Predictive factors of occult cystobiliary fistulas during conservative treatment of hepatic hydatid cyst: a prospective study.

BACKGROUND: Occult cystobiliary fistula (CBF) is a common complication of hepatic hydatid cyst (HHC). It is often the cause of high morbidity of conservative treatment of HHC. This study aimed to determine the predictive factors of occult CBF to establish the indications for the investigation and treatment of these CBFs. METHODS: This was a prospective study that included all operated HHCs over a 3-year period. HHCs complicated with large CBFs were not included in the study. Systematic cholecystectomy and methylene blue test for all cysts were performed. RESULTS: A total of 46 patients operated on with 113 cysts were included in this study. The median cyst size was 6.7 cm (IQR, 1-38). A total of 114 CBFs were detected in 51 cysts (45.1%). The postoperative course was simple in 95.0% of cases. The specific morbidity rate was 2.7%. In a bivariate study, absence of mass and abdominal pain on palpation, hemoglobin level >11.55 g/dL, negative hydatid serology, cyst size, absence of calcifications, vascular compression, existence of a single cyst, and localization at segment VIII were predictive factors of occult CBF. At the end of the multivariate study, cyst size was determined to be the only predictive factor for occult CBF. A threshold of 3 cm was used. CONCLUSION: Cyst size is a major predictive factor for occult CBF.

Cystic Echinococcosis of the Liver: Correlation Between Intra-Operative Ultrasound and Pre-Operative Imaging.

Background: Imaging plays an essential role in the management of hepatic hydatid cysts (HCE). The objective of our study was to determine the correlation between pre-operative ultrasound, computed tomography (CT), and intra-operative ultrasound (IOUS) in studying the characteristics and complications of HCE. Patients and Methods: This was a prospective, descriptive, and analytical study conducted in the General Surgery Department of Habib Bourguiba Hospital in Sfax. The study included patients with HCE who underwent conservative surgery between April 2017 and June 2022. Results: We enrolled 49 patients with 94 cysts. At the end of our study, IOUS allowed for better detection of HCE (98.8%) regardless of the number of cysts per patient. IOUS and CT were accurate in studying the location of cysts (κ = 1), whereas pre-operative abdominal ultrasound was less efficient (κ = 0.870). IOUS was the best examination for detecting exocysts (κ = 0.961), studying daughter cysts (κ = 0.823), and exploring vascular relations, but it was less effective (κ = 0.523) in detecting calcifications. Regarding classifications, ultrasound and CT had similar results. However, IOUS was most reliable in differentiating between CE3b and CE4 types (κ = 0.653). Ultrasound, CT, and IOUS were not sensitive in detecting latent HCE suppurations and cystobiliary fistulas. Conclusions: Performing IOUS is essential to prevent recurrences and reduce post-operative morbidity.

Primary cystic echinococcosis of the peritoneum: a case report.

BACKGROUND: Peritoneal cystic echinococcosis happens usually after traumatic rupture or after surgical treatment. Primary peritoneal cystic echinococcosis is a very rare case that constitutes a diagnostic and therapeutic challenge. CASE REPORT: A 30-year-old Tunisian man was admitted for hypogastric pain since 4 months. He has a 10 cm hypogastric mass. Biological-tests were normal. A computed tomography Scan showed a cystic mass on the pelvis measuring 13 × 17 cm without echinococcosis cyst in the liver. The patient was operated and we found a cystic mass of 17 cm located on the Douglas cul-de-sac that suggest a pelvic hydatid cyst. We have performed an aspiration of the cyst confirms the diagnosis followed by injection of hypertonic solution, extarction of the germinal layer and a maximal reduction of the pericyst. The postoperative course was uneventful. CONCLUSION: Trough our case, we try to focus on the diagnosis and therapeutic options of this rare entity that we should think of in front of a patient with isolated peritoneal cyst especially in endemic country.

Spontaneous perforation of the common bile duct in adults presenting as biliary peritonitis: a case report and literature review.

