Small bowel obstruction in adults, Ladd's band is an exceptional cause: a case report.

Malrotation of the gut is a congenital anomaly of foetal intestinal rotation and it's principally discovered in early childhood as acute intestinal obstruction. This condition is veritably rare and constantly silent in adults. Intestinal malrotation in adults is frequently asymptomatic and is diagnosed as a casual finding during a radiological examination performed for other reasons. Infrequently, it can be diagnosed in adults, associated with an acute abdomen. Adult patients rarely present with acute midgut volvulus or internal hernias caused by Ladd's bands. We present a case of an admitted 18-year-old female with a small bowel obstruction due to an intestinal volvulus complicating intestinal malrotation in the presence of Ladd's band. Laparotomic Ladd's procedure was performed successfully with division of Ladd's band, adhesiolysis, appendicectomy, and reorientation of the small bowel on the right and the cecum and colon on the left of the abdominal cavity; the postoperative evolution was favorable. Although it is a rare pathology, it should be kept in mind in cases of patients presenting small bowel obstruction.

Pseudotumor inflammatory of the spleen: A rare entity with diagnostic and therapeutic challenges: A case report.

INTRODUCTION AND IMPORTANCE: Inflammatory pseudotumor (IPT) of the spleen is a rare entity that can be difficult distinguishing it from malignancies, both in clinical presentation and radiological imaging. CASE PRESENTATION: We present the case of a 43-year-old female presented with 15-cm left hypochondrial mass, Initial imaging studies raised concerns of malignancy, leading to a splenectomy. However, the final pathological examination determined that the patient had IPT of the spleen with focal expression of Smooth Muscle Antibody (SMA). CLINICAL DISCUSSION: This case highlights the importance of considering IPT as a potential diagnosis of splenic masses that was difficult to diagnose before surgery. CONCLUSION: The uniqueness of the case under consideration lies in the rarity and the atypical localization of IPT of the spleen.

Digestive cancer surgery in low-mid income countries: analysis of postoperative mortality and complications in a single-center study.

PURPOSE: This study aimed to analyze postoperative and 90-day morbidity and mortality and their risk factors in all digestive cancer curative intent resections of a single digestive surgical department in a low-mid income country. METHODS: All consecutive patients who underwent a surgical resection for digestive cancer with a curative intent between January 1, 2021, and December 31, 2021, were included. This is a retrospective analysis of a prospective cancer surgery database managed during the period. Patterns and factors associated with increased morbidity and mortality were analyzed and presented in tabular and descriptive forms. RESULTS: Seventy-six patients were included, 38 (50%) were men with a mean age of 59 years (±13.5). Forty patients (52.63%) had tumors locally advanced, staged CT3-CT4 on preoperative imagery. Thirty-three of our population (43.42%) had laparoscopic surgery (conversion rate at 12.12%). In immediate preoperative, the morbidity rate was 36.84%; among each, 7 patients (9.21%) had serious complications (>2 Clavien-Dindo grade), and mortality rate was 5.26%. At 90 days after surgery, morbidity remained the same, and mortality increased to 7.9%. Risk factors for increased morbidity and mortality were female gender, obesity, high levels of carcinoembryonic antigen, hypoalbuminemia, laparotomy approach, hand sewn anastomosis, prolonged operating time, and wide drainage (p < 0.05). CONCLUSIONS: This study provides figures on mortality and morbidity related to digestive cancer curative surgery in a low-mid income country digestive department and discusses risk factors increasing postoperative complications and death.

A colic mesothelial cyst, mimicking an appendicular mucocoele in an elderly patient: A case report and a literature review.

Benign cystic mesothelioma is a very rare and uncommon lesion, first reported by Plaut in 1928. It affects young women of reproductive age. It is usually asymptomatic or has non-specific symptoms. Diagnosis remains difficult despite the evolution of imaging, and the histopathological study is the key examination to make the diagnosis. Surgery remains the only curative treatment, regardless of significant rate of recurrence, and until today, no consensus on the therapeutic strategy is established.

