Encapsulating sclerosing peritonitis : two rare observations and literature review.

Sclerosing encapsulating peritonitis (SEP) is a rare and little known pathological entity. It is a chronic fibro-inflammatory disease of the peritoneum, resulting in the formation of a thick fibrous membrane, which engages partially or totally the abdominal organs. Clinical and radiological signs make the diagnosis difficult to establish preoperatively. We present two original observations of SEP illustrating different clinical presentations, diagnostic and therapeutic means. His diagnosis requires a peritoneal biopsy. The treatment is not completely established. Surgical treatment is difficult, involving viscerolysis and multiple incisions of the fibrous membrane. Despite the current progress in therapeutic management, the prognosis remains pejorative, with significant mortality.

Fistulizing nodular lymphoid hyperplasia.

BACKGROUND: Nodular lymphoid hyperplasia (NLH) of the gastrointestinal (GI) tract is a rare condition in adults. It is usually asymptomatic. Few complications have been described. AIM:   We report an unusual clinical presentation of focal lymphoid hyperplasia of the GI. CASE REPORT: A 23-year-old female patient presented with a fistulizingdisease of the terminal ileum and the caecum complicated with an abscess of the lower right quadrant if the abdomen. CT-guided drainage with antibiotic therapy failed to control the abscess. Thus, surgery was undertaken and ileocaecal resection was performed. Focal lymphoid hyperplasia was confirmed by the pathology of the specimen. CONCLUSIONS: NLH is an uncommon condition in adults. To the best of our knowledge, no previous cases have been reported with fistulizing NLH. The management should follow the same algorithm as fistulizing ileitis. Surgery is indicated only in cases of complicated disease after the failure of medical treatment.

Laparoscopic treatment of a cephalic pancreatic leiomyoma.

BACKGROUND: Leiomyoma of the pancreas is very rare. Symptoms and signs are not specific. It has the clinical presentation of a pancreatic mass. The preoperative clinical and radiological assessments are fundamental to establish a therapeutic schema. The curative treatment is surgical resection. A methodical histological examination is required to confirm the final diagnosis of Leiomyoma. CASE REPORT: A 52-year-old female patient presented with a mass of the head of the pancreas. After preoperative assessment, the patient had laparoscopic enucleation. Postoperative course was no remarkable for complications. Pathology examination concluded to leiomyoma. CONCLUSION: Preoperative diagnosis of pancreatic leiomyoma is difficult. It has the features of a pancreatic mass. The preoperative assessment aims to identify signs of malignancy. In its absence, laparoscopy is feasible and safe. Enucleation, if indicated, is a surgical option for a benign disease sparing the patient a pancreatic resection.

Anal imperforation in adults: Diagnostic difficulties and therapeutic options.

Anorectal malformations are congenital anomalies ranging from simple perineal fistulas to complex malformations. They are usually treated inchildhood, and exceptionally in adult. We herein report the case of a 22 years aged patient and relate the diagnosis difficulties and therapeuticoptions. She consulted for anal imperforation discovered since birth. Initially, His parents refused the surgical management. It was an analimperforation with a vestibular fistula. The patient was operated by a low approach. She had a disconnection of the recto-vestibular fistula,dissection of the anal canal and a perineal posterior transposition. Postoperative course was uneventful. The evaluation of continence usingKelly's score found good Functional result.

Laparoscopic ileo-cecal resection: the total retro-mesenteric approach.

BACKGROUND: Ileo-cecal resection is the most performed procedure in Cohn's disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn's disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach. METHOD: The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt's fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis. RESULTS: This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn's disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %. CONCLUSION: We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn's disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.

Laparoscopic resection of gastric stromal tumors.

Gastro-intestinal stromal tumors (GIST) are the most common mesenchymal gastrointestinal tumors. The Gastric location represents 60% of cases [1,2]. Complete surgical excision remains the treatment of reference for the localized forms. This surgery can be made by laparoscopy when the lesion's size doesn't exceed 5 cm. Some principles must e respected: a mono-block complete surgical resection, with healthy margins and without effraction. This technique will be reserved for trained teams and for selected cases according to the size and location. We herein try to explain the surgical laparoscopic excision of gastric stromal tumors explaining .

