Acute appendicitis in pregnant women: A Tunisian center experience.

Acute appendicitis is the most common surgical pathology during pregnancy. It occurs in about 1 in 500 to 1 in 635 pregnancies per year,[1] and appendectomy is the gold standard in the treatment approach.[2] However, its diagnosis represents a challenge to both surgeons and obstetrician-gynecologists. In addition, the role of laparoscopy remains controversial. This study discusses the diagnostic approach and reviews the appropriate surgical approach while evaluating the part of laparoscopy. This is a retrospective descriptive analysis reviewing 36 patients who underwent surgery for acute appendicitis during pregnancy at the "Surgery Department of Jendouba Hospital from January 1, 2005 to December 31, 2019. Data include age, comorbidities, previous abdominal surgery, symptoms, physical examination findings, complementary exams results, operative treatment details, the emergency status of the procedure, associated medical treatment, antibiotics and tocolysis, the pathology reports, and follow-up. The mean age of patients was 27 years. Twenty-one patients (58, 33%) were in the second trimester of pregnancy, 6 patients (16, 66 %) were in the first trimester, and 9 (25%) in the third one. The physical examination reported a right iliac fossa tenderness in 27 patients (75%). The abdominal ultrasound was performed in all cases and guided the diagnosis in 24 cases (66, 66%). 18 patients (50%) underwent laparoscopy, 12 patients (33, 33%) underwent laparotomy. The remaining 6 patients (16, 66%) required a conversion from laparoscopic to open surgery. The clinical presentation of appendicitis in pregnancy is often misguiding. Therefore, an abdominal ultrasound should be performed for all pregnant patients having abdominal pain. The difficulty of operating under laparoscopy increases with the pregnancy term, leading to a higher risk of conversion, which increases the operating time and the doses of anesthetics, causing a maternal and fetal risk.

Perforated jejunal diverticulum as an unsual cause of acute abdomen: A case report.

INTRODUCTION AND IMPORTANCE: Jejunal divertica is a rare entity with an often clinically silent course. However, it may be associated to life-threatening complications such as perforation. Therefore it should be considered in every case of acute abdomen. CASE PRESENTATION: A 60-year-old female presented with a generalized abdominal pain associated with vomiting evolving for 24 h. Physical examination found an irreducible and tender hernia in the umbilical region with abdominal guarding. Laboratory test results showed a biological inflammatory syndrome. The primary diagnosis of strangulated umbilical hernia was suspected and the patient underwent an emergency laparotomy. Intra-operative examination revealed mutiple jejunal diverticula, with a perforation in one diverticulum leading to generalized peritonitis. A bowel resection and peritoneal lavage were performed with good outcome. CLINICAL DISCUSSION: Jejunal diverticula is a challenging condition with various non-specific clinical presentations. Jejunal perforation is its most feared complication. Deceitful abdominal examination among elderly patients and lack of specific signs may lead to diagnostic delay responsible for high mortality rate and poor prognosis. Adjunctive imaging modalities may be needed to help establish a prompt diagnosis and dictate management strategy. Treatment of perforated jejunal diverticulum is based on limited bowel resection associated to primary anastomosis. CONCLUSION: Jejunal diverticulitis should be kept in mind as a differential diagnosis in every case of acute abdomen. High index of clinical suspicion and eventual further radiological examinations are required to avoid misdaignosis and save patients' lives.

The uncommon diagnosis of hiatal hernia associated pancreatitis: A case report.

INTRODUCTION AND IMPORTANCE: Hiatal hernia (HH) contents commonly include stomach, transverse colon, small intestine, and spleen but herniation of the pancreas is an extremely rare phenomenon, even rarer when HH is associated with acute pancreatitis. CASE PRESENTATION: A 56-year-old female with hypertension and gastroesophageal reflux disease presented with abdominal pain, vomiting and chest discomfort evolving for 24 h. Physical examination revealed left-upper quadrant tenderness without guarding. Blood tests showed elevated serum amylase and lipase levels. An abdominal CT scan demonstrated a large type-IV hiatal hernia involving the entire stomach, transverse and right colon, small intestine, duodenum as well as the head, body and the tail of pancreas. The pancreas was enlarged consistent with pancreatitis. Patient clinical status improved with conservative treatment. CLINICAL DISCUSSION: The stomach is the most common organ to herniate through the diaphragm and pancreatic herniation is extremely rare with only few cases in the literature. Even rarer when associated with acute pancreatitis. This diagnosis is a major diagnostic and therapeutic challenge that has to be evoked in elderly presenting with chest pain and a negative cardiopulmonary evaluation. The ideal treatment is still unclear, however, conservative treatment is the initial management and surgery may be considered in case of recurrent episodes of acute pancreatitis. CONCLUSION: HH associated with acute pancreatitis is a major diagnostic and therapeutic challenge. Clinicians should consider this rare diagnosis in every case of chest pain with negative cardiopulmonary evaluation.

