A case report of idiopathic sclerosing encapsulating peritonitis causing an acute bowel occlusion in adult.

INTRODUCTION: Sclerosing peritonitis (SP), also known as abdominal cocoon, is a and potentially serious condition characterised by the fibrous encapsulation of the small intestine within the peritoneal cavity. CASE PRESENTATION: In this report, we detail the case of a 67-year-old male with SP who initially presented with symptoms of constipation, vomiting, and abdominal pain. Despite a previous computed tomography (CT) scan revealing ileal thickening, the accurate diagnosis remained elusive until exploratory laparotomy. The patient underwent successful excision of the thick fibro-collagenous membrane, and histopathological examination revealed fibro-collagenous tissue with mild chronic inflammation. DISCUSSION: SP can be classified into primary (idiopathic) and secondary forms. Primary SP, also referred to as cocoon abdomen, is more common in young females from tropical regions, while secondary SP is associated with peritoneal dialysis and other causative factors. Diagnosing SP presents challenges, as clinical symptoms may mimic those of other conditions. Imaging studies, especially CT scans, play a crucial role in the diagnostic process, yet the rarity of SP often leads to misdiagnosis. Although there is no consensus on treatment options, surgical intervention is generally recommended for symptomatic cases, involving excision of the cocoon and adhesiolysis. Conservative management may be considered for asymptomatic cases. The mortality rate for SP is high, emphasizing the importance of early diagnosis and intervention. CONCLUSION: Primary sclerosing encapsulating peritonitis is a and complex, primarily affecting young individuals. Maintaining a high index of suspicion is crucial for an accurate diagnosis, and surgical intervention remains the primary treatment for symptomatic cases. The prognosis is generally favourable with timely and appropriate management.

Colocutaneous fistula due to an infected sigmoid adenocarcinoma: A case report of an unusual revelation.

INTRODUCTION AND IMPORTANCE: As revealed as a colocutaneous fistula with an abscess in the abdominal wall, colon cancer is rare. It should be suspected in case of a painful abdominal wall mass in elderly patients. This case presentation of an infected sigmoid adenocarcinoma aims to highlight this uncommon presentation presenting some therapeutic issues. CASE PRESENTATION: A 90-year-old woman with a past medical history of hypertension and major depressive disorder consulted the Emergency Department for lower left quadrant abdominal pain. The physical examination objectified a mild fever; lower left abdominal quadrant guarding, and abdominal mass of 10 cm with inflammatory signs. The abdominal CT scan showed a concentric thickness of the sigmoid colon with an abdominal wall abscess. She underwent an emergent laparotomy. Intraoperatively, we found an infected sigmoid tumour that invades the abdominal wall and is associated with a peritumoral abscess. This tumour was at the origin of the abdominal wall fistula. She underwent surgical drainage of the abscess, sigmoid colectomy, and colostomy. The postoperative follow-up was uneventful. The pathological examination of the operative specimen concluded with a colonic adenocarcinoma with lymph node invasion classified as pT4N2M0. CASE DISCUSSION: Despite initial medical and radiological interventions, emergent surgery became necessary to address the infected sigmoid tumour invading the abdominal wall. Pathological examination revealed advanced cancer, but timely intervention and adjuvant therapy resulted in a positive outcome with no recurrence after two years. This case emphasizes the importance of recognizing unusual colon cancer presentations and the need for swift diagnosis and intervention. CONCLUSIONS: The diagnosis of colon cancer complicated with a colocutaneous fistula remains based on pathological examination after surgical management. These tumours presented an advanced stage and correlated to a poor prognosis. This highlights the interest in screening colonoscopy in front of any digestive symptoms in elderly patients.

Upper gastrointestinal haemorrhage caused by duodenal metastasis from primary lung cancer: A case report.

Duodenal metastases from primary lung carcinoma are uncommon. They usually occur in terminal-stage disease. Bleeding, as the first presentation of duodenal metastases, is rare. This case reports a rare mechanism of upper gastrointestinal bleeding due to a metastatic involvement of the duodenum and gastroduodenal artery. A 58-year-old man with a past medical history of pulmonary carcinoma presented an episode of hematemesis of great abundance with melena. On physical examination, he was afebrile and pale. The biological data found an anaemia with haemoglobin at 6 g/dL. The upper gastrointestinal endoscopy revealed a congestive duodenal lesion with signs of recent bleeding. An angio CT scan localized the bleeding from the gastroduodenal artery. A few hours later, the patient presented a recurrent episode of hematemesis with deglobalization. So we performed a radiologic embolization of the gastroduodenal artery. Haemorrhage as the first presentation of small bowel metastases is rare, especially when these are located in the duodenum, with a poor prognosis. Radiological embolisation could be the best choice for treatment.