Spontaneous perforation of the common bile duct (SPCBD) is an exceptional disease, especially in adults. The cause is often idiopathic once trauma and choledochal cyst are excluded. Early diagnosis is often difficult because of its often-misleading appearance. Case presentation: The authors report the case of a 54-year-old man, a known case of type 2 diabetes mellitus, who presented to our emergency department for acute abdominal pain that had evolved for 2 days. Clinical findings and investigations: On physical examination, the patient had a fever of up to 38.5°C, and the abdomen was distended and generally tight. The abdominal computerized tomography scan confirms the presence of free fluid. In addition, the thickness of the gallbladder wall had increased in contrast with a resolved gallbladder distention. Because exploration failed to demonstrate the cause of ascites, the authors performed a diagnostic paracentesis, which revealing ascites with a dark yellow-green color, which implied bile leakage.After initial resuscitation, an emergent exploratory laparotomy was performed. The authors found biliary peritonitis secondary to SPCBD. After peritoneal lavage, the perforation was repaired over a T-tube. The postoperative course was uneventful. Histological findings were consistent with ulcerous acalculous cholecystitis. The patient was disease-free after a 3-month follow-up. Discussion: SPCBD is an uncommon condition in adults, and it is rarely reported in the literature. The pathogenesis of this disease is not clear and may be related to single or multiple factors. Usually, this disease is diagnosed in the postmortem. Early diagnosis and optimal surgical treatment are challenging. Conclusion: This present case highlighted the preoperative diagnostic difficulties of the SPCBD. Emergent surgical management should be instituted in the shortest time possible to reduce the high mortality.

Spontaneous perforation of primary gastric diffuse large B-cell lymphoma.

Primary gastric malignant lymphoma is a rare tumor. The complications associated with lymphoma are perforation, bleeding, or upper gastrointestinal stricture. While it is well known that perforations in gastric lymphoma often occurs during chemotherapy, spontaneous perforation is extremely rare in patients who did not receive chemotherapy. This complication requires a surgical treatment.

A rare case of small intestinal metastasis from lung cancer.

We report the case of a 61-year-old male patient who was admitted with abdominal pain, vomiting and constipation. He had a past medical history of epidermoid lung cancer .computed tomography revealed distended stomach with mural bowel thickening. It was peroperatively two small-bowel metastasis from lung cancer that we resect.

Acute post-traumatic dermoid peritonitis: A rare entity.

Rupture of ovarian dermoid-cyst is rare case. We report the case of a woman admitted for acute post-traumatic abdominal pain due to ruptured ovarian cyst. The patient was operated and we found a very abundant peritoneal effusion with left ovarian cyst which was broken. we performed a left adnexectomy.

Laparoscopic diverticulectomy of perforated right-sided colonic diverticulitis.

The perforation of the right-sided colonic diverticulitis (RSCD) is a rare surgical emergency with highly variable clinical presentations. The preoperative distinction between acute appendicitis and perforated diverticulitis represent a dilemma for surgeon. The laparoscopic repair is a feasible method instead of ileocecectomy in selected cases.

Mesenteric lipoma revealed by chronic abdominal pain: A rare case report.

Mesenteric lipoma is a rare entity. It can be asymptomatic or revealed by unspecific clinical symptoms. Complete resection of the lipoma is often proposed to prevent complications. We report a case of mesenteric lipoma revealed by chronic abdominal pain, and we performed a literature review regarding this rare condition.

Gastric trichobezoar: An uncommon cause of epigastric pain: A case report.

Trichobezoars are foreign and indigestible materials in the gastrointestinal tract and are usually found in psychiatric females, who often deny eating their own hair, but also at situations of gastric dysmotility and prior gastric surgery. Although rare, gastric trichobezoar should not be forgotten as a differential diagnosis in females presenting with vague epigastric pain. Its treatment well in time will prevent complications.

[Surgical treatment of hydatid cysts with large biliocystic fistula in conservative strategy]. / Prise en charge des larges fistules bilio-kystiques lors de la chirurgie conservatrice du kyste hydatique du foie.

