Laparoscopic treatment of a cephalic pancreatic leiomyoma.

BACKGROUND: Leiomyoma of the pancreas is very rare. Symptoms and signs are not specific. It has the clinical presentation of a pancreatic mass. The preoperative clinical and radiological assessments are fundamental to establish a therapeutic schema. The curative treatment is surgical resection. A methodical histological examination is required to confirm the final diagnosis of Leiomyoma. CASE REPORT: A 52-year-old female patient presented with a mass of the head of the pancreas. After preoperative assessment, the patient had laparoscopic enucleation. Postoperative course was no remarkable for complications. Pathology examination concluded to leiomyoma. CONCLUSION: Preoperative diagnosis of pancreatic leiomyoma is difficult. It has the features of a pancreatic mass. The preoperative assessment aims to identify signs of malignancy. In its absence, laparoscopy is feasible and safe. Enucleation, if indicated, is a surgical option for a benign disease sparing the patient a pancreatic resection.

Hydatid cyst prolapsed in a hernia sac.

A 70-year-old patient with a 20-year history of  gastric ulcer intervention presented for an abdominal mass appeared for 3 years . The clinical examination found a herniation on the median abdominal scar which is containing an irregular mobile renient mass. Computed abdominal tomography had objectified two voluminous liquid multilocular formations completely prolapsed in the hernia sac.

Laparoscopic ileo-cecal resection: the total retro-mesenteric approach.

BACKGROUND: Ileo-cecal resection is the most performed procedure in Cohn's disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn's disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach. METHOD: The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt's fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis. RESULTS: This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn's disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %. CONCLUSION: We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn's disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.

Laparoscopic resection of gastric stromal tumors.

Gastro-intestinal stromal tumors (GIST) are the most common mesenchymal gastrointestinal tumors. The Gastric location represents 60% of cases [1,2]. Complete surgical excision remains the treatment of reference for the localized forms. This surgery can be made by laparoscopy when the lesion's size doesn't exceed 5 cm. Some principles must e respected: a mono-block complete surgical resection, with healthy margins and without effraction. This technique will be reserved for trained teams and for selected cases according to the size and location. We herein try to explain the surgical laparoscopic excision of gastric stromal tumors explaining .

Predictive factors of Gastrointestinal motility Dysfunction after gastrojejunostomy for peptic ulcer stenosis.

BACKGROUND: Despite the establishment of effective medical therapies in peptic ulcer disease, gastric outlet obstruction remains one of the most common health problem in Tunisia. Various operations have been attempted, which may lead to postoperative morbidity. Gastrointestinal (GI) motility dysfunction is the most common complications. AIM: to determine the predictive factor of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis. METHODS: We carried out a retrospective study to evaluate the postoperative recovery of the motility of the upper gastrointestinal tract after gastrojejunostomy for peptic ulcer stenosis. During the 9- year study, 138 patients underwent operations for ulcer peptic stenosis. Among the patients, 116 (84,1%) were treated with gastrojejunostomy. Descriptive statistics, univariate and multivariate analyses were performed. RESULTS: The mean age of patients was 47.85 years (range: 19- 92years) and most. Were male (84, 5 %). Ninety two (79.3%) patients had a documented history of peptic ulcer disease. The duration of symptoms ranged from 10 to 372 days (mean: 135.86 days). Eighty two (71%) patients were operated on through laparotomy. Laparoscopic procedure was performed in 29% of the patients. There was no operative mortality. Perioperative morbidity occurred in 12.4% (14 patients). Gastrointestinal motility dysfunction occurred in 12 patients (10.3%). It was treated by nasogastric aspiration and prokinetics. By univariate analysis; diabetes (0,010), cachexia (0,049), ASA class (0.05) were all statistically associated with gastrointestinal motility dysfunction in this series. Multivariate logistic regression analysis (table 2) showed that the cachexia (0,009), ASA class (0.02) were the main predictors of gastrointestinal motility dysfunction after gastrojejunostomy for peptic ulcer stenosis in the followed patients. CONCLUSION: Gastrointestinal motility dysfunction is the most common complications after gastrojejunostomy for pyloric adult stenosis. Surgery must be preceded by careful medical preparation. It is more likely to occur in patients with an ASA class 2 or greater. Those patients should be considered for other treatment options, such as endoscopic balloon dilation.

Dieulafoy's lesion: Is there still a place for surgery? About 2 cases.

