Jejunogastric intussusception associated with jejunojejunal intussusception (double telescoping) occurring 20 years after gastrojejunostomy

INTRODUCTION

Jejunogastric intussusception (JGI) is a rare but potentially lethal complication following gastrectomy or gastrojejunostomy surgeries. Diagnosis of this condition can be challenging due to its rarity and non-specific symptoms. This article presents a case report of a 60-year-old male with a history of trans mesocolic gastrojejunostomy who developed acute symptoms of JGI.

CASE REPORT

The patient presented with acute epigastric pain, vomiting, and hematemesis. Physical examination and laboratory tests indicated dehydration, tachycardia, and leukocytosis. Computed tomography (CT) revealed intussuscepted loops within the stomach. Emergency laparotomy was performed, and the intussusception was manually reduced without the need for resection. The patient recovered well and was discharged five days post-surgery.

DISCUSSION

Retrograde jejunogastric intussusception is a rare complication, often occurring years after gastric surgery. It can be classified into acute and chronic forms, with the former presenting with intense pain and potential hematemesis. The condition can arise in different surgical contexts and even spontaneously. The cause of JGI remains unclear, but factors such as hyperacidity, abnormal motility, and increased intra-abdominal pressure have been implicated. Diagnosis can be made through endoscopy or alternative imaging modalities such as CT. Surgical intervention is the treatment of choice, with various options available based on intraoperative findings.

CONCLUSION

Retrograde jejunogastric intussusception is challenging to diagnose and treat due to its rarity and lack of understanding of its causes. Imaging techniques and endoscopy play important roles in diagnosis, while surgery remains the primary treatment option. Vigilance is necessary among medical professionals to consider JGI in cases of acute abdominal pain and vomiting following gastric surgery, allowing for prompt diagnosis and intervention to prevent bowel necrosis. Further research is needed to establish optimal surgical strategies and evaluate recurrence rates.

Dieulafoy's lesion: Is there still a place for surgery? About 2 cases

INTRODUCTION

Dieulafoy's lesion, a rare but life-threatening condition accounting for a small percentage of acute gastrointestinal bleeding cases, has historically posed diagnostic and therapeutic challenges.

CASE PRESENTATION

In this article, we present two cases that required surgical intervention due to unsuccessful attempts with endoscopy. Case 1 involved a 40-year-old patient with a history of treated duodenal ulcers, while Case 2 featured a 74-year-old woman with no notable medical history. Both patients exhibited severe bleeding, necessitating urgent surgical procedures. The surgical approach involved wide gastrotomy, careful inspection, and successful suturing of the bleeding vessel.

DISCUSSION

Dieulafoy lesions, discovered by French surgeon Georges Dieulafoy in 1885, constitute 1-2 % of acute gastrointestinal bleeding cases. These anomalies involve enlarged submucosal arteries, predominantly in the stomach, but occurrences in other sites are documented. Endoscopic methods, surpassing surgical intervention, are preferred for treatment, boasting success rates over 90 %. Surgical measures become a last resort for uncontrolled bleeding, with laparoscopic surgery emerging as a minimally invasive alternative, facilitated by various intra-operative localization techniques. Laparoscopic wedge resection, in particular, exhibits lower re-bleeding rates than traditional oversewing methods, although feasibility depends on lesion location.

CONCLUSION

While endoscopic methods are preferred, surgery remains a vital option when bleeding persists or endoscopic intervention fails. This report highlights the significance of surgical management in selected cases of Dieulafoy's lesion.

Dropped gallstone-related perihepatic abscess 20 years after open cholecystectomy

INTRODUCTION

Gallstone spillage during cholecystectomy is a recognized complication that can lead to various postoperative complications.

CASE PRESENTATION

We present a rare case of a gallstone abscess that developed 20 years after an open cholecystectomy. An 80-year-old woman with a history of high blood pressure and previous gallbladder removal presented with severe abdominal pain. Imaging revealed a large abscess with a suspicious calcification, indicating a lost gallstone. Surgical intervention was performed, resulting in the removal of multiple gallstone fragments from the abscess cavity.

CLINICAL DISCUSSION

Gallbladder perforations and the spillage of gallstones are common complications during cholecystectomies, with laparoscopic procedures being more prone to stone spillage. Studies show a significant difference between open and laparoscopic cholecystectomies, with laparoscopy having a higher risk of spilled stones. Complications from spilled gallstones are rare but can vary in presentation and location. They may lead to long-term issues such as abscesses and even erosion into other organs. These complications can manifest years after surgery. Treatment involves evacuating the abscess and addressing the gallstone. Surgical intervention, like laparotomy or laparoscopy, is required for retrieval. Ensuring proper traction during surgery is crucial to prevent gallbladder perforation and stone spillage. Consideration of alternative, gentler instruments for traction may be beneficial.