Synchronous anal mucinous adenocarcinoma and anal tuberculosis presenting as chronic anal fistula: Challenging management.

Metachronous anal tuberculosis to an anal adenocarcinoma is an exceptional condition. The aim of our study was to report management of the first case of synchronized anal canal adenocarcinoma and anal canal tuberculosis and report our multidisciplinary approach. A 71-year-old man was admitted for non-healing anal fistula. Rectal examination at supine position showed an ulcerative growth at the medio-superior quadrant on a radius of 2cm from the anal verge. Digital rectal examination assessed no tumor in the anorectum. Biopsy of fistulae confirmed diagnosis of anal mucinous adenocarcinoma with coexisting anal tuberculosis. Further exploration confirmed diagnosis with no distal metastasis, no active pulmonary tuberculosis and no immunodepression. Adjuvant anti-bacillary chemotherapy was initiated 1 month prior to adjuvant radio-chemotherapy. Patient was re-admitted at the 6th week following the last dose of radio-chemotherapy for surgery. On long-term evaluation at 10 months, the patient reported absence of symptoms with weight gain. Association of both entities is rare. Chronic inflammatory damage may possibly initiate a sequence of metaplasia and dysplasia, resulting in neoplastic transformation. Anal canal adenocarcinoma treatment follows same guidelines as rectal cancer. Extra-pulmonary tuberculosis treatment follows anti-bacillary protocol with consequent side effects. Therefore, our case is a unique clinical challenge for physicians. Management decision was multidisciplinary process. Their pathophysiology relationship is yet to be understood. Moreover, each entity has defined and individual therapeutic protocols and indications. All this taken into consideration, such case presents a clinical and therapeutic challenge for physicians.

Atypical mid rectal localization of squamous cell carcinoma: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Squamous cell carcinoma occurring in the rectum is a very rare malignancy. When encountered in the gastrointestinal tract, it usually involves the esophagus or the anal canal. The rare incidence of rectal squamous cell carcinomas has raised quite a few questions on the hypothetical etiologies and prognosis. CASE PRESENTATION: In this report, we present a case of a 73 years old woman who presented a rare case of squamous cell carcinoma, at 8 cm from the anal margin. CLINICAL DISCUSSION: Optimal treatment sequence of such an uncommon disease is yet to be standardized, surgery was the gold standard management for rectal squamous cell carcinoma, but exclusive chemoradiotherapy is slowly but surely supplanting it. CONCLUSION: This case allows us to engage in discussions over the uncommon location of the rectal SCC and its current treatment management. The exclusive chemoradiation therapy has given excellent results becoming the gold standard treatment of this rare entity.

Audit of laparoscopic surgery for colon cancer in Morocco: A report of the results of a prospective multicentre cohort study.

Background: Little data is available about colon laparoscopic surgery in low mid-income countries. The aim of this study was to audit the status and results of laparoscopic colon cancer surgery in Morocco. Patients and methods: This was a prospective study performed at 4 academic departments in Morocco between January 1, 2018, and March 31, 2020. All adult patients who underwent elective right or left colonic resection for colon adenocarcinoma were included. The main outcomes were the rate of laparoscopic surgery (LS) and the comparison of its short-term outcomes with open surgery (OS). Results: Among 121 patients included, 52 (43%) underwent laparoscopic resection (0-49.3%). Five surgeons (29%) performed at least one laparoscopic resection. There were more left colectomies in the laparoscopic group (71.2% vs. 39.1%. p = 0.0004), and more extended resections (23.1% vs. 40.6%. p = 0.043) and T4 stage (19% vs. 37.5%. p = 0.037) in the open group. There were no differences in 90-days overall and serious complications. OS patients had significantly more harvested lymph nodes (14 vs. 18. P = 0.007) and higher median surgical margins (6 cm vs. 9 cm. P = 0.003) than LS patients. Conclusions: LS for colon cancer in Morocco is performed by few surgeons, who apply strict patient selection for laparoscopic cases. It was associated with lower quality resections compared to open surgery. There are still many challenges requiring more focus on training, certification, centralization and standardisation of care across the nation.