INTRODUCTION: Dieulafoy's lesion, a rare but life-threatening condition accounting for a small percentage of acute gastrointestinal bleeding cases, has historically posed diagnostic and therapeutic challenges. CASE PRESENTATION: In this article, we present two cases that required surgical intervention due to unsuccessful attempts with endoscopy. Case 1 involved a 40-year-old patient with a history of treated duodenal ulcers, while Case 2 featured a 74-year-old woman with no notable medical history. Both patients exhibited severe bleeding, necessitating urgent surgical procedures. The surgical approach involved wide gastrotomy, careful inspection, and successful suturing of the bleeding vessel. DISCUSSION: Dieulafoy lesions, discovered by French surgeon Georges Dieulafoy in 1885, constitute 1-2 % of acute gastrointestinal bleeding cases. These anomalies involve enlarged submucosal arteries, predominantly in the stomach, but occurrences in other sites are documented. Endoscopic methods, surpassing surgical intervention, are preferred for treatment, boasting success rates over 90 %. Surgical measures become a last resort for uncontrolled bleeding, with laparoscopic surgery emerging as a minimally invasive alternative, facilitated by various intra-operative localization techniques. Laparoscopic wedge resection, in particular, exhibits lower re-bleeding rates than traditional oversewing methods, although feasibility depends on lesion location. CONCLUSION: While endoscopic methods are preferred, surgery remains a vital option when bleeding persists or endoscopic intervention fails. This report highlights the significance of surgical management in selected cases of Dieulafoy's lesion.

Incidental pneumoperitoneum due to pneumatosis intestinalis: A rare case of benign pneumoperitoneum.

INTRODUCTION AND SIGNIFICANCE: Pneumatosis intestinalis (PI), the presence of gas within the intestinal wall, is a rare but significant gastrointestinal condition. It may be associated with underlying gastrointestinal disorders or detected incidentally, posing diagnostic challenges. This article emphasizes the importance of recognizing and managing this condition conservatively when appropriate. CASE PRESENTATION: A previously healthy 40-year-old Caucasian female patient presented with left lumbar fossa pain, initially suggestive of renal colic. Physical examination revealed stable vital signs and a soft abdomen. Laboratory tests showed no signs of inflammation or renal abnormalities. Abdominal CT scan ruled out urinary lithiasis but identified pericolonic pneumoperitoneum on the left side. Due to the absence of peritonitis signs, surgical intervention was deferred. Over 72 h of close monitoring, the patient remained stable without clinical deterioration. Subsequent CT scans confirmed pneumatosis intestinalis. The patient remained asymptomatic and underwent a confirming colonoscopy. CLINICAL DISCUSSION: Pneumatosis intestinalis can manifest with varying severity and is often linked to underlying gastrointestinal conditions. It can mimic life-threatening conditions like bowel perforation, necessitating careful differentiation. Non-surgical pneumoperitoneum, exemplified in this case, may result from benign causes like PI, warranting meticulous evaluation to prevent unnecessary surgery. CONCLUSION: This case highlights the need to recognize and manage asymptomatic PI. A multidisciplinary approach and CT imaging play pivotal roles in ensuring optimal patient outcomes. Vigilance among healthcare professionals is essential to consider PI in asymptomatic patients, mitigating the risk of undue surgical interventions, and facilitating timely diagnosis and intervention when necessary.

A case report of intestinal acute intussusception secondary to a lipoma: Imagery has a great value.

INTRODUCTION: Acute intestinal intussusception (AII) in adults, unlike in children, is a rare manifestation that is frequently secondary to malignant or benign tumors and intestinal intussusception on a lipoma is more exceptional. CASE PRESENTATION: We present a rare case of AII caused by a lipoma in a previously healthy 44-year-old man. He experienced severe right lower quadrant pain and constipation. An abdominal CT scan revealed ileocecal intussusception, displaying the classic "sandwich" and "cocarde" images. Additionally, a Caecal lipoma was identified. The patient underwent midline laparotomy, revealing significant small bowel distention upstream of the ileocolic intussusception. Subsequently, a right hemicolectomy with ileocolostomy was performed. Pathological examination confirmed colonic ischemic necrosis attributed to AII originating from a submucosal caecal lipoma. CLINICAL DISCUSSION: AII is a rare cause of abdominal pain and accounts for 1 to 5 % of adult intestinal obstructions. In adults, an organic cause is found in 70 to 90 % of cases, often secondary to an endoluminal lesion of malignant nature. Pure colonic intussusception on a lipoma is exceptional. CT scan, can show characteristic images and confirms the fatty nature of the lipoma. Surgical intervention is necessary as treatment for intussusception and anatomopathological examination is required for diagnostic confirmation. CONCLUSION: Intestinal intussusception caused by an intestinal lipoma is rare. Imaging, mainly ultrasound and CT scan, plays a crucial role in providing a positive and etiological diagnosis of the condition by showing characteristic images. Treatment is always surgical, and there is no place for reduction under radiological control.

