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.

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.

[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.

[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.

[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.

[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.

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.

[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.

Budd-Chiari syndrome secondary to hepatic echinococcosis.

OBJECTIVES: Hydatid cyst of liver is a parasitosis which is an endemic state in Tunisia and is a very rare cause of Budd-Chiari syndrome. The purpose of this study was to report the clinical features, radiological investigations and therapeutic management. PATIENTS AND METHODS: A retrospective analysis of 12 patients who underwent surgery for Budd-Chiari syndrome secondary to hepatic echinococcosis between January 1990 and December 2004 was performed. RESULTS: The series included ten females and two males with a mean age of 36 years. Budd-Chiari syndrome was subacute in 75% of cases. Ultrasound showed a compression of hepatic veins by cysts with a mean diameter of 13 cm situated in at least two hepatic segments. US Doppler and CT-scan of the liver provided the diagnosis in all cases. Laparotomy was performed in all cases. Operative mortality was 8% and morbidity 66% due to biliary fistula and deep abscess formation. Hepatic vein outflow was successfully re-established in four patients. CONCLUSION: Budd-Chiari syndrome is a rare but severe complication of hydatid cyst of the liver. Early diagnosis is necessary to improve prognosis.

[Laparoscopic ileocecal resection for Crohn's disease]. / Resection ileo-caecale laparoscopique pour maladie de Crohn.

UNLABELLED: The aim was to evaluate the reliability and safety of laparoscopic ileocecal resection for Crohn's disease and to report our preliminary results. METHODS: A retrospective analysis of 20 patients undergoing a laparoscopic ileocecal resection for Crohn's disease was carried out between November 2003 and June 2005. First of all, we defined the inclusions and exclusions criteria which allowed us to select the patients who would be resected laparoscopically. Fistulizing disease, emergent surgery (perforation, occlusion), large mass and patients with previous laparotomy were excluded. Duration of operation, rate of conversion, complications and time from discharge from hospital were evaluated. RESULTS: Median operation time was 160 min. Conversion to laparotomy was needed in three cases. There was no death. Minor complications occured in 2 patients. Median postoperative time for discharge was 5 days. CONCLUSION: These preliminary results indicate that laparoscopic ileocecal resection is a feasible and safe alternative in patient with Crohn's disease offering many advantages thanks to a strict patient selection.