[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

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

Curative resection with adequate lymph node dissection is the treatment of choice for gastric cancer. To determine the prognostic factors after R0 resection with DII lymph node dissection. 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. 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. 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

[ caroli's disease. Report of 16 cases]

Caroli's disease is a congenital dilatation of the intrahepatic biliary duct. To analyse and discuss diagnostic and therapeutics difficulties through 16 patients with Caroli's disease. Between January 1990 and September 2010, 16 patients underwent surgical procedure for Caroli's disease. Data recorded for each patient included clinical symptoms, biologic findings, previous biliary procedures, and the presenting symptoms. The distribution of the biliary lesions, the surgical procedure and the postoperative outcomes and follow up were detailed. The mean age was 55 years. the mean interval between the first symptoms and diagnosis was 27 months. Five of 16 patients had undergone 12 surgical or dneoscopic procedures prior to liver resection. Before the definitive diagnosis, 9 patients presented 15 episodes of acute cholangitis. The diagnosis was established preoperatively in 13 cases, 5 among them underwent previous biliary surgical procedures. The diagnosis was documented peroperatively in 2 cases and postoperatively in 1 case. The distribution of the biliary lesions was monolobar in 13 and bilobar in 3 patients. 13 patients underwent liver resection, in two cases we performed bilio-jejunostomy and the last one had endoscopic sphyincterotomy. There was no mortality and the overall postoperative morbidity is about 43%. The follow-up shows that 12 patients still alive with a mean follow up for 53 months, from whom only one patient have intrahepepatic lithiasis. The clinical course of Caroli's disease is often complicated by recurrent episodes of angiocholitis and requires iterative surgery. The hepatectomy which prevented septic complications and degenerescence is possible only in a restricted number of patients

Acute peritonitis complicating Crohn's disease: epidemiologic and physiopathological characteristics

An uncommon event in the natural course of Crohn's disease is the spontaneous perforation. It's the most serious intestinal complication. To report the incidence of this complication and to discuss the mechanism of the perforation. We report, retrospectively, 4 cases [3 men and one woman; median age: 30 years] of peritonitis complicating Crohn's disease and study their clinical characteristics intra operatively findings and course evolution. Steroid therapy was administrated to all patients before the perforation. The perforation sites are on the ileum in three cases and on the jejunum in one case. The treatment consists in a resection of the perforated intestine with stoma in all cases. Perforation in Crohn's disease is a rare event. The exact mechanism of the perforation is still unknown and many hypotheses are presented

[Malignant intraductal papillary mucinous tumours of the pancreas: a three cases report]

Intra ductal papillary mucinous tumors of pancreas are rare and are characterized by a risk of malignant transformation. To clarify their clinical presentation and the performance of different imaging examinations to determine their benign or malignant and achieve their staging. We report three cases of degenerate intra ductal papillary mucinous tumors of pancreas. The combination of CT, the pancreato- MRI and duodenoscopy has led to the diagnosis in all cases. A pancreaticoduodenectomy were performed in two cases. The various imaging techniques allow better detection and analysis of the tumor including the evaluation criteria of degeneration. The treatment of these lesions is still surgery

[Anatomic variations of the hepatic artery: a study of 33 cases and review]

The hepatic artery is prone to numerous anatomic variations dictated by certain variables of the organogenesis. To research study the anatomic variations of the hepatic artery as well as their implications within surgical practice. Study of a post-mortem series of 33 cases of dissection of the hepatic pedicle with fresh corpses [deaths amounting no longer than 24 hours], carried out in conditions that are quite close to those met with the living ones. The common hepatic artery was divided at the foot of the hepatic pedicle into a gastro duodenal artery and into a proper hepatic artery in 94% of the cases. In 6% of the cases, we noticed a three level change, a branching of the average hepatic artery into a gastro duodenal artery, a right hepatic artery and a left hepatic artery. The proper hepatic artery represented the pedicle segment of the hepatic artery in 94% of the cases. In 36% of the cases, the liver was irrigated by two hepatic arteries. In 12% of the cases, there was the matter of the right hepatic artery, branch of the mesenteric artery. In 24% of the cases, there was the matter of the left hepatic artery branch of the left gastric artery. The perfect knowledge in preoperative and preoperative stages of the anatomic variations of the hepatic pedicle is quite essential. Actually, the lack of knowledge of these variations exposes to the risk of certain complications which are sometimes deadly during hepatic transplants, pancreatic surgery, cholecystectomies, through laroscopic way as well as in the treatment of gastro-esophagus surging

