21 years of evolution of primary hepatic neuroendocrine neoplasm in a patient with primary sclerosing cholangitis: A case report.

INTRODUCTION AND IMPORTANCE: Primary hepatic neuroendocrine neoplasms(PHNEN) are among the rarest primitive neuroendocrine neoplasms. Main prognostic factor is histological. We report an unusual case of a PHNEN with 21 years of evolution in the setting of a primary sclerosing cholangitis(PSC). CASE PRESENTATION: A 40 year old man presented in 2001 with clinical signs of obstructive jaundice. CT-scan and MRI showed a 4 cm large hypervascular proximal hepatic mass evoking hepatocellular carcinoma(HCC) or cholangiocarcinoma. Exploratory laparotomy found an aspect of advanced chronic liver disease of the left lobe. Extemporaneous biopsy of a suspicious nodule showed signs of cholangitis. Left lobectomy was performed and postoperatively the patient received ursodeoxycholic-acid and biliary stenting. After 11 years of follow-up, jaundice reappeared with a stable hepatic lesion.A percutaneous liver biopsy was done. Pathology showed a G1 neuroendocrine tumor. Endoscopy, imagery and Octreoscan were normal, supporting the diagnosis of PHNEN. PSC was diagnosed on tumor-free parenchyma. The patient is on liver transplantation waiting list. CLINICAL DISCUSSION: PHNENs are exceptional. Pathology findings, endoscopy and imagery are necessary to rule out an extra hepatic NEN with liver metastasis. While G1 NEN are known for their slow evolution, this 21 year latency is extremely rare. The presence of PSC adds to the complexity of our case. Surgical resection is recommended when possible. CONCLUSION: This case showcases the extreme latency of some PHNEN as well as possible overlap with PSC. Surgery is the most recognized treatment. Liver transplantation seems to be necessary for us, as the rest of the liver shows signs of PSC.

Long term results of laparoscopic gastric band.

BACKGROUND: Laparoscopic gastric band (LAGB) has gained popularity among the surgical community since its first description in the early 90'. Actually, it is the third most practiced bariatric procedure in the world. The mean advantage of LAGB is a low rate of early postoperative morbidity. These satisfactory early results are in complete opposition with relatively high long term morbidity and a high rate of weight loss failure. AIM: Long term morbidity, weight loss and life quality index after LAGB were analyzed. METHODS: Data of patients eligible for LAGB between January 2005 and November 2016 in the surgical department of La Rabta teaching hospital were retrospectively analyzed. Weight loss curves, long term complications and quality of life were evaluated. RESULTS: Between 2004 and 2008, 28 patients had LAGB. Mean preoperative BMI was 44.6 Kg/m². No immediate complications occurred. Mean EWL were 39% and 37% respectively after 24 and 60 months. EWL was above 50% in only 4 patients. Coming to long term morbidity, 10 (35%) patients had complications. Reintervention rate was 39%. The gastric band was removed in 9 (32%) patients. Mean quality of life BAROS score was 4.21. CONCLUSIONS: Judging for its long term morbidity with a high reintervention rate, the LAGB raises the question of its valuable position as a surgical procedure against morbid obesity.

Laparoscopic-assisted versus conventional ileocolectomy for primary Crohn's disease: results of a comparative study.

INTRODUCTION: The laparoscopic approach is becoming the gold standard in the surgical treatment of primary Crohn's disease. The aim of this study was to compare laparoscopic-assisted and open ileocolic resection for primary Crohn's disease. METHODS: We conducted a non-randomized, comparative, retrospective analysis of a prospective database from 1998 to 2010. The remaining 129 patients were divided into two groups: laparoscopic-assisted group (Group L; n=64) and conventional group (Group C; n=65). There were no differences between the two groups as regards preoperative patient characteristics. Complications were graded according to the Clavien-Dindo classification. RESULTS: One hundred and seventeen (90.7%) patients had no complications. Out of 12 patients (9.3%) with complications, four (3.1%) had Grade I, six (4.7%) had Grade II and two (1.6%) had Grade III. There were no postoperative deaths (Grade V). Operating time was longer in Group L compared with Group C (P<0.001). Bowel function returned more quickly in the laparoscopic group in terms of return of bowel movements (P=0.018) and resumption of a regular diet (P=0.06). The mean length of stay was significantly shorter in the laparoscopic group (P=0.001). The mean follow-up was 26 months in Group L versus 34 months in Group C (P=0.06). During follow-up, six patients presented with small bowel obstruction in Group C, which was not statistically different from Group L (3 patients) (P=0.25). During the follow-up period, there have been no recurrences of Crohn's disease in the laparoscopic group while 11 patients (16.9%) have developed a recurrence in the conventional group (P=0.001). CONCLUSION: Laparoscopic-assisted ileocolectomy for primary Crohn's disease of the terminal ileum and/or cecum is safe and successful in most cases. Laparoscopic surgery for Crohn's disease should be considered as the preferred operative approach for primary resections.