Surgical features to reduce anastomotic recurrence of Crohn's disease that requires reoperation: a systematic review.

Anastomotic recurrence after intestinal resection is one of the main embarrassing problems encountered during Crohn's disease (CD) management. This complication is often associated with an expected consequence, mainly a multiple intestinal resection. This systematic review evaluates published evidence on surgical features to reduce surgical recurrence after bowel resection and provide surgeons with recommendations based on published evidence. We conducted bibliographic research on September 05, 2020, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis, randomized clinical trials, and controlled clinical trials. The strength of clinical data and subsequent recommendations were graded according to the Oxford Centre for Evidence-Based Medicine. Fourteen articles were retained. Early resection reduces surgical relapse and the need for additional medical treatment. There was no difference between conventional and laparoscopic bowel resection. Mesenteric excision seems to reduce surgical recurrence. Stapled side-to-side anastomosis reduces surgical recurrence. However, no difference was observed between Kono-S anastomosis ensure at least similar anastomotic recurrence rate compared to conventional anastomosis. Surgical recurrence was reduced after bowel resection when compared to stricturoplasty. There was no difference between the one and two steps resection. Several surgical features have been investigated. Some of them were unanimously found to be effective in lengthening the disease-free relapse. However, others are still controversial.

Neurofibromatosis Type I and Stromal Tumor with a Multiple Digestive Localization.

Neurofibromatosis type I (NF1) is also known as von Recklinghausen disease. It is a genetic disorder that affects the growth and development of nerve cell tissue, which is characterized by a multisystem disorder and an increased risk for cancer. The incidence of gastroduodenal stromal tumor during Recklinghausen disease can reach 35% in autopsies and 5% in clinical cases. In our case, the diagnosis of neurofibromatosis type I was made in a middle-aged women initially diagnosed with a pancreaticoduodenal tumor.

Retrorectal Schwannomas: Atypical Presentation and Controversial Surgical Management.

Schwannomas also known as neurilemomas are benign tumors. Retrorectal schwannomas are extremely rare, accounting for 1 to 5% of all schwannomas. They are mostly asymptomatic but may present with symptoms such as pelvic pain, back pain, lower extremities pain, or constipation. Physical examination is often poor. Imaging (CT, MRI) and fine needle biopsy can often help orient the diagnosis. The treatment of choice is monoblock resection of the mass. The prognosis is good. Recurrence has been reported especially after intralesional enucleation. We report a case of a 41-year-old male patient consulting for chronic low back pain eventually diagnosed with retrorectal schwannoma. We performed a surgical resection and the histological examination was consistent with the diagnosis of benign (ancient) schwannoma.

Fournier's gangrene: its management remains a challenge.

Fournier's gangrene (FG) is a rapidly progressive necrotizing bacterial dermo-hypodermitis of the perineum and external genitalia. It represents a real medical and surgical emergency requiring multidisciplinary care. Our study was based on the retrospective analysis of 18 cases of FG, collected in the Department of General and Visceral Surgery of Fattouma Bourguiba University Hospital in Monastir over an 18-year period extending from January 2000 to December 2018. Our series included 18 cases of FG collected over an 18-year period, an annual incidence of one case per year. The average age of our patients was 58 years (36 to 77). The male prevalence was clear. Diabetes and old age were found to be the major risk factors. The treatment was based on an aggressive surgical debridement remains to be the cornerstone of therapy and is commonly preceded by patient preparation for the surgical act by perioperative resuscitation and broad-spectrum antibiotic therapy, possibly accompanied by hyperbaric oxygen therapy (HBOT). The vaccum assisted closure (VAC) therapy is also used, which is a non-invasive system that promotes open wound healing. Healing techniques can be once the septic risk is controlled. Dressings topical treatments, such as fatty substances or calcium alginate, in addition to skin grafts, musculo-neurotic or musculo-cutaneous cover flaps can be used. During the follow-up period, no reccurrence occurred in 14 out of the 18 cases (2 patients were lost to follow-up and 2 patients died). A colostomy was closed in 10 out of 11 cases with simple follow-ups. Restorative surgery (partial thickness skin graft) at the perineal level was performed in only one case. Despite the better understanding of its etiopathogenesis, the advent of targeted antibiotic therapy, the establishment of a better codification of surgical procedures, the contribution of hyperbaric oxygenation and reconstruction techniques, mortality rates are still high and FG remains a real health threat, thus constituting a real medical and surgical emergency.

