications of the tumor but frequently the role of surgery is restricted to histological biopsy.

Small Bowel Intussusception Caused by Multiple Intestinal Metastases from a Giant Cell Carcinoma of the Lung: a Case Report

Small bowel obstruction (SBO) due to intussusception in adults is a rare condition. Diagnosis at the time of admission is usually challenging. More often than not, a bowel intussusception in adults is secondary to an organic condition, frequently malignancies. Therefore, a surgical approach is indicated most of the times. We report the case of a forty-nine years old lady presenting with a SBO secondary to small bowel metastases with two ileo-ileal intussusceptions, one of which was missed at initial surgical exploration. A giant cell carcinoma of the lung (GCCL) with small bowel metastases was diagnosed subsequently. The case is presented as well as a brief review of literature.

Small bowel intussusception caused by multiple intestinal metastases from a giant cell carcinoma of the lung: a case report

Small bowel obstruction (SBO) due to intussusception in adults is a rare condition. Diagnosis at the time of admission is usually challenging. More often than not, a bowel intussusception in adults is secondary to an organic condition, frequently malignancies. Therefore, a surgical approach is indicated most of the times. We report the case of a forty-nine years old lady presenting with a SBO secondary to small bowel metastases with two ileo-ileal intussusceptions, one of which was missed at initial surgical exploration. A giant cell carcinoma of the lung (GCCL) with small bowel metastases was diagnosed subsequently. The case is presented as well as a brief review of literature.

Can a flap help the plug ? Or vice versa ? Proposing a combined sphincter-sparing anal fistula repair

BACKGROUND

To evaluate the results of a combination of fistulectomy with a rectal advancement flap and an anal fistula plug in the treatment of transsphincteric anal fistulas.

METHODS

All patients with a transsphincteric fistula and a limited number of anterior intersphincteric fistulas in female patients were registered from July 1(st), 2010 until November 30(th), 2012. All operations were performed by one surgeon (CdG). Patient data and results (healing, continence) were collected in a prospective database.

RESULTS

28 patients were treated with a healing rate of 75% after one procedure. Four out of seven patients who failed to heal underwent a redo anal fistula plug and rectal advancement flap. Three of them were cured. Cumulative healing rate was 86% after two procedures. There were four minor complications. Mean postoperative Wexner score was 0.62.

CONCLUSIONS

Combination of anal fistula plug and rectal advancement flap in treating transsphincteric anal fistulas can result in good healing rates with minimal incontinence.

Revisiting the role of herniography in the preoperative work-up of groin hernias?

INTRODUCTION

The diagnosis of groin hernia is based on clinical symptoms and physical examination. In the case of equivocal clinical findings, patients are often referred for subsequent diagnostic imaging. Accurate detection is important to minimize the inherent risk of complications or to avoid unnecessary surgery. Although herniography has been reported as a save and highly accurate procedure, it has not gained widespread acceptance in the diagnostic work-up of groin hernias.

METHODS

We retrospectively analysed 157 patients who underwent herniography in our department, which is to date the third largest study reporting on this technique. The diagnostic value of herniography was investigated--with laparascopic surgical findings serving as a gold standard--in comparison to clinical symptoms, physical examination and ultrasound.

RESULTS

Herniography showed a substantial agreement with the surgical findings, but only a slight to fair agreement was found between surgery and clinical symptoms and examination. Poor agreement was found between sonographic and surgical findings.

CONCLUSION

Based on the presented data and previously reported studies, we can conclude that herniography is a safe technique with a high accuracy to detect groin hernias in patients with equivocal clinical presentation, whereas ultrasound has a wide range in reported sensitivity. Clinicians and surgeons should take this into account when referring patients for subsequent imaging.

Incisional surgical site infections after colorectal surgery: time to appraise its true incidence

BACKGROUND

Surgical site infections (SSI) are the leading cause of complications in surgical patients. For colorectal surgery the reported incidence of SSI varies between 10 and 15%. This incidence however, has been challenged recently. In this study, we evaluated the incidence of incisional SSI after colorectal surgery in our department.