Gastrointestinal perforations by ingested foreign bodies: A preoperative diagnostic flowchart-based experience. A case series report.

BACKGROUND: Gastrointestinal tract perforation is the most harmful complication of Foreign Body (FB) ingestion, besides diagnostic delay adversely affects the outcome. This paper aims to present our preoperative diagnostic flowchart and describe the surgical management in a Tunisian center. METHODS: A retrospective review of 48 patients with gastrointestinal perforation by ingested FB treated in the surgery department of Jendouba Hospital. January 2010-December 2020. RESULTS: 48 patients were treated for gastrointestinal tract perforation induced by FB ingestion. The mean age was 56.6 years. The sex ratio was 2/1. Acute abdominal pain was reported in all the patients. 35 patients had abdominal X-ray that showed a FB in 12 cases. CT scan was performed in 38 patients and identified the FB in 28 cases. Postoperative proofreading has identified a preoperative missed diagnosis of FB perforation in 5 cases, all before applying the diagnostic flowchart. All patients underwent open surgery after a median time of 7.12 h. This duration decreased after applying the flowchart (8.21 h versus 5.6 h). 33 patients had a terminal ileum perforation. Enterectomy was performed in 33 patients. Postoperatively, there was one abdominal abscess, one pulmonary embolism, one refractory septic choc, and one wound abscess. The median hospital stay was 6.35 days. The mortality rate was 6.25%. All patients managed with enterostomy had their stoma closed after 3-5 months. CONCLUSIONS: The challenge of gastrointestinal perforation due to FB ingestion is accurate diagnosis and early management. A standardized initial assessment based on a diagnostic flowchart is helpful to achieve this goal and improve outcomes.

The management of appendicular abscesses in a Tunisian Tertiary Care Hospital.

BACKGROUND: This study aims to describe the epidemiological, clinical, and radiological features of appendicular abscesses, compare the different approaches, and assess the safety and utility of laparoscopy in its management. METHODS: This descriptive retrospective study was carried out over 3 years extending from January 2017 to December 2019, reporting 150 appendicular abscesses cases. Data were collected from the register of the general surgery department B of the Rabta hospital. Cases with appendicular abscess were included. Files concerning patients with early appendicitis, non-appendicular abscesses or generalized appendicular peritonitis were excluded. Data were analysed with Statistical Package for the Social Sciences (SPSS) software. In univariate analysis, we used the chi2 test, the Fischer test, the Student t test. The factors retained by the univariate analysis were introduced into a logistic regression model. The significance level was set to 0.05. RESULTS: The mean age was 40.51 years. The gender ratio in patients with appendicular abscesses was M:F 1.94:1. Pain in the right iliac fossa associated with fever was the most common symptom (78% of cases). Clinical examination showed tenderness in the right iliac fossa in 38% of cases, rebound and guarding were found in 77 patients (51.3%), and a palpable mass was noted in 4 cases (4.2%). Imaging was done to confirm diagnosis; 46 patients underwent ultrasonogram and this confirmed the diagnosis in 26 patients (56%), while among the 71 patients who underwent CT abdomen confirmatory diagnosis was made in 65 patients (91.55%). An appendectomy was performed in 148 patients (98.6%) via laparoscopic approach in 94 patients, open Mac burney procedure in 32 cases (21.3%) and midline incision in 24 cases (16%). Two patients had an ileocecal resection. The appendix was most commonly located retrocecally (55.3%) in our cohort. The laparoscopic approach was performed in 94 patients (62.6%), and we had to convert in 44 patients due to dissection difficulties (46.8%). Among patients who underwent laparascopic approach 7 had developed peritonitis.. There were only 2 deaths. The mortality rate was 0,013%. The median duration of outpatient followup was 6 months (4-24 weeks) and was uneventful. CONCLUSION: Appendicular abscess is a disease of young adults more common in men. Location of the appendix in our case series was mostly retroceacal. Laparoscopy was associated with good outcomes; peritonitis was uncommon and mortality was rare. The laparoscopic approach is a safe surgical technique for treating appendicular abscess and it can be considered as the routine approach for this condition In developing countries with limited technical resources, laparoscopy guarantees the absence of recurrence, reduces healthcare costs and decreases the risk of treating a severe disease conservatively.