Incidence and Preoperative Predictor Factors of Gallbladder Cancer Before Laparoscopic Cholecystectomy: a Systematic Review.

INTRODUCTION: Many cases of gallbladder cancer (GBC) were made incidentally after cholecystectomy for presumed benign disease. The aim of this review is to assess the preoperative predictor factors of gallbladder cancer. METHODS: This systematic review was conducted according to PRISMA guidelines when it was applicable. We conducted bibliographic researches on October 2nd, 2019, in the following sources: The National Library of Medicine through PubMed, Cochrane database, and Google scholar. We have assessed the univariate and multivariate analysis outcomes. RESULTS: We included ten studies. Incidence of incidental GBC was 0.36%. Seven studies reported age as a significant predictive factor of iGBC. Comorbidities were the second significant predictor. One study found that iGBC group was more likely to have elevated TB, DB, PAL, and ALT. Another study reported a significantly higher rate of TB, PAL, and AST. One study concluded that elevated CA19-9 combined with CEA or CA-125 was significantly more frequent in the group with iGBC. Polyps, porcelain GB, GB wall thickness, and CBD dilation were reported to be associated with iGBC. iGBC group were more likely to have solitary and larger GS and gallbladder wall thickening, essentially focal. CONCLUSION: Incidence of iGBC was 0.365% varying between 0.19 and 1.6% of laparoscopic cholecystectomy and about 50% of GBC cases. This highlights the deficiency of preoperative diagnostic features. Despite the efforts made, the rate of this condition is still high, underlining the need of new radiological technologies.

Barbed versus conventional thread used in laparoscopic gastric bypass: a systematic review and meta-analysis.

INTRODUCTION: Hand-sewn gastrointestinal anastomosis during laparoscopic gastric bypass (GBP) could be performed using the conventional multifilament suture (CS) or a barbed suture (BS). This systematic review with meta-analysis aimed to assess the advantages and disadvantages of these two anastomosis alternatives. METHODS: Bibliographic search for relevant studies was performed, according to the PRISMA guidelines, to perform the systematic review with meta-analysis. RevMan was applied to analyze the data using the random effects size. RESULTS: Eight studies were eligible for analysis including 26,340 patients. These patients underwent a single gastric bypass or Roux-en-Y gastric bypass. According to the available data from this systematic review with meta-analysis, BS in GBP ensures similar morbidity rate (OR = 1.04, 95% CI: 0.82 to 1.31, p = 0.74) with shorter operative time (MD = - 7.90, 95% CI: - 12.95 to - 2.84, p = 0.002). BS is similar to CS in terms of anastomotic leak (OR: 1.25, 95% CI: 0.90 to 1.73, p = 0.19), stricture (OR: 0.89, 95% CI: 0.32 to 2.44, p = 0.82), bleeding (OR: 0.62, 95% CI: 0.20 to 1.86, p = 0.39), and hospital stay (MD: 0.04, 95% CI: - 0.28 to 1.86, p = 0.81). On the other way, BS is cheaper than CS. CONCLUSION: The majority of studies were retrospectives. One study included the large majority of retained patients; thus then, this comparison should be interpreted with caution. BS and CS in gastrointestinal anastomosis during GBP are feasible and safe. BS is faster and cheaper with similar postoperative outcomes.

Primary pancreatic tuberculosis mimicking pancreatic body cancer. A case report and review of the literature.