Pancreaticojejunostomy vs. pancreaticogastrostomy following pancreaticoduodenectomy: results of comparative study.

AIM: Several techniques have been proposed for reconstructing pancreatico-digestive continuity, which the first goal is reducing the rate of pancreatic leakage after pancreaticoduodenectomy. Only a limited number studies have been carried out. Our objective is to compare the results of pancreaticojejunostomy versus pancreaticogastrostomy following pancreaticoduodenectomy. METHODS: This is a retrospective and comparative study about 80 patients who underwent pancreaticoduodenectomy. These patients were divided into two groups: pancreaticojejunostomy (group PJ) and pancreaticogastrostomy (group PG). RESULTS: The PJ group included 39 patients, while 41 patients were included in the PG group. There were no differences between the two groups concerning: patients' demographics, risk factors, indication, mean duration of surgery, texture of pancreatic tissue, need for intraoperative blood transfusion and postoperative prophylactic octreotide. Overall, the mortality postoperative rate was 7.5% (N.=6), the incidence of surgical complications was 50% (51.3% in PJ, 48.8% in PG; P=0.823, not significant). Pancreatic fistula was the most frequent complication, occurring in 17.5% of patients (25.6% in PJ and 9.8% in PG; P=0.062, almost significant). 7.7% of patients who underwent PJ and 14.6% of patients who underwent PG required a second surgical intervention (P=0.326, not significant). There were no differences between the two groups PG and PJ concerning: Postoperative hemorrhage (P=0.63), biliary fistula (P=0.09), acute pancreatitis (P=0.95), delayed gastric emptying (P=0.33). The mean postoperative hospitalisation period stay was similar in both groups (P=0.63) CONCLUSION: There were not any significant differences between the two groups in the overall postoperative complication rate, the incidence of postoperative haemorrhage, biliary fistula, acute pancreatitis, and delayed.

[Complicated sigmoid tumor: perforated amebiasis]. / Une tumeur sigmoïdienne compliquée: amoebome perforé.

Amoeboma is an inflammatory mass of the colon. It can be an inaugural symptom and thus pose the problem of differential diagnosis with colon cancer. The purpose of this report is to describe the case of a 43-year-old patient who presented with acute abdomen. Physical examination revealed a perforated circumferential mass in the sigmoid colon. Based on a presumptive diagnosis of colonic cancer complicated by perforation, segmental colectomy was performed. Histological examination of the surgical specimen demonstrated colonic amoeboma. The patient was treated using metronidazole. Although rare, amoeboma must be considered in differential diagnosis of cancer of any colonic mass.

Abdominal metastasis of a parosteal osteosarcoma of the femur: an unusual cause of large-bowel obstruction.

BACKGROUND: Parosteal osteosarcoma is a rare, well-differentiated, predominantly fibro-osseous variant of osteosarcoma. It is regarded as a distinct form of osteosarcoma with better prognosis than conventional osteosarcoma. AIM: We report an unusual case of abdominal mass recurrence of parosteal osteosarcoma of the left distal femur treated eight years previously with wide resection, hip disarticulation and chemotherapy, which presented as an acute abdomen: we discuss the clinical outcomes of this rare entity. CASE PRESENTATION: We present a 54-year-old patient with low-grade parosteal osteosarcoma of the left distal femur. Left total hip disarticulation was indicated after several local relapses of the tumour following extensive resection and chemotherapy. Eight years later, he presented with an acute large bowel obstruction secondary to a compression of the large bowel by an abdominal mass. Abdominal computed tomography showed a large abdominal calcified mass with dilated large bowel loops. During laparotomy, the mass was unresectable. So, the patient underwent emergent colostomy of diversion. Biopsy of the lesion yielded grade III parosteal osteosarcoma material. The patient received adjuvant chemotherapy, but the response was poor: six months later, the patient presented with a peristomal mass and two pulmonary metastases. CONCLUSION: Abdominal recurrence of parosteal osteosarcoma of the distal femur eight years after definitive surgery is rare. This case emphasises the importance of the long-term follow-up of patients with parosteal osteosarcoma.

