Gallstone ileus: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Gallstone ileus (GI) is defined as the occlusion of the intestinal lumen due to the impaction of one or more gallstones. The optimal management of GI is not consensual. We report a rare case of GI with a successful surgical treatment for a 65 year-old-female. CASE PRESENTATION: A 65 year-old-woman, presented with biliary colic pain and vomiting for three days. On examination, she had a distended tympanic abdomen. A computed tomography scan revealed signs of small bowel obstruction due to a jejunal gallstone. She had pneumobilia due to a cholecysto-duodenal fistula. We performed a midline laparotomy. We found a dilated and ischemic jejunum with false membranes regarding the migrated gallstone. We performed a jejunal resection with primary anastomosis. We performed cholecystectomy and closed the cholecysto-duodenal fistula at the same operative time. The postoperative course was uneventful. CLINICAL DISCUSSION: We reported successful surgical treatment for GI. It was a one-step procedure. GI is a rare situation. Due to their restricted lumen, the terminal ileum and the ileocaecal valve are where GI occurs most commonly. GI appears usually in elderly patients with comorbidities. The clinical presentation is not specific. CT scan evokes the diagnosis with high specificity. The surgical management of GI is not consensual. In our case, we performed bowel resection due to the presence of an ischemic intestine. CONCLUSION: GI is a rare situation. It appears usually in elderly patients with comorbidities. The clinical presentation is not specific. The surgical management of GI is not consensual.

Spontaneous rupture of an infected pseudocyst of the pancreas: A case report.

INTRODUCTION AND IMPORTANCE: A pancreatic pseudocyst is a known complication of acute and chronic pancreatitis. A pseudocyst rupture into the abdomen causes peritonitis, which can be fatal if surgical treatment is delayed. Here in we report the case of a 46-year-old woman presenting with a pancreatic pseudocyst doubly complicated with infection and rupture causing sepsis shock. CASE PRESENTATION: A 46 year-old-woman, with a history of chronic pancreatitis four years prior complicated with a pancreatic pseudocyst of 3 cm, presented to our emergency department with clinical signs of generalized peritonitis. After a brief resuscitation, we performed a midline laparotomy. It showed purulent peritonitis due to a rupture of an infected pseudocyst of the pancreas. We performed an abundant peritoneal toilet with drainage. The patient was discharged after 25 days. In the one month follow-up, there were no unfavourable outcomes. CLINICAL DISCUSSION: In presence of ruptured and infected pancreatic pseudocyst, surgical treatment should be performed as soon as possible after brief resuscitation. Laparotomy is the gold standard treatment. The main objective of surgical treatment is to perform abundant peritoneal toilet with large external drainage. In our case, the pancreatic pseudocyst didn't communicate with the Wirsung duct allowing us to withdraw the drainage. Otherwise, the drainage should be retained longer to treat the pancreatic leakage. CONCLUSION: Rupture and infection of pancreatic pseudocysts is a rare situation. Diagnosis is assessed via computed tomography scan. Emergency laparotomy should be performed timely to make the peritoneal toilet and drain the pancreatic pseudocyst.

Are biopsies during endoscopic ultrasonography necessary for a suspected esophageal leiomyoma? Is laparoscopy always feasible?

The present letter to the editor is related to the work entitled "Large leiomyoma of lower esophagus diagnosed by endoscopic ultrasonography-fine needle aspiration: A case report." Although endoscopic ultrasonography seems necessary in a suspected leiomyoma of the esophagus, the performance of biopsies via fine needle aspiration is controversial as it increases the risk of complications such as bleeding, infection, and intraoperative perforations. Laparoscopy is the best treatment strategy for small tumors. Laparotomy with tumor enucleation or esophageal resection can be considered in large leiomyomas.

Hydatid cyst of the ilium: A case report.