CONCLUSION

Surgeons should be vigilant, proactive, and employ prophylactic measures to minimize complications related to gallstone spillage, ensuring the best possible patient outcomes.

Caecal volvulus in an adult with an incomplete common mesentery: A case report

INTRODUCTION AND IMPORTANCE

A common mesentery is defined by the persistence of an embryonic anatomical arrangement secondary to an anomaly of rotation of the primary umbilical loop. Caecal volvulus is a rare cause of intestinal obstruction, which account for 1 to 1.5 % of all intestinal obstructions. A combination of both, intestinal mal rotation and caecal volvulus is rare.

CASE PRESENTATION

We report this rare entity in a 50 year old male with no history of abdominal surgery who was admitted for an acute intestinal obstruction. Clinical examination found a non-complicated right inguinal hernia. Radiological assessment showed signs of an incomplete common mesentery and an important small bowl distention with a transitional zone near the profound inguinal ring. Emergency surgery was performed. Surgical exploration didn't find signs of strangulation in the inguinal hernia which motivated midline laparotomy. We discovered a caecal volvulus with an incomplete common mesentery and ischemic lesions in the caecum. Ileocaecal resection was performed with ileocolostomy.

DISCUSSION

Common mesentery can be complete or incomplete. It is often well tolerated in adulthood. This intestinal malrotation can sometimes cause serious complications such as volvulus. Their association is rare. Radiology can be very helpful in leading to the diagnosis, but the diagnostic process should not delay surgical intervention which is the basis of the treatment.

CONCLUSION

Caecal volvulus is a serious complication of intestinal malrotation. This association is rare in adulthood and symptoms are not specific. Emergency surgery is necessary.

Surgical treatment for bleeding ileal varices: A case report

Introduction and importance

Bleeding from ileal varices is a rare and a life-threatening situation. Its management is difficult and includes endoscopic, surgical and interventional radiology treatment.

Here we report a successful emergency surgery for bleeding ileal varices in a patient with cirrhosis due to autoimmune hepatitis.

Presentation of a case

A 60-year-old woman was admitted for rectal bleeding. She had a history of autoimmune hepatitis. She was treated by endoscopic ligation for oesophageal varices.

Eso-gastro-duodenal fibroscopy and colonoscopy failed to reveal the bleeding site.

CT scan was then performed showing ileal varices due to a portocaval shunt, there was a communication between the superior mesenteric vein and the right internal iliac vein.

As the embolization was not feasible and the bleeding did not stop, an exploratory laparotomy was performed showing two dilated veins on the surface of the ileal wall, communicating with the right internal iliac vein. We performed a ligation of the vessels. Postoperative course was uneventful.

Discussion

Ectopic varices are a rare case of gastrointestinal bleeding. Most of those patients have portal hypertension and liver cirrhosis.

Diagnosing bleeding ileal varices is difficult because endoscopic examination can't always reveal the bleeding site.

Interventional radiology is a good option for patients having bleeding ileal varices knowing that they often have advanced liver cirrhosis making them poor candidates for surgery.

Haemostasis by endoscopy is often temporary and bleeding frequently recurs.

Surgery should be considered if non-invasive treatments failed to ensure the haemostasis.

Conclusion

Bleeding ileal varices is a rare situation. Interventional radiology and endoscopy can be good options. If not feasible, surgical treatment should not be delayed.

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Ectopic varices are a rare case of gastrointestinal bleeding.

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Diagnosing bleeding ileal varices is difficult.

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Surgical treatment is the best option to stop the bleeding.

Tuberculous severe acute colitis. A case report

Introduction

and importance: Intestinal tuberculosis represents 2% of the ten million cases of tuberculosis reported in 2018. Herein, we report a case of tuberculous severe acute colitis. It is a rare and life-threatening condition. Our literature review found only five published cases. It occurs generally in immunocompromised patients. Extended colonic inflammation seems to be the main predictive factor of death. Moreover, an early diagnosis and rapid onset of antituberculous treatment are mandatory to save the patient's life.

