Median arcuate ligament syndrome (Dunbar syndrome): A diagnosis not to be underestimated.

Medial arcuate ligament syndrome (MALS) is an anatomoclinical entity underestimated in most situations due to the lack of specific signs. However, the consequences can be disastrous if the diagnosis is not seriously considered and investigations are not fully undertaken to confirm this hypothesis. We report a case of Median Arcuate Ligament Syndrome in a young woman who presented to the Emergency Department with moderate postprandial pain. All investigations were carried out promptly, with no abnormalities, and the diagnosis was retained on the evidence of a well-performed and appropriately interpreted abdominal CT. This case illustrates a rare cause of epigastralgia simulating a surgical emergency. This condition should be considered when biological and often radiological investigations are inconclusive. The relative youth of the patient is often suggestive, but confirmation is based on a CT scan with injection of a well-technical contrast product, or angiography. Treatment is debatable between a conservative approach and surgery. Surgical approach is discussed depending on the degree of vascular stenosis and the impact on the digestive tract. However, the recurrence of symptoms may be a contributory factor in the therapeutic decision. The impact could be lethal depending on the degree of stenosis and consequently on the repercussions on the digestive tract. A multidisciplinary approach is required for its management.

An unusual etiology of acute intestinal occlusion: The swallowed missing dentures a case reports and literature review.

INTRODUCTION: Denture swallowing is an uncommon incident. However, it should be suspected in edentulous elderly patients who wear removable dentures which are poorly cared for and maintain. The existence of neuro-psychiatric disorders may contribute to the occurrence of this adverse event. CASE PRESENTATION: We report the case of an 85-years-old woman admitted to emergency with acute intestinal occlusion. The investigations concluded that the bowel was obstructed by a foreign body blocked in the terminal ileum. There was a high suspicion that his dental prosthesis had been swallowed. Removal of the dental prosthesis was achieved surgically after laparotomy. DISCUSSION: Foreign bodies in the esophagus could be responsible of a variety of symptoms, including dysphagia, airway obstruction and even perforation. In the gastrointestinal tract foreign bodies may be responsible of fewer specific symptoms, including abdominal pain, melena or perforation. The blockage will occur in anatomical strictures. At the most appropriate situations, removal should be performed through endoscopy, although in case of failure of procedure or complication, surgery will be unavoidable. CONCLUSION: Ingestion of a dental or other foreign object is a clinical condition that is more common in pediatric populations, but is very rare in healthy individuals. Denture swallowing is insidious in itself and may lead to a complicated course, if not properly managed. Although most of these can be conservative, careful monitoring is necessary to avoid such adverse event.

Acute intestinal obstruction: What if it is instead colonic tuberculosis? What diagnostic and management dilemmas are there?

INTRODUCTION AND IMPORTANCE: Colonic tuberculosis is rare. Clinical, biologic endoscopic and radiological features are not unequivocal. A multitude of differential diagnoses interfere, including Crohn's disease and cancer. CASE PRESENTATION: we present a case of a 48-year-old Tunisian female who complained from occlusive syndrome. For whom none of the various elements of the medical record, the clinical, endoscopic and radiological investigations had enabled a decision to be reached in favor of one diagnosis over the other. Several diagnoses were suggested, including Crohn's disease, neoplastic diseases and, ultimately, colonic tuberculosis, since our country was endemic for this pathology. The collegial decision of the medical staff involved in the management was to operate on the patient. Surgery was required with the intention to treat and mainly to provide histological proof of the disease. A right colectomy allowed histological examination and a diagnosis of colonic tuberculosis. DISCUSSION: The diagnosis should be discussed in patient from endemic countries, who complain chronic abdominal pain, vesperal fever and weight loss for who endoscopy shows the presence of nodules or ulcers. The diagnosis is retained on the basis of pathological findings. CONCLUSIONS: Because of a nonspecific clinical and endoscopic presentations, multiples biopsies even surgical resection are mandatory to rule out differential diagnosis and to confirm the diagnoses of colonic tuberculosis.

Management of pheochromocytoma during pregnancy. A multidisciplinary challenge: A case reports.

INTRODUCTION: Identification of pheochromocytoma during pregnancy is unusual. Lack of appropriate management may be responsible of high risk for both mother and fetus. The guarantee of a successful management of a pheochromocytoma during pregnancy is the establishment of an early diagnosis as well as the prevention of a hypertensive crisis during delivery and surgical treatment and without compromising the maternal-fetal prognosis. CASE PRESENTATION: A 31-year-old female patient, without any notable pathological history, pregnant at 20 weeks of amenorrhea was diagnosed for a Menard's triad. The medical investigations had allowed to confirm the diagnosis of left secretory pheochromocytoma. The surgical indication was taken in concertation between surgeons, endocrinologists, gynecologists and anesthesiologists. The parturient had undergone an uneventful laparoscopic left adrenalectomy without incidents. CASE DISCUSSION: Our case well illustrates that when the operative indication is posed, laparoscopic surgery can be performed safely during any trimester. However, it is legitimate to modulate the incisions according to gestational age and the height of the fundus. The involvement of all disciplines intervening in the management of the pregnant woman with pheochromocytoma is the guarantor of a favorable maternal-fetal prognosis. CONCLUSION: A well-established diagnosis for pregnant women with severe secondary hypertension, multidisciplinary management, and safe laparoscopic approach are crucial to prevent perinatal morbidity and mortality.