A retroperitoneal pseudomyxoma of the appendix: A case report.

INTRODUCTION: Retroperitoneal pseudomyxoma (RP) is a rare condition characterized by mucinous tumor growth within the retroperitoneal space, commonly originating from the appendix or other abdominal organs. RP presents with non-specific symptoms such as abdominal pain, bloating, and weight loss, making accurate diagnosis challenging. Due to its rarity and symptom overlap with other conditions, RP requires careful management by a multidisciplinary healthcare team. CASE PRESENTATION: An 82-year-old female with a three-month history of abdominal pain and an abdominal mass underwent diagnostic imaging, revealing a retroperitoneal cystic mass. Exploratory laparotomy identified gelatinous masses originating from the retrocaecal appendix, which were resected. Histopathological examination confirmed a diagnosis of retroperitoneal pseudomyxoma with mucinous appendicular low-grade cystadenoma as the primary source. The patient had an uneventful postoperative course and remained disease-free at a 12-month follow-up. DISCUSSION: RP's exact cause is unknown but often originates from the appendix, leading to mucinous fluid accumulation in the retroperitoneal cavity. This condition presents with varied symptoms, including abdominal pain and distension, mimicking other abdominal diseases. Diagnosis involves clinical, radiological, and pathological assessments, with imaging showing characteristic features. Treatment comprises surgical resection, potentially combined with HIPEC, aiming for complete cytoreduction. Prognosis depends on factors like tumor grade, extent, and cytoreduction completeness. CONCLUSION: Retroperitoneal pseudomyxoma is a rare condition with challenging diagnosis due to its non-specific symptoms. Early recognition, surgical resection, and appropriate adjuvant therapies like HIPEC or chemotherapy can improve outcomes in patients with this uncommon disease.

Ileal duplication in adults: A rare case.

INTRODUCTION AND IMPORTANCE: Intestinal duplication is an uncommon congenital malformation affecting the alimentary tract. This article presents a case of enteric duplication cyst (EDC) in an adult, accompanied by a review of the available literature. CASE PRESENTATION: A 34-year-old woman with polymyositis underwent a routine CT scan as part of her medical assessment revealing an 8 cm mass near the caecum and terminal ileum. Diagnostic procedures confirmed a cystic spherical mass. The patient underwent ileo-cecal resection, with primary anastomosis and an uneventful recovery. CLINICAL DISCUSSION: Studies indicate that the frequency of polymyositis coexisting with a neoplasm range from 6 % to 40 %. Therefore, a body CT scan is recommended for patients with myopathy as in our patient. Intestinal duplications are predominantly found in children but can also occur in adults, often discovered incidentally or due to complications. Diagnostic imaging techniques, such as ultrasonography and CT scan, are crucial in identifying duplication location and characteristics. In this case, colonoscopy indicated ileocecal valve compression, and histological examination confirmed an enteric duplication cyst with ectopic gastric mucosa. CONCLUSION: Enteric duplication cysts are rare, and the existing literature on the topic somewhat limited. Early diagnosis and surgical intervention are essential to stave off potential complications and reduce morbidity. Clinician awareness of enteric duplication cysts enables timely management, enhancing patient outcomes. Further research is needed to improve understanding and optimize patient care.

Abdominal pseudohernia as an exceptional complication of herpes-zoster.