METHODS

We performed a retrospective analysis of 115 non-laparoscopic colorectal resections between July 1st 2004 and July 31st 2005. After exclusion, 101 patients were retained. Demographic, clinical and operative variables were collected. Univariable and multivariable analysis were performed to identify risk factors for the development of incisional SSI.

RESULTS

21 SSI were diagnosed (20.7%). Seventeen cases were incisional SSI (16.8%). Multivariable analysis identified longer operation time (p = 0.014), pre-operative obstructive lung disease (p = 0.02) and fewer postoperative days on TPN (p = 0.04) as independent predictors of incisional SSI.

CONCLUSION

In comparison with recent publications, the incidence of SSI in our series was higher compared to what is generally reported.

A ruptured gastrointestinal stromal tumour of the transverse mesocolon: a case report

We discuss the long history of a patient still alive with a primary gastrointestinal stromal tumour (GIST) of the transverse mesocolon: initially it presented as an acute complication, namely a haemorrhagic shock caused by rupture of the tumour and it recurred twice locally in the years following primary resection. Each time, a macroscopically complete resection could be achieved. Six years after the resection of the primary tumour, a liver metastasis was discovered, which was removed by radio frequency ablation (RFA). Eight months later, the patient developed a new liver metastasis and a retropancreatic mass deemed unresectable. He is treated with imatinib mesylate (Glyvec, Novartis, Vilvoorde, Belgium) since and has had a stable disease for 6 months. Gastrointestinal stromal tumours outside the gastrointestinal tract are rare. Until a few years ago the only possible therapy was surgical resection. Nowadays radio frequency ablation can be a solution for irresectable liver metastases, and imatinib mesylate can bring improvement for advanced and metastasized tumours. Whether this could also be useful as an adjuvant therapy has not yet been investigated, but it could be important knowing that 38% of the tumours recur locally and 15% metastasize. The most important prognostic factors for gastrointestinal stromal tumours are grading and complete resection.

Transmesosigmoid hernia: report of a case and review of the literature

We report a case of a transmesosigmoid hernia in a 6 weeks postpartum woman. We found 14 previous reports of this rare type of internal hernia. Our patient presented with acute abdominal pain and developed a small intestinal obstruction. History, clinical and radiographic examination were not diagnostic. An early laparoscopy was performed and a herniation of a small intestine loop through a hole in the sigmoid mesocolon was seen. The hernia was reduced and the defect in the sigmoid mesocolon was closed laparoscopically. The small intestine was viable and enterectomy could be avoided. The role of laparoscopy and potential causes of this type of hernia are discussed.

Laparoscopic inguinal hernia repair: review of 6 years experience

Since 6 years, the totally extraperitoneal laparoscopic hernia repair has become our procedure of choice to manage inguinal hernia in adult patients, especially for bilateral hernias and recurrences after classical anterior repair. Between March 1993 and March 1999, 976 patients underwent 1259 hernia repairs by an endoscopic total extraperitoneal approach. A large polypropylene prosthesis (15 x 15 cm) is placed and covers all potential defects. Follow-up on patients ranged from 6 to 79 months (mean, 39 months). Per- and postoperative morbidity and complications were acceptable (8.4%) and included conversion to open surgery (0.4%), bleedings (0.3%), urinary retention (4.2%), seromas (2.7%), neuralgias (0.2%), vague persistent groin discomfort (0.4%), orchitis (0.08%) and sigmoido-cutaneous fistula (0.08%). Recurrence rate so far is 0.1%. This retrospective study shows that the totally extraperitoneal repair for inguinal hernia should have a promising future because of low morbidity and low recurrence rate.

Focal transmural necrosis of the gallbladder with bleeding resulting in a massive haemoperitoneum

A case of massive haemoperitoneum as a complication of focal transmural necrosis of the gallbladder with bleeding during acute cholecystitis is reported. Urgent laparotomy and cholecystectomy was performed to secure an adequate haemostasis. A review of the literature confirmed that this condition is a very rare complication of acute cholecystitis. Only 44 similar cases have been reported between 1858 and 1996. In our case, bleeding was caused by the edges of a necrotic zone in the gallbladder wall.

