Surgical management of primary crohn's disease. descriptive study about 226 patients.

BACKGROUND: The surgery is required in more than 80% of patients with Crohn's disease (CD). Studies before confirm the specific genetic variation of CD in the Tunisian population compared with the others ethnic groups. AIM: This article aims to study the epidemiological, anatomical and therapeutic principles of surgical forms of CD in a cohort of Tunisian patients. METHODS: We report a retrospective study from January 1998 to September 2010 that studied 226 patients originated only from Tunisia (in North Africa), operated on for MC. We had been interested in epidemiological, anatomical, clinical, therapeutic, topographic progression of the disease, the procedure and the postoperative follow-up. RESULTS: The median age was 33 years. The average time between the onset of the disease and the surgical procedure was 31 months. The diagnosis of CD was established preoperatively in 213 patients (94%). The diagnosis was made intraoperatively because of an acute complication in 5 cases (2.2%) and postoperatively in 8 cases (3.5%). The most common location was the ileocecal junction in 184 cases (81.4%). Achieving the most common was the mixed form (stricture and fistula) in 123 cases (54.4%). Operative mortality was 0.04% (n = 1). Specific morbidity was 8.4% (n = 19). In long term, a surgical recurrence was noted in 17 patients (7.5%). In multivariate analysis the independent risk factors for surgical recurrence were: smooking (p = 0.012, ORs = 3.57) and post-operative medical treatment (p = 0.05, ORs = 2.6). CONCLUSIONS: Achieving stenosing and fistulizing the ileocecal junction is the most frequent surgical form in Crohn's disease. Our series is unique for a lower rate of the postoperative recurrence (7.5%).

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 .

[Surgical management of entero-vesical fistulas in Crohn's disease]. / Traitement chirurgical des fistules entéro-vésicales secondaires à la maladie de Crohn.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. aim: To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula (EVF) during the CD. methods: We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. results: The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted. CONCLUSION: Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term.

Surgical management of intra-abdominal cystic lymphangioma. Report of 20 cases.

BACKGROUND: Cystic lymphangioma (CL) is a benign rare malformation of lymphatic vessels. Its discovery in adults is rare. Although it can affect any organ, the common forms found in adults are mesenteric and/or retroperitoneal CL. This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma in adults. METHODS: We report a retrospective study from January 1998 to September 2010 concerning 20 patients who underwent surgical removal of a CL. We were interested in discovering the clinical, biological, and radiological characteristics of CL. The localization, size, and number of cysts have been reported, as well as the surgical intervention used and the postoperative immediate and late complications. RESULTS: The median age was 46 years. Abdominal pain was the main symptom and was found in 15 patients (75%). Physical examination revealed an abdominal mass in 12 patients (60%). In four patients (20%), the cystic lymphangioma was incidental. Abdominal ultrasound and abdominal CT scan helped to highlight 22 cystic masses. CL diagnosis was established preoperatively in 13 patients (65%). Six patients (30%) were operated with a diagnosis other than CL. The diagnosis was made intraoperatively in one case (5%). Only two patients (10%) were operated on in emergency: one due to an infected CL and the other was CL complicated with intracystic hemorrhage. A laparotomy in 13 cases (65%) was the surgical approach used, whereas 7 cases (35%) benefited from a laparoscopy. No conversion was noted. The majority of the patients, 18 cases (90%), received a total cystectomy. Only two patients (10%) had recurrences of which only one was reoperated. CONCLUSIONS: The diagnosis of CL often is facilitated by means of modern imaging; however, other diagnoses may be discussed, particularly hydatid disease endemic areas. If symptomatic lesions or complications arise, complete surgical excision, when possible without major sacrifice, seems to be the best therapeutic option to reduce the risk of recurrence.

Giant retroperitoneal liposarcoma. Report of 5 cases.

BACKGROUND: Liposarcoma is the most frequent histopathological variety of the retroperitoneum, surgery is the gold standard for treatment. CLINICAL SERIES: We report, retrospectively over 7 years (2000-2006), 5 cases (four men and one woman, the mean age was 48 years) of giant retroperitoneal liposarcomas and study their clinical characteristics intra operatively findings and course evolution. None of our patients had a percutaneous biopsy of his tumour. Surgery was indicated to all patients. Resection was performed in 4 cases (we performed a bloc resection in three cases and a simple tumour resection in one case), and in one case, abstention was decided. None of patients had an adjuvant therapy Three of the patients still alive after the follow up of 2, 3 and 4 years. CONCLUSION: Retroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach including multiple resections for recurrences. Based on the ability of the patient to tolerate the procedure, surgery is suggested to evaluate resectability of the tumor. We must take into consideration whether prolonged survival will be attained and tumor removal will result in palliation of symptoms.