Case presentation

Herein, we present a case of tuberculous severe acute colitis with a review of the reported cases. The patient presented with a severe and idiopathic acute colitis. He was put on broad-spectrum antibiotics and intravenous corticosteroids. At day two, he developed septic shock and colic perforation. Colectomy was performed. Microbiology investigation and pathology examination confirmed tuberculous colitis.

Clinical discussion

Tuberculous severe acute colitis occurs generally in immunocompromised patients. Extended colic inflammation seems to be the main predictive factor of death. Moreover, an early diagnosis and rapid onset of antituberculous treatment are mandatory to save the patient's life. However, diagnosis is difficult as symptoms aren't specific. Microbiology and pathology were compulsory to retain colic tuberculosis in all the reported cases.

Conclusion

Tuberculous severe acute colitis is a challenging and life-threatening condition. It usually occurs in immunocompromised patients. Abdominal CT-scan may evoke the diagnosis. Microbiology and pathology are mandatory to retain the diagnosis. Early diagnosis and onset of antituberculous treatment are compulsory to save the patient's life.

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Diagnosis of tuberculous severe acute colitis is difficult.

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It usually occurs in immunocompromised patients.

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Surgery is mandatory if perforation occurs.

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Early diagnosis and onset of antituberculous treatment are compulsory to save the patient's life.

Enterosalpingeal fistula complicating Crohn's disease: Report of two cases and review of the literature

Introduction and importance

Reports of enterosalpingeal fistulae complicating Crohn's disease are scarce. They involve the last ileal loop and lead to a progressive destruction of the salpinx. Usually, no genital symptoms are found. In all the cases reported in the literature, the fistula was diagnosed intra-operatively and resection of the right salpinx was performed without the patient's pre-operative consent.

Case presentation

We describe 2 cases of women presenting with an Enterosalpingeal fistulae complicating Crohn's disease. Radiological findings allowed a pre-operative diagnosis. Thus, the patients were warned of the right salpinx resection and consent was obtained.

Clinical discussion

Enterosalpingeal fistulae complicating Crohn's disease are exceptional. Indeed, to the best of our knowledge, only five cases have been reported till now. In all the reported cases, no genital signs were present. As for our patients who didn't experience such symptoms. Moreover, no radiological evidence of the enterosalpingeal fistula was found in the literature. Consequently, the fistula was always diagnosed intra-operatively. For our patients, radiological findings allowed a pre-operative diagnosis. This permitted to warn them of a possible resection of the fallopian tube. Intra-operative findings were unfortunately conflicting with its preservation.

Conclusion

Enterosalpingeal fistula is an exceptional complication of the Crohn's disease. No clinical findings are present. The diagnosis should be evoked when the CT-scan or the MRI show an abnormal apposition between the fallopian tube, the last loop and the cecum. Surgical resection of the involved salpinx with the diseased intestinal segment is unfortunately usually needed in a young patient population.

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Report of two cases of an unusual form of Crohn's disease.

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Unique preoperative imaging.

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Preoperative diagnosis of the fistulae. Thus, patients were warned of salpingectomy.

Intraperitoneal migrating mesh plug wrongfully taken for right colon cancer: A case report

BACKGROUND

The use of mesh has become nowadays a standard for hernia repairs. It allows a tension-free hernioplasty and has shown that it is an effective way to prevent recurrences. But complications have been described. Intraperitoneal migration of mesh plug is an uncommon complication.

CASE REPORT

In this paper we report a case of a 57 year old male who has been operated on 12 years ago, he had a mesh plug repair for a ventral incisional hernia. The mesh migrated into the abdominal cavity and it was wrongfully taken for a locally advanced right colon cancer. Colonoscopy was done and biopsies were taken, but the results were not conclusive. He was operated on. We found the mesh that had migrated and eroded the hepatic flexure. There was a granulation tissue that also included some of the small intestine. There was also an abscess in the abdominal wall. He had an en-bloc resection of a part of the abdominal wall, small intestine and right colon.

CONCLUSION

Mesh hernioplasty is a frequent, simple and effective procedure with a low recurrence rate but it can be associated to serious complications such as mesh migration.