Cystic lymphangioma of the pancreas: an unusual cause of the acute surgical abdomen

Cystic lymphangioma of the pancreas is a rare tumour. The authors report on a case of cystic lymphangioma of the pancreas in a 6-year-old boy, presenting an acute abdomen. These tumours are benign and must be differentiated from other cystic abdominal lesions. Histological diagnosis is required in all cases. Treatment consists in a complete resection of the tumour. In most cases a tumorectomy is sufficient, although sometimes pancreatic resection might be necessary.

Duodenal transection in a battered child: a case report

A case of severe duodenal injury following child abuse is presented. Perforating duodenal injuries are seldom seen after blunt abdominal trauma. A high energy force directed to the center of the upper abdomen may result in disruption of the duodenum. Early diagnosis and appropriate treatment are necessary to improve the outcome. Most children indeed are seen too late and in septic shock because of neglect.

Laparoscopic repair of a Morgagni hernia

The authors present a case of laparoscopic repair of a symptomatic Morgagni hernia in an adult patient. The indication for surgery was based on symptoms of dyspnea and sensation of thoracic tightness. A tension-free closure of the defect using a Marlex mesh was carried out. Recovery was quick and uneventful. One year after surgery, no complaints were noticed. Aetiology, diagnosis and treatment are discussed.

The totally extraperitoneal laparoscopic hernia repair. Preliminary results

BACKGROUND

The totally extraperitoneal laparoscopic hernia repair has become our procedure of choice to manage inguinal hernia in adult patients since March 1993. This technique was developed in an attempt to diminish postoperative pain, shorten the convalescence period and equal the recurrence figures of the classical tension-free repair.

METHODS

A complete extraperitoneal dissection is performed. A large Marlex prosthesis (15 x 15 cm) is placed and covers all potential defects.

RESULTS

A consecutive series of 195 hernias in 158 patients is proposed. The minimum follow-up in our series is at least 6 months. Morbidity is low and so far, no recurrences have been seen.

CONCLUSIONS

The totally extraperitoneal laparoscopic approach for repairing inguinal hernia should have a promising future, because the same principles as the classical tension-free repair are followed. Preliminary results are promising. Further studies, even randomized prospective trials and fair reports of complications, will determine the future of laparoscopic hernia surgery.

Strangulation: a late presentation of right-sided diaphragmatic rupture

A case of late presentation of a right-sided diaphragmatic rupture due to blunt chest trauma is presented. The patient suffered from strangulation of a herniated segment of small bowel into the chest. Chest radiography suggested diaphragmatic rupture, computed tomography and sonography established the correct preoperative diagnosis. The prevalence, mechanism of injury and possible complications are reviewed. The value of chest radiography and other imaging techniques is discussed.

[Surgery of foreign bodies in the esophagus in case of failure of noninvasive extraction technics]

In the period 1957-1987, 240 corpora aliena in the esophagus were treated. The foreign body could be extracted under endoscopy in 228 cases (95%). In 12 cases the non-invasive extraction technic failed, so we have to remove the foreign body surgically. The most difficult bodies to extract by endoscopic way are the big, the sharp or pointed ones. On the surgical point of view, the way of approach depends on the level of the impacted body. The problem of post-operative fistula and abscess formation after surgery, can be avoided by a correct technic, exclusion of underlying pathology, an adequate drainage and consequent infection treatment.

[Paraduodenal hernia: an unusual cause of intestinal obstruction]

Paraduodenal hernia. The paraduodenal hernia is the most common type of intraabdominal hernia. There exists a right and left variety, both of them with their own specific pathogenesis. The clinical manifestations range from intermittent and mild digestive problems to acute intestinal obstruction. An exact preoperative diagnosis is seldom made. The knowledge of their pathogenesis and the anatomical characteristics is very important for a successful surgical treatment.