Rupture of Hydatid Cyst in the Gallbladder Leading to Acute Cholangitis.

Hydatid disease is a health problem in endemic areas such as the Mediterranean region caused by Echinococcus granulosus which can develop anywhere in the human body, but it is most frequently located at the liver. Liver hydatid cyst may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract, or skin, but its rupture in the gallbladder remains rare. We report a rare case of rupture of liver hydatid cyst in the gallbladder leading to acute cholangitis. The diagnosis was suspected on radiological imaging, and the patient was taken to open surgery which confirmed the imaging findings. The gallbladder and adjacent cyst were excised, and a transcystic drain was placed. Postoperative recovery was uneventful.

Synchronous sigmoid cancer and abdominal aortic aneurysm treated by laparoscopic colectomy followed by endovascular aneurysm repair.

INTRODUCTION: The occurrence of synchronous abdominal aorta aneurysms and colorectal cancer represents a real management challenge. Up till now, there is no evidence-based consensus recommendation in the surgical management of such patients. Herein we reported the clinical management challenge of synchronous abdominal aorta aneurysms (AAA) and colorectal cancer (CRC). PRESENTATION OF CASE: 78-year-old man was admitted in our structure for acute abdominal pain, vomiting and constipation. His past medical history included type 2 diabetes, arterial hypertension and a stable infra-renal aortic aneurysm documented 2 years ago. Physical examination found a stable patient with blood pressure and heart rate within normal range, pulsatile mass along with abdominal distension with vital signs within normal limits. Abdominal CT scan and subsequent CT angiogram confirmed an 88 × 75 mm infra-renal aortic aneurysm concomitant with considerable lumen reduction due to asymmetric wall thickening of the sigmoid. Colonoscopy combined with biopsy examination confirmed structuring irregular sigmoid adenocarcinoma Therefore we report a case of a large AAA and concomitant sigmoid adenocarcinoma tumor causing stricture. DISCUSSION: In such situation, the main controversy is the necessity of treating the diseases simultaneouslor in two stages favoring the AAA management first. To our best knowledge, we report the first case published in literature in which the patient was treated for colorectal cancer first by laparoscopic surgery followed by AAA management with EVAR. CONCLUSION: In this case report, we highlight some tricks required in performing laparoscopic sigmoid colectomy for patient with large AAA to prevent per-operative pitfalls. Evidence-based consensus is required to determine the optimal surgical treatment.

Predictive factors of disease-free survival after complete pathological response to neoadjuvant radiotherapy for rectal adenocarcinoma: retrospective case series.

BACKGROUND: Many data suggest that patients with low rectal adenocarcinoma who achieved ypT0N0 status have improved survival and disease-free survival (DFS) compared to all other stages however only few data are available regarding the specific prognosis factors of this subgroup. This study aimed to evaluate predictive factors for disease free survival after complete pathological response (CPR) in cases of low rectal adenocarcinoma. MATERIALS AND METHODS: From January 2005 to December 2013, all patients with low rectal adenocarcinoma who underwent neoadjuvant chemoradiotherapy followed by total mesorectal excision and achieved CPR were included at 7 Moroccan and 1 Algerian centres. Predictive factors for disease-free survival were analysed by uni and multivariate analysis. RESULTS: Eigthy-four (12.1%) patients achieved a CPR (ypT0N0). Multivariate analysis revealed that both poorly differentiated tumors (OR, 9.23; 95 CI 1.35-62.82; P = 0.023) and the occurrence of perineal sepsis (OR, 13.51; 95 CI 1.96-93.12; P = 0.008) were independently associated with impaired DFS. CONCLUSIONS: Patients with low rectal cancer who exhibited a CPR after neoadjuvant therapy have good prognoses; however, the occurrence of perineal sepsis and/or poor initial differentiation may be associated with impaired DFS in these patients. TRIAL REGISTRATION: The study was retrospectively registered the 28th July 2018 in ClinicalTrials.gov register with the reference NCT03601689.