Primary duodenal tuberculosis complicated with perforation: A review of literature and case report

Tuberculous (TB) disease remains an endemic pathology in Tunisia. the ileocecal region is the predominant site of involvement while gastroduodenal tuberculosis is very rare, this form is often presenting as one of the complications, mainly upper gastrointestinal stenosis or exceptionally as a perforation. We describe a case of female patient aged 33 years-old presented with a 2-day history of acute abdominal pain, with a tenderness of the right hypochondrium and the epigastrium, ultrasound of the abdomen revealed gallbladder distension with a wall thickening. The diagnosis of acute cholecystitis was suspected and the patient had an exploratory laparoscopy that revealed the presence of a perforated duodenal ulcer which was blocked by the gallbladder and several peri-duodenal lymph nodes. Cholecystectomy was performed and the edges of the ulcer were resected and the ulcer was sutured. Histological examination revealed duodenal tuberculosis and the patient was referred to the TB eradication program.

A rare association of caecal volvulus and intestinal malrotation causing an acute abdomen: Case report

Introduction

and importance: Caecal volvulus represents 30% of colonic volvulus. It happens due to torsion or hyperflexion of a hypermobile caecum. Usually it is secondary to an axial rotation of the caecum and the ileum around the mesentery. On the other hand Intestinal malrotation occurs due to incomplete or faulty rotation and fixation of the gut during fetal life. The occurrence of these two anomalies together is scarse which makes this case report interesting.

Case presentation

A 75 year old man with medical history of terminal kidney failure, presented to the emergency room with an intestinal obstruction syndrome. On examination the patient had a distended abdomen with tenderness in the left upper quadrant. Biology found an important biological inflammatory syndrome with hyperleukocytosis and elevated CRP. Plain X-ray of the abdomen in erect posture showed an air fluid colonic level in the left hypochondrium. CT scan showed signs of caecal volvulus with intestinal malrotation. A brief reanimation and nasogastric aspiration couldn't solve the problem therefore emergency laparotomy was needed ileocaecal resection was performed associated with LADD's procedure in order to treat both anomalies and prevent further gut volvulus.

Clinical discussion

Despite it's rareness, caecul volvulus represents the second cause of large bowel volvulus just behind sigmoid volvulus. Intestinal malrotation in adults subjects is estimated to occur in 0.2–0.5%.The uniqueness of our case is that these two anomalies were associated in such a way that it made both the diagnosis and the therapy even more difficult. Abdominal CT has become mandatory for pre-operative diagnosis of intestinal volvulus. Surgery is the gold standard treatment for caecal volvulus. The usual options are manual detorsion, carcopexy, caecostomy and colectomy.

Conclusion

This case reports a rare association of a caecum volvulus with intestinal malrotation that emphasis the place of modern technologies such as CT scan in order to achieve correct preoperative diagnosis. We also describe our approach to this uncommon surgical emergency in order to provide an efficient treatement.

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Caecal volvulus associated with intestinal malrotation is rare.

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CT scan is mandatory for preoperative diagnosis of caecal volvulus.

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Surgery is the only permanent solution.

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Association of procedures for the caecal volvulus and the intestinal malrotation is the only prevention from recurrence.

Management of a primary retroperitoneal hydatid cyst ruptured in the abdominal wall: A case report

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Hydatid disease is endemic in North Africa countries such as Tunisia.

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Retroperitoneal location is scarce.

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Parietal complications are rarely described even in endemic geographic locations.

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Management of parietal complications of hydatid cysts is not consensual.

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Surgical drainage remains the gold standard.

Introduction

Hydatid disease is a global zoonosis. Any organ of the human body can be involved. Single or multiple locations are reported. However, retroperitoneal hydatid cysts are uncommon. Furthermore, parietal complications are rarely reported in literature. Therefore, the management of hydatid cysts ruptured in the abdominal wall remains challenging.

Presentation of case

In this case report, we aim to describe our experience in treating a primary retroperitoneal hydatid cyst with rupture into abdominal wall in an 87-year-old woman who presented with a 15-centimeter mass of the right flank. Hydatid serology test was positive. An abdominal CT scan showed a 20-centimeter cystic mass of retroperitoneum extended to the abdominal wall with several septa within and enhanced thick wall. The patient underwent a surgical elective drainage with perioperative antiparasitic chemotherapy. Follow-up showed no recurrence.

Discussion

Primary retroperitoneal hydatid cyst with parietal complications is scarce and barely described in literature. We performed a review of the recent relevant literature that deals with this subject. None of the hydatid cysts reported in 55 cases was located in retroperitoneum. The top seven countries of origin are located in Mediterranean region except for India. Imaging is compulsory for the diagnosis along with patient’s history, physical examination and hydatid serology. The treatment is surgical and must be must be covered by antiparasitic chemotherapy.

Conclusion

Primary retroperitoneal hydatid cyst extended to the abdominal wall remains a rare and challenging diagnosis that must be considered in endemic countries.