INTRODUCTION: Herpes zoster (HZ), caused by the reactivation of the Varicella-Zoster virus, is typically characterized by sensory complications. However, motor complications, such as abdominal pseudohernia, are rare and exceptional. This report presents a case of post-herpes zoster pseudo-hernia in a previously healthy 54-year-old man. CASE PRESENTATION: A 54-year-old Caucasian patient developed an abdominal wall protrusion over two weeks, following a resolved herpes zoster infection. Physical examination revealed healed skin lesions and a painless protrusion on the right flank, triggered by coughing, suggesting an abdominal wall hernia. Abdominal CT scan ruled out parietal but noted asymmetry in the abdominal wall muscles, particularly thinning on the right side. The diagnosis of post-herpes zoster pseudo-hernia was established, with spontaneous resolution occurring after four months. DISCUSSION: Herpes zoster typically manifests as a sensory condition. However, motor complications can lead to muscle weakness or paralysis. Pseudo-herniation is a rare motor complication, affecting less than 1 % of cases. It must be differentiated from true abdominal wall hernias, which require surgical intervention. Pseudo-hernia typically presents as painless abdominal bulging, often asymptomatic, but can lead to gastrointestinal issues if visceral nerves are affected. Imaging studies and EMG may be employed for diagnosis. Treatment for pseudo-hernia is conservative, addressing the underlying HZ, and the prognosis is favorable, with most cases resolving within 3 to 12 months. CONCLUSION: Abdominal post-herpes zoster pseudo-hernia is a rare HZ complication. Recognizing this entity is crucial, as it typically resolves spontaneously without surgical intervention. This case aims to enhance awareness of this exceptional clinical manifestation.

Torsion of funiculocele presenting as an incarcerated hernia: A rare case.

INTRODUCTION: Inguinal hernia is common, but the groin area can host various pathologies. Distinguishing clinically between hernias and rare conditions like torsion of funiculocele poses challenges due to similar presentations. CASE PRESENTATION: A 50-year-old man, with a 10-year-history of a groin mass, presented with a painful groin mass, initially diagnosed as a strangulated hernia. In surgery, a torsion of a cyst was identified, and it was attached to the spermatic cord. A detorsion of the cyst and an excision were successfully performed. The patient recovered well with no recurrence. DISCUSSION: The most common causes of acute groin pain are injury, incarcerated hernia, kidney stone and bone fracture. Additionally, funiculocele can cause groin pain or discomfort. Funiculocele, a rare congenital anomaly, typically affects pediatric patients. A torsion of funiculocele is easily confused with an incarcerated hernia. Ultrasonography plays a crucial role in confirmation. Although unusual, a torsion of a cyst can occur, necessitating surgical excision. CONCLUSION: Funiculocele in adults, mimicking hernias, is rare but requires timely surgical intervention to prevent complications. Awareness of this anomaly is vital for accurate diagnosis and appropriate management.

Jejunogastric intussusception associated with jejunojejunal intussusception (double telescoping) occurring 20 years after gastrojejunostomy.

INTRODUCTION: Jejunogastric intussusception (JGI) is a rare but potentially lethal complication following gastrectomy or gastrojejunostomy surgeries. Diagnosis of this condition can be challenging due to its rarity and non-specific symptoms. This article presents a case report of a 60-year-old male with a history of trans mesocolic gastrojejunostomy who developed acute symptoms of JGI. CASE REPORT: The patient presented with acute epigastric pain, vomiting, and hematemesis. Physical examination and laboratory tests indicated dehydration, tachycardia, and leukocytosis. Computed tomography (CT) revealed intussuscepted loops within the stomach. Emergency laparotomy was performed, and the intussusception was manually reduced without the need for resection. The patient recovered well and was discharged five days post-surgery. DISCUSSION: Retrograde jejunogastric intussusception is a rare complication, often occurring years after gastric surgery. It can be classified into acute and chronic forms, with the former presenting with intense pain and potential hematemesis. The condition can arise in different surgical contexts and even spontaneously. The cause of JGI remains unclear, but factors such as hyperacidity, abnormal motility, and increased intra-abdominal pressure have been implicated. Diagnosis can be made through endoscopy or alternative imaging modalities such as CT. Surgical intervention is the treatment of choice, with various options available based on intraoperative findings. CONCLUSION: Retrograde jejunogastric intussusception is challenging to diagnose and treat due to its rarity and lack of understanding of its causes. Imaging techniques and endoscopy play important roles in diagnosis, while surgery remains the primary treatment option. Vigilance is necessary among medical professionals to consider JGI in cases of acute abdominal pain and vomiting following gastric surgery, allowing for prompt diagnosis and intervention to prevent bowel necrosis. Further research is needed to establish optimal surgical strategies and evaluate recurrence rates.

[Sigmoid diverticulitis]. / Les sigmoidites diverticulaires.