INTRODUCTION AND IMPORTANCE: Hydatid cyst is a common parasitic disease in endemic countries. It frequently occurs in the liver and lungs. Ilium involvement is extremely rare. We report the case of a 47-year-old man presenting with a hydatid cyst of the left ilium. CASE PRESENTATION: A rural 47-year-old patient, presented with pelvic pain and limping on walking for six months. He had a pericystectomy 10 years prior for a hydatid cyst of the left liver. A pelvic computed tomography scan showed an osteolytic remodeling of the left iliac wing associated with a large multiloculated cystic mass fusing along the left ilium. The patient had partial cystectomy and curettage of the ilium. The postoperative course was uneventful. CLINICAL DISCUSSION: Hydatid cysts of the bone are exceptional but aggressive due to the absence of a pericyst limiting the extension of the lesions. We report a rare case of a patient presenting with a hydatid cyst of the ilium. The prognosis is poor even in patients who undergo extensive surgical treatment. CONCLUSION: Early and adequate management can improve the prognosis. We highlight the importance of conservative treatment consisting of partial cystectomy with curettage of the bone to avoid morbidity related to radical surgery.

Primary small bowel volvulus: A case report and literature review.

Background: Small bowel volvulus (SBV) is an aberrant rotation of the small bowel segment along the axis of its mesentery.Secondary SBV is the most frequent situation. Postoperative adhesions represent the main cause. On the other hand, primary SBV is an extremely rare situation. There are no predisposing anatomical abnormalities.Herein, we present a case of a 73-year-old-patient, with no surgical history, presenting primary SBV. Case presentation: A 73-year-old-patient presented to the emergency department with a one-day history of acute abdominal pain and vomiting. He had no medical comorbidities and no previous abdominal surgery.On examination, he was agitated and afebrile.Urgent computed tomography (CT) scan showed dilated small bowel loops with a "whirl sign".A laparotomy was performed. It revealed a 320° SBV of the distal jejunum and the proximal ileum. The small bowel was ischemic. There were no congenital malformations, no adhesions, and no internal hernia.We performed a detorsion of the small bowel. It regained good vitality. To avoid recurrence, we performed enteropexy of the terminal ileum, and the caecum to widen the mesenteric base.We noted no recurrence of the pathology after three months of follow-up. Conclusion: Primary SBV is an extremely rare situation. Physiopathology is still misunderstood. The clinical presentation is not specific. Diagnosis can be evoked by CT scan but can only be confirmed intraoperatively. The surgical treatment should be performed timely. Different techniques have been described to avoid recurrence. None of those techniques is consensual.

5-mFI is more accurate than ASA score in predicting postoperative mortality in rectal cancer: A case series of 109 patients.

Introduction: The aim of this study was to compare the accuracy of 5-mFI (modified frailty index) to ASA score (American Society of Anesthesiologists score) in predicting postoperative mortality in patients with rectal cancer. Materials and methods: The ability of each parameter to predict postoperative mortality was attested in 2 ways: Area under the curve (AUC) was determined using ROC curves analysis. A comparison of AUC was performed using Delong test and Henley-McNeil test.-Multivariate analysis to determine the weight of each variable in predicting postoperative mortality. Results: The records of 109 patients undergoing surgical resection, for curative intent, for rectal cancer, were analyzed. Nine patients died during the 30-day postoperative period (8.25%). The optimum cutoff for 5-mFI to predict mortality using the ROC analysis was 1.5. The AUC at the cut-off point was 0.93. The optimum cutoff for ASA score to predict mortality was 1.5 and the AUC at the cut-off point was 0.81. The AUC of 5-mFI was significantly higher than the AUC of ASA score (p < 0.0001 using Delong test and p = 0.0024 using Hanley and McNeil test).On univariate analysis, predictive factors of mortality were: age (p = 0.002), ASA score≥2 (p = 0.0001) and 5-mFI≥2 (p = 0.0001). On multivariate analysis, 5-mFI≥2 was the only factor significantly associated with increased odds of postoperative mortality (OR = 1.73; 95% CI 1.05-2.01). Conclusion: 5-mFI was more accurate than ASA score in predicting postoperative mortality in patients with rectal cancer.

Leiomyosarcoma of the small bowel: A case report and literature review.

INTRODUCTION