Gas spread following endoscopic sphincterotomy: Challenging diagnosis and management: A case reports.

INTRODUCTION AND IMPORTANCE: Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum simultaneously are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP) that usually indicates free perforation to the peritoneal cavity or the retroperitoneal space. CASE PRESENTATION: We report an unusual case of a subcutaneous emphysema, pneumomediastinum and pneumoperitoneum following an ERCP for removal of a common bile duct stone. There was no radiological evidence of peritoneal or retroperitoneal perforation. CLINICAL DISCUSSION: This complication seems to be relative to duodenal perforation. However, hypotheses of transdiaphragmatic pressure effects and gas diffusion within the mucosa are discussed in the literature pneumomediastinum and pneumoperitoneum, must be recognized, because it is benign and needs exceptionally surgical or radiological intervention. Management of this adverse event depends on type of perforation and clinical presentation. CONCLUSION: ERCP has facilitated innovative diagnosis and treatment of pancreatobiliary tract diseases. Nevertheless, some complications may occur such gas diffusion in the peritoneal cavity or the retroperitoneal space with or without perforation. Our case our case illustrates such incidents could be benign, self-limited and need no intervention.

Extensive small bowel necrosis due to congenital para duodenal hernia: A diagnostic and therapeutic challenge: Case Report.

INTRODUCTION: A paraduodenal hernia is a rare variety of hernia, however it is the most usual type of internal hernias. Clinical presentation is nonspecific. The clinical presentation is variable: indeed, the patient can be completely asymptomatic or present with symptoms which severity is variable according to the mechanism. The most common cause is an acute intestinal occlusion that could progress even to ischemia and intestinal necrosis. Depending on the clinical presentation and the suspected diagnosis, computed tomography can be of considerable help in demonstrating a para duodenal hernia. CASE PRESENTATION: We describe the case of a young man aged 18 years, who presented to the emergency unit with severe abdominal pain associated with incoercible vomiting. The surgical exploration had confirmed a para duodenal hernia responsible for an extensive necrosis of the small intestine allowing viable 90 cm only. CASE DISCUSSION: Paraduodenal hernias are rare and their diagnosis is not always easy. Therefore, they should be considered especially in the case of an occlusive syndrome occurring in a young patient who has never been operated on. If no treatment is undertaken, the evolution is drastic and the mortality rate is significant. CONCLUSION: Successful surgical management requires knowledge of the intra-abdominal peritoneal spaces and management of suggestive clinical situations in order to reduce postoperative morbidity and mortality resulting from delayed diagnosis and treatment.

Recurrent caecal volvulus in an adult: Should we practice coecopexy systematically at neonatal age for incomplete common mesentery? A case report.

INTRODUCTION AND IMPORTANCE: Malrotation is usually revealed early in infancy and or later in childhood, even more unusually in adulthood. This disorder is treated through Ladd's procedure. Literature is limited on the long-term outcomes of this approach, especially into adulthood. CASE PRESENTATION: We present a case of a 33 years male with a history of a laparotomy as a new born for a bowel obstruction secondary to malrotation, presenting with an obstruction and colonic volvulus. Laparotomy reveals a volvulus of the coecum secondary to a failure of the coecum to attach during surgery performed at neonatal age. CLINICAL DISCUSSION: For a patient operated on during the neonatal period for intestinal malrotation, the examination for sub occlusive episodes should suggest a recurrence of malrotation such as coecal volvulus, and the possibility of technical malfunction during the previous procedure. This reflection leads us to consider the necessity of performing coecopexy systematically during the first surgery. CONCLUSION: Ladd's technique is the surgical treatment of the incomplete common mesentery. The fixation of the coecum could be done in a systematic way to prevent a possible coecal volvulus which can be responsible for digestive necrosis and often even a fulminant evolution.

An epigastric mass? And what if it was an intra-abdominal esophageal duplication cyst: Case report.