BACKGROUND: The sigmoid diverticulitis is the most common complication of diverticulosis of the colon. The remaining questions concern the current risk factors for recurrence after a first acute episode, radiological asking immediately upon suspicion of diverticulitis and therapeutic management including the indications of surgical treatment, what to conduct and its principles. METHODS: Literature review. RESULTS: Risk factors of recurrence are: persistent or recurrent diverticulitis, abscess, stenosis and / or fistula. Abdominal CT is recommended in all patients clinically suspected diverticulitis of the colon. Treatment of acute diverticulitis is medical. The emergency surgical treatment depends on the stage of Hinchey. Stage I: In case of failure of medical treatment, resection-anastomosis in an emergency time delay to be proposed. Stage II: a percutaneous drainage followed by resection-anastomosis in 1 time. Stage III: surgery in emergency sigmoid colectomy based on. Stage IV: Hartmann procedure is the procedure of reference. Prophylactic colectomy is proposed in the case of presence of risk factors of recurrence. CONCLUSION: Comparison with other literature review were allowed to find that ultrasound made by an experienced radiologist could replace abdominal CT, and for stage III and IV Hinchey, laparoscopic resection can be performed with an immediate restoration of digestive continuity in well selected patients.

A uterine fibroid presenting as an incarcerated epigastric hernia: a case report and review of the literature.

BACKGROUND: Uterine fibroids incarcerated in abdominal wall hernias during pregnancy are rare, with only six cases reported in umbilical hernias. This case report presents the first reported case of an incarcerated uterine fibroid in an epigastric hernia. CASE PRESENTATION: A 31-year-old primigravid Caucasian woman at 28 weeks gestational age presented with sudden onset abdominal pain and vomiting. Physical examination revealed an incarcerated epigastric hernia containing a non-reducible firm mass. Ultrasound showed a healthy fetus, and during surgery, a subserosal and sessile fibroid originating from the anterior uterine wall was found in the hernia sac. It was easily reduced, and the hernia was repaired with no complications. The patient proceeded to deliver a healthy baby boy by cesarean section at full term. CONCLUSION: Uterine fibroids incarcerated in abdominal wall hernias during pregnancy are rare and affect mostly primigravid women in the third trimester. Abdominal ultrasound may facilitate the diagnosis, and pedunculated fibroids may be resected while sessile fibroids should be simply reduced. Clinicians should consider incarcerated fibroid as a differential diagnosis in pregnant women with irreducible ventral abdominal wall hernias. This case report aims to contribute to the literature and optimize the management of abdominal wall hernias in pregnant women.

Dropped gallstone-related perihepatic abscess 20 years after open cholecystectomy.

INTRODUCTION: Gallstone spillage during cholecystectomy is a recognized complication that can lead to various postoperative complications. CASE PRESENTATION: We present a rare case of a gallstone abscess that developed 20 years after an open cholecystectomy. An 80-year-old woman with a history of high blood pressure and previous gallbladder removal presented with severe abdominal pain. Imaging revealed a large abscess with a suspicious calcification, indicating a lost gallstone. Surgical intervention was performed, resulting in the removal of multiple gallstone fragments from the abscess cavity. CLINICAL DISCUSSION: Gallbladder perforations and the spillage of gallstones are common complications during cholecystectomies, with laparoscopic procedures being more prone to stone spillage. Studies show a significant difference between open and laparoscopic cholecystectomies, with laparoscopy having a higher risk of spilled stones. Complications from spilled gallstones are rare but can vary in presentation and location. They may lead to long-term issues such as abscesses and even erosion into other organs. These complications can manifest years after surgery. Treatment involves evacuating the abscess and addressing the gallstone. Surgical intervention, like laparotomy or laparoscopy, is required for retrieval. Ensuring proper traction during surgery is crucial to prevent gallbladder perforation and stone spillage. Consideration of alternative, gentler instruments for traction may be beneficial. CONCLUSION: Surgeons should be vigilant, proactive, and employ prophylactic measures to minimize complications related to gallstone spillage, ensuring the best possible patient outcomes.

Surgical management of intra-abdominal cystic lymphangioma. Report of 20 cases.