INTRODUCTION: the treatment of large biliocystic fistulas is not unanimous among authors in the absence of consensus or a high level of evidence. There is a controversy over the use of a radical approach which allows the fistula to be sutured in a healthy area or conservative treatment that poses repair issues. The purpose of this study is to compare different conservative techniques to treat large biliocystic fistulas. METHODS: we conducted a retrospective study of 54 patients with large fistulas in the Department of General Surgery at the Habib Bourguiba University Hospital in Sfax over a period of 9 years (2010 - 2018). RESULTS: fourty-four patients were enrolled in the study. Abdominal ultrasound suggested opening of the bile ducts in 18 cases (47.4%) while computed tomography (CT) scan suggested opening in 28 patients (68.3%). The treatment of fistulas was based on DITFO (internal trans-fistulary drainage) in 18 cases (33.3%), cystobiliary disconnection (PERDROMO) in 11 cases (20.4%) and bipolar drainage in 25 cases. Specific surgical morbidity rate was 31.5% and it was dominated by postoperative biliary fistula in 18.5% of cases. DITFO technique was associated with shorter hospital stay (p=0.028) and lower morbidity rates (22.2%) with no statistically significant difference. CONCLUSION: DITFO technique is the gold standard technique in the treatment of biliocystic fistula because it is associated with lower morbidity rates and the shortest hospital stay.

[Hemocholecyst complicated by rupture of the gallbladder]. / Hémocholécyste compliquée d'une rupture de la vésicule biliaire.

Hemocholecyst is defined as a hemorrhage into the gallbladder. It is a rare complication of anticoagulant therapies which can progress to spontaneous rupture of the gallbladder with hemorrhagic shock. We report the case of a 75-year old hypertensive, dyslipidemic man with hypertensive heart disease initially hospitalized for left hemiplegia. The patient received antiplatelet and anticoagulant therapy with low molecular weight heparin (LMWH) as prevention strategy. After 5 days of treatment the patient developed hemocholecyst and hemoperitoneum, confirmed by angio-abdominal computerized tomography scan in emergency assessment. The patient underwent cholecystectomy, hemostasis of the gallbladder fossa and evacuation of the hemoperitoneum.

[Splenic artery aneurysm rupture at the end of pregnancy: a case study]. / Rupture d'un anévrisme de l'artère splénique en fin de grossesse: à propos d'un cas.

Bleeding during pregnancy may not be due to obstetric causes. Pregnancy is a predisposing factor for some disorders due to physiological changes. These obstetric bleedings are rare but are responsible for high materno-fetal mortality. Prognosis depends on the speed of diagnosis as well as on multidisciplinary management. Splenic artery aneurysm (SAA) rupture during pregnancy is rare with a dreadful prognosis. Common clinical signs including abdominal pain associated with hypotension and anemia are very misleading for the obstetrician who usually suspects retroplacental hematoma or uterine rupture. We report the case of a pregnant patient requiring emergency laparotomy due to the detection of splenic artery aneurysm rupture on imaging test.

Nodular Hepatic Tuberculosis Masquerading as a Seminoma Liver Metastasis.

Isolated macro-nodular liver tuberculosis is a very rare condition. It may mimic primitive or secondary tumors of the liver. This could delay or mislead the therapeutic management. An immunocompetent 48-year-old man with a history of non-metastatic seminoma was treated with right orchidectomy followed by 20 Gy radiotherapy. The discovery, 8 months later, of a 2 cm nodule of the hepatic dome evoked a liver metastasis. Percutaneous biopsy was not feasible. Wedge resection was performed whereas medical treatment would have sufficed, as pathologic examination of the resected specimen showed a macro-nodular hepatic tuberculosis. The patient received anti-tuberculosis drugs for 9 months. The diagnosis of isolated macro-nodular liver tuberculosis is frequently misleading, particularly in immunocompetent and paucisymptomatic patients. Thus percutaneous biopsy is mandatory for diagnosis and also prior to any major surgeries.

Hydatid Cyst of the Spleen: Tunisian Series of 21 Cases.

Hydatid disease is a parasitic infection caused by Echinococcus granulosus. Splenic involvement is rare even in endemic areas. The aim of this study is to specify epidemiologic features, diagnostic tools, and therapeutic modalities of this uncommon entity. This is a retrospective study of 21 patients operated on for a splenic hydatid cyst between January 1996 and December 2011. The mean age was 43.8 years (range 15-72 years). Sixteen patients (76.2 %) had symptoms related to a splenic location of hydatid disease. While splenic hydatid disease was solitary in 8 patients (38.1 %), other locations were present in 13 patients (61.9 %), mainly in the liver. Most splenic cysts were type I (39.3 %) or III (42.8 %). Nine patients (42.8 %) underwent resection of the protruding dome with one postoperative complication (suppuration of residual cavity). Total and partial splenectomies were performed in nine and three patients, respectively, without any complication. No death was noted. After a mean follow-up period of 36 months (range 2-108 months), no recurrence was observed. Splenic hydatid cyst is a rare location. The diagnostic is usually easy, based on serology and imaging. The surgery is the mainstay of treatment. The type of surgical procedure depends on size, number, and location of the cyst. Total splenectomy is more effective but may have high morbidity and mortality and must be reserved to specific situations. Conservative procedure is safer but could increase the rate of recurrence and postoperative collection. Puncture aspiration injection reaspiration could be proposed for small cyst in inoperable patients.

