Gallbladder primary well-differentiated neuroendocrine tumor: A misdiagnosed case.

INTRODUCTION: Gallbladder (GB) Well-Differentiated (WD) Neuroendocrine Tumor (NET) are extremely rare tumors. They represent only about 0.5 % of all Neuroendocrine Neoplasms (NENs). Most GB-NETs are diagnosed after cholecystectomy. They are often misdiagnosed and have good prognosis. CASE PRESENTATION: We share our experience of a 42-year-old woman operated on for symptomatic cholelithiasis. We discover on the anatomopathological piece that it was a Grade 1 NET of the GB. Staging scans and octreotide-scans were normal: there is no distant or nodal metastasis. This tumor was classified as T1bN0M0. After multidisciplinary team discussion, additional treatment is deemed unnecessary. She didn't receive any treatment after the surgery. At one year after the cholecystectomy, she is symptom free and there is no sign of recurrence. DISCUSSION: The diagnosis of GB-WD NET is difficult at the first evaluation. Surgical management for GB cancer has shown increased survival rates, a similar strategy seems reasonable for GB-NETs. Patients with Grade,1 well-differentiated GB-NETS have an excellent prognosis overall. CONCLUSION: Research is required to facilitate earlier diagnosis and to develop management guidelines for GB-NETs.

Surgical management of giant hepatic hemangioma: A 10-year single center experience.

BACKGROUND: Hepatic hemangiomas are the most typical benign mesenchymal lesions of the liver. Most of these lesions are asymptomatic. Giant hepatic hemangiomas (GHH) (>10 cm) are often symptomatic and require surgical intervention. This study aimed to describe the clinical findings, risk factors, diagnostic approach and management of GHH. METHODS: We performed a retrospective analysis of patients with GHH treated at our hospital from January 2008 to December 2018. The medical records of each patient were reviewed to obtain the clinical and surgical data. RESULTS: Twelve patients with GHH were treated during the study period. 9 were female and 3 were male. The mean age of diagnosis was 48,2 years. The most common presenting symptom was abdominal pain. Eight patients presented an abdominal mass. Indications for surgical resections were rupture (n = 2), Kasabach-Merritt syndrome (n = 1) and abdominal pain (n = 9). Right hepatectomy was done in four patients, left lobectomy in four patients, and enucleation in four patients. Embolization was performed in 4 patients, but due to the persistence of symptoms or bleeding, surgery was indicated. The mean operative time was 3.5 h, and median blood loss was 870 ml. The median hospital stay was 5.3 days. For four patients, we registered postoperative complications causing death in one case. All alive patients were asymptomatic at a median follow-up of 55 months. CONCLUSION: Despite limitations and alternative modalities, surgery remains the only effective curative treatment for GHH.

Diverticular disease of the small bowel: a rare cause of the duodenojejunal flexure obstruction (a case report).

The small bowel is the least common site for diverticula in the entire gastrointestinal tract. Chronic upper intestinal obstruction due to diverticula is very rare. We report a case of multiple small bowel diverticula causing mechanical obstruction of the duodenojejunal flexure.

[Left paraduodenal hernia: a rare cause of acute intestinal obstruction]. / Hernie para duodénale gauche: une cause rare d'occlusion intestinale aiguë.

Left paraduodenal hernia is a congenital internal hernia rarely complicated by acute intestinal occlusion and resulting, sometimes, in life-threatening loops ischemia. We report the case of a 28-year old man treated for occlusive syndrome. Abdominal computerized tomography (CT) scan objectified acute upper intestinal obstruction; intraoperative exploration found jejunal loops incarcerated into left paraduodenal hernia. The neck was closed and the operative suites were simple. Left paraduodenal hernia is often diagnosed when patients have complications. Surgery is the treatment of choice, in particular laparoscopy.

Isolated hepatic tuberculosis presenting as hydatid cyst.

Primary hepatic tuberculosis is a rare manifestation of extra-pulmonary tuberculosis even in highly endemic countries. The incidence of hepatic tuberculosis has increased in the recent years due to high prevalence of HIV/AIDS. Radiological imaging is an important tool for making the diagnosis, but often the imaging findings are non-specific and may mimic other benign or malignant hepatic diseases. We report a case of 54-year-old woman who was detected to have hepatic mass on radiological imaging which was misdiagnosed as hydatid cyst. Intraoperatively, the characteristic features of hydatid cyst were absent. A partial resection of this cystic mass was performed. Histopathological examination of the resected specimen revealed granulomatous inflammation consisting of histiocytes and Langhans-type giant cells surrounded by lymphocytes suggestive of hepatic tuberculosis. The patient was administered antitubercular therapy for 1 year. Repeat imaging on follow up showed disappearance of the hepatic lesion.

Factors predicting recurrence after curative resection for rectal cancer: a 16-year study.