Predictive factors of Gastrointestinal motility Dysfunction after gastrojejunostomy for peptic ulcer stenosis.

BACKGROUND: Despite the establishment of effective medical therapies in peptic ulcer disease, gastric outlet obstruction remains one of the most common health problem in Tunisia. Various operations have been attempted, which may lead to postoperative morbidity. Gastrointestinal (GI) motility dysfunction is the most common complications. AIM: to determine the predictive factor of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis. METHODS: We carried out a retrospective study to evaluate the postoperative recovery of the motility of the upper gastrointestinal tract after gastrojejunostomy for peptic ulcer stenosis. During the 9- year study, 138 patients underwent operations for ulcer peptic stenosis. Among the patients, 116 (84,1%) were treated with gastrojejunostomy. Descriptive statistics, univariate and multivariate analyses were performed. RESULTS: The mean age of patients was 47.85 years (range: 19- 92years) and most. Were male (84, 5 %). Ninety two (79.3%) patients had a documented history of peptic ulcer disease. The duration of symptoms ranged from 10 to 372 days (mean: 135.86 days). Eighty two (71%) patients were operated on through laparotomy. Laparoscopic procedure was performed in 29% of the patients. There was no operative mortality. Perioperative morbidity occurred in 12.4% (14 patients). Gastrointestinal motility dysfunction occurred in 12 patients (10.3%). It was treated by nasogastric aspiration and prokinetics. By univariate analysis; diabetes (0,010), cachexia (0,049), ASA class (0.05) were all statistically associated with gastrointestinal motility dysfunction in this series. Multivariate logistic regression analysis (table 2) showed that the cachexia (0,009), ASA class (0.02) were the main predictors of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis in the followed patients. CONCLUSION: Gastrointestinal motility dysfunction is the most common complications after gastrojejunostomy for pyloric adult stenosis. Surgery must be preceded by careful medical preparation. It is more likely to occur in patients with an ASA class 2 or greater. Those patients should be considered for other treatment options, such as endoscopic balloon dilation.

Inferior vena cava resection for a leiomyosarcoma: A case report.

INTRODUCTION AND IMPORTANCE: Leiomyosarcomas of the inferior vena cava are scarce. Surgery is the only potential curative treatment. Such a surgery is complex and technically demanding, requiring a huge experience in both visceral and vascular surgery. Indeed, enlarged visceral resection may be needed to achieve a free tumor margins as the tumor may invade the duodenum, the head of the pancreas and the liver. Moreover, vascular reconstruction is mandatory which might be complex as both venal reins are usually invaded by the tumor like in our case below. CASE PRESENTATION: A 53-year-old woman presented with abdominal vague pain. Imaging consisting in abdominal CT-scan with contrast and magnetic resonance angiography were suggestive of the diagnosis of leiomyosarcoma of the inferior vena cava. A surgical complete resection with free margins was conducted. A primary repair of the inferior vena cava and the right renal vein walls. End-to-side anastomosis with a polytetrafluorethylene (PTFE) prosthesis was mandatory to reconstruct the renal left vein to the inferior vena cava. Postoperative outcomes were uneventful. Pathology examination confirmed the diagnosis. DISCUSSION: The optimal management of leiomyosarcoma of inferior vena cava is controversial. Surgery remains the cornerstone of treatment. However, not all patients are qualified for surgical resection. The prognosis depends on the early diagnosis and histology type. CONCLUSION: The management of leiomyosarcomas of inferior vena cava requires a multidisciplinary consensus involving experienced surgery and oncology teams.

Prognostic factors in gastric carcinoma after R0 resection with DII lymph node dissection. Tunisian experience.