INTRODUCTION AND IMPORTANCE: Duplication of the alimentary tract are uncommon congenital malformations that may be found anywhere from mouth to anus. Esophageal cystic duplication is a congenital cystic malformation of the alimentary tract consisting of a duplication of the segment of the esophagus to which it is adjacent. CASE PRESENTATION: We report the case of a 29-year-old female who had complained of intermittent epigastric pain and post prandial nausea for several weeks. Physical examination was without particularity except for the presence of abdominal epigastric mass. Transabdominal sonography combined with CT scan showed an epigastric cyst with no topographic relation to the pancreas measuring about 80 mm in diameter. Because of persistence of the epigastric pain and the nausea we decided to operate the patient. Histological exam than showed that the cystic mass was in fact an esophageal cystic duplication with no histological signs of malignancy. CLINICAL DISCUSSION: Here we describe a case of intra-abdominal esophageal duplication cyst in adult patient. Most of duplications cause symptoms in infancy or early childhood. Digestive duplication revealed at adulthood is a condition considered rare. CONCLUSION: Esophageal duplication cysts are uncommon developmental lesions arising from the primitive foregut, when diagnosed or encountered incidentally. The diagnosis of this anomaly in adulthood is exceptional and requires surgery.

Surgical management of benign noninfected urachal cysts in adult patients: two case reports.

BACKGROUND: Abnormalities of the urachus include the patent urachus, cysts, sinus, and fistula. Each of these entities represents a failure of complete obliteration of the urachus. Contrary to other urachus anomalies, urachal cysts are usually small and silent unless they are infected. The diagnosis is often made during childhood. A benign noninfected urachal cyst discovered in adulthood is a rare condition. CASE PRESENTATION: Herein we report two cases of benign noninfected urachal cysts in adults. The first case is a 26-year-old Tunisian white man who presented with complaints of clear fluid draining from the base of the umbilicus evolving for a week, with no other associated symptoms. The other case was 27-year-old Tunisian white woman who was referred to the surgery department with a history of intermittent draining of clear fluid from the umbilicus. The two cases had laparoscopic resection of urachus cysts. DISCUSSION: Laparoscopy represents a good alternative for the management of persistent or infected urachus, especially when this is suspected, despite a lack of radiological evidence. Laparoscopy in the management of urachal cysts is safe, effective, and offers good cosmesis, with all the advantages of a minimally invasive approach. CONCLUSION: Managing persistent and symptomatic urachal anomalies requires a wide surgical excision. Such intervention is recommended to prevent symptom recurrence and complications, most notably malignant degeneration. A laparoscopic approach offers excellent outcomes, and is recommended to treat these abnormalities.

Closed loop small bowel obstruction due to small intestine volvulus associated with early adhesion after laparoscopic appendectomy: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Nowadays the majority of appendectomies are undertaken laparoscopically. The associated per and postoperative complications are well established and known. However, some rare postoperative complications continue to be reported such as small bowel volvulus. CASE PRESENTATION: We report the case of 44-year-old women who developed a small bowel obstruction from acute small bowel volvulus due to early postoperative flanges five days after a laparoscopic appendectomy. CLINICAL DISCUSSION: Laparoscopy is associated with less adherences and morbidity however we must be careful in post operative course. Mechanical obstruction can happen even with laparoscopy procedure. CONCLUSION: Occlusion earlier after surgery even with laparoscopy procedure must be explored. Volvulus can be incriminated.

East-central Tunisian patients with colorectal adenocarcinoma: a comparative study of the clinicopathological features between patients under 50 years of age and older patients.

INTRODUCTION: Colorectal cancer is a major public health problem. In younger patients, its incidence continues to rise and its prognosis appears to be worse. Its treatment is based on curative surgery associated with neo-adjuvant and adjuvant therapies. AIM: To describe the clinical and pathological characteristics of colorectal cancers in young patients. METHODS: In this monocentric cohort study, we retrospectively analyzed the clinicopathological features in colorectal cancer patients who underwent treatment from 2002 to 2014. Data of younger (group A, ≤50years) vs older (group B, >50years) patients were compared. RESULTS: Two hundred and sixty-six patients met inclusion and non-inclusion criteria. The younger and older groups consisted respectively of 25.2% and 74.8% of patients. Both groups were comparable regarding the symptom presentation and duration. Synchronous tumors were more frequent amongst the group A (10.7% vs 1.0%, p = 0.024). Preoperative staging showed a higher frequency of tumors classified as advanced stage (stages III and IV) in the group A (p = 0.001). The patients of group A were diagnosed with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas (13.4% vs 3.5%, p = 0.005), the mucinous character was also more frequent in the group A (28.4%). According to the pTNM (tumor, nodes and metastases) classification, tumors were more advanced in the group A than in group B (80.6% vs 48.7%, p <0.001). CONCLUSION: This study revealed that colorectal adenocarcinomas in the younger patients, compared to the older ones, were more aggressive with a higher proportion of poorly differentiated or undifferentiated adenocarcinomas, more often mucin production and more advanced tumors.