Laparoscopic cholecystectomy decreases extra surgical site morbidity compared with open cholecystectomy: A propensity matched analysis

BACKGROUND

The ideal way to show treatment effectiveness is through randomized controlled trials the 'gold standard' in evidence-based surgery. Indeed, not all surgical studies can be designed as randomized trials, sometimes for ethical and otherwise, for practical reasons. This article aimed to compare laparoscopic cholecystectomy to open cholecystectomy, according to data from an administrative database, managed by a propensity matched analysis.

METHODS

Were included all patients with cholelithiasis admitted in Department B between June 1st, 2008 and December 31st, 2009. In this study, the propensity score represented the probability that a patient would be treated by a procedure based on variables that were known or suspected to influence group assignment and was developed using multivariable logistic regression used here to match patients who had laparoscopic cholecystectomy to a control patient who had open cholecystectomy. The main outcome measure was morbidity. This was expressed as the number of patients with 1 or more complications occurring during the hospital stay or within 30 days following discharge.

RESULTS

According to intention to treat, 535 patients had a laparoscopic approach (LC group) and 60 patients had a traditional open approach (OC group) regarding associated cardiac disease, previous laparotomy or when choledocholithiasis was suspected, however intra operative cholangiography showed that there was no choledocolithiasis. According to the propensity score, 28 patients in OC were matched with 58 in LC. Comparison between OC and LC before and after propensity matched analysis showed that OC was associated with a higher rate of Extra Surgical Site morbidity (p= 0.010), a longer median duration of intervention, post-operative stay and overall hospital stay (p= 0. 0001).

CONCLUSION

LC should be considered as first-line therapy to treat cholelithiasis surgically even if it becomes necessary to convert to OC because of intra operative findings.

[Stromal gastrointestinal tumors: retrospective study of 24 cases]

BACKGROUND

Gastrointestinal stromal tumors (GIST) are the most common digestive sarcomas. They develop in most cases in the stomach and small intestine, more rarely rectum, colon, esophagus or mesentery. These tumors typically express the phenotype CD117/KIT + and CD34 +.

AIM

To evaluate epidemiologic, clinical, pathologic, therapeutic, characteristics and evaluative pattern of gastrointestinal tumor treated in our surgical department.

PATIENTS AND METHODS

We collected 24 cases of GIST (confirmed by the positivity of CD 117 and/or CD 33) treated between 1997 and 2010 in the department of surgery B of Charles Nicolle's Hospital. We analyzed demographic characteristics, clinic pattern, investigations treatment and therapeutic variables of our patients. We calculated the survival rate and identified prognostic predictive factors of survival.

RESULTS

Our retrospective study interested, during 13 years, 24 patients presenting GIST with a median age of 66 years and a sex ratio of 0.8. The median time for diagnosis was two months (3 days to 24 months). Abdominal pain, gastrointestinal bleeding and vomiting were the most common symptoms. The endoscopic appearance was tumor arising from muscular layer found in the stomach (13/24 cases; 54%), small bowel in four cases (16.5%) and duodenal or rectum three patients (12,5 %). Twenty three within 24 patients underwent surgical resection with R0 in 20/23 cases. Three patients were treated with neoadjuvant imatinib for an average of 12 months, one patient had adjuvant treatment and four patients in locoregional evolutive tumor and / or metastatic. The overall survival was 70% at one year and 65% at two years with a pejorative impact, in univariate analysis of abdominal pain, asthenia, anorexia, weight loss, cytonuclear atypia, tumor size ≥ 10 cm and a mitotic index ≥ 5/50. Multivariate analysis showed that tumor size (Hazard Ratio = 6 if size ≥ 10 cm 95% CI [1,539-24,017]) and weight loss (Hazard Ratio = 7 95% CI [1,664-29,100]) were influential factors on overall survival and recurrence-free survival.

CONCLUSION

The prognostic predictive factors identified were the size of tumor ≥ 10cm and the mitotic index.

[Spinal anesthesia versus general anesthesia for inguinal hernia repair: propensity score analysis]

BACKGROUND

Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting information's in the field of descriptive and analytic epidemiology with less cost.

AIM

To compare spinal to general anesthesia for inguinal hernia repair concerning a population extracted from administrative database after propensity matched analysis.