[Aseptic pseudarthrosis of the tibial shaft: cause and treatment]

A consecutive series of 23 aseptic pseudarthroses of the tibial shaft is proposed. The aetiology of a pseudarthrosis of the tibia depends on the original fracture form, the associated soft tissue injury, the treatment technique and the surgical procedure. Twelve times the pseudarthrosis developed after a primary treatment with an external fixation device, 6 times after plaster cast immobilization, and 5 times after plate osteosynthesis. Fifteen times, the pseudarthrosis was hypertrophic, and 8 times hypotrophic. Sixteen pseudarthroses were treated with a plate osteosynthesis, 8 times in combination with a decortication and a cancellous bone grafting. Seven times, a closed intramedullary nailing was performed. Healing was achieved after an average time of 5.1 month. After plaster cast immobilization and external fixation treatment, the non-union is caused by a lack of stability in the fracture region; after plate osteosynthesis by a too extensive decortication, resulting in fragment necrosis. Stability and vitality in the fracture site are the principles in the treatment of the pseudarthrosis.

[Rupture of the ulnar, collateral ligament of the metacarpophalangeal joint of the thumb, so-called 'wobbly thumb']

A stable metacarpophalangeal joint of the thumb is indispensable for a normal grip function of the hand. The joint is stabilized by collateral ligaments. A rupture of the ulnar, collateral ligament is often caused by a sports trauma, as indicated by the denominations "skiërs duim", "goalkeeper's thumb" and "baseball thumb". Many surgeons are not familiar with the phenomenon of an insufficient collateral ligament, also called "wackeldaum". In the period 1981-1985 a consecutive series of 35 patients with a ruptured ulnar collateral ligament was operated in the De Wever hospital Heerlen (Netherlands). On the basis of our own patients, attention is given to the diagnosis, therapy and results of the operative treatment of these lesions.

Treatment of unstable, intracapsular fractures of the femoral neck by the cementless self-locking cephalic endoprosthesis

Between July 1981 and July 1986, 152 patients with an unstable, intracapsular fracture of the femoral neck were treated with a prosthetic replacement. In a selected group of 75 very old individuals, with an average age of 82 years, a self-locking cephalic endoprosthesis was chosen. These patients were closely followed prospectively, during 3 months. The operative technique, the pre- and postoperative management are discussed. There was no peroperative mortality. The postoperative mortality rate (30 days) was very low (5.3%). Accidental fracture of the proximal femoral shaft occurred twice, during insertion of the prosthesis. No postoperative luxation was seen. The walking capacity of the survivors, 3 months after surgery, was compared with the status before injury. The self-locking cephalic endoprosthesis is a safe and time-economizing operative procedure. In our opinion, it is the treatment of choice for unstable, medial neck fractures of the femur in elderly patients, with a poor general condition and a limited life expectancy.

[Intramural bronchogenic esophageal cyst: an uncommon event in esophageal surgery]

Intramural bronchogenic cysts of the esophagus are uncommon. These benign esophageal tumors result from a wrong cleavage of the primitive gut in the 4 weeks old embryo. Symptoms are often absent or atypical. By roentgenography and esophagoscopy, the diagnosis of benign tumor can be made. Even CT-scan can't give absolute certainty about the exact nature of the lesion. An exploratory thoracotomy, with enucleation of the tumor, is needed in all cases for definite diagnosis and treatment. The cysts are lined by columnar ciliated epithelium of the respiratory type. The presence of hyaline cartilage within the wall of the cyst allows to make the difference for sure between an esophageal cyst of bronchogenic origin and a cyst of enterogenous origin.

Omphalocele: mode of management. A case report and review of literature

Management of "giant" omphaloceles has always been a challenge to pediatric surgeons. The primary goal is to minimize the mortality and morbidity by creating an optimum protection of the exposed viscera. The ideal approach of this congenital defect has not yet been found. Over the years, a number of authors have introduced new and modified techniques to solve the problem. Some results are encouraging. Selection of management method should always be based on complete evaluation of the individual characteristics of each case.