BACKGROUND: The recurrence after curative surgery of the rectal adenocarcinoma is a serious complication, considered as a failure of the therapeutic strategy. The aim of this study was to identify the different prognostic factors affecting the recurrence of adenocarcinoma of the rectum. METHODS: A retrospective analysis of patients operated for adenocarcinoma of the rectum between January 2000 and December 2015 was conducted. The study of the recurrence rate and prognostic factors was performed through the Kaplan Meier survival curve and the Cox regression analysis. RESULTS: During the study period, 188 patients underwent curative surgery for rectal adenocarcinoma, among which 53 had a recurrence. The recurrence rate was 44.6% at 5 years. The multivariate analysis identified four parameters independently associated with the risk of recurrence after curative surgery: a distal margin ≤ 2 cm (HR = 6.8, 95% CI 2.7-16.6, 6), extracapsular invasion of lymph node metastasis (HR = 4.4, 95% CI 1.3-14), tumor stenosis (HR = 4.3, 95% CI 1.2-15.2), and parietal invasion (pT3/T4 disease) (HR = 3, 95% CI 1.1-9.4). CONCLUSION: The determination of the prognostic factors affecting the recurrence of rectal adenocarcinoma after curative surgery allows us to define the high-risk patients for recurrence. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03899870 . Registered on 2 February 2019, retrospectively registered.

Appendicular endometriosis: A case report and review of literature.

INTRODUCTION: Patients with appendicular endometriosis (AE) constitute <1% cases of all pelvic endometriosis cases. AE presents with pain in right iliac fossa and symptomatically mimics appendicitis and definitive diagnosis is possible only after histopathological examination of excised appendix. PRESENTATION OF CASE: In this case report, we present a rare case of appendicular endometriosis in a young woman suffering from pain in right iliac fossa and periumbilical region (on/off) for the past one year. She had a past history of infertility. Blood investigations were normal and CT scan of abdomen demonstrated findings suggestive of appendicitis. Laparoscopic appendicectomy was performed, which revealed 2 cm tumor-like mass (1.5 cm diameter) present at the tip of appendix involving the mesoappendix. There was no ascites, peritoneal or omental deposits or any signs of inflammation. Post-operative recovery was good. Dissected appendix specimen was sent for histopathological examination which confirmed endometriosis of appendix. DISCUSSION: Gastrointestinal endometriosis (GE) accounts for 3-37% of all endometriosis cases, whereas AE is present in only ∼3% of all GE cases and constitutes <1% of all the endometriosis cases. AE frequently involves tip and body of the appendix. The layers of appendix most commonly affected are muscular and seromuscular (∼2/3rd cases), followed by the serosa (∼1/3rd cases). CONCLUSION: Thus, appendicular endometriosis is a rare entity and should be included in differential diagnosis in young women presenting with pain in right iliac fossa and having history of infertility.

Gallbladder volvulus: A case report and review of the literature.

INTRODUCTION: Gallbladder volvulus (GV) is a rare disease with less than 400 cases reported in the English literature. The pre-operative diagnosis of GV is difficult as none of the imaging modalities are accurate. Once diagnosed, the mainstay of treatment is emergency surgical derotation and cholecystectomy. PRESENTATION OF CASE: A 83-old lady presented with right upper quadrant pain and fever for 3 days. Abdominal imaging revealed the presence of a distended, floating gallbladder located outside its normal fossa with thickened non-enhancing wall and a twisted pedicle suggestive GV. The patient underwent emergency laparotomy because the laparoscopic approach was refused by the anesthetist due to the history of pulmonary emphysema. Intraoperatively, the gallbladder was found be gangrenous and rotated in anti-clockwise direction around the cystic pedicle. The gallbladder was de-rotated followed by cholecystectomy. DISCUSSION: GV is an uncommon cause for abdominal pain and occurs due to rotation of gall bladder on its mesentery along the axis of the cystic duct and the cystic artery. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging. This case is one of the rare cases diagnosed with pre-operative imaging. It is often misdiagnosed as acute cholecystitis before surgery. However, critical constellation of presenting signs and symptoms along with radiological findings may guide the surgeon to accurate and timely diagnosis of GV before surgical intervention. CONCLUSION: Although rare, it is important to consider GV as a differential diagnosis in an elderly patient with acute cholecystitis.

Idiopathic segmental infarction of the omentum mimicking acute appendicitis: A case report.

INTRODUCTION: Omentum is a well vascularized organ. Omentum infarction is uncommon. Most of the cases are secondary due to torsion, intra-abdominal infections and vascular thrombosis. Primary idiopathic segmental omental infarction is rare. PRESENTATION OF CASE: A 26-year-old male presented with acute onset right iliac fossa pain mimicking acute appendicitis. On radiological imaging, early acute appendicitis was suspected. On diagnostic laparoscopy, appendix appeared normal and there was idiopathic infarction of a part of the greater omentum lying close to the cecum. Patient underwent laparoscopic appendectomy with excision of the diseased segment of the omentum and had uneventful recovery. CONCLUSION: Idiopathic omental infarction should be included in the differential diagnoses while treating patient with acute abdomen.

