Thrombotic microangiopathy with liver, gut, and bone infarction (catastrophic antiphospholipid syndrome) associated with HELLP syndrome.

Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome is a thrombotic microangiopathy complicating pregnancy and shares many clinical and biological features with thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Thrombotic microangiopathy is also a pathological feature of catastrophic antiphospholipid syndrome (CAPS). An association between refractory HELLP syndrome and antiphospholipid syndrome (APS) has been reported in a few cases. We describe a 19-year-old woman with APS and multiorgan failure conforming to a diagnosis of CAPS who developed refractory HELLP syndrome.

Intussusception of the Meckel's diverticulum within its own lumen: Unknown complication.

INTRODUCTION: Intussusception with the Meckel's diverticulum (MD) is a rare cause of chonic abdominal pain in the adults. We wish to present this first case of intussusception of MD within its own lumen without small bowel obstruction. PRESENTATION OF CASE: We report the case of a 27-year-old man who was admitted to the emergency room due to a diffuse abdominal pain. Abdominal CT scan showed invagination of MD. The exploratory laparoscopy revealed the presence of intussusception of MD within its own lumen. Segmental resection of the small intestine was performed. The patient was discharged on the third post-operative day. DISCUSSION: The prevalence of MD is 1 to 4%. Diagnosis is often difficult and delayed because clinical symptoms are not specific and the diagnosis is performed mainly by imaging studies. Factors pre-disposing these patients to intussusception of MD within its own lumen include a narrow diverticulum, large diverticululm, and associated inflammation of the diverticulum. Intestinal obstruction is a more common complication in adults, whereas in children, bleeding is the more common complication. In our case, the patient had a diffuse abdominal pain without small bowel obstruction because the intussusception of MD was within its own lumen. Laparoscopy may be useful for confirming the presence of intussusception, and demonstrating the underlying organic lesion serving as the lead point. CONCLUSION: It is important to differentiate this rare pathological feature of MD from other entities as the treatment is surgical rather than medical. Abdominal surgeons should bear in mind this rare entity.

Jejuno-ileal diverticulitis: Etiopathogenicity, diagnosis and management.

INTRODUCTION: Although diverticular disease of the duodenum and colon is frequent, the jejuno-ileal diverticulosis (JOD) is an uncommon entity. The perforation of the small bowel diverticula can be fatal due to the delay in diagnosis. PRESENTATION OF CASE: We report the case of a 79-year-old man presenting with generalized abdominal pain and altered bowel habits. Physical examination revealed a severe diffuse abdominal pain. A CT scan of the abdomen and pelvis with oral contrast showed thickening of the distal jejunal loop and thickening and infiltration of the mesenteric fat and the presence of free air in the mesentery suggesting a possible perforation adjacent to the diverticula. A midline laparotomy was performed. The jejunal diverticula were found along the mesenteric border. Forty centimeters of the jejunum were resected. Histopathology report confirmed the presence of multiple jejunual diverticula, and one of them was perforated. The patient tolerated the procedure and the postoperative period was uncomplicated. DISCUSSION: The prevalence of small intestinal diverticula ranges from 0.06% to 1.3%. The etiopathogenesis of JOD is unclear, although the current hypothesis focuses on abnormalities in the smooth muscle or myenteric plexus, on intestinal dyskinesis and on high intraluminal pressures. Diagnosis is often difficult and delayed because clinical symptoms are not specific and mainly imaging studies performs the diagnosis. CONCLUSION: Because of the relative rarity of acquired jejuno-ileal diverticulosis, the perforation of small bowel diverticulitis poses technical dilemmas.

A rare variant of inguinal hernia: Cryptorchid testis at the age of 50 years. Etiopathogenicity, prognosis and management.

INTRODUCTION: Cryptorchidism is characterized by the extra-scrotal position of the testis. The surgical community has little to no knowledge of cryptorchid testis in adults apart from of pediatric surgeons. Therefore, we sought to describe this unusual cause of inguinal hernia. PRESENTATION OF CASE: A 50-year-old man was referred with a inguinal hernia. Diagnosis of cryptorchidism was made during surgery, as the patient underwent an operation for repair of his left inguinal hernia. The testicle was non-viable and a left testicle was resected. Histopathology report confirmed a atrophic testis without testicular germ cell tumor (TGCT). DISCUSSION: This is an extremely rare case of cryptorchidism revealed in an adult. The patient remained asymptomatic for 50 years. Most studies have concluded that there is a direct correlation between how long the testis was subjected to a cryptorchid position and TGCT incidence. The recommended age of surgical correction is before the age of 2 years. In our case, we did not find correlation between the time of surgery and risk of TGCT. Histopathology report confirmed the presence of leydig cells, seminiferous tubule and Sertoli cells without TGCT. Very little is known about link between cryptorchidism and TGCT. The correct diagnosis of inguinal hernia is usually made during an inguinal hernia repair. CONCLUSION: The surgeon must always be alert to the possibility of cryptorchid testis during a surgical exploration of an inguinal hernia. In suspected cases, laparoscopy ultrasonographic, CT scan and laparoscopy evaluation may be helpful in diagnosing of this atypical inguinal hernia before surgery.

