[Laparoscopic cholecystectomy on previous operated abdomen]

laparoscopic cholecystectomy is the "gold standard" reference treatment of gall bladder stones. Laparoscopy is still contra-indicated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. This study aimed to assess outcomes of laparoscopic cholecystectomy on a scarred abdomen. We have carried out a retrospective study on a number of consecutive patients operated between the first januar 2000 and 31 december 2006, who underwent laparoscopic cholecystectomy with previous abdominal surgery [one or several].during this period, laparoscopic cholecystectomy was performed on 2281 patients, including 233 patients who had at least one abdominal scar [10%]. We have noted on the records of these patients all the data relating to the epidemiological, clinical and therapeutical aspects. We have worked out a descriptive analysis of the series and we have thus studied the rate of operative and post-operative complications, the rate of conversion, the duration of the operation and the duration of post-operative stay. Then we have compared two groups of patients, those with an upper abdominal surgery: group 1[G1] and those with lower abdominal surgery: group 2 [G2]. The groups consist of 200 women and 33 men aged on average 13, 8 +/- 49, 6 years. The indication for cholecystectomy was a symptomatic cholelithiasis in 78%of cases [n=181], an acute cholecystitis in 22%of cases. The adhesions were believed numerous or very numerous in only 46 patients [20%]. Four patients had interventional adverse events: a small intestine injury, a choledoch injury, a gastric injury and a least known colic injury. The rate of open conversion was 2, 1%. Post-operative complication was 2, 1%. The evolution was satisfactory in all cases. Mean operating time was 50 minutes [15-230]. Mean post operative stay was one day [1-29 days]. When comparing the above mentioned two groups of patients [G1: 45 patients and G2:188 patients], we can conclude that the first group [G1] is made up of more male patients aged over 60 years [p<10-3] It also appears that the existence of an upper umbilical scar is correlated to a, greater number of adhesions [p<10-3], an increased risk of operative complications [p=0, 01], a greater conversion rate [p<10-4], a prolonged operating time [p<10-3] and a longer stay [p=0, 017]. On the other hand, post-operative complications was similar in group I and 2. Previous abdominal operations, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a higher rate of adhesions, an increased risk of operative complications, a greater conversion rate, a prolonged operating time and longer stay

[Intraductal papillary mucinous tumor of the pancreas mimicking pancreatic pseudocyst]

Most of pancreatic cysts are in fact pseudocysts. Only 10 to 20% are real cystic tumors. Intraductal papillary mucinous tumors of the pancreas represent nearly 15% of them. To illustrate, by an observation, the difficulties to diagnose a cystic tumor of the pancreas. We report the case of a 55 year old woman complaining of epigastric pain for one month with an elevated pancreatic enzymes level. Ultrasonography and computed tomography scan showed two cystic formations measuring 6 and 7cm localized respectively in the head and the body of the pancreas. The diagnosis of pancreatic pseudocysts was maintained. The appearance of a jaundice made us think about a pseudocyst's compression of the common bile duct. A cysto-gastric anastomosis was made. The recurrence of the jaundice associated to diabetes and a general state deterioration led to the practice of magnetic resonance cholangiopancreatography. It revealed an intraductal papillary mucinous tumor of the pancreas affecting secondary ducts. The presence of a peritoneal carcinosis led to therapeutic abstention. The diagnosis of intraductal papillary mucinous tumor of the pancreas must be referred to in case of pancreatic cystic tumor without extrapancreatic necrosis. This kind of tumor can simulate a pancreatic pseudocyst

[Hydatid cysts of the pancreas, report of two cases]

Hydatid cyst of the pancreas is a rare affection with a frequency less than one percent of the various sites of hydatid disease. Rreport two cases of hydatid cyst of the pancreas. A 49 year old woman with a history of laparotomy for liver and peritoneal hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 3 cm in size. Surgical treatment consisted in a resection of the protruding dome with uneventful postoperative course. A 45 year old man who underwent laparotomy four years ago for hepatic hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 4 cm in size. At laparotomy it was a head pancreatic hydatid cyst without duct pancreatic lesion. The treatment consisted in the resection of the protruding dome. The postoperative evolution was simple. Hydatid cyst of the pancreas is rare. If associated with another hydatid localization, the diagnosis is generally easy. It can however be more difficult if the pancreatic localization is isolated. In most cases, resection of the protruding dome is sufficient

aggressive course of de novo ulcerative colitis after renal transplantation: colonic adenocarcinoma with choriocarcinomatous differentation

A rare case of colonic carcinoma arising in de novo ulcerative colitis after renal transplantation in a 42-year-old woman is reported. Clinically, the patient presented ulcerative colitis 8 years after renal transplantation, developed colonic cancer with liver metastasis 2 years later and died one month post operatively. Histologically, the removed tumor was composed of two distinctive elements consisting of adenocarcinoma and choriocarcinoma. The metastatic foci in the liver were composed exclusively of choriocarcinoma. Identification as choriocarcinoma was made on the basis, of typical histological appearance, immunohistochemical demonstration of human chorionic gonadotropin [hCG] in the tumor cells and the high serum hCG level, unrelated to trophoblastic disease. In this report, pathogenesis is briefly discussed and clinical conditions are reviewed. In conclusion, the issue of de novo UC after organ transplantation is still a matter of debate. Further investigations are necessary to understand the tumorogenesis of colorectal cancer in de novo UC after renal transplantation

[Myofibroblastic tumor of the great omuntum]

