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.

Enterosalpingeal fistula complicating Crohn's disease: Report of two cases and review of the literature.

INTRODUCTION AND IMPORTANCE: Reports of enterosalpingeal fistulae complicating Crohn's disease are scarce. They involve the last ileal loop and lead to a progressive destruction of the salpinx. Usually, no genital symptoms are found. In all the cases reported in the literature, the fistula was diagnosed intra-operatively and resection of the right salpinx was performed without the patient's pre-operative consent. CASE PRESENTATION: We describe 2 cases of women presenting with an Enterosalpingeal fistulae complicating Crohn's disease. Radiological findings allowed a pre-operative diagnosis. Thus, the patients were warned of the right salpinx resection and consent was obtained. CLINICAL DISCUSSION: Enterosalpingeal fistulae complicating Crohn's disease are exceptional. Indeed, to the best of our knowledge, only five cases have been reported till now. In all the reported cases, no genital signs were present. As for our patients who didn't experience such symptoms. Moreover, no radiological evidence of the enterosalpingeal fistula was found in the literature. Consequently, the fistula was always diagnosed intra-operatively. For our patients, radiological findings allowed a pre-operative diagnosis. This permitted to warn them of a possible resection of the fallopian tube. Intra-operative findings were unfortunately conflicting with its preservation. CONCLUSION: Enterosalpingeal fistula is an exceptional complication of the Crohn's disease. No clinical findings are present. The diagnosis should be evoked when the CT-scan or the MRI show an abnormal apposition between the fallopian tube, the last loop and the cecum. Surgical resection of the involved salpinx with the diseased intestinal segment is unfortunately usually needed in a young patient population.

Tuberculous severe acute colitis. A case report.

INTRODUCTION: and importance: Intestinal tuberculosis represents 2% of the ten million cases of tuberculosis reported in 2018. Herein, we report a case of tuberculous severe acute colitis. It is a rare and life-threatening condition. Our literature review found only five published cases. It occurs generally in immunocompromised patients. Extended colonic inflammation seems to be the main predictive factor of death. Moreover, an early diagnosis and rapid onset of antituberculous treatment are mandatory to save the patient's life. CASE PRESENTATION: Herein, we present a case of tuberculous severe acute colitis with a review of the reported cases. The patient presented with a severe and idiopathic acute colitis. He was put on broad-spectrum antibiotics and intravenous corticosteroids. At day two, he developed septic shock and colic perforation. Colectomy was performed. Microbiology investigation and pathology examination confirmed tuberculous colitis. CLINICAL DISCUSSION: Tuberculous severe acute colitis occurs generally in immunocompromised patients. Extended colic inflammation seems to be the main predictive factor of death. Moreover, an early diagnosis and rapid onset of antituberculous treatment are mandatory to save the patient's life. However, diagnosis is difficult as symptoms aren't specific. Microbiology and pathology were compulsory to retain colic tuberculosis in all the reported cases. CONCLUSION: Tuberculous severe acute colitis is a challenging and life-threatening condition. It usually occurs in immunocompromised patients. Abdominal CT-scan may evoke the diagnosis. Microbiology and pathology are mandatory to retain the diagnosis. Early diagnosis and onset of antituberculous treatment are compulsory to save the patient's life.

Characterization of Kef Shfeir phosphate sludge (Gafsa, Tunisia) and optimization of its dewatering.

Water separation and recovery through thickening require adapted flocculants and densification processes. This study aimed to maximize water recovery from phosphate sludge (PS) at Kef Shfeir mine operation, Gafsa Phosphate Company, Tunisia. Representative samples of PS, PS treated with flocculant (F-PS), raw water, and recycled water were collected on the mine site. Solid samples (PS and F-PS) were characterized physically, chemically and mineralogically. To maximize water recovery, thickening tests were performed on the PS using different flocculants to optimize flocculant concentration, the agitation speed and the settling time. Results showed that PS had positive surface charge since its paste pH (7.3) was lower than pHPZC (8.0), whereas the tested flocculant (Slim Floc used by the company) showed negative surface charge. Solid samples contained coarse medium and fine particles of carbonates, silicates and residual hydroxyapatite. The cumulative fractions +32 µm of PS contained a promising residual potential of fluorapatite (up to 39.2%). Water recovery was about 58.1%, when the anionic Slim Floc was used, for a consumption rate of 1200 g/t of dry solids. Best efficiency (84%) of water recovery was obtained with the anionic flocculant E24 for a consumption rate of 360 g/t of dry solids, which is 3 times lower than actual flocculant consumption.