Acute intraperitoneal rupture of hydatid cysts of the liver: Case series.

ABSTRACT: Hydatid cyst is a parasitic infection caused mainly by Echinococcus granulosus, which is generally considered benign. However, the hepatic hydatid cyst rupture in the abdominal cavity is a life-threatening incident that requires urgent and multidisciplinary management (emergency physicians, radiologists, anesthetists, and surgeons). This study describes clinical and paraclinical liver hydatid cyst rupture in the peritoneal cavity and details the appropriate treatment.A retrospective review of clinical records of patients hospitalized in Jendouba Hospital for liver hydatid cyst was performed over 8 years, from January 1, 2012 to December 31, 2019. Fifteen cases of liver hydatid cyst complicated with acute rupture into the abdominal cavity were collected out of 625 hydatid liver cysts. All patients underwent emergency laparotomy allowing conservative unroofing procedure associated with peritoneal lavage and external drainage combined with necessary intensive care measures. Clinical features, therapeutic procedures' details as well as postoperative outcomes are reported. Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows version 20.There were 9 men and 6 women. Patients' age ranged from 14 to 59 years, with an average of 38 years. Two patients were admitted with abdominal trauma. Acute abdominal pain was the most common complaint. Only 1 patient had an anaphylactic shock. Abdominal ultrasonography and computed tomography scan showed discontinuous cyst wall associated to intraperitoneal fluid in all cases. Intraoperatively, the intraperitoneal effusion was clear in 13 cases and purulent in 2. All patients underwent unroofing procedures associated with intra-operative peritoneal lavage and external drainage. The mean hospital stay was 6.11 days, and the mean follow-up was 19 months. No case of recurrence was reported among the patients.In endemic areas, rupture of a hepatic hydatid cyst in the abdominal cavity should be considered in every case of acute abdominal pain, especially if associated with anaphylaxis signs. Early management starting in the emergency room is needed to ensure good outcome.

De Garengeot hernia doubly complicated: A case report.

INTRODUCTION: A strangulated De Garengeot's hernia with appendicitis is an extremely rare surgical presentation. Therefore, the diagnosis is challenging, and there are no recommendations regarding a specific surgical approach. PRESENTATION OF CASE: We present the case of a 56-year-old woman with a De Garengeot's hernia doubly complicated: strangulated and with appendicitis in the hernia sac. The diagnosis was made intraoperatively, and it was managed fully through a single inguinal incision. No postoperative complication was presented, and the patient was discharged 48 h after. DISCUSSION: The clinical presentation of this sub-type of hernia is non-specific. Precise knowledge of the hernia sac content preoperatively is not mandatory, and it should not delay prompt emergency surgery. As long as there are no local signs of complicated appendicitis, a single inguinal incision may be sufficient to perform appendectomy and hernia repair. In the event of complicated appendicitis, an exploratory of the abdominal cavity is mandatory, and hybrid approaches are recommended. For an experienced surgeon, the laparoscopic approach (TAPP), including the treatment of the two pathologies and the exploration of the peritoneal cavity, represents the surgical technique of choice. CONCLUSION: De Garengeot's strangulated hernia with appendicitis is an exceedingly rare double surgical emergency. When uncomplicated appendicitis, a single inguinal incision is sufficient to treat both appendicitis and abdominal wall defect. Hernia reduction, which young surgeons in the emergency room commonly attempt, should be abolished.

The deceitful diagnosis of gallbladder volvulus: A case report.