Perineal skin recurrence on the site of Lone Star Retractor: case report.

BACKGROUND: Local recurrence of colorectal cancer is a major cause of morbidity and mortality that usually implies a worse prognosis. Its etiopathogenesis is still a subject of debate. Recurrence on the perineal wound caused by anal retractor device is rarely reported. CASE PRESENTATION: We present the case of a 75-year-old woman with perineal skin recurrence on the site of Lone Star Retractor™ from rectal adenocarcinoma. The patient underwent a curative proctectomy followed by a hand-sewn coloanal anastomosis using Lone Star Retractor™ 2 years ago for a tumor of the lower rectum. The recurrence was most likely caused by the seeding of exfoliated tumor cells into the perianal skin which was abraded by the retractor. CONCLUSION: This case is the fourth case reported in the literature and highlights the importance of the use of less traumatic endoanal retractors to prevent such perianal recurrence. Recurrence on the perineal wound caused by anal retractor device is rare but possible. Further studies are needed to define preventive measures able to reduce cutaneous implants.

Giant gastric trichobezoar in a young female with Rapunzel syndrome: case report.

Rapunzel syndrome is an extremely rare complication of a gastric trichobezoar in. We report here the unusual case of a case of a 16 years old girl presented with severe abdominal pain and vomiting. Clinical examination revealed a malnourished girl, with presence of a mobile and sensitive abdominal mass of 20x15 cm witch filled the upper quadrant. An abdominal computed tomography scan showed a heterogeneous mass occupying the whole stomach cavity with extension into the third portion of the duodenum. A diagnostic of giant trichobezoar is suspected after further questioning reveling a trichotillomania, trichophagia and onychophagia. The removal of the trichobezoar endoscopically failed and it was possible to pull only few fibers of hair to comfort the diagnostic. She was subjected to an exploratory laparotomy. An antral gastrostomy were performed and a 25x10x7 cm trichobezoar was extracted. The patient had an uneventful postoperative outcome and was derived to psychiatry. Rapunzel syndrome is an uncommon trichobezoar, it's commonly found in young females usually with an underlying psychiatric disorder. Management requires gastrotomy. A psychiatric assessment and a long-term follow-up are advocated as a regular part of treatment to prevent recurrence.

Risk Factors for Conversion and Morbidity During Initial Experience in Laparoscopic Proctectomies: a Retrospective Study.

The aim of this study was to determine the predictable factors for conversion during laparoscopic proctectomies, and for postoperative morbidity, in order to assist in defining the best candidates of patients for initial experience in laparoscopic proctectomies for rectal adenocarcinoma. A retrospective analysis of consecutive patients who underwent laparoscopic rectal resection for rectal adenocarcinoma operated by a single surgeon, between 2005 and 2012, were performed. Predictive factors for conversion and for postoperative morbidity were analyzed using univariate and multivariate analysis. Sixty-nine patients were included. There were 35 (50.7 %) men with a median age of 53 years. Forty-seven patients had tumors located below 8 cm from the anal verge, and sphincter-preserving surgery was performed in 52 (75.4 %) patients. Thirty-four patients were operated in the early period (before 2009). Conversion rate was 17.4 %. In multivariate analysis, the independent predictive factors for conversion were time period (before 2009) (p = 0.007, Exp. 19.9; CI (95 %) 2.2-177.4) and tumors located 8 cm above the anal verge (p = 0.028, Exp. 5.23, CI (95 %) 1.2-22.8). Twenty-two patients (31.9 %) had a complicated postoperative course. Only male gender was associated with postoperative complications (p = 0.01, CI (95 %) 1.3-11.8). Our study showed that conversion rate is influenced by surgeon's experience, and height of the tumor and that male gender is a predisposing factor for a higher morbidity rate. These results suggest that women with low rectal tumors requiring colo-anal anastomosis or abdomino-perineal resection would be the best candidates for early surgeons' experience in laparoscopic proctectomies for rectal adenocarcinoma.