[Surgical complications of colostomies]. / Les complications chirurgicales des colostomies.

BACKGROUND: The colostomy may be terminal or lateral, temporary or permanent. It may have psychological, medical or surgical complications. AIM: reporting the incidence of surgical complications of colostomies, their therapeutic management and trying to identify risk factors for their occurrence. METHODS: A retrospective study for a period of 5 years in general surgery department, Habib Bourguiba hospital, Sfax, including all patients operated with confection of a colostomy. Were then studied patients reoperated for stoma complication. RESULTS: Among the 268 patients who have had a colostomy, 19 patients (7%) developed surgical stoma complications. They had a mean age of 59 years, a sex ratio of 5.3 and a 1-ASA score in 42% of cases. It was a prolapse in 9 cases (reconfection of the colostomy: 6 cases, restoration of digestive continuity: 3 cases), a necrosis in 5 cases (reconfection of the colostomy), a plicature in 2 cases (reconfection of the colostomy) a peristomal abscess in 2 cases (reconfection of the colostomy: 1 case, restoration of digestive continuity: 1 case) and a strangulated parastomal hernia in 1 case (herniorrhaphy). The elective incision and the perineal disease were risk factors for the occurrence of prolapse stomial. CONCLUSION: Surgical complications of colostomies remain a rare event. Prolapse is the most common complication, and it is mainly related to elective approach. Reoperation is often required especially in cases of early complications, with usually uneventful postoperative course.

[Treatment of acute colonic pseudo-obstruction (Ogilvie's Syndrome). Systematic review]. / Traitement dela Pseudo-Obstruction Colique Aigue (Syndrome d'Ogilvie) Revue Systématique de la Littérature.

BACKGROUND: Ogilvie's syndrome is acute colonic dilatation without organic obstacle in a previously healthy colon. Surgery is the only treatment of cases complicated by necrosis or perforation. In contrast, treatment of uncomplicated forms is not unanimous, and is the subject of this literature review. AIMS: Determine the results of different therapeutic methods of uncomplicated forms of Ogilvie's syndrome in terms of efficiency of removal of colonic distension, recurrence, morbidity and mortality. Clarify their respective indications. METHODS: An electronic literature search in the "MEDLINE" database, supplemented by hand searching on the reference lists of articles, was conducted for the period between 1980 and 2012. RESULTS: Conservative treatment is effective in 53 to 96% of cases with a risk of colonic perforation less than 2.5% and a mortality of 0 to 14% % (level of evidence 4, recommendation grade C). Neostigmine is effective in 64 to 91% of cases after a first dose, with a risk of recurrence of 0 to 38%. It remains effective in 40 to 100% of cases after a second dose (evidence level 2, grade recommendation B). Endoscopic decompression is a safe and effective technique with a success rate of 61 to 100% at the first attempt , a recurrence rate of 0 to 50%, a rate of colonic perforation less than 5% and a mortality less than 5% (level evidence 4, recommendation grade C). PEG may be recommended for the prevention of recurrence of the ACPO after successful treatment with neostigmine or endoscopic decompression (evidence level 2, recommendation grade B). The cecostomy is more effective and safer than conventional colostomy (level of evidence 4, recommendation grade C). The cecostomy is highly effective in colonic decompression but associated with a high mortality (level of evidence 4, recommendation grade C). CONCLUSION: Conservative treatment is recommended in first intention. In case of failure, neostigmine should be tried. If unsuccessful, the endoscopic decompression is proposed. The cecostomy is indicated as a last resort after failure of endoscopic decompression.

Mature cystic teratoma of the pancreas.

The pancreatic teratoma is a congenital tumor which results from abnormal embryonic development of totipotent cells. The preoperative diagnosis is challenging. We report, to our knowledge, the 26th case in a 64-year-old man in whom the diagnosis was made preoperatively on imaging.