INTRODUCTION AND IMPORTANCE: The gallbladder volvulus is a rare but life-threatening condition characterized by an axial torsion of the gallbladder along the cystic pedicle, causing gallbladder ischemia and necrosis. This paper aims to present and discuss a rare case of gallbladder volvulus. This case report has been reported in line with the SCARE criteria 2020 [1]. CASE PRESENTATION: We report the case of a 90-year-old female patient who presented to the emergency room with sharp right upper abdominal quadrant pain of acute onset associated with vomiting, evolving for the last 12 h. She had no fever nor jaundice. Her body mass index (BMI) was 22. She had kyphosis, and scoliosis. Physical examination found tenderness with a palpable mass in the right upper abdominal quadrant. Laboratory test results showed leukocytosis at 11600 /mL and a high C-reactive protein rate at 40 mg/L revealed acute calculous cholecystitis features. However, emergency laparotomy was performed and discovered a gallbladder volvulus. A detorsion and cholecystectomy were performed with a good outcome. CLINICAL DISCUSSION: The preoperative diagnosis of gallbladder volvulus is difficult due to its misleading clinical presentation mimicking acute cholecystitis. The presence of the three highly suggestive triad clinical signs should encourage the radiologist to search for a gallbladder with a horizontal orientation and located outside its anatomical fossa connected to the liver by a conical structure corresponding to the twisted pedicle in ultrasonography. Unlike ordinary acute cholecystitis, which may sometimes tolerate an initial conservative medical treatment, gallbladder volvulus management is always an emergency cholecystectomy. CONCLUSION: Despite the clinical similarities with the classical acute calculous cholecystitis, gallbladder volvulus is more likely to result in fatal outcome. Therefore, a high level of clinical suspicion is necessary to save lives.

Gallbladder adenomyomatosis: Diagnosis and management.

INTRODUCTION: Gallbladder adenomyomatosis is a benign acquired gallbladder disease. It can mimic cancer on radiological findings, leading to a diagnostic dilemma. The management and prognosis of these two gallbladder anomalies are entirely different. Therefore, it is essential to recognize the pathognomonic features of gallbladder adenomyomatosis is in order to accurately diagnose this pathology. This paper presents two encountered cases of gallbladder adenomyomatosis is, their diagnostic modalities as well as the algorithmic approach of their management. These two-case reports have been reported in line with the SCARE Criteria 2020 [1]. PRESENTATION OF CASE: Patient-1 was symptomatic. He was explored by an abdominal ultrasound picturing gallbladder wall thickening while the biopsy showed pleomorphic proliferation of inflammatory cells. An examination of the liver with MRI was indicated, showing diffuse parietal thickening with multiple cystic pockets. He underwent laparoscopic cholecystectomy with simple operative follow-up. Patient 2 was asymptomatic, a staging CT scan of acute pancreatitis revealed focal mural thinking of the gallbladder wall. A liver MRI showed an intramural cystic formation in the vesicular fundus. Given the inconclusive imaging results, laparoscopic cholecystectomy was performed. Histological examination confirmed the diagnosis of GA. DISCUSSION: Adenomyomatosis is usually asymptomatic. Imaging can confirm the diagnosis of gallbladder adenomyomatosis without the need for invasive procedures such as vesicular biopsy. Histologic examination can also confirm the diagnosis when cholecystectomy is done. High resolution ultra-sound is the most efficient radiological examination. Laparoscopic cholecystectomy is the gold standard for symptomatic GA or radiological suspicion of a gallbladder cancer. CONCLUSION: The practitioner should always consider gallbladder carcinoma before confirming the GA, as they share the same features but with a far worse prognosis. The likelihood of malignancy depends on radiological characteristics. In the case of inconclusive findings, cholecystectomy is justified.

Phytobezoar: A train can hide another.

INTRODUCTION AND IMPORTANCE: Acute bowel obstruction is a life-threatening condition; late or incomplete management worsens the prognosis. Bezoars are a rare etiology of this disease, and the diagnosis can be confusing. This study aims to present and discuss a very rare case of concomitant bezoars. CASE PRESENTATION: We report the case of a 22-year-old male with a history of mental retardation who was admitted to the emergency department for acute intestinal obstruction with diffuse abdominal guarding. Laboratory findings revealed a biological inflammatory syndrome and an electrolyte imbalance. The abdominal X-ray was without abnormalities. Intraoperatively, a phytobezoar in the jejunum was initially discovered. However, the entire digestive tract's meticulous exploration discovered a concomitant vegetable bezoar in the stomach. CLINICAL DISCUSSION: Phytobezoar obstruction is very rare and usually located in the distal small bowel, related to the reduced intraluminal diameter, the decreased mobility, and the higher water absorption in this portion. The clinical presentation is non-specific and reflects acute intestinal obstruction in the majority of cases. The abdominal CT-scan is useful for diagnosis. However, Surgeons should not delay the intervention until they recognize the etiology preoperatively because it is not always obvious. Besides, surgeons should explore the entire gastrointestinal tract during the intervention; a second phytobezoars' location is undoubtedly exceptional but exists, as evidenced by our case. CONCLUSION: When phytobezoar obstruction, urgent care is required, and the intraoperative exploration of the entire digestive tract is a simple gesture with capital importance. It allows to prevent avoidable complications, especially a second surgery.