Impact of Conversion to Open Surgery on Early Postoperative Morbidity After Laparoscopic Resection for Rectal Adenocarcinoma: A Retrospective Study.

BACKGROUND: The impact of conversion to open surgery after a laparoscopic resection for rectal adenocarcinoma on postoperative morbidity is still unclear. Most previous studies included colon and rectal carcinomas and produced conflicting results. The aim of this study was to investigate the impact of conversion to open surgery on early postoperative morbidity in patients who underwent a laparoscopic resection for rectal adenocarcinoma. METHODS: This was a retrospective bicentric study. It included all consecutive patients who underwent a laparoscopic resection for nonmetastatic rectal adenocarcinoma between January 2005 and December 2013. The impact of conversion to open surgery on 30-day postoperative morbidity was analyzed by univariate and multivariate analyses. Risk factors for conversion were also investigated by univariate and multivariate analyses. RESULTS: One hundred thirty-one patients were included. The conversion rate was 26.7%. The global 30-day morbidity rate was 31.3% (41 patients). The conversion to open surgery was associated with higher rates of postoperative complications, anastomotic leaks, and reoperations. It was also an independent predictive factor to postoperative morbidity in the multivariate analysis (P = .01; odds ratio 2.86; 95% confidence interval [CI] 1.23-6.63), in addition to T4 tumors (P = .04; odds ratio 3.92; 95% CI 1.05-14.61). Risk factors for conversion in the multivariate analysis were T4 tumors (P = .006; odds ratio 6.09; 95% CI 1.66-22.32) and the height of the tumor (P = .025; odds ratio 2.7; 95% CI 1.13-6.43). CONCLUSIONS: This study showed that conversion to open surgery after laparoscopic proctectomy for rectal adenocarcinoma was associated with higher rates of early postoperative complications. It also showed that T4 tumors and the height of the tumor were independent factors associated with the conversion to open surgery. Reducing postoperative morbidity could be achieved by a better patient selection and a policy of early conversion.

Perineal schwannoma.

BACKGROUND: Schwannoma is a benign tumor arising from Schwann cells of the peripheral nerve sheath. Perineal schwannomas are exceptional, and rarely reported in the literature. We report a case of a perineal schwannoma, close to the anal sphincter, and provide a short summary of clinical, radiological and surgical features of this rare entity. CASE PRESENTATION: A 62 year-old male patient was admitted for a suspected perineal mass. At clinical examination, he had a soft mass, located on the right of the anus. Computed tomography showed a perineal mass, located on the right side of the anal sphincter that enhanced after injection of the contrast medium. Complete surgical excision of the tumor was performed. The most challenging part during the surgery was the dissection and preservation of the anal sphincter to avoid anal incontinence. Pathologic examination revealed a completely excised schwannoma. CONCLUSIONS: Perineal schwannomas are very rare tumors that are usually asymptomatic, and which present as large masses. Complete excision is necessary to avoid recurrences. Surgical resection may be difficult depending of proximity to the anal sphincter. A cautious dissection in such cases is required in order to reduce the risk of incontinence.

Abdominal wall recurrence of a gastrointestinal stromal tumor: case report.

INTRODUCTION: The gastrointestinal stromal tumors (GIST) are mesenchymal tumors, most commonly affecting the stomach and small bowel. Only few cases of port-site recurrence after laparoscopic treatment have been reported. We herein report the case of a parietal recurrence on the extraction incision site, 7 years after laparoscopic surgery for small bowel GIST. CASE REPORT: A 47 years-old female patient was hospitalized in November 2007 for isolated pelvic pain. CT scan showed an intestinal tumor with a benign aspect measuring 50 mm. A laparoscopy-assisted resection was performed. Surgical exploration found a 7 cm small bowel tumor. It was extracted through a supra-pubic transversal incision without a wound protector and then resected. Histologic analysis revealed an intestinal GIST with high aggressive potential (five mitosis per field), with CD117 positive at the immunohistochemical examination. The patient had no adjuvant chemotherapy. Seven years later, the patient was readmitted for an abdominal mass at the site of the supra-pubic scar. Abdomino-pelvic CT scan showed a 10 × 7.5 cm solid mass of the abdominal wall. Percutaneous biopsies were done and the pathological analysis revealed a mesenchymal-cell tumor, positive to CD117 and DOG1 at the immunohistochemical examination. Final diagnosis was abdominal wall recurrence of GIST secondary to tumor-contamination during the first surgery. CONCLUSION: Abdominal wall recurrence of GIST after laparoscopic surgery is rarely reported. This complication should be avoided with preventive measures such as the use of extraction bags or wound protectors.