BACKGROUND: Curative resection with adequate lymph node dissection is the treatment of choice for gastric cancer. AIM: To determine the prognostic factors after R0 resection with DII lymph node dissection. METHODS: We retrospectively assessed 126 patients who underwent R0 resection with DII lymph node dissection for gastric cancer (excluding the upper third of the stomach) in a single institution between 1991 and 2006 with median follow-up of 38.5 months (6 - 219). Prognostic factors were assessed by Cox proportional hazard model. RESULTS: There were 45 women and 81 men. The median age was 60 years (21 - 87). Four patients died (3.2 %). Postoperative hospital morbidity was 16.7 %. The pathologic review of the slides revealed that 50% of the tumors were stage T3 (63 cases). The median number of lymph node removed was 11 (8-40), 50% were involved. Five and 10 years survival rates were respectively 56.9 % and 40.2 %. In multivariable analysis, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were found to be independent prognosis factors. CONCLUSION: After R0 resection with DII lymphadenectomy, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were independent predictive factors for survival.

[The Caroli's disease. Report of 16 cases]. / La maladie de caroli. A propos de 16 cas.

BACKGROUND: Caroli's disease is a congenital dilatation of the intrahepatic biliary duct. AIM: To analyse and discuss diagnostic and therapeutics difficulties through 16 patients with Caroli's disease. METHODS: Between January 1990 and September 2010, 16 patients underwent surgical procedure for Caroli's disease. Data recorded for each patient included clinical symptoms, biologic findings, previous biliary procedures, and the presenting symptoms. The distribution of the biliary lesions, the surgical procedure and the postoperative outcomes and follow up were detailed. RESULTS: The mean age was 55 years. The mean interval between the first symptoms and diagnosis was 27 months. Five of 16 patients had undergone 12 surgical or endoscopic procedures prior to liver resection. Before the definitive diagnosis, 9 patients presented 15 episodes of acute cholangitis. The diagnosis was established preoperatively in 13 cases, 5 among them underwent previous biliary surgical procedures. The diagnosis was documented peroperatively in 2 cases and postoperatively in 1 case. The distribution of the biliary lesions was monolobar in 13 and bilobar in 3 patients. 13 patients underwent liver resection, in two cases we perfomed biliojejunostomy and the last one had endoscopic sphincterotomy. There was no mortality and the overall postoperative morbidity is about 43%. The follow-up shows that 12 patients still alive with a mean follow up for 53 months, from whom only one patient have intrahépepatic lithiasis. CONCLUSION: The clinical course of Caroli's disease is often complicated by recurrent episodes of angiocholitis and requires iterative surgery. The hepatectomy witch prevented septic complications and degenerescence is possible only in a restricted number of patients.

[Anatomic variations of the hepatic artery : a study of 33 cases and review]. / Variations anatomiques de l'artère hépatique et applications pratiques: a propos de 33 cas et revue de la littérature.

BACKGROUND: The hepatic artery is prone to numerous anatomic variations dictated by certain variables of the organogenesis. Aim : To research study the anatomic variations of the hepatic artery as well as their implications within surgical practice. METHODS: Study of a post-mortem series of 33 cases of dissection of the hepatic pedicle with fresh corpses (deaths amounting no longer than 24 hours), carried out in conditions that are quite close to those met with the living ones. RESULTS: The common hepatic artery was divided at the foot of the hepatic pedicle into a gastro duodenal artery and into a proper hepatic artery in 94% of the cases. In 6% of the cases, we noticed a three level change, a branching of the average hepatic artery into a gastro duodenal artery, a right hepatic artery and a left hepatic artery. The proper hepatic artery represented the pedicle segment of the hepatic artery in 94% of the cases. In 36% of the cases, the liver was irrigated by two hepatic arteries. In 12% of the cases, there was the matter of the right hepatic artery, branch of the mesenteric artery. In 24% of the cases, there was the matter of the left hepatic artery branch of the left gastric artery. CONCLUSION: The perfect knowledge in preoperative and preoperative stages of the anatomic variations of the hepatic pedicle is quite essential. Actually, the lack of knowledge of these variations exposes to the risk of certain complications which are sometimes deadly during hepatic transplants, pancreatic surgery, cholecystectomies, through laroscopic way as well as in the treatment of gastro-esophagus surging.