Myofibroblastic tumors are a spindle cell lesion at indeterminate malignant potential. Abdominal location was rare. We report a case of an unusual location at myofibroblstic tumors in the great omuntum. A 63-year-old women presented with a one year of isolated left hypochondrium pain. Physical examination was normal. CT scan of the abdomen showed a multicystic and a multilocular building-up of the great omentum suggestive of a peritoneal haemolymphangioma. Besides, at the MRI, this lesion showed up with threefold component: cystic, plump and fibrous, all leading towards a myofibroblastic tumor. At laparotomy, there was already a 10 cm diameter cystic tumor of the great omentum, composed of numerous cystic sockets, all filled with a thick brunish substance. A total resection of the great omentum was done, thus taking away the whole tumor. The histological examination confirms the diagnosis of myofibroblastic tumor of great omentum. Post operative evolution was uneventful. One year later there were no signs of recurrence. Myofibroblastic tumors of the great omentum are rare. The diagnosis is often confirmed by careful microscopic examination or immunohistochemical markers. Treatment consists on a complete surgical resection and life time follow-up is needed because the risk of recurrence

[Squamous cell carcinoma arising in Verneuil's disease]

Verneuil's disease or hidradenitis suppurativa is a chronic suppurative, and cicatricial inflammatory disease, mainly affecting apocrine-bearing area of the skin. Squamous cell carcinoma is an uncommon but a frightening complication of hidradenitis suppurativa. To report a new case of squamous cell carcinoma arising in Verneuil's disease. We reported a case of 60 year old man with a 30 years history of hidradenitis suppurativa in which squamous cell carcinoma arise. A wide surgical excision removing the tumour and leaving a large defect was performed. The patient had a well recovery, wounds healed well by primary intention. No recurrence observed at 18 months of follow up. Squamous cell carcinoma is an uncommon complication of hidradenitis suppurativa. Surgical excision represents also the treatment of choice

Analyses des connaissances attitudes et pratiques du personnel soignant face aux accidents d'exposition au sang en chirurgie generale

In order to assess the degree of knowledge, attitudes and the personnel's practices exercising in a service of general surgery of the hospital Charles Nicolle of Tunis, concerning blood exposure accidents, we did a transverse survey during the month of January of the year 2002. A questionnaire has been addressed to 114 people while using the technique of the direct interview. The middle age of investigated is 35,7 years. The sex ratio is 0,7. Only the 2/3 declare have been vaccinated against the B hepatitis. The results show a good knowledge of the exposure risk to a communicable disease by blood [95,6%], but less good for the risk of contamination by the three viruses HBV, HCV and HIV. The resheathing of needles, considered like gesture to risk, is underestimated by 71,2% of investigated. the majority of investigated declare to know universal precaution principles [85,8%]. However, to the maximum 4 measures only on the 1 0 advisable have been mentioned by investigated. The conduct to hold in case of blood exposure accident seems insufficientiy known by our sample- It is represented, in 78,8% of cases, in the application of disinfectants Betadin' type or alcohol Iodized, whereas the practice of 0 serology to the patient source is ignored completely. 75% of investigated having had a blood exposure accident lasting the last 12 months [n = 44] didn't declare their blood exposure accident and only 11,4% declare to have undergone cares. Actions of information and Formation, to the intention of the whole of the personnel of the service, on risks incurred by the nursing, gestures and procedures to risk, the universal precaution respect, the conduct to hold in case of a blood exposure accident, the interest of the declaration and the interest of the vaccination against the B hepatitis, are primordial

Facteurs predictifs de morbidite et de mortalite de la chirurgie du vieillard

The aim of the study was to determine prognostic factors of post operative morbidity and mortality for patients aged 80 years and older. We compared two groups of patients aged 80 and over operated to determine predictive factors of morbidity and mortality group of patients who presented post operative complication within 30 days after surgery and group of patients without any complication. Comparison of the two groups for global morbidity using univariate analysis showed only one prognostic factor: surgery of diabetic foot [p = 0.034]. Predictive factors of mortality according to univariate analysis were: pre-operative shock [p = 0.001], abdominal wall pathology [p = 0.027], gastric or duodenal ulcer diseases [p= 0.011] and global morbidity [p = 0.006]. After logistic regression, only pre-operative shock was an independent predictive factor of mortality [p = 0.0023]. Risk for morbidity after surgery in the elderly 80 years and over is linked with type of surgery and not with soil. Likewise, risk for mortality is linked with advanced stage of disease that is presence of pre-operative shock and not with soil

[Trauma of an ectopic kidney. A case report]

Ectopic kidney is a rare pathology. It is usually misknown and often revealed by a complication. We report a case of a 30- year-old male patient who presented in emergency with a right thoraco-abdominal trauma and a benign head trauma. Injury evaluation revealed a right ectopic pelvic kidney with a grade IV laceration. Furthermore, there was a hepatic contusion in the sixth segment and a fracture of the ninth, tenth and eleventh right ribs. Therapeutic attitude consisted on a successful conservative and nonoperative treatment for both lesions. CT scan is of utmost importance in diagnosis. Management is the same as for normally positioned kidney

Facterus pronostiques des splenectomies pour rate hematologique

The aim of this study was to identify the prognostic factors of intraoperative haemorrhage, perioperative blood transfusions and morbidity. We collected 120 splenectomies in Beau sejour department of surgery, charles' Nicolle Hospital, Tunis, Tunisia between 1979 and 1999. the descriptive analysis showed sex ratio 0.82 with mean age [ +/- standard deviation] 30.6 +/- 15 year. Idiopathic thrombopenic purpura was the principal disease indicating splenectomy. Morbidity was defined as occurrence of post operative peritoneal sepsis or bleeding. The mortality and morbidity rates were respectively 0.8% and 6.6%. the prognostic anlysis didn't identify predictive factors of intraoperative haemorrhage, however it identified two independent predictive actors of specific morbidity: intraoperative haemorrhage [p = 0.03] and preoperative rate of haemoglobin [p = 0.0049]