Cystic echinococcosis in Tunisia: analysis of hydatid cysts that have been surgically removed from patients.

Echinococcosis/hydatidosis caused by Echinococcus granulosus has a widespread distribution in the human population of Tunisia, particularly in the north-west and centre-west of the country. In a recent study, the morphological features, fertility and viability of hydatid cysts that had been excised from patients in Tunis were explored, and the E. granulosus strain or genotype involved in each case was identified from morphology of the protoscolex hooks and the results of molecular genotyping. The hepatic cysts investigated came from 41 patients [31 women and 10 men, with a mean (S.E.) age of 43.41 (14.25) years] who were treated for cystic echinococcosis, by surgery but rarely with chemotherapy, at the La Rabta Hospital in Tunis, in the 12 months ending in June 2008. Most (56%) of these patients originated from rural areas in endemic governorates. Of the 60 hepatic cysts that were studied, 38.3% were located in the right lobe of the liver and 35.0% each involved both hepatic lobes. Almost a third (31.7%) of the excised cysts were degenerating, with the rest considered viable and either multivesicular (38.3%) or univesicular (30.0%). Almost all (93.3%) of the cysts were categorized as fertile, with a mean protoscolex viability of 21.8%. Protoscolex viability was relatively high in the viable univesicular cysts with a visible cyst wall and in the multivesicular and multiseptate cysts with daughter cysts, and lowest in the cysts that appeared to be solid calcified masses. The observed variation in protoscolex viability with cyst type, in cysts excised from patients before any chemotherapy, supports the cyst classification recommended by the World Health Organization but could also be compatible with the imaging-based 'Gharbi' classification. The results of the molecular genotyping showed that all 23 cysts investigated (which came from 20 of the patients) were caused by E. granulosus of the G1 genotype (also known as the 'sheep' or 'sheep-dog' strain).

[Primary hydatid cyst of the psoas muscle: description of 9 cases in Tunisia and review of the literature]. / Kyste hydatique primitif du psoas: 9 cas tunisiens et revue de la littérature.

The psoas muscle is an uncommon location for hydatid cyst accounting for only 1 to 3% of cases. The purpose of this report is to describe the epidemiologic, clinical, paraclinical, and therapeutic features of primary hydatid cyst of the psoas muscle. A retrospective study conducted in Surgery Department A at the Rabta Hospital in Tunisia compiled a total of 9 cases of primary hydatid cyst of the psoas muscle treated between 1980 and 2006. There were 6 men and 3 women with a mean age of 42.8 years. Symptomatology was nonspecific with pain in 6 cases. Discovery was coincidental in two cases. Clinical examination detected a mass in the presents of an abdominal mass in 7 cases. Radiologic findings (ultrasound and/or CT scan) confirmed diagnosis in 8 cases. In one case a mistaken diagnosis of psoas muscle abscess was made in a patient with an infected hydatid cyst. Serological tests were performed in 4 cases and were positive in 3. All patients underwent surgical treatment. The extraperitoneal approach (Leriche) was used in 7 cases and the transperitoneal approach via median laparotomy in 2. In all cases the surgical procedure consisted of partial cystectomy leaving a part of the pericystic against neurovascular structures. There was no operative mortality. The only postoperative complication was urinary infection in one patient. Mean follow-up was 2.5 years. One local recurrence was observed 4 years after surgical treatment and required reoperation.

A report of 15 cases of small-bowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties.