Risk factors associated with pancreatic fistula after distal pancreatectomy.

BACKGROUND: Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. AIM: To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP). METHODS: 35 patients underwent DP during a 10-year period (2000- 2009). Informations regarding diagnosis, operative details, and perioperative morbidity and mortality were collected. Nine risk factors were examined. RESULTS: Indications for DP included primary pancreatic disease (n=23; 66 %) and non-pancreatic disease (n = 12; 34 %). Postoperative morbidity rate was 43 % and none patient died. No patients required a reoperation. Pancreatic fistula was occurred in 11 patients (31 %). On univariate analysis, incidence of pancreatic fistula rate was not significantly associated with these risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, additional procedures, intra operative bleeding and texture of pancreatic parenchyma. We observed significant statistical difference between male and female, 47 % of females experienced a pancreatic fistula, while 17 % males developed a pancreatic leakage (p =0.05). The role of the technique of pancreatic stump closure in the development of pancreatic leak remains unclear because of the few number of patients on who we used stapler. CONCLUSION: The rate of pancreatic fistula after left pancreatectomy is 31 %. The female was identified as a risk factor for occurrence of pancreatic fistula after left pancreatectomy. The role implicated in the use of a mechanical claw for the treatment of pancreatic stump requires a larger number of patients to conclude. The body mass index has not been studied in our series.

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.

[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.

[Colo-urachal-cutaneous fistula in an adult]. / Fistule colo-cutanée d'origine allantoïde chez un adulte

BACKGROUND: An infected urachal cyst is an uncommon finding in adults. AIM: To report a case of a sigmoid- urachal- cutaneous fistula. CASE REPORT: A 51 years old adult male presented with fecaloid leaking from rupture of an infected urachal cyst. Definitive management consisted of resection of the urachus with a bladder cuff, along with removal of the affected bowel segments. CONCLUSION: Colo-urachal-cutaneous fistula is a rare condition; its management is rather complex.

[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.

Presentation with perforation of the terminal ileum and acute limb ischemia in Crohn's disease: A case report.

INTRODUCTION AND IMPORTANCE: Crohn's disease is a chronic inflammatory bowel disease with complex pathophysiology and multiple complications, some of which can be fatal. We report herein the management of an unusual case of Crohn's disease revealed by two life-threatening complications. CASE PRESENTATION: A 59-year-old patient presented with an acute abdominal pain evolving for one day with a clinical presentation in favor of peritonitis by perforation of the last ileal loop and acute limb ischemia. At emergency laparotomy, we found a fecal peritonitis by perforation of the last ileal loop. The patient underwent an ileo-caecal resection with rifle barrel ileo-colostomy associated with embolectomy using a Fogarty catheter of the femoral artery. Pathological examination of the specimen showed an aspect consistent with an ileo-caecal Crohn's disease and blood clot embolus of the femoral artery. Postoperative course was uneventful and the patient was kept in remission with immunosuppressants. DISCUSSION: Several complications may arise during the evolution of the disease. However, Life-threatening complication scarcely inaugurate crohn's disease like in our patient. Free perforation of the small intestine in crohn's disease occurs rarely, which makes its statistical study difficult. Risk factors for perforation are still poorly identified. Patients diagnosed with crohn's disease have a higher risk of thromboembolic complications. Indeed, there is an association between the activity of the disease and thromboembolic events. In our case, the severity of the clinical presentation as well as its inaugural character are unique. CONCLUSION: The management of inaugural two uncommon acute conditions in Crohn's disease is challenging.

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.

[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.

[Peripancreatic sporadic gastrinoma]. / Gastrinome sporadique péri-pancréatique.

BACKGROUND: The peri-pancreatic sporadic gastrinoma represents a paradigm of digestive endocrinology. It was originally an abnormal secretion of gastrin fits the syndrome Zollinger-Ellison. AIM: The objective of our work is to clarify the diagnostic strategy and therapeutic conduct of gastrinoma. CASE: We report the case of a patient aged 42 years, hospitalized for bleeding duodenal ulcer, revealed a Zollinger-Ellison syndrome. The different explorations have shown that it was a primitive péripancréatique sporadic gastrinoma. In surgery, we discover a rétropancréatique tumor associated to a stenosis post-bulbar ulcer. It was conducted a enucleation of the tumor with vagotomie troncular and gastroenteroanastomosis. The forecast was favourable with normalization of the values of gastrinémie. CONCLUSION: The sporadic gastrinoma is rare, its emphasis is increasingly being facilitated by the technology of modern medical imaging, belonging to a polyendocrinopathie must be systematic search. Treatment of pancreatic gastrinoma is multidisciplinary. Surgery is the only cure for this disease.

[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.