Imaging features of adrenal ganglioneuroma: a case report.

BACKGROUND: Adrenal ganglioneuroma is a rare tumor constituting 20-30% of all ganglioneuromas. It is a benign tumor and can present diagnostic problems when confused with other adrenal solid tumors. CASE PRESENTATION: We herein report a case of adrenal ganglioneuroma in a 28-year-old Arabic patient and emphasize the diagnostic role of cross-sectional imaging modalities (computed tomography and magnetic resonance imaging). CONCLUSION: Imaging of adrenal ganglioneuromas is diagnostically challenging. Differentiation between adrenal ganglioneuroma and other solid adrenal tumors can be difficult. However, some suggestive features on computed tomography and magnetic resonance imaging are helpful in achieving a correct diagnosis.

Asymptomatic intra-peritoneal rupture of hydatid cyst of the liver: case report.

BACKGROUND: Intra-peritoneal rupture of hydatid cyst is a rare complication and there is no consensus about its treatment. CASE PRESENTATION: The reported case concerns a 25 years old female patient who had been complaining for four months from a moderate pain in the right upper quadrant. No clinical or biological signs of sepsis or allergic reactions were witnessed. Ultrasound and CT examinations showed a multilocular hepatic cyst in addition to multiple unilocular cysts in the abdomen. The suspected diagnosis was hepatic and peritoneal HC and a surgical treatment was scheduled four weeks later. Surgical exploration showed a large ruptured HC on the left lobe of the liver, with daughter cysts in the peritoneal cavity. Left lobectomy of the liver with complete ablation of all daughter cysts and a wide peritoneal lavage were performed. For the three months following the surgery, Albendazole had been given to the patient. No recurrence occurred after four years of follow-up. CONCLUSION: Intra-peritoneal rupture of liver HC could be asymptomatic. This case showed that in some cases, occurrence of complications is not systematic. This suggests that urgent surgical treatment is not always mandatory in the absence of alarming signs. Well-conducted medical treatment would reduce the risk of occurrence of secondary peritoneal hydatidosis.

Risk factors for anastomotic leakage after anterior resection for rectal adenocarcinoma.

BACKGROUND: Anastomotic leakage (AL) is an important cause of morbidity after surgery for rectal cancer. AIM: to analyze the risk factors associated with anastomotic leakage after anterior resection for rectal adenocarcinoma. METHODS: We collected data from all the patients who had surgical resection with an anastomosis, for rectal adenocarcinoma at the Surgical Clinic C (Ibn Sina Hospital, Rabat, Morocco), between January 2001 and December 2010. The associations between variables and anastomotic leakage were studied using univariate and multivariate analysis. RESULTS: Our study included 130 patients. Anastomotic leakage occurred in 28 patients (21.5%). Univariate and multivariate analysis showed that the rate of anastomotic leakage was significantly higher in patients who received preoperative radiotherapy (34.2% vs. 12 %, p = 0.002 - OR 3.8 - CI 95%: 1.5 - 9.4). There was no significant difference in the rate of AL between patients with or without a protective stoma. In the group of patients with AL, the rate of reoperation was significantly lower in patients with a stoma protection (31.8% vs. 83.3%, p = 0.04). CONCLUSION: Radiotherapy is a risk factor for anastomotic leakage. The systematic design of a protective stoma in patients receiving neoadjuvant radiotherapy is advisable to reduce the rate of reoperations associated with AL.