[Tomodensitometric diagnosis of internal herniation: report of 3 cases]. / Apport de l'enteroscanner dans le diagnostic pre operatoire des hernies internes: a propos de 3 cas.

AIMS: To study the value of the CT scan in the diagnosis of internal herniation and to evaluate its performance comparing its features to preoperative data. CASES: We report 3 cases of patients with internal hernias (two men and one woman whose age is 23, 45 and 60 years) hospitalised in emergency for a small bowel obstruction. There were no previous abdominal surgeries or trauma, The three patients underwent CT scan. Signs of tranmesenteric hernias and hernia through the falciform ligament were diagnosed preoperatively and confirmed at laparotomy. CONCLUSION: The internal hernia is rare cause of small bowel obstruction. The CT scan is an important way to make diagnosis and to choose the surgical strategy.

[Malignant intraductal papillary mucinous tumours of the pancreas. A three cases report]. / Tumeurs intracanalaires papillaires et mucineuses dégénérées du pancréas: à propos de trois cas.

BACKGROUND: Intra ductal papillary mucinous tumors of pancreas are rare and are characterized by a risk of malignant transformation. AIM: To clarify their clinical presentation and the performance of different imaging examinations to determine their benign or malignant and achieve their staging. CASES: We report three cases of degenerate intra ductal papillary mucinous tumors of pancreas. The combination of CT, the pancreato- MRI and duodenoscopy has led to the diagnosis in all cases. A pancreaticoduodenectomy were performed in two cases. CONCLUSION: The various imaging techniques allow better detection and analysis of the tumor including the evaluation criteria of degeneration. The treatment of these lesions is still surgery.

[Totally implantable venous access ports by cephalic vein cut-down for patients receiving chemotherapy]. / Impact thérapeutique de l'utilisation de la veine céphalique pour la mise en place des chambres implantables pour chimiothérapie.

BACKGROUND: The use of an implantable room has become indispensable in the clinical practice for the cancer patients. The increasing use of these devices was associated with a greater incidence of complications. AIM: To verify the feasibility of the cephalic vein cut-down technique for placement of venous access devices. METHODS: A prospective study of 58 port placements was performed at our department of general surgery. The surveillance of devices was collectively insured by the operator and by the oncologists. RESULTS: The indication for implantation was the infusion of intravenous chemotherapy in patients with colorectal cancer in 55.1% cases and breast cancer in 27.5%. The specific complication rate was 7%. The cephalic vein cut-down approach was used successful in 45 (77.5%) patients. When the cephalic vein could not be used, a percutaneous technique was employed using the subclavian vein in 22.4% of the patients. CONCLUSION: Cephalic vein cut-down technique should be considered a safe and feasible approach for placement of venous access devices.

[Acute peritonitis complicating Crohn's disease: epidemiologic and physiopathological characteristics]. / Peritomite aigue generalisee compliquant une maladie de Crohn: aspects epidemiologiques et physiopathologiques.

BACKGROUND: An uncommon event in the natural course of Crohn's disease is the spontaneous perforation. It's the most serious intestinal complication. AIM: To report the incidence of this complication and to discuss the mechanism of the perforation. OBSERVATIONS: We report, retrospectively, 4 cases (3 men and one woman; median age: 30 years) of peritonitis complicating Crohn's disease and study their clinical characteristics intra operatively findings and course evolution. Steroid therapy was administrated to all patients before the perforation. The perforation sites are on the ileum in three cases and on the jejunum in one case. The treatment consists in a resection of the perforated intestine with stoma in all cases. CONCLUSION: Perforation in Crohn's disease is a rare event. The exact mechanism of the perforation is still unknown and many hypotheses are presented.

Pseudoaneurysm of the splenic artery presenting with gastrointestinal bleeding.

