Gallstone ileus of the sigmoid colon: case report.

Gallstone ileus is an uncommon cause of intestinal obstruction. It is caused when a gallstone migrates through an enterobiliary fistula (most often between the duodenum and the gallbladder) and is impacted in the digestive system, most often in the terminal ileum toward the ileocaecal valve. Case Presentation: Here the authors report the case of a 74-year-old woman who was admitted to Compiegne Hospital in France for a gallstone ileus with the sigmoid colon as the impaction site, which is an even more rare cause of intestinal obstruction. The enterobiliary fistula was between the colon and the gallbladder.The gallstone was removed surgically with a colotomy, without treating the fistula, and after a failed endoscopic attempt to extract the stone. The follow-up was without complications, and a colposcopy showed spontaneous closure of the fistula after 6 weeks. Discussion and Conclusion: The surgical closure of an enterobiliary fistula is an option that should be considered, but it can lead to higher morbidity. That is why the authors opted out of it, especially considering that spontaneous closure of the fistulae can happen, as it did in our case.

Intraesophageal Migration of a Paraesophageal Hernia Mesh: A Case Report.

Paraesophageal hernias (PEH) have a high recurrence rate, which can justify the use of a mesh during their repair. Mesh use in PEH repair is highly debated as it can lead to many complications like erosion and migration of the mesh, like in our case. Here, we present a case of a 23-year-old woman operated on multiple occasions for a recurring PEH and who presented an intraesophageal migration of the mesh. Partial upper gastrectomy and lower esophagectomy were performed to remove the mesh and the recurrent hernia was repaired using primary sutures of the hiatus. The surgery was without complications and there are no signs of recurrence up to a year later. Reoperation on a recurring PEH can be more difficult in case of mesh use in previous intervention and can lead to other complications like mesh erosion or migration, even so, some surgeons choose this option because it has a lower recurrence rate.

Circular Mini-Incision in the Left Iliac Fossa Followed by Purse-String Closure as a Minimally Invasive Approach for the Sigmoid Volvulus: A Technical Note.

INTRODUCTION: Volvulus of the sigmoid is a common cause of intestinal obstruction in Morocco. It is a serious condition with substantial mortality. Initial endoscopic decompression followed by resection of the redundant colon via laparotomy or laparoscopy is the procedure of choice. Exteriorization of the sigmoid colon through a linear skin incision in the left iliac fossa has been described as an alternative approach for the classic midline incision, with or without laparoscopic assistance, with acceptable results. METHODS: We describe herein a novel, minimally invasive approach for fit patients with non-complicated volvulus sigmoid. This approach consists of a skin-disk incision in the left iliac fossa, exteriorization of the redundant colon, and resection with or without primary anastomosis, followed by a purse-string closure. RESULTS: A 65-year-old patient with no prior notable medical history, presented to the emergency department with his first episode of sigmoid volvulus. A skin-disk incision was made in the left iliac fossa, exteriorization of the sigmoid was done easily through the incision, and resection and manual anastomosis were done. The closure was made in a purse-string fashion. Recovery was uneventful and the patient was discharged home on the fourth postoperative day. No wound infection was noted and the cosmetic result was satisfactory. CONCLUSION: Left iliac skin-disk incision followed by a purse-string closure is an option for approaching the abdomen in the case of sigmoid volvulus. It has been demonstrated that this technique helps reduce wound-related complications in patients undergoing stoma reversal. Authors suggest that cosmetic results are better and the incidence of surgical site infection can be lower with this technique as compared to the classic linear skin incision. Results, however, should be confirmed by larger studies.

Impact of the COVID-19 pandemic on digestive cancer staging, a case series.

Introduction: The COVID-19 pandemic had an undeniable impact on the health system worldwide, this lead to a delay in the diagnosis and treatment of digestive cancers.The purpose of our study was to assess this delay and its impact on patient care. Method: Our work is a retrospective study about 165 patients that were admitted for digestive cancers at Sheik Khalifa hospital, Casablanca morocco during a 3-year period, that we divided into three. We included all the digestive adenocarcinomas (esophagus excluded) whether they were operated on or not. We excluded all other types of cancers (GIST, serous tumors …). We assessed the time between the beginning of the symptoms and the beginning of the treatment and the number of patients that were diagnosed at the complication stage. We also assessed the staging of the tumor at the moment of diagnosis and the complete surgical resection rate. Results: Among the 165 patients admitted for digestive cancer, 54,9% were males with a sex ratio of 1,22 M/F. The average age of our patients was 62,8 years varying between 25 and 86 years old and with a standard deviation of 11,8 years. Digestive cancers were diagnosed in 79 patients during period 1, 43 patients during period2, and 43 during period 3. We found a statistically significant increase in the percentage of patients with advanced cancer by 21,7% (p = 0,045) from 2019 to 2020. The delay in diagnosis (p = 0,275), percentage of cancer discovered at the stage of complication(p = 0,728), and the reduction in complete surgical resection (p = 0,177) were not statistically significant. Conclusion: Our results show an undeniable impact of the COVID-19 pandemic on the staging of digestive cancers but the impact on their care remains to be proven and needs a long-term survival follow-up.