[Totally implantable venous access ports by cephalic vein cut-down for patients receiving chemotherapy]

The use of an implantable room has become indispensable in the clinical practice for the cancer patients. The increasing use of these devices was associated with a greater incidence of complications. To verify the feasibility of the cephalic vein cut-down technique for placement of venous access devices. A prospective study of 58 port placements was performed at our department of general surgery. The surveillance of devices was collectively insured by the operator and by the oncologists. The indication for implantation was the infusion of intravenous chemotherapy in patients with colorectal cancer in 55.1% cases and breast cancer in 27.5%. The specific complication rate was 7%. The cephalic vein cut-down approach was used successful in 45 [77.5%] patients. When the cephalic vein could not be used, a percutaneous technique was employed using the subclavian vein in 22.4% of the patients. Cephalic vein cut-down technique should be considered a safe and feasible approach for placement of venous access devices

[Mesenteric panniculitis simulating malignancy]

Panniculitis mesenteritis is a rare, benign, and chronic fibrosing inflammation disease with unknown aetiology that affects the mesentery of small bowel and colon. To report a new case of this entity and to highlight its diagnostic difficulties especially when it affects the mesocolon. A 37 years-old women presented with chronic abdominal pain; physical examination found mass of left ilaca fossa. Closcopy and abdominal CT scan showed a thickness of bowel wall with negative biopsies. The patient underwent a colectomy. Histologic examination concluded to the diagnosis of Mesenteric panniculitis without malignant lesion. Mesenteric panniculitis is a rare pathology which diagnosis is difficult to establish. It can simulate malignancy. A better knowledge of its clinical and radiological features could ovoid unecessary digestive resection

[Early gastric adenocarcinoma]

the purpose of this study was to determine the epidemiological and clinical behaviour of the superficial adenocarcinoma of the stomach, to clarify its pathological characteristics, therapeutic as well as his its prognosis. Over a period of 14 years [1990-2004], 16 patients were operated for a superficial gastric adenocarcinoma among 155 gastric cancers treated during the same period in the service of general surgery [A] La Rabta. The superficial gastric adenocarcinoma represented 10.3% of our series. The mean age was 59 years. It was about 8 men and 8 women. Two patients was followed for a chronic stomach ulcer, a patient is followed for Biermer anaemia and another one for Menetrier disease. Among these cancers, 12 were intra mucosal and 4 invaded the submucousa. Lymph node involvement was present only in one case. The cancer was located in the antrium in 8 cases and was multifocal in 3 cases. One patient died in postoperative case because of a medical cause. The 5-year-overall survival was 65.6%. The recurrence had interested only one patient. the superficial gastric adenocarcinoma is rare. The follow up of precancerous states allows its diagnosis. The treatment is based on the gastric resection associated to the DI-type lymph node clearance. The multifocal character imposes a surveillance of the remaining gastric stump

[Laparoscopic appendicectomy versus conventional appendicectomy prelliminary results of a retrospective comparative study]

The value of laparoscopic surgery in appendicitis is not established. Studies suffer from many controversies. The aim of this study is to compare the safety and benefits of laparoscopic versus open appendectomy in patients with clinically non complicated acute appendicitis. One hundred thirty nine patients wore analyzed retrospectively following either laparoscopic or open appendectomy. We excluded peritonitis, appendicular abscesses and patients with history of digestive surgery. The main outcome measures wore operative duration, postoperative complications and length of hospital stay. There was no mortality. The overall complication rate was similar in both groups [13,9%versus 7,4%in the laparoscopic and open groups respectively p=0,22]. Operating duration was significantly longer in the laparoscopic group [62 minutes versus 40 minutes p=0,001] while there was no difference in length of stay. Laparoscopic appendectomy did not offer a significant advantage over open appendectomy in acute non complicated appendicitis. The choice of the procedure should be based on surgeon or patient preferences