Adult intussusceptions: Clinical presentation, diagnosis and therapeutic management.

BACKGROUND: Adult intussusception is a rare clinical entity. It is an uncommon cause of intestinal obstruction in adult. It often presents with nonspecific symptoms and preoperative diagnosis remains difficult. The purpose of this study was to determine the clinical entity and surgical approach of adult intussusception. METHODS: We have conducted a retrospective descriptive study starting from 2006 until 2014. We reviewed data for all patients that had been admitted to our department for intestinal intussusception. RESULTS: Eight consecutive patients were admitted to our department. The mean age was 48 years old (20-71). The sex ratio was 0,6. The clinical presentation was acute in 5 cases. A computed tomography was performed in 6 cases. The diagnosis of gastrointestinal intussusception was made preoperatively in 100% of patients. All patients underwent surgery. An organic lesion was identified in 100% of the cases. In all cases, resection of the intussuscepted intestinal loop was done without intestinal reduction. All patients were well followed up and recurrences have been documented. CONCLUSION: In adults, intussusception is usually secondary to an organic cause. In the absence of signs of severity, etiologic diagnosis based on CT allows the diagnosis of the intussusception and sometimes can detect the causal lesion. Therapeutic sanction of intussusception is surgery and there is more emphasis towards resection without reduction.

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.

[Recurrence of hydatid cyst of liver: predictive factors: Tunisian experience]. / Les facteurs prédictifs de récidive du kyste hydatique du foie : l'expérience tunisienne.

Cystic echinococcosis is a public health problem. Surgery represents the basic treatment and the surgeon is regularly faced with the choice of the appropriate surgical procedure (radical versus conservative surgical approach). The conservative procedure is safe and easy but can lead to a recurrence in the site of residual cavity. The aim of this study was to evaluate the predictive factors of the recurrence of hepatic hydatid cysts, to optimize surgical management and to implement preventive measures. The current retrospective study included 391 patients with hepatic hydatid cysts operated at our institution from 1996 to 2006. The diagnosis of recurrence was suspected by radiological survey and confirmed at laparotomy. The univariate study of predictive factors of recurrence was based on the Fisher test and the multivariate one on the logistic regression model. The recurrence rate reached 12% in our study with an average period of 50 months. Univariate analysis showed that the predictive factors of recurrence were: the rural origin of patients, the voluminous cysts larger than 7 cm, and unilocular hydatid cyst. Multivariate analysis showed that only voluminous cysts and unilocular ones were the predictive factors of recurrence. The unilocular and voluminous hydatid cysts represent the cysts that relapse frequently because of their immunogenic character and the presence of exocysts in the pericysts. This is very important for the therapeutic strategy the main aim of which is to prevent the recurrence.

[Primary and isolated phrenic hydatid cyst in Tunisia]. / Kyste hydatique primitif et isolé du diaphragme en Tunisie.

The hydatid cyst of the diaphragm is defined as the development of a hydatid cyst in the diaphragm muscle. The purpose of this study is to identify the specific pathogenic, clinical and therapeutic aspects of this hydatid cyst. It is important to confirm the diagnosis of the location before surgery. We report the case of a patient aged 40 years, in whom the diagnosis of hydatid cyst of the diaphragm was made incidentally in the course of a gastric stromal tumour. The patient was operated by a midline laparotomy. Resection of the protruding dome of hydatid cyst of the diaphragm was carried out along with total gastrectomy. The postoperative course was uneventful. After 12 months, the results were negative. The diagnosis of hydatid cyst of the diaphragm is based on the thoraco-abdominal CT scan. The treatment is surgical based on the topographic features of the cyst.

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.

Paratesticular Liposarcoma: what is the best Therapeutic Strategy?

Introduction: Liposarcomas are neoplasms of mesodermal origin derived from adipose tissue and correspond to 10-14of all soft tissue sarcomas. Paratesticular liposarcoma is very rare. Case report: We report a 60-year old man who presented with a left testicular tumor 20 cm in diameter. Initial incisional biopsy was reported as fibromatosis. Chest and abdominal CT scan did not show distant metastases. Through an inguinal incision orchidectomy with homolateral inguinal node dissection was performed. Histopathological examination showed a paratesticular myxoid liposarcoma. Adjuvant radiotherapy without chemotherapy was administered. The patient remains well at 11 months followup; with no evidence of recurrence. Conclusion: Complete surgical extirpation reduces the risk of local recurrence. Neoadjuvant chemotherapy or radiotherapy may reduce the tumor size; thus facilitating complete excision

[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.