UNLABELLED: Phytobezoars are a rare cause of acute bowel obstruction. The purpose of this work was to identify the predisposing factors and diagnostic difficulties of this rare entity. MATERIAL AND METHODS: This was a retrospective study including all cases of small-bowel obstruction secondary to phytobezoars observed between April 2001 and August 2007. The diagnosis of bezoars was established by surgical exploration or by computed tomography (CT). RESULTS: During the study period, 375 patients were hospitalized at our institution with a diagnosis of bowel obstruction that, in 15 (4%) cases, was secondary to phytobezoars. The average patient age was 55 years, with a gender ratio of 1.7, favoring men. The predisposing factors were gastroduodenal surgery for peptic ulcer in nine patients, and excessive consumption of prickly pears (cactus figs) in 12. The diagnosis was established by CT scans in three patients, who were successfully treated with gastric aspiration, thereby avoiding surgery. Laparotomy was performed in 12 patients to allow digital fragmentation of the bezoar, which was then washed into the colon. There were no postoperative deaths and morbidity was about 13%. CONCLUSION: An abdominal CT scan should be obtained for patients with small-bowel obstruction. This examination offers a precise diagnosis of bezoars, reducing the number of unnecessary surgical procedures, and helping to guide the approach if surgery is needed.

[Primary hydatid cyst of the pancreas: Diagnosis and surgical procedures. Report of three cases]. / Kyste hydatique primitif du pancreas: diagnostic et modalites chirurgicales. A propos de trois cas.

The pancreas is an uncommon site of a hydatid cyst, even in countries where echinococcal disease is endemic. We report three cases of primary hydatid cysts of the pancreas revealed by abdominal pain. The diagnosis was based on ultrasound and CT-scan, which showed a cystic mass in the tail of the pancreas in the two first cases. In the third case, the diagnosis was determined preoperatively and a pancreatic fistula was found in the head of the pancreas during peroperative cholangiography. The echinococcal immunological test (Elisa) was positive in all cases. Surgical treatment included resection of the prominent lump in two patients and a cystogastric anastomosis in the third. Based on these three cases and a study of the literature, the difficulties of diagnosing this rare disease and the surgical procedures are discussed.

[Radiologic diagnosis of enterosalpingeal fistula complicating Crohn's disease]. / Diagnostic radiologique d'une fistule entérotubaire compliquant une maladie de Crohn.

Enterosalpingeal fistula is a rare complication of Crohn's disease which is rarely diagnosed preoperatively. We describe a new case of this complication suspected by CT scan and confirmed by hysterosalpingogram and contrast from the ileum. This case is about a 50-year-old woman suffering from ileal Crohn's disease diagnosed two years previously and actually complicated by stenosis and entero-salpingeal fistula. The treatment consisted on resection of the ileocaecal region with salpingectomy. Postoperative course was uneventful.

Kyste hydatique primitif du psoas : 9 cas tunisiens et revue de la litterature

Le muscle psoas est une localisation exceptionnelle du kyste hydatique ne representant que 1 a 3des cas. Le but de ce travail est d'etudier les caracteristiques epidemio- logiques; cliniques; paracliniques et therapeutiques de cette entite. Notre etude est retrospective consecutive portant sur 9 cas de kystes hydatiques primitifs du psoas colliges entre 1980 et 2006 dans le service de chirurgie A de l'Hopital La Rabta. Il s'agissait de 6 hommes et 3 femmes dont l'age moyen etait de 42;8 ans. La symptomatologie etait atypique dominee par les douleurs retrouvees dans 6 cas. La decouverte etait fortuite dans deux cas. L'examen physique retrouvait une masse du flanc dans 7 cas. Le diagnostic etait confirme par la radiologie (echographie et/ou tomodensitometrie) dans 8 cas. Dans 1 cas; le diagnostic d'abces du psoas etait pose a tort chez un patient porteur d'un kyste hydatique infecte. La serologie hydatique pratiquee dans 4 cas etait positive dans 3 cas. Tous les patients etaient operes. La voie d'abord etait extra peritoneale (Leriche) dans 7 cas et transperitoneale a travers une laparotomie mediane dans 2 cas. Le geste a consiste dans tous les cas en une kystectomie partielle laissant une calotte de perikyste contre les elements vasculo-nerveux. La mortalite etait nulle. Un seul patient s'est complique en postoperatoire d'une infection urinaire. Le suivi moyen etait de 2;5 ans. Au cours de la surveillance postoperatoire; une seule recidive locale etait diagnostiquee a 4 ans postoperatoire ayant necessite une nouvelle intervention

[Subcutaneous hydatid cyst. Case report of an exceptional location]. / Kyste hydatique sous-cutané: à propos d'une localisation exceptionnelle.