Gastrointestinal bleeding from a pancreatic pseudocyst is a rare condition that is diagnostically and therapeutically challenging. A 78-year-old woman with a history of acute pancreatitis due to gallstones was hospitalized for abdominal pain and gastrointestinal bleeding. Gastroscopy revealed blood extruding from the papilla of Vater. A computed tomography scan revealed hemorrhage into a pancreatic pseudocyst. The patient was successfully treated by coil embolization.

[Mesenteric panniculitis simulating malignancy]. / La panniculite mésentérique simulant un processus tumoral.

BACKGROUND: Panniculitis mesenteritis is a rare, benign, and chronic fibrosing inflammation disease with unknown aetiology that affects the mesentery of small bowel and colon. AIM: To report a new case of this entity and to highlight its diagnostic difficulties especially when it affects the mesocolon. CASE REPORT: A 37 years-old women presented with chronic abdominal pain; physical examination found mass of left ilaca fossa. Closcopy and abdominal CT scan showed a thickness of bowel wall with negative biopsies. The patient underwent a colectomy. Histologic examination concluded to the diagnosis of Mesenteric panniculitis without malignant lesion. CONCLUSION: Mesenteric panniculitis is a rare pathology which diagnosis is difficult to establish. It can simulate malignancy. A better knowledge of its clinical and radiological features could ovoid unnecessary digestive resection.

[Early gastric adenocarcinoma]. / Adénocarcinome superficiel de l'estomac.

AIM: the purpose of this study was to determine the epidemiological and clinical behaviour of the superficial adenocarcinoma of the stomach, to clarify its pathological characteristics, its therapy and prognosis. METHODS: Over a period of 14 years (1990-2004), 16 patients were operated for a superficial gastric adenocarcinoma among 155 gastric cancers treated during the same period in the service of general surgery "A" La Rabta. RESULTS: The superficial gastric adenocarcinoma represented 10.3% of our series. The mean age was 59 years, 8 men and 8 women. Two patients were followed for a chronic stomach ulcer, a patient is followed for Biermer anaemia and another one for Menetrier disease. Among these cancers, 12 were intra mucosal and 4 invaded the submucousa. Lymph node involvement was present only in one case. The cancer was located in the antrum in 8 cases and was multifocal in 3 cases. One patient died in postoperative case because of a medical cause. The 5-year-overall survival was 65,6%. The recurrence had interested only one patient. CONCLUSION: the superficial gastric adenocarcinoma is rare. The follow up of precancerous states allows its diagnosis. The treatment is based on the gastric resection associated to the D1-type lymph node clearance. The multifocal character imposes a surveillance of the remaining gastric stump.

[Internal herniation through the falciform ligament revealed by acute intestinal obstruction]. / Hernie interne du ligament falciforme révélée par une occlusion intestinale aiguë

INTRODUCTION: Internal hernias are a rare cause of acute intestinal obstruction. Herniation through the falciform ligament is rare and often diagnosed only during surgery. Abdominal computed tomography (CT), performed on an emergency basis, can help to diagnose this obstruction before surgery and select a therapeutic approach. CASE: A 60-year-old man was hospitalized on an emergency basis for symptoms that had been developing for 3 days, including tympanites and epigastric pain (torsion), associated with vomiting and the cessation of both feces and flatus. Abdominal radiography showed multiple levels of air-fluid levels in the small bowel, some projecting towards the liver area, as well as the presence of a flat intestinal loop continuous with a distended small-bowel segment. Abdominal CT suggested a diagnosis of small-bowel herniation and obstruction, very probably through the falciform ligament. The patient then underwent emergency surgery after a brief resuscitation. Intraoperative exploration confirmed the diagnosis of internal hernia through the falciform ligament. The postoperative course was without problems. DISCUSSION: Abdominal CT is the examination of choice in cases of a "new" acute intestinal obstruction. It makes it possible to diagnose the mechanism of the occlusion and especially the cause, especially for an internal hernia through the falciform ligament. It thus guides the choice of emergency surgical procedure and of appropriate approach. Once diagnosed, emergency surgery is essential to free the intestinal loop, with or without intestinal resection as a function of vitality.