Isolated Roux loop pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: A case-control study.

OBJECTIVES: The aim of this study was to compare the postoperative outcomes of isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD). METHODS: Data of patients who underwent IPJ were compared with those of a pair-matched equal number of patients undergoing CPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality. RESULTS: Seventy patients treated by PD (35 patients in each group) were included in the study. The two groups were comparable with regards to the pre-operative and intra-operative parameters. Postoperative pancreatic fistula developed in 10 out of 35 patients in the CPJ group and 3 out of 35 patients in the IPJ group (p = 0.031). Nine CPJ patients and one IPJ patient had POPF of type B or C (p = 0.006). Re-laparotomy was significantly more frequent in the CPJ group (11.1% versus 34.6%; p = 0.04). Time to resumption of oral feeding was shorter in the IPJ group (p = 0.001). CONCLUSIONS: The use of IPJ is associated with decrease in the rate of postoperative PF in patients undergoing PD. In addition, patients with IPJ reconstruction have lesser need for re-laparotomy and early resumption of oral feeding.

Large bronchogenic cyst of stomach: A case report.

INTRODUCTION: Bronchogenic cysts are congenital cysts arising as an abnormal budding from primitive tracheobronchial tree. They are lined by pseudostratified columnar or cuboidal ciliated epithelium and contain smooth muscle fibers, submucosal bronchial glands and/or cartilage. They are most frequently located in the mediastinum or the lung parenchyma. Intramural occurrence of bronchogenic cyst in the gastric wall is very rare. PRESENTATION OF CASE: We present a case of 65-year-old lady with a 7×8cm lesion in the gastric cardia suspicious of gastrointestinal stromal tumor. Because of the large size, total gastrectomy with Roux-en-Y esophagojejunal anastomosis was performed. The postoperative course was uneventful. Histopathological examination revealed a sub-mucosal cyst lined by PCCE with presence of smooth muscle fibers and focal mucous glands. Final diagnosis of bronchogenic cyst was made. On the last follow up at one year, she was symptom free. DISCUSSION: On extensive Medline/Pubmed search, only 38 cases of gastric bronchogenic cysts were found to be reported till date. They are typically located in the posterior gastric wall close to the gastric cardia. On radiological imaging, they appear as well defined intramural cystic lesion without any characteristic features. Surgical resection is considered in symptomatic cases or in case of diagnostic dilemma. CONCLUSION: Gastric bronchogenic cysts often mimic gastrointestinal stromal tumor on preoperative imaging. They should be included in the differential diagnosis while dealing with an intramural gastric lesion close to the cardia or gastroesophageal junction.

Wide local excision for anal GIST: A case report and review of literature.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are tumors of mesenchymal origin commonly detected in stomach and small bowel. GIST arising primarily from the anal canal is extremely rare. Due to the malignant potential, these tumors are treated with radical surgery like abdominoperineal resection. But with the advent of imatinib therapy and a better understanding of the tumor biology, some cases have been successfully treated with wide local excision. PRESENTATION OF CASE: We describe a case of a 70-year-old lady presenting with a 2cm mass in the anal canal. Endoanal ultrasound revealed a well-circumscribed solid nodule in the intersphincteric space. The patient was successfully treated by wide local excision and adjuvant therapy with imatinib mesylate. DISCUSSION: Only 14 confirmed cases of primary anal GIST have been reported in the literature. It appears as a well circumscribed hypoechoic mass arising from the intersphincteric space encroaching into the lumen on endorectal ultrasound. Lymphadenopathy is absent. Anal sphincters get involved as the lesion increases in size. Treatment is often planned based on the extent of the disease, the mitotic rate, patient's general condition and willingness for a permanent colostomy. CONCLUSION: Small lesions (<2cm) with low mitotic rate may be successfully managed by local excision. Radical surgery should be reserved for large, aggressive tumors.

Gastrointestinal stromal tumor of the pancreas: A case report and review of the literature.

CONTEXT: Primary stromal tumors of the pancreas are extremely rare. Only four cases have been reported in the literature. We describe a new case and analyze, through a review of the literature, the clinical and pathological data, and the outcome of the previously reported cases. CASE REPORT: We report the case of a 52-year-old-woman who presented with epigastric pain. Preoperatively, abdominal pelvic computed tomography revealed a pancreatic head mass. The surgery confirmed the presence of a large tumor of the pancreatic head. Pathologic results revealed a malignant gastrointestinal stromal tumor of the pancreatic head, completely removed. There is no recurrence or metastases 10 months after surgery. CONCLUSION: The current case consolidates the possibility that this rare tumor can involve the pancreas as a primary site and that GIST of primary pancreatic localization are usually of high risk of malignancy.