BACKGROUND: Cystic lymphangioma (CL) is a benign rare malformation of lymphatic vessels. Its discovery in adults is rare. Although it can affect any organ, the common forms found in adults are mesenteric and/or retroperitoneal CL. This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma in adults. METHODS: We report a retrospective study from January 1998 to September 2010 concerning 20 patients who underwent surgical removal of a CL. We were interested in discovering the clinical, biological, and radiological characteristics of CL. The localization, size, and number of cysts have been reported, as well as the surgical intervention used and the postoperative immediate and late complications. RESULTS: The median age was 46 years. Abdominal pain was the main symptom and was found in 15 patients (75%). Physical examination revealed an abdominal mass in 12 patients (60%). In four patients (20%), the cystic lymphangioma was incidental. Abdominal ultrasound and abdominal CT scan helped to highlight 22 cystic masses. CL diagnosis was established preoperatively in 13 patients (65%). Six patients (30%) were operated with a diagnosis other than CL. The diagnosis was made intraoperatively in one case (5%). Only two patients (10%) were operated on in emergency: one due to an infected CL and the other was CL complicated with intracystic hemorrhage. A laparotomy in 13 cases (65%) was the surgical approach used, whereas 7 cases (35%) benefited from a laparoscopy. No conversion was noted. The majority of the patients, 18 cases (90%), received a total cystectomy. Only two patients (10%) had recurrences of which only one was reoperated. CONCLUSIONS: The diagnosis of CL often is facilitated by means of modern imaging; however, other diagnoses may be discussed, particularly hydatid disease endemic areas. If symptomatic lesions or complications arise, complete surgical excision, when possible without major sacrifice, seems to be the best therapeutic option to reduce the risk of recurrence.

Giant retroperitoneal liposarcoma. Report of 5 cases.

BACKGROUND: Liposarcoma is the most frequent histopathological variety of the retroperitoneum, surgery is the gold standard for treatment. CLINICAL SERIES: We report, retrospectively over 7 years (2000-2006), 5 cases (four men and one woman, the mean age was 48 years) of giant retroperitoneal liposarcomas and study their clinical characteristics intra operatively findings and course evolution. None of our patients had a percutaneous biopsy of his tumour. Surgery was indicated to all patients. Resection was performed in 4 cases (we performed a bloc resection in three cases and a simple tumour resection in one case), and in one case, abstention was decided. None of patients had an adjuvant therapy Three of the patients still alive after the follow up of 2, 3 and 4 years. CONCLUSION: Retroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach including multiple resections for recurrences. Based on the ability of the patient to tolerate the procedure, surgery is suggested to evaluate resectability of the tumor. We must take into consideration whether prolonged survival will be attained and tumor removal will result in palliation of symptoms.

Risk factors associated with pancreatic fistula after distal pancreatectomy.

BACKGROUND: Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. AIM: To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP). METHODS: 35 patients underwent DP during a 10-year period (2000- 2009). Informations regarding diagnosis, operative details, and perioperative morbidity and mortality were collected. Nine risk factors were examined. RESULTS: Indications for DP included primary pancreatic disease (n=23; 66 %) and non-pancreatic disease (n = 12; 34 %). Postoperative morbidity rate was 43 % and none patient died. No patients required a reoperation. Pancreatic fistula was occurred in 11 patients (31 %). On univariate analysis, incidence of pancreatic fistula rate was not significantly associated with these risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, additional procedures, intra operative bleeding and texture of pancreatic parenchyma. We observed significant statistical difference between male and female, 47 % of females experienced a pancreatic fistula, while 17 % males developed a pancreatic leakage (p =0.05). The role of the technique of pancreatic stump closure in the development of pancreatic leak remains unclear because of the few number of patients on who we used stapler. CONCLUSION: The rate of pancreatic fistula after left pancreatectomy is 31 %. The female was identified as a risk factor for occurrence of pancreatic fistula after left pancreatectomy. The role implicated in the use of a mechanical claw for the treatment of pancreatic stump requires a larger number of patients to conclude. The body mass index has not been studied in our series.

Prognostic factors in gastric carcinoma after R0 resection with DII lymph node dissection. Tunisian experience.

BACKGROUND: Curative resection with adequate lymph node dissection is the treatment of choice for gastric cancer. AIM: To determine the prognostic factors after R0 resection with DII lymph node dissection. METHODS: We retrospectively assessed 126 patients who underwent R0 resection with DII lymph node dissection for gastric cancer (excluding the upper third of the stomach) in a single institution between 1991 and 2006 with median follow-up of 38.5 months (6 - 219). Prognostic factors were assessed by Cox proportional hazard model. RESULTS: There were 45 women and 81 men. The median age was 60 years (21 - 87). Four patients died (3.2 %). Postoperative hospital morbidity was 16.7 %. The pathologic review of the slides revealed that 50% of the tumors were stage T3 (63 cases). The median number of lymph node removed was 11 (8-40), 50% were involved. Five and 10 years survival rates were respectively 56.9 % and 40.2 %. In multivariable analysis, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were found to be independent prognosis factors. CONCLUSION: After R0 resection with DII lymphadenectomy, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were independent predictive factors for survival.