A Fatal Case of Strangulated Pericecal Hernia.

Pericecal hernia, a subtype of internal hernia, is a rare and unusual cause of small-bowel obstruction (SBO). We report the case of a pericecal hernia in an 80-year-old woman who presented to the emergency department with symptoms of SBO. She experienced colicky diffuse abdominal pain associated with vomiting and obstipation for over five days. Abdominal examination showed rebound tenderness in the right iliac fossa without any mass palpation. Computed tomography noted a "sac-like" structure in the right iliac fossa with dilated and ischemic small-bowel loops within. Exploratory laparotomy showed strangulated pericecal hernia and non-viable small bowel loops in the inferior ileocecal recess. Extensive resection and defect repair followed by small-bowel end-to-end primary anastomosis was made. After two days of ICU admission, patient died from septic shock. This case report highlights the need for prompt diagnosis, followed by surgical intervention to lower mortality of SBO of internal hernia origin, especially in cases where no previous surgery is noted.

Medial pancreatectomy for a neuroendocrine tumor invading the splenic artery and vein.

CONTEXT: Pancreatic tumors in the midportion have traditionally been treated by an extended right or left pancreatectomy. A medial or central pancreatectomy is an alternative technique for benign or low-grade malignant neoplasms located to the left of the gastroduodenal artery and close to the splenomesenteric confluence. CASE REPORT: A 38-year-old woman with no previous surgical history presented with epigastric abdominal pain. A computed tomography scan showed a 4 cm heterogeneous lesion within the pancreatic body. This tumor invaded the splenic artery and vein. There was no postoperative diabetes mellitus or exocrine insufficiency. The patient continues to be well after a 10-month follow-up without pancreatic insufficiency or local recurrence, and CT has demonstrated splenic perfusion by the collateral vessels. CONCLUSION: We believe that a medial or central pancreatectomy may be a safe procedure where there is involvement of the large splenic vessels by a low grade malignant pancreatic tumor and that a systematic splenectomy is not justified.

Case note: retroperitoneal nonfunctioning paraganglioma.

Paragangliomas are extra-adrenal chromaffin tumours that develop at the expense of neuroectodermal cells of the autonomous nervous system. Retroperitoneal and nonfunctioning forms are very rare. They are often asymptomatic and can reach a substantial size. Treatment usually involves surgery with the goal of total excision. We report the case of a patient who presented with indistinct abdominal pain. This case demonstrates how the diagnosis of retroperitoneal nonfunctioning paragangliomas relies mostly on histological results.

Sacral hemangiopericytoma involving the retrorectal space: report of a case.

A primary hemangiopericytoma (HP) of the bone is rare, because the vast majority of these tumors arise in soft tissue. This report presents a case of a hemangiopericytoma in the sacrum (S1-S2) with extension to the retrorectal space. Only a few cases of osseous hemangiopericytomas in the sacrum and involving the retrorectal space have so far been reported. The difficult diagnosis of HP and the surgical strategy was chosen according to the location of the lesion in the sacrum and retrorectal space. A local excision was indicated. A sacral resection should be considered for tumors below S4. This report demonstrated the safety of this strategy. Adjuvant radiotherapy is useful in HP. The value of chemotherapy is still doubtful, although patients with high-grade tumors or metastatic spread seem to gain substantial benefit. Due to the often unpredictable behavior of this neoplasm, extended follow-up is strongly recommended.

[Parietal-scar endometriosis after cesarean section: a rare entity]. / L'endométriose pariétale cicatricielle après césarienne: une entité rare.

Wall endometriosis is a rare clinical entity whose pathophysiology remains unclear. It occurs most frequently after gynecologic or obstetric surgery. We report the case of a patient with cyclic pain at the caesarean section scar. Clinical examination showed a 5 cm mass in the right iliac fossa. Tomodensitometry revealed a tissue density mass (45mm on the major axis). Hence, the decision to perform a wide excision of the lesion. Anatomo-pathological examination confirmed the diagnosis of parietal endometriosis. Postoperative sequelae were simple with a follow-up period of 20 months with no recurrence of the mass or of the pain. Our study highlights the characteristics of this disease to allow the health practitioner to understand the importance of diagnosis, of early treatment of this disease as well as of the possibility to prevent it during each gynecologic or obstetric surgery.

Extra-Gastrointestinal Stromal Tumor of the Greater Omentum: Unusual Case Report.

