[Primary necrosis of the ligamentum teres hepatis]

Report a new case of primary necrosis of the ligamentum teres hepatis and discuss preoperative diagnosis strategy and therapeutic options. This is a patient of 76 years, hypertensive, who was admitted for an acute abdomen. The diagnosis of acute pancreatitis was referred to the poor clinical examination and amylase to six times normal. Abdominal CT scan showed a normal pancreas appearance and hypodense infiltration extended along the round ligament of the liver to the anterior abdominal wall that did not take the contrast. The patient was operated 24 hours after admission to the signs of clinical and biological severity. There was gangrene of the round ligament and the suspensory ligament of the liver. We performed a resection of all necrotic tissue and cholecystectomy. The postoperative course was uneventful. Primary necrosis of the round ligament of the liver is an extremely rare cause acute abdomen. Its diagnosis is difficult despite the contribution of the abdominal CT scan. Treatment is surgical

Spontaneous fistulization of hepatic hydatid cyst into the duodenum: an exceptional complication

Hydatid disease is a worldwide zoonosis and is localized in the liver in most cases. Its complications are numerous and include those related to the compression of adjacent viscera, infection of the cyst's contents or perforation of the cyst. Spontaneous rupture of the hepatic hydatid cyst into the duodenum is an extremely rare complication. The communication is, typically, not discovered until surgery. We present two cases of perforation of a liver cyst into the duodenum. One of them was diagnosed pre-operatively by a barium study. The surgical treatment of the lesion and its complications was complex but successful in both cases

[Relationship between subcutaneous adipose tissue expression of leptin and obesity in Tunisian patients]

The incidence of obesity has dramatically increased in overall the world. It is a consequence of imbalance between energy intake and energy expenditure. Leptin is a fat derived adipokine that has emerged over the past decade as a key hormone in the regulation of food intake and energy expenditure. Elevated leptin levels are found in obese humans, suggesting a role of leptin in regulating body weight and adiposity. The aim of this study was to investigate the change of leptin mRNA expression level and its correlation with obesity and several metabolic variables in Tunisian patients. Real time quantitative polymerase chain reaction [QPCR] analysis was carried out among two groups who underwent an abdominal surgery: controls [n=9] and obese patients [n=7]. Leptin mRNA expression in subcutaneous adipose tissue was markedly increased in obese patients [p<0.01]. It was positively correlated with measures of obesity waist circumference [WC] [r=0, 71, p<0.01] and body mass index [BMI] [r=0, 68, p<0.01]. Interestingly, leptin gene expression was also correlated to insulin resistance index [r=0, 72, p<0.01]. The present study is the first investigation of leptin regulation in subcutaneous adipose tissue of Tunisian population. Our data showed that leptin levels are higher in obese subjects than in control subjects. This indicates that the subcutaneous adipose plays an important role in impaired adipokine regulation, and consequently in developing metabolic disorder

Rare cause of a lower gastrointestinal bleeding

Leiomyoma of the colon are rare benign smooth muscle tumours. Report a new case of colic leiomyoma revealed by gastrointestinal bleeding. A 71-year-old man, diabetic, consulted the emergencies for acute per-rectal bleeding. The physical examination was essentially normal. Haemoglobin level was 3.7g/dl.. The upper digestif endoscopy was normal. The colonoscopy showed an active bleeding from the right colon but it was enable to specify the nature and the exact seat of the bleeding lesion. An emergent operation showed a tumor of the right colic angle of 8 cm. A right hemicolectomy was performed with immediate ileocolic anastomosis. Pathology showed a leiomyoma. Postoperative course mentioned a nosocomial pneumopathy. Colic leiomyomas are rare benign tumours. The determination of the mitotic index is of primary importance to differentiate them from the leiomyosarcomas of low rank of malignancy whose prognosis is unfavourable

Primary anorectal melanoma: a case report

Anorectal melanoma is a rare but highly lethal malignancy. Clinical symptoms are non-specific and treatment is still debated. The aim of this study was to report a case concerning diagnostic and management of Anorectal melanoma. A 66-year-old man was admitted in our surgical unit with a 3-month history of pain and rectal bleeding. Rectal examination revealed a tender mass arising from the 5 o'clock position of the anal canal that bled on touch. A provisional diagnosis of rectal polyp was made and it was removed by local excision under general anaesthesia. Histopathologic examination reported it as an anorectal malignant melanoma. The postoperative course was uneventful. Extension staging showed a 15 mm nodule on the left lung. The patient underwent a metastasectomy of the left lung. No adjuvant therapy was given. He died one year later. With this case we want to illustrate that malignant melanoma can be difficult to diagnose, as patients have non-specific symptoms and histology may be misleading. Surgery remains the mainstay of treatment. Wide local excision combined with adjuvant loco-regional radiotherapy should be preferred when technically feasible. Abdominoperineal resection has to be done only in the case of large tumors or when the anal sphincter is involved. Overall 5-year survival is less than 20%. It's correlated to extension of disease regardless of initial surgical therapy

Stromal tumor of the ampulla of vater: report of a case and systematic review of reported cases