Isolated pancreatic tuberculosis (PT) is an extremely rare disease, with non-specific clinical characteristics, making the diagnosis often challenging with pancreatic cancers. Here we report a case of a 36-year-old female, who was admitted to our hospital after suffering from a 3-month history of epigastric abdominal pain, night sweats and weight loss. The physical examination was normal. The radiological findings revealed the presence of a pancreatic mass and multiple abdominal lymphadenopathy, suggestive of malignancy. The initial differential diagnosis suspected was pancreatic tuberculosis. Tuberculosis skin test was performed and was highly positive (>22 mm). Computed tomography (CT)-guided biopsy of peripancreatic lymph node was carried out and the histopathological exam confirmed the diagnosis of PT. Therefore, anti-tuberculous therapy was initiated, leading to clinical and radiological improvement. The diagnosis of PT is rare and can sometimes be misleading. It should be considered when a pancreatic mass is observed, especially in endemic countries, to ovoid unnecessary interventions.

How to Prevent Anastomotic Leak in Colorectal Surgery? A Systematic Review.

Anastomosis leakage (AL) after colorectal surgery is an embarrassing problem. It is associated with poor consequence. This review aims to summarize published evidence on prevention of AL after colorectal surgery and provide recommendations according to the Oxford Centre for Evidence-Based Medicine. We conducted bibliographic research on January 15, 2020, of PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. We retained meta-analysis, reviews, and randomized clinical trials. We concluded that mechanical bowel preparation did not reduce AL. It seems that oral antibiotic or oral antibiotic with mechanical bowel preparation could reduce the risk of AL. The surgical approach did not affect the AL rate. The low ligation of the inferior mesenteric artery could reduce the AL rate. The mechanical anastomosis is superior to handsewn anastomosis only in case of right colectomies, with similar results in rectal surgery between the 2 anastomosis techniques. In the case of right colectomies, this anastomosis could be performed intracorporeally or extracorporeally with similar outcomes. The air leak test did not reduce AL. There is no interest of external drainage in colonic surgery but drains reduced the rate of AL and rate of reoperation after low anterior resection. The transanal tube reduced the rate of AL.

Intestinal intussusception in Peutz Jeghers syndrome: A case report.

Hamartomatous polyposis is a rare cause of intussusception in adults. But this complication is the most frequent for patient with Peutz Jeghers syndrome. Small bowel screening is recommended for those patients in order to prevent emergency repetitive surgeries. We report here the case of a 20-year-old patient with confirmed Peutz Jeghers syndrome since eight years for whom a scheduled laparotomy was indicated. Asymptomatic intestinal intussusception was discovered intraoperatively. The patient was treated successfully with enterectomy and side to side anastomosis. Postoperative course was uneventful. Regular assessment as recommended for those patients is performed. Gastrointestinal intussusception in adults is rare and is often diagnosed preoperatively in a context of bowel obstruction. In the case of our patient, intussusception was diagnosed intraoperatively. This fact confirms the necessity of well-timed polypectomy in order to prevent this complication and the risk of extended resection in patients who are exposed to short gut syndrome by requiring iterative resections.

Strangled rectal prolapse in young adults: A case report.

BACKGROUND: Rectal prolapse (RP) is an uncommon perineal disease. It is defined as a complete protrusion or intussusception of the rectum through the anus. Strangulation of the RP is rare. This complication presents requires an emergent surgery. This case presentation aims to report the therapeutic management and results of this condition. OBSERVATION: A 29-year-old men, who consulted for a sudden, painful, irreducible rectal prolapse. At the anus, there was an irreducible, edematous, without signs of ischemia or necrosis rectal prolapse measuring 25*10 cm wide. The laboratory data showed a high white blood cell count and elevated C-reactive protein. After a failure of external manual reduction under general anesthesia, the patient underwent emergent surgery. The procedure consisted of a rectosigmoidectomy with coloanal anastomosis using a perineal approach according to the Altemeier technique associated to a diverting ileostomy. The postoperative follow-up was uneventful. The patient was discharged at post-operative day five. CONCLUSION: Strangulated RP is a rare complication. Altemeier procedure remains the intervention of choice in this situation.

Management of liver hydatid cyst with cystobiliary communication and acute cholangitis: a 27-year experience.