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract, originating from the interstitial cells of Cajal and most frequently expressing CD-117, a C-kit proto-oncogene, which can be detected immunohistochemically. Extra-gastrointestinal stromal tumors are neoplasms with similar immunohistological features arising outside the gastrointestinal tract with no connection to the gastric or intestinal wall.We report the case of a 61-year-old Moroccan man who presented with chronic abdominal pain along with progressive abdominal distension for the past last year. The clinical examination demonstrated a large abdominal mass and an abdominal computed tomography scan revealed a voluminous intraperitoneal mass measuring 30 cm in its greatest diameter. At laparotomy, this mass seemed to be arising from the greater omentum without continuity to the gastrointestinal tract. The mass was completely removed with clear margins and pathological examination was suggestive for high-risk gastrointestinal stromal tumor of the greater omentum. Due to the aggressive nature of this patient's tumor, he was assigned to receive imatinib as adjuvant chemotherapy for 3 years. He remains alive without any sign of recurrence after 4 years of follow-up.Extra-gastrointestinal stromal tumors of the greater omentum can grow slowly and remain clinically silent despite the large size of the tumor. Complete surgical resection is the only effective treatment approach. Nevertheless, adjuvant therapy following resection with imatinib has become a standard of care in cases of high risk disease.

Huge plastic bezoar: a rare cause of gastrointestinal obstruction.

Bezoars are rare causes of gastrointestinal obstruction. Basically, they are of four types: trichobezoars, phytobezoars, pharmacobezoars, and lactobezoars. Some rare types of bezoars are also known. In this article a unique case of plastic bezoars is presented. We describe a girl aged 14 years who ingested large amounts of plastic material used for knitting chairs and charpoys. The conglomerate of plastic threads, entrapped food material and other debris, formed a huge mass occupying the whole stomach and extended into small bowel.

Giant adrenal hemangioma: Unusual cause of huge abdominal mass.

Adrenal hemangioma is an extremely rare benign and non-functioning neoplasm of the adrenal gland. We report a case of a 71-year-old woman admitted for intermittent abdominal pain and abdominal distension associated with vomiting and chronic constipation for 5 years. Physical examination revealed a large abdominal mass. Both computed tomography scan and magnetic resonance imaging suggested hemangioma in the right lobe of the liver. Laboratory examinations and tumour markers were within normal limits, except for hypochromic microcytic anemia. The mass was removed intact by conventional surgery and histopathology revealed a cavernous hemangioma of the adrenal gland with no signs of malignancy. Surgical resection was curative, with no recurrence at the 2-year follow-up.

Giant inguinoscrotal hernia containing intestinal segments and urinary bladder successfully repaired by simple hernioplasty technique: a case report.

INTRODUCTION: Giant inguinoscrotal hernias are extremely rare nowadays, but they may still be encountered after years or even decades of neglect. Such hernias containing both bowel loops and urinary bladder have not been reported in the medical literature to date, to the best of our knowledge. CASE PRESENTATION: We report a case of a 65-year-old Moroccan man who presented with giant right-sided and long-standing inguinoscrotal hernia with compromised quality of life due to walking difficulties and sexual discomfort. Computed tomography revealed a voluminous hernia sac containing small and large bowel loops, greater omentum, and urinary bladder. Surgical repair was done through the classical inguinal incision using the Lichtenstein tension-free hernioplasty technique. No debulking or abdominal enlargement procedure had to be performed, apart from a partial omentectomy. CONCLUSIONS: Giant inguinoscrotal hernia containing intestinal segments and urinary bladder is a challenging surgical disease. A Lichtenstein tension-free technique seems to be the best surgical procedure for both the patient and the operating surgeon. It should be used whenever possible in such cases.

Intranodal palisaded myofibroblastoma: a case report from an unusual site.

Intranodal palisaded myofibroblastoma is a rare lymph node benign tumor, of unknown pathogenesis. Although benign, this lesion is frequently confused with metastatic lesions, especially in atypical sites. We report a 39-year-old man with a history of testicular malignant mixed germ cell tumor, presented with abdominal painless mass. The computed tomography of the abdomen confirmed the presence of 180 × 140 mm2 mass in the retroperitoneum with lympadenopathy on the right measuring 20 x 15 mm. The patient underwent exploratory laparotomy, and a surgical exerese of the retroperitoneeum lymph node was made. Histological and immunohistochemical examination confirmed the diagnosis of intranodal palissaded myofibroblastoma. This entity has been previously described, only once, in retroperitoneal region. Despite to the rarity of this neoplasm, we discuss clinicopathologic features and differential diagnosis.

Analysis of prognostic factors affecting mortality in Fournier's gangrene: A study of 72 cases.