Primitive isolated hydatid cyst of the spleen: total splenectomy versus spleen saving surgical modalities.

BACKGROUND: This study aims to describe the clinical features of the isolated primitive splenic hydatid cyst, discuss and compare the different surgical approaches of this uncommon disease. METHODS: This is a descriptive retrospective study carried out over a period of 7 years extending from January 2013 to December 2019 reporting eight cases of isolated primitive splenic hydatid cysts. Data were collected from the register of the general surgery department of the Jendouba regional hospital. Files concerning another associated hydatid localization were excluded. Four patients underwent total splenectomy and four of them underwent different spleen preserving surgical techniques including resection of the protruding dome, partial splenectomy and pericystectomy. RESULTS: The diagnosis was incidentally made in 50% of cases. The main other revealing complaints are pain in the left upper quadrant of abdomen in 25% of cases and a painless renitent mass in the same quadrant in only 12,5%. None of patients who underwent total splenectomy had fever or sings of postoperative sepsis. Compared to those who had total splenectomy, patients who underwent spleen preserving surgery had a longer average hospital stay (9 vs 6,25 days) related to post-operative complications including abscess in the residual cavity after protruding dome resection in one patient and post-operative haemorrhage in one patient. CONCLUSIONS: The current case series argues in favor of total splenectomy, preferably by laparoscopic route whenever the technical platform allows it, associated with some specific peri-operative therapeutic measures. It seems to be the safest way that helps to avoid post-operative complications of spleen saving surgical modalities. These complications are usually difficult to manage in poor countries with limited technical resources. Total splenectomy guarantees at least a decreased hospital stay, reduced healthcare costs, and the absence of recurrence in highly endemic underdeveloped countries.

Gossypiboma: the failure of a successful intervention.

If successful surgery is the primary quest of any surgeon, unintentionally leaving behind surgical items in the operative field remains his most feared obsession. This rare but dramatic accident can lead to potentially fatal complications and turn both lives of the surgeon and the patient upside down. We present the case of a 29-year-old female patient who presented to the ER with three days history of severe diffuse abdominal pain associated with fever, biological inflammatory syndrome and well-tolerated iron deficiency anaemia. She had no past medical history except for a lower segment cesarean section 5 months ago. Abdominal MRI allowed the diagnosis of two gossypibomas responsible for two intra-abdominal collections. An emergency laparotomy allowed the removal of these foreign bodies and the management of their serious complications of intestinal perforation by the construction of a double intestinal stoma. The patient made a post-operative uneventful recovery. This observation emphasizes the need to raise the practitioner´s awareness about this differential diagnosis in every case of any poorly localized abdominal pain occurring after surgery.

Stump appendicitis: a myth that can become reality.

Stump appendicitis is a rare etiology of acute lower right quadrant abdominal pain often forgotten in the emergency room (ER). The Mac Burney scar or a previous laparoscopic appendectomy always rule out the eventuality of appendicitis and mislead management. Advanced imaging tools are more than compulsory to help correct the diagnosis. Computed tomography (CT) scan is the option of choice that may be replaced if unavailable by simple ultrasound examination. The treatment is mainly surgical. We report the case of a stump appendicitis occurring 12 years after laparoscopic appendectomy in an 18-year-old girl. The diagnosis was based on consistent clinical signs and conclusive radiological data. A successful completion appendectomy was performed with good outcome.

Pediatric Primary splenic angiosarcoma: A very rare disease.

The primary splenic angiosarcoma is a rare and aggressive tumor. Diagnose primarily in adults over 40 years. There were less than ten pediatric cases reported. A 13-year-old presented to the emergency with left upper quadrant pain. Laboratory results revealed anemia (11.3 g / dL) with normal platelets (166. 109 / L). A heterogeneous formation with a major axis of 5 cm has been identified on the scan of the abdomen. Splenectomy by a laparotomy was performed, and angiosarcoma Primary splenic was discovered. Seven months later, a scanner control showed no progressive disease, in particular, no liver metastases. She is currently alive without signs of progression. The primary splenic angiosarcoma is almost universally fatal, despite treatment. The best chance of survival is early diagnosis and splenectomy before the breaking of the spleen.