PURPOSE: The rupture of the hydatid cyst into the bile ducts is a common and serious complication. The rupture can be latent or revealed after a complication such as acute cholangitis. The objective of this study was to discuss the clinical features, radiographic findings, and surgical treatment of this rare complication. METHODS: A retrospective analysis of patients operated for acute cholangitis caused by hydatid cyst between January 1990 and May 2016 was conducted. RESULTS: Our study included 55 cases of acute cholangitis caused by ruptured hydatid cyst: 35 were men and 20 were women. Five patients had medical history of hydatid cyst. On imaging, all patients had a dilated bile duct. In 51 cases, there was a single hydatid cyst. Hydatid cysts with fistula were located in the right lobe of the liver in 49 cases and in the left lobe in 6 cases. Seven patients underwent an emergency surgery after admission, while others were operated after 3-8 days. A conservative procedure associated with drainage was applied in 49 cases. Endoscopic treatment was performed in four cases which failed in two cases. Twenty-eight cases developed postoperative complications, among which the most common complication was biliary fistula (n - 17). There were eight cases of postoperative deaths (14.5%). CONCLUSIONS: Liver hydatid cyst with cystobiliary communication and superadded acute cholangitis is a serious clinical problem requiring the early diagnosis and surgery in the absence of endoscopic therapy.

Adenosquamous carcinoma of the right colon: A case report and review of the literature.

INTRODUCTION: Adenosquamous carcinoma is a rare colorectal tumor with both an adenocarcinoma and a squamous cell carcinoma component. To the best of our knowledge, only few cases have been reported in the literature. CASE PRESENTATION: We report a case of a 46-year-old woman, hospitalized for large bowel obstruction syndrome. Computed tomography scan showed an irregular mass of the right colic angle, responsible for an occlusive syndrome with distension of the right colon, the appendix and the terminal ileum. The patient underwent right hemicolectomy with D2 lymphadenectomy. Histopathological examination revealed mixed adenocarcinoma and squamous carcinoma. Adjuvant chemotherapy was prescribed for the patient. DISCUSSION: Adenosquamous carcinoma is a rare colorectal neoplasm revealed by non-specific complaints. Its clinicopathology is not yet understood. Preoperative diagnosis is often difficult. Surgical resection remains the mainstay of treatment. CONCLUSION: Adenosquamous carcinoma is a malignant tumor with poorer prognosis than adenocacinomas.

Contribution of microRNA-149, microRNA-146a, and microRNA-196a2 SNPs in colorectal cancer risk and clinicopathological features in Tunisia.

BACKGROUND AND AIM: Colorectal cancer (CRC) is a worldwide leading cause of mortality. Genetic studies have associated single nucleotide polymorphisms in genes encoding microRNAs with CRC risk but results are mostly inconclusive across variable ethnicities. In this study, we investigated the association of hsa-mir-149 rs2292832 C/T, hsa-mir-146a rs2910164 G/C and hsa-mir-196a2 rs11614913 C/T and explored their roles in clinicopathological features of CRC progression in an Eastern Tunisian cohort. SUBJECTS AND METHODS: Three hundred thirteen subjects were enrolled in our retrospective study including 152 CRC cases and 161 controls. Genotyping was assayed by RFLP-PCR (Restriction Fragment Length Polymorphism-Polymerase Chain Reaction) method. SPSS v.18.0, R and SNP Stats online software performed statistical analysis. RESULTS: Significantly higher hsa-mir-149C/T rs2292832 minor allele frequency was associated with increased risk of CRC [p = .03; OR = 1.54 (1.08-2.19)]. In addition, significant crude associations of hsa-mir-149C/T rs2292832 polymorphism were detected under codominant, dominant and additive models of inheritance. After adjusting for covariates and performing FDR correction, these associations did not remain. No associations were detected for hsa-mir-146a G/C rs2910164 and hsa-mir-196a2 C/T rs11614913. When performing stratified analysis of clinicopathological features according to genotypes, a significant association (p = .004) was found between hsa-mir-146a G/C rs2910164 and tumour differentiation grade. Regression analysis according to CRC progression features had demonstrated a trend toward significance in overdominant model of inheritance for hsa-mir-149C/T rs2292832 with a protective effect [p = .05; OR = 0.51 (0.26-1.02)]. CONCLUSION: Hsa-mir-149C/T rs2292832 and hsa-mir-146a G/C rs2910164 may influence CRC risk in an ethnicity-dependent manner by interfering with CRC progression parameters in Tunisian cohort.