INTRODUCTION: Fournier's gangrene is a rapidly progressing necrotizing fasciitis of the perineum and genital area associated with a high mortality rate. We presented our experience in managing this entity and identified prognostic factors affecting mortality. METHODS: We carried out a retrospective study of 72 patients treated for Fournier's gangrene at our institution between January 2005 and December 2014. Patients were divided into survivors and non-survivors and potential prognostic factors were analyzed. RESULTS: Of the 72 patients, 64 were males (89%) and 8 females (11%), with a mean age of 51 years. The most common predisposing factor was diabetes mellitus (38%). The mortality rate was 17% (12 patients died). Statistically significant differences were not found in age, gender, and predisposing factors, except in heart disease (p = 0.038). Individual laboratory parameters significantly correlating with mortality included hemoglobin (p = 0.023), hematocrit (p = 0.019), serum urea (p = 0.009), creatinine (p = 0.042), and potassium (p = 0.026). Severe sepsis on admission and the extent of affected surface area also predicted higher mortality. Others factors, such as duration of symptoms before admission, number of surgical debridement, diverting colostomy and length of hospital stay, did not show significant differences. The median Fournier's Gangrene Severity Index (FGSI) was significantly higher in non-survivors (p = 0.002). CONCLUSION: Fournier's gangrene is a severe surgical emergency requiring early diagnosis and aggressive therapy. Identification of prognostic factors is essential to establish an optimal treatment and to improve outcome. The FGSI is a simple and valid method for predicting disease severity and patient survival.

An unusual localization of retroperitoneal paraganglioma: a case report.

Paragangliomas are rare tumors arising from extra-adrenal chromaffine tissues. The diagnosis of non-functional retroperitoneal paraganglioma and its surgical management can be difficult. We report a case of a retroperitoneal paragangliomaof an unusual localization that renders the surgery more challenging. A 40 year-old woman presented to our department with a four-month history of upper quadrant pain with no vomiting, no fever, nor jaundice. Physical examination was normal. Ultrasonography showed a retro duodenal homogenous mass and computed tomographyscan showed a well-circumscribed round mass of heterogeneous density, which was in close contact with the aorta and the left kidney vein. Laboratory tests were normal. The patient underwent surgical management. The surgical exploration found a retroperitoneal tumor that was encapsulated and showing intimate contact with the abdominal aorta. We performed a complete resection of the tumor. Histological examination of the surgical specimen revealed a paraganglioma. The post operative course was uneventful. Paragangliomas are rare tumors. They can be asymptomatic for a long time and thus be diagnosed at late stage. A follow-up of patients is then essential. Surgical treatment is the only radical treatment and should be performed even in paragangliomas in close contact with the great vessels.

An exceptional collision tumor: gastric calcified stromal tumor and pancreatic adenocarcinoma.

The authors report an exceptional case of collision tumor comprised of a gastric calcified stromal tumor and a pancreatic adenocarcinoma. The pancreatic tumor was detected fortuitously on the histological exam of resection specimen.

Long-standing insulinoma: two case reports and review of the literature.

BACKGROUND: Insulinomas are rare pancreatic endocrine tumors. Most are benign and solitary. However, the nonspecific symptoms and small size of these tumors led to difficulties of diagnosis and localization. CASE PRESENTATION: We present two Arab patients with pancreatic long-standing insulinoma. Both patients presented episodic hypoglycemic symptoms respectively during 10 and 2 years. Biochemical and morphological workup detected localized pancreatic insulinoma. Open procedure surgery was done for the two patients and insulinomas were successfully removed by enucleation. CONCLUSION: Insulinoma remains a diagnostic challenge to practitioners. Diagnosis of suspected cases is easily confirmed by standard endocrine tests, especially the supervised fasting test. Accurate preoperative localization is essential for more effective and safest surgery.

Perineal approach for surgical treatment in a patient with retro-rectal tumor: a case report and review of the literature.

BACKGROUND: Retrorectal tumors in adults are very rare and little known condition. These tumors, often misdiagnosed or mistreated, should be completely excised because of the potential for malignancy or infection. A suitable operative approach is the key to the successful surgical management. CASE PRESENTATION: We report the case of a 45-year-old Arab male who presented with chronic pelvic pain accompanied by straining to defecate and dysuria. The clinical examination showed a painless mass in the left perineal area. Pelvic magnetic resonance imaging and computed tomography scan demonstrated a huge and well-limited pelvic mass causing displacement and compression of the rectum and bladder. Although the large size of the mass (>7 cm in the greater diameter), it was successfully and completely excised through only perineal approach without undertaking coccygectomy or sacrectomy. The histopathological study revealed a low-grade leiomyosarcoma. The patient is currently in 4-years follow-up with no signs of recurrence or metastasis. CONCLUSION: Even large retro-rectal tumors may be successfully excised by the perineal approach especially in carefully selected patients, but require extensive knowledge of pelvic anatomy and expertise in pelvic surgery.