Squamous cell carcinoma of middle rectum: Literature review.

INTRODUCTION: Squamous cell carcinoma SCC of the rectum is a distinct entity. We report a very rare case of squamous cell carcinoma of the middle rectum. PRESENTATION OF CASE: The patient was a 62-year-old woman who presented with a history of rectal bleeding and discomfort. Colonoscopy revealed a polypoid tumour of the middle rectum. Biopsies of this mass revealed a poorly differentiated SCC of the rectum. CT scan of the chest, abdomen and pelvis was negative for distal metastases. The patient received combined chemo-radiation followed by surgical excision. The postoperative period was uncomplicated. DISCUSSION: The pathogenesis of rectal SCC remains unclear and diagnosis is often delayed. Diagnostic criteria have been proposed. MRI of the rectum and trans-rectal endoscopic ultrasound R-EUS provide essential information to plan a therapeutic approach. The squamous cell carcinoma antigen level is not suitable for initial diagnosis of rectal SCC. Most authors conclude that the surgery is the gold standard treatment. Tumour stage is the most important prognostic predictor of SCC. CONCLUSION: Squamous cell carcinoma of the rectum is a distinct entity. Before the final choice of treatment is made, digestive surgeons should bear in mind this rare tumour.

Perforated diverticulitis of the sigmoid colon causing a subcutaneous emphysema.

INTRODUCTION: Although diverticular disease of the colon is frequent, perforated diverticulitis causing subcutaneous emphysema is a uncommon entity. We wish to present this extremely rare case of perforated colonic diverticulum in the subcutaneous tissue, which is the first one that we have encountered in our practice, along with the accompanying diagnostic and therapeutic issues and a review of the literature. PRESENTATION OF CASE: We report the case of an 83-year-old man who admitted to the emergency room due to an abdominal subcutaneous emphysema. Physical examination revealed a severe subcutaneous emphysema especially in the left iliac fossa and abdominal pain. An urgent contrast enhanced abdominal CT scan showed multiple diverticula in the sigmoid colon and multiple air bubbles in the subcutaneous tissue. The exploratory laparotomy identified a perforation of diverticular in subcutaneous tissue. Forty centimeters of colon were resected. The subcutaneous emphysema resolved without specific treatment. The postoperative period was uncomplicated. DISCUSSION: Subcutaneous emphysema of anterior abdomen wall is an obvious physical sign but its etiology is complex to determine and may be potentially lethal. The pathophysiological mechanism involved is the emergence of a pressure gradient between the peritoneum and surrounding structures, causing rupture of the anterior abdominal wall, allowing gas from a perforation to diffuse along tissue planes. CONCLUSION: This physical sign may be of especial value in elderly patient groups amongst whom perforation may be less clinically obvious. General surgeons should bear in mind this rare complication of colonic diverticulosis.

Combining radioisotopic and blue-dye technique does not improve the false-negative rate in sentinel lymph node mapping for colorectal cancer.

PURPOSE: This study was designed to assess the feasibility of a combined colorimetric and radioisotopic technique in the detection of the sentinel lymph node in colorectal cancer. METHODS: This prospective dual-center study included 64 patients. Using endoscopy on D0, a radiolabeled colloid was injected into the peritumoral submucosa, followed by a lymphoscintigraphy. Intraoperatively, on D1, lymphatic mapping was performed by using a visual method and radioguided detection after subserosal peritumoral injection of patent blue. Twenty-nine patients were injected only with the patent blue, 18 patients only with the radioactive tracer, and the other 17 patients benefited from both techniques. RESULTS: The detection rate was 92 percent. The average number of sentinel nodes harvested was 2.8. Twenty-four of 59 patients were pN+ (40 percent) and in 12 cases the sentinel lymph node was histologically negative, although there was a positive nonsentinel node (false-negative rate, 50 percent). The false-negative rate for the combined, radioisotopic, and colorimetric techniques were 63, 60, and 36 percent, respectively. In four patients, the sentinel node was the only metastatic site (4/24, 17 percent), and in two of these four patients, the sentinel lymph node presented with micrometastases (<2 mm). The radioisotopic technique allowed us to highlight a lateral drainage of two rectal cancers (2/13, 15 percent). The concordance between the blue and radioactive sentinel nodes was 43 percent. CONCLUSIONS: The addition of a radioisotopic method using submucosal injection does not improve the false-negative rate. The sentinel lymph node technique in colorectal cancer is feasible, although the false-negative rate is such that the technique should still be considered as experimental.