Pelvic abscess complicating sigmoid colon perforation by migrating intrauterine device: A case report and review of the literature.

INTRODUCTION: Intrauterine devices (IUDs) are commonly used as a contraceptive method. However, they may cause rare but potentially serious complications such as migration through the uterine wall and gastrointestinal perforation. PRESENTATION OF CASE: We report a case of a 26-year woman, carrying an IUD for 2 years, who presented to the emergency with pelvic pain with breakthrough bleeding. Abdominal imaging revealed the presence of two devices the first of which was located in the uterine cavity and the other in the wall of the sigmoid colon associated with a 5-centimeter pelvic collection. Intraoperatively, the IUD was found to be embedded in the wall of the sigmoid colon which was removed by wedge resection of the involved segment followed by a closure of the puncture with drainage. DISCUSSION: The Intrauterine Device (IUD) is an effective method of contraception, relatively well tolerated, reversible, inexpensive and widely used. However, it is not without risk. Indeed, serious complications can occur such as uterine perforation and migration to adjacent abdomino-pelvic structures. Our observation illustrates its rarity given the fact that this complication has been observed the first time in our department over the last ten years. CONCLUSION: The migration of IUD must be treated even in asymptomatic patients due to the risk of severe complications.

Gastroblastoma, a biphasic neoplasm of stomach: A case report.

INTRODUCTION: Gastroblastoma is a rare gastric biphasic tumor with both epithelial and mesenchymal components. To the best of our knowledge only eight cases have been reported in the English literature till date. PRESENTATION OF CASE: We report a case of a 29-year-old female, hospitalized for epigastric pain with poor general condition. An upper gastrointestinal endoscopy showed a polypoid mass in the stomach near the gastric cardia suspicious of gastrointestinal stromal tumor. The patient underwent atypical proximal gastrectomy with splenectomy. Detailed histopathological examination of the resected specimen revealed the diagnosis of gastroblastoma. After six months, the patient developed loco-regional recurrence for which surgical debulking was performed. DISCUSSION: Gastroblastoma is predominantly seen in young adults with non-specific complaints. They appear as submucosal lesion in the stomach mimicking gastrointestinal stromal tumor. Preoperative diagnosis is often difficult. Surgical resection remains the mainstay of treatment. On histology, they consist of mesenchymal component which stain positively for vimentin and CD10 and epithelial component which is positive for cytokeratin on immunohistochemistry. CONCLUSION: Gastroblastoma is a malignant tumor with risk of local recurrence after curative resection.

Adult's congenital bile duct cysts.

INTRODUCTION: Congenital bile duct cysts (CBDC) is a rare congenital malformation. It results from an anomaly of the biliopancreatic junction (AJBP). This condition is often diagnosed at a young age. Although, it can be asymptomatic and discovered only at an advanced age. The aim of our work was to describe the diagnosis, therapeutic and evolutionary aspects of BVCD through a series of 11 cases diagnosed in adult cases. METHODS: This is a descriptive, retrospective and monocentric study. It collects patients operated for CBDC between 01/08/1999 and 30/06/2009. RESULTS: The mean age was 45.3 years. Two men and nine women. The right hypochondria pain has been reported by all patients. On physical examination, jaundice was noted in five cases and the rest of the examination was normal. Biology showed cholestasis in six cases and cytolysis in four cases. Only one patient had hyperamylasaemia (five times normal). The preoperative diagnosis of a VBCD was reported in eight cases. Peroperative cholangiography (OCP) allowed to make the diagnosis and classify the CBDC according to the classification of Todani. Microscopic examination demonstrated three cases of associated gallbladder adenocarcinoma. The operative follow-up was simple for ten cases. A case of surgical recovery was necessary due to infection of necrotic pancreatitis. The mean follow-up was 40.6 months with extremes from one month to seven years. Only one case of death has been reported. No patient has presented a later biliary tract degeneration. Only one case of secondary biliary cirrhosis due to repeated attacks of angiocholitis has been reported. CONCLUSION: CBDC is rare. It must be suspected at any age. It is characterized by the increased risk of degeneration. Radiological examinations can suspect the diagnosis in younger and asymptomatic patients to ensure a well-conducted and timely surgical treatment.