METHODS

Prospective study concerning 4690 hospitalizations in Department B of General Surgery of Charles Nicolle hospital during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a comparison between spinal and general anesthesia according propensity matched analysis were performed. Résultats: 595 inguinal hernias were operated on. Mean age was 55±15.We mentioned a male predominance: 326 men (84.2%) and 61 women (15.8%). 137 patients had previous medical diseases(35.4%). 47(12.1%) patients were operated on in emergent situation on the other hand 340(87.9%) had elective surgery.264(68.2%) were ASA I, 110(28.4%) ASA II, 13(3.4%) ASA III. Post operative course were uneventful in 96.1% (372) and complicated in 11 patients (2.9%).Four deaths were observed (1%). Comparison before and after propensity matched analysis showed a statistical difference regarding postoperative stay and all hospital stay in favor of spinal anesthesia (p=0.007).

CONCLUSION

Postoperative stay is significantly shorter in the group of spinal anesthesia (p=0.007). A randomized clinical trial comparing spinal anesthesia to general anesthesia is needed.

[Assessment of care quality in department of general surgery : usefulness of administrative database]

BACKGROUND

Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting informations in the field of descriptive and analytic epidemiology with less cost.

AIM

To assess the usefulness of administrative database for quality of care and research.

METHODS

It was a prospective study concerning 4690 hospitalisations in Department B of General Surgery of hôpital Charles Nicolle during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a pronostic study with a univariate and multivariate analysis was performed. RÉSULTATS : Our study showed the usefulness of an administrative database in assessing the quality of care, it allowed us to determine postoperative mortality rate (2.7%), deep morbidity (2.5%), parietal morbidity (1.2%), medical complications (6%), nosocomial infections (3.6%) and re intervention (2.7%), with independent predictive factors of these events. To reduce the incidence of these events we should reduce length of pre-operative stay, prevent intra operative accidents, avoid intra operative bleeding in order to reduce intra operative transfusions and avoid as far as possible the stay in ICU Independent predictors of post trauma death are multiple trauma [OR: 6.14, 95% (from 1.68 to 16.94), p = 0.002], a traumatized patient in distress on arrival [OR: 8.74, 95% (3.59 -27.77), p = 0.000] and overall medical complications [OR: 13.18, 95% (from 4.01 to 31.25), p=0.000]. The ISS is a good discriminative indice to assess the severity and life-threatening risk.

CONCLUSION

Administrative databases provide information on the efficiency of care, it helps to realise observational studies on large samples representative of the population at low cost. They are very useful in the research, despite the lack of clinical data.

Validation of the Lacaine-Huguier predictive score for choledocholithiasis: prospective study of 380 patients

The aim of this study was to validate the Lacaine-Huguier score for the prediction of asymptomatic choledocholithiasis.

METHODS

The study enrolled patients over age 18 with symptomatic chronic or acute calculous cholecystitis. Patients already known to have common bile duct stones (CBDS), as evidenced by symptomatic presentation with acute cholangitis or acute gallstone pancreatitis, were not included. We compared the group of patients with a score less than 3.5 versus those with a score greater or equal to 3.5; we also compared the group of patients who underwent intraoperative cholangiography (IOC) with those who did not undergo IOC. The negative predictive value of the Lacaine-Huguier score was calculated.

RESULTS

We note that 308 women and 72 men were consecutively enrolled between February 2008 to March 2009; the average age was 51±16.4 years. The score was less than 3.5 in 154 patients (40.5%). IOC was only performed in 135 of the 226 patients with a score greater or equal to 3.5; reasons for this included a very narrow cystic duct in 67 cases, preoperative miscalculation of the score in nine cases, a technical problem in eight cases, an unspecified reason in four cases, contraindication due to pregnancy in two cases, and intraoperative difficulties in one case. CBDS were detected by IOC in 18 cases. Performance of IOC lengthened the median operative time by 20 minutes. The median follow-up was 8 months (range: 0-30 months). Eleven patients were lost to follow-up (2.9%), six of these had a score less than 3.5. Two patients had residual common bile duct (CBD) stones, one of whom had a score less than 3.5. The negative predictive value was 99.4% (95% confidence interval (CI 95%)=[98-100%]). The risk of leaving a stone in the CBD was 0.6%. When data was analyzed according to the worst case scenario, the negative predictive value became 95.5% (CI 95%=[92-99%]) with a risk of residual CBDS of 4.5%.

CONCLUSION

This study confirmed the validity of the Lacaine-Huguier score. When the score is less than 3.5, the surgeon can refrain from performing IOC with a risk of asymptomatic residual CBDS ranging from 0.6% to 4.5%.

[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.