[Laparascopic cholecystectomy on a previously operated abdomen]. / Les choléystectomies sous coelioscopie sur abdomen cicatriciel.

BACKGROUND: Laparoscopic cholecystectomy is the "gold standard" reference treatment of gall bladder stones. Laparoscopy is still contra-indicated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. AIM: This study aimed to assess outcomes of laparoscopic cholecystectomy on a scarred abdomen. METHODS: We have carried out a retrospective study on a number of consecutive patients operated between the first januar 2000 and 31 december 2006, who underwent laparoscopic cholecystectomy with previous abdominal surgery (one or several) during this period, laparoscopic cholecystectomy was performed on 2281 patients, including 233 patients who had at least one abdominal scar (10%). We have noted on the records of these patients all the data relating to the epidemiological, clinical and therapeutical aspects. We have worked out a descriptive analysis of the series and we have thus studied the rate of operative and post-operative complications, the rate of conversion, the duration of the operation and the duration of post-operative stay. Then we have compared two groups of patients, those with an upper abdominal surgery: group 1 (G1) and those with lower abdominal surgery: group 2 (G2). RESULTS: The groups consist of 200 women and 33 men aged on average 13.8 +/- 49.6 years. The indication for cholecystectomy was a symptomatic cholelithiasis in 78% of cases (n = 181), an acute cholecystitis in 22% of cases. The adhesions were believed numerous or very numerous in only 46 patients (20%). Four patients had interventional adverse events: a small intestine injury, a choledoch injury, a gastric injury and a least known colic injury. The rate of open conversion was 2.1%. Post-operative complication was 2.1%. The evolution was satisfactory in all cases. Mean operating time was 50 minutes (15-230). Mean post operative stay was one day (1-29 days). When comparing the above mentioned two groups of patients (G1: 45 patients and G 2: 188 patients), we can conclude that the first group (G1) is made up of more male patients aged over 60 years (p < 10-3). It also appears that the existence of an upper umbilical scar is correlated to a greater number of adhesions (p < 10-3), an increased risk of operative complications (p = 0.01), a greater conversion rate (p < 10-4), a prolonged operating time (p < 10-3) and a longer stay (p = 0.017). On the other hand, post-operative complications was similar in group 1 and 2. CONCLUSION: Previous abdominal operations, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a higher rate of adhesions, an increased risk of operative complications, a greater conversion rate, a prolonged operating time and longer stay.

[Hydatid cysts of the pancreas, report of two cases]. / Kyste hydatique du pancréas: propos de deux observations.

BACKGROUND: Hydatid cyst of the pancreas is a rare affection with a frequency less than one percent of the various sites of hydatid disease. AIM: We report two cases of hydatid cyst of the pancreas. CASE 1: A 49 year old woman with a history of laparotomy for liver and peritoneal hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 3 cm in size. Surgical treatment consisted in a resection of the protruding dome with uneventful postoperative course. CASE 2: A 45 year old man who underwent laparotomy four years ago for hepatic hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 4 cm in size. At laparotomy it was a head pancreatic hydatid cyst without duct pancreatic lesion. The treatment consisted in the resection of the protruding dome. The postoperative evolution was simple. CONCLUSION: Hydatid cyst of the pancreas is rare. If associated with another hydatid localization, the diagnosis is generally easy. It can however be more difficult if the pancreatic localization is isolated. In most cases, resection of the protruding dome is sufficient.

Squamous cell carcinoma arising in Verneuil's disease.

BACKGROUND: Verneuil's disease or hidradenitis suppurativa is a chronic suppurative, and cicatricial inflammatory disease, mainly affecting apocrine-bearing area of the skin. Squamous cell carcinoma is an uncommon but a frightening complication of hidradenitis suppurativa. AIM: To report a new case of squamous cell carcinoma arising in Verneuil's disease. CASE REPORT: We reported a case of 60 year old man with a 30 years history of hidradenitis suppurativa in which squamous cell carcinoma arise. A wide surgical excision removing the tumour and leaving a large defect was performed. The patient had a well recovery, wounds healed well by primary intention. No recurrence observed at 18 months of follow up. CONCLUSION: Squamous cell carcinoma is an uncommon complication of hidradenitis suppurativa. Surgical excision represents also the treatment of choice.