Gastrointestinal stromal tumours are a large category of primary no epithelial neoplasms of the digestive tract. The localization of stromal tumours in the ampulla of Vater [STAV] is very rare. The aim of this study was to describe clinical, endoscopic and therapeutic particularities of STAV. We reported a new case and we carried out an extensive electronic search for the relevant literature using Medline. Key words used were "ampulla of Vater" and "Gastrointestinal stromal tumor" and "CD 117". With our case, we collected seven other cases in the literature. The analysis of the sample of these eight cases leads us to propose the following conclusions. STAV is a tumor of adult after the age of fifty. There is no specific symptomatology. Gastroduodenal endoscopy with biopsies and immunoassaying allows positive preoperative diagnosis in the 5 cases. Treatment should be duodenopancreatectomy since the tumor is often malignant [5 cases]

[Odontogenic descending necrotizing mediastinitis]

Descending necrotizing mediastinitis [DNM] following an oropharyngeal infection is a rare disease with a rapid course and a mortality rate of up to 40%. The aim of this study, is to outline the diagnosis and the appropriate treatment of DNM. A retrospective study [1986-2007] of patients with DNM was made. Only patients with cervical cellulitis associated with DNM were included. Eight men and two women with an average age of 43 years were treated. Five had diabets. The average for diagnosis and treatment was eight days. In eight cases, we found a dental origin and in two cases a pharyngeal origin. The diagnosis of DNM was made thanks to cervico thoracic CT scan in six cases. In the others patients. they had at presentation clinical and radiological evidence of mediastinal diffusion. All patients were treated by broad spectrum antibiotherapy. All had cervical drainage. Mediastinal drainage was made by cervical approach in 2 two cases and via a right thoracotomy in eight cases. Eight patients died. Odontogenic DNM is a rare disease with rapid course Clinical diagnosis is difficult and early recognition with a lowi thresold for CT scanning is essential. CT is also useful for the treatment and in the post operative assessment. All affected tissue plane must be debrided. Surgical management and mediastinal drainage remain controversial about the indication of thoracotomy

[Primary carcnoid hepatic tumour: a case report]

Primary carcinoid tumour of the liver is rare and poses a diagnostic and management dilemma. Report a new cases. A 48 year-old patient man, with a 8-months history of abdominal pain and weight loss, was operated on in December 2000, in another centre with the diagnosis of caudate pancreatic cancer. At laparotomy, Resection was deemed to be not feasible. Histological examination of biopsy was for carcinoid tumor. The patient underwent post operative radiotherapy and four courses of chemotherapy and he was referred to our hospital. Physical examination was normal. Based on radiological examination, the diagnosis was endocrine tumor of the pancreas. The patient underwent relaparotomy, the lesion was independent from the pancreas but linked to the liver; the caudate lobe. Complete macroscopic resection was performed. Histological examination of operative specimen concludes to carcinoid tumor with invasion of hepatic margins. The patient underwent adjuvant chemotherapy; he was free from disease 6 months after surgery. The diagnostic of primary carcinoid tumors is based principally in the histopathological confirmation of neuroendocrine origin and the exclusion of non hepatic primary tumour. This requires preoperative imaging but most importantly a thorough laparotomy and rigorous follow-up. Surgical resection if possible is recommended

[Impact of esophageal manometry before anti-reflux surgery]

Esophageal hypomotility is frequent in patients with gastroesophageal reflux disease [GERD]. To precise the frequency and the patterns of esophageal manometric abnormalities in GERD patients referred before anti-reflux surgery, to determine the frequency of post-operative dysphagia and to look for associated factors with high risk of dysphagia, with special interest on pre-operative esophageal manometric study. We conducted a retrospective study based on patients having anti-reflux surgery and pre-operative esophageal manometry. Post-operative dysphagia was prospectively assessed during the follow-up. We studied 33 patients [mean age: 46 years; sex ratio: 0.4]. Pre-operative esophageal manometry was abnormal in 1/3 of cases, with a high prevalence of non specific motor disorders and hypomotility. Nor epidemiological, clinical or pH metric factor was associated with the risk of motor esophageal abnormalities. Post-operative dysphagia was noted in 21% of the cases, with any correlation with results of pre-operative manometry. Esophageal hypomotility is frequent in patients with GERD; and not associated with a higher risk of post-operative dysphagia after anti-reflux surgery

[Primary aorto-enteric fistula in a 52 -year- old man]

Aorto/ilio enteric Fistula [AEF] is defined is a communication between the aorta or iliac artery and any adjacent segment of the bowel. It may be primary or secondary. The former occurs in patients with intestinal or vascular disease and mostly complicates abdominal aortic aneurysm [AAA], whereas secondary aorto-enteric fistula is a dreadful complication of aortic reconstruction with vascular prosthesis. Of this study is to report this case of unusual presentation of PAEF as a rare cause of low enteric bleeding and discuss the path physiology, etiology, diagnosis and management of this entity. The authors report a case of 52-year-old man who presented with acute rectal bleeding. Esophago-gastro-duodenoscopy and colonoscopy were non diagnostic. Because of persistence of bleeding and hemodynamic instability, patient underwent urgent laparotomy. At surgery, diagnosis of primary aorto enteric fistula [PAEF] was made between the right iliac artery and the sigmoid complicating an iliac pseudo aneurysm. Direct repair of the vascular and digestive defects and sigmoidostomy were performed. The patient died two hours after surgery of cardiac arrest. AEF is a rare but a life threatening cause of GI bleeding. A delay in identification, as in our observation, may partly explain the high morality and morbidity