Primary subcutaneous cyst hydatid disease is an exceptional entity. We report a new case involving a 70-year-old woman hospitalized for a subcutaneous mass in the hypogastric area with no local inflammatory signs. Radiological examination was consistent with a partially calcified subcutaneous cyst in the hypogastric area. Complete surgical resection of the mass was performed with uneventful postoperative recovery. Histopathological examination of the surgical specimen demonstrated multivesicular hydatid cyst.

[A previously unreported late complication of Finney strictureplasty]. / Une complication tardive et inédite d'une stricturoplastie à la Finney.

We report the case of a 23 year old woman, treated for Crohn's disease for 11 years. She was operated on for multiple obstructing jejuno-ileal strictures using strictureplasty technique. Nine stricturoplasties of Heineke-Mikulicz type and one Finney type were performed without immediate postoperative complication. The patient received Imurel(R) and remained in remission for 15 months. Peritonitis due to a perforation of the Finney strictureplasty required re-operation; an ileostomy was performed. Such a late complication of a strictureplasty has not previously been reported in the literature. Although this complication was severe, the indication for this procedure in the surgical management of Crohn's complications should not be modified.

[Unopened colostomy in colorectal surgery: a renewal interest?]. / La colostomie à ouverture potentielle en chirurgie colorectale: un regain d'intérêt?

INTRODUCTION: Anastomotic leak or disruption is a grave complication of colorectal surgery. Protection of an at-risk anastomosis by an upstream open diverting colostomy (OC) reduces this gravity. An unopened upstream loop colostomy is a surgical alternative which may diminish the unpleasant consequences of an open colostomy while maintaining the option of diversion in case of need. The aim of this study is to report the results of this approach and to define its indications. MATERIAL AND METHODS: [corrected] We report a retrospective series of 34 cases of unopened diverting loop colostomy to protect an at-risk colorectal anastomosis. Indications for this procedure were stool-laden bowel (59%), low serum albumin (11.5%), local inflammation (11.5%), and very low placed anastomosis (17.5%). RESULTS: The loop colostomy was eventually opened after surgery in six cases because of anastomotic leakage diagnosed clinically and/or detected by water soluble contrast opacification which was performed routinely on the sixth post-operative day. In all six cases, there was no need for an urgent surgical intervention. In 28 cases, the anastomosis healed without complication and the exteriorized loop was returned to the abdominal cavity seven days after the initial surgery. This was a short, simple procedure with an average operating time of ten minutes. Average hospital stay after returning the unopened colostomy to the abdomen was two days. CONCLUSION: Unopened loop colostomy offers the advantages of protection of a colorectal anastomosis without proper morbidity or mortality, shorter hospitalization, and improved psychological comfort for the patient. It's principal indication is to minimize the risks related to leakage from an at-risk colorectal anastomosis.

[Gastric amyloidosis mimicking malignancy. A case report]. / Amylose gastrique simulant une linite plastique. A propos d'une observation rare.

Amyloidosis is an abnormal extracellular deposition of insoluble proteins, which is associated with an involvement of the gastrointestinal tract in 50 to 70% of cases. In primary amyloidosis (light chain amyloidosis), localized gastric involvement is a rare finding which can mimic malignancy. We report the case of a 56-year-old man, admitted with upper digestive outlet obstruction. Linitis plastica with lymph node involvement was suspected by gastroscopy, barium meal and endoscopic ultrasonography but was not confirmed by gastric biopsies. The patient was treated with total gastrectomy with lymph node dissection. Pathological examination demonstrated gastric and lymph nodes amyloidosis and no malignant tumor was found. The patient died 9 months later from cardiac failure due to amyloidosis.

[Laparoscopic cholecystectomy in a patient with situs inversus]. / Cholécystectomie laparoscopique chez un patient porteur d'un situs inversus.

Laparoscopic cholecystectomy is the standard approach to manage symptomatic gallbladder stones. However, only twelve patients with total situs invertus have been previously reported in the literature. We report a new case of a 58-year-old patient hospitalized for acute pain of the left hypochondrium with fever. The diagnosis of acute cholecystitis with situs inversus totalis was made following clinical examination and radiological investigations. Laparoscopic cholecystectomy was subsequently performed through a modification of the technique to adapt to the mirror image anatomy.