[Myofibroblastic tumor of the great omentum]. / Tumeur inflammatoire myofibroblastique du grand épiploon.

BACKGROUND: Myofibroblastic tumors are a spindle cell lesion of indeterminate malignant potential. Abdominal location was rare. AIM: We report a case of an unusual location of myofibroblastic tumors in the great omuntum. CASE REPORT: A 63-year-old women presented with a one year of isolated left hypochondrium pain. Physical examination was normal. CT scan of the abdomen showed a multicystic and a multilocular building-up of the great omentum suggestive of a peritoneal haemolymphagioma. Besides, at the MRI, this lesion showed up with threefold component: cystic, plump and fibrous, all leading towards a myofibroblastic tumor. At laparotomy, there was already a 10 cm diameter cystic tumor of the great omentum, composed of numerous cystic sockets, all filled with a thick brunish substance. A total resection of the great omentum was done, thus taking away the whole tumor. The histological examination confirms the diagnosis of myofibroblastic tumor of great omentum.. Post operative evolution was uneventful. One year later there were no signs of recurrence. CONCLUSION: Myofibroblastic tumors of the great omentum are rare. The diagnosis is often confirmed by careful microscopic examination or immunohistochemical markers. Treatment consists on a complete surgical resection and life-time follow-up is needed because the risk of recurrence.

[Predictive factors of morbidity and mortality after surgery in the elderly]. / Facteurs prédictifs de morbidité et de mortalité de la chirurgie du vieillard.

UNLABELLED: The aim of the study was to determine prognostic factors of post operative morbidity and mortality for patients aged 80 years and older. We compared two groups of patients aged 80 and over operated to determine predictive factors of morbidity and mortality: group of patients who presented post operative complication within 30 days after surgery and group of patients without any complication. Comparison of the two groups for global morbidity using univariate analysis showed only one prognostic factor: surgery of diabetic foot (p = 0.034). Predictive factors of mortality according to univariate analysis were: pre-operative shock (p = 0.001), abdominal wall pathology (p = 0.027), gastric or duodenal ulcer diseases (p = 0.011) and global morbidity (p = 0.006). After logistic regression, only pre-operative shock was an independent predictive factor of mortality (p = 0.0023). CONCLUSION: Risk for morbidity after surgery in the elderly 80 years and over is linked with type of surgery and not with soil. Likewise, risk for mortality is linked with advanced stage of disease that is presence of pre-operative shock and not with soil.

[Acute pancreatitis due to lupus]. / La pancréatite aiguë lupique.

Among digestive clinical presentations of systemic lupus erythematosus, acute pancreatitis remains a serious affection with very poor prognosis. To date, pathogenesis is still unclear. We report two cases of fatal acute pancreatitis related to systemic lupus erythematosus.

Trauma of an ectopic kidney. A case report.

Ectopic kidney is a rare pathology. It is usually misknown and often revealed by a complication. We report a case of a 30-year-old male patient who presented in emergency with a right thoraco-abdominal trauma and a benign head trauma. Injury evaluation revealed a right ectopic pelvic kidney with a grade IV laceration. Furthermore, there was a hepatic contusion in the sixth segment and a fracture of the ninth, tenth and eleventh right ribs. Therapeutic attitude consisted on a successful conservative and nonoperative treatment for both lesions. CT scan is of utmost importance in diagnosis. Management is the same as for normally positioned kidney.

Neuroendocrine tumours of the digestive tract report of two cases and literature review.

Neuroendocrine tumors (NET) of the digestive system are rare. They comprise only 1% of all the tumors of the gastrointestinal tract. The aim of this study is to report two cases of exceptional localization of non secretary neuroendocrine tumors. Their difficulty in diagnosis, treatment and controversy in chemotherapy merit their study in depth. These are two patients that were treated in the department of general surgery (Beau Séjour) in Charles Nicolle Hospital for non secretary (NET) of the pancreas and stomach. The first was presented as a painless epigastria mass with frequent diarrhea. The second was presented as a painful mass in the left hypochondriac area without any other symptoms. Biochemical evaluation confirmed their non secretary properties. Surgery remains the first line of treatment. It was possible for the gastric, but not for the pancreatic tumor. Both were very advanced and had metastasis. Histopathological evaluation and immunohistochemical study using the method of peroxydase antiperoxydase (PAP) complexes for some special monoclonal antibodies confirmed the diagnosis. Chemotherapy of both cases was mal tolerated and was discussed in details.

[Prognostic study of liver abscess]. / Etude pronostique des abcès du foie.

The objective of this work is to study factors of prognostic of mortality of abscesses of the liver. We have treated between 1990 and 2000 in our service, 38 patient for abscess of the liver. The symptoms are dominated by the pain of the right hypochondria (37 cases) and the fever (34 cases). An unique abscess has been recovered in 25 cases. Some multiple localizations have been observed in 12 cases. 21 patients have been operated. The bacteriological study at all patients revealed the presence of germ in 27 cases. In 6 cases, there were two germs. It was a bacillus negative gram in 26 cases and a cocci positive gram in 7 cases. Six complications have been observed at the operated patients. In 5 cases, it was a septic shock having leads to the death. After survey univariate and multivariate the only factor of bad prognostic recovered is the septic shock. The aetiology was identified in only 9 cases; it was abscess cholangiotis.

[Acute cytomegalovirus colitis after bone marrow transplantation]. / Colite aiguë grave à cytomégalovirus après greffe de moëlle osseuse.

Cytomegalovirus infection of the digestive tract is rare and particularly severe after transplantation. Colon is the most often affected part of the digestive tube. We present the case of acute cytomegalovirus colitis that occurred five months after a bone marrow transplantation. An emergency subtotal colectomy with sigmoidostomy and ileostomy was performed followed six weeks later by an ileorectal anastomosis. The pathologic specimen showed cytomegalovirus inclusion bodies proving the diagnosis.

[Small bowel neurofibromatosis in Von Recklinghausen's disease. A rare cause of emergency surgery]. / Les neurofibromes du grele au cours de la maladie de von Recklinghausen. Une cause rare d'urgence chirurgicale.

Two cases of small bowel neurofibromatosis in patients with Von Recklinghausen's disease are reported. Diagnosis of small bowel neurofibromatosis was made on the occasion of a complication for the two cases. We insist on the difficulty of diagnosis as well as in presence or not of complications. Treatment of these most often benign tumours remains surgical based on a segmental small bowel resection.

[Abdomino-pelvic actinomycosis: a case report]. / Actinomycose abdomino-pelvienne: à propos d'un cas.

The actinomycosis is a chronic suppurative granulomatosis disease. It is owed to a bacillus gram positive; actinomycès israelli. The cervical and thoracic localizations are most frequent. The digestive localization represents 20% of cases. It interest very rarely the pelvis and the genital tracts. We bring back the observation of a patient old of 30 years admitted for mass abdominal. To the exam, the patient had a sensibility of the left hypochondriac area and we found a mass of 6 cm of diameter. To the rectal touch, we found a mass in the bag of Douglas. The echography and the computed tomography revealed a collection under the spleen and a pelvic collection. A rectotomy is performed. The bacteriological study isolates actinomycès israelli. The collection under the spleen is drained under radiological control. Actinomycès israelli is also recovered in the pus brought back by the puncture. The patient is treated by Penicillin. The patient had a favourable evolution. No etiology is found at this patient. For this observation, the collection was accessible to a drainage permitting the diagnosis and the treatment of the actinomycosis while avoiding a mutilated surgery.

[Prognostic factors for splenectomy for hematologic diseases]. / Facteurs pronostiques des splenectomies pour rate hematologique.

The aim of this study was to identify the prognostic factors of intraoperative haemorrhage, perioperative blood transfusions and morbidity. We collected 120 splenectomies in Beau Séjour department of surgery, Charles' Nicolle Hospital, Tunis, Tunisia between 1979 and 1999. The descriptive analysis showed sex-ratio 0.82 with mean age (+/- standard deviation) 30.6 +/- 15 year. Idiopathic thrombopenic purpura was the principal disease indicating splenectomy. Morbidity was defined as occurrence of post operative peritoneal sepsis or bleeding. The mortality and morbidity rates were respectively 0.8% and 6.6%. The prognostic analysis didn't identify predictive factors of intraoperative haemorrhage, however it identified two independent predictive actors of specific morbidity: intraoperative haemorrhage (p = 0.03) and preoperative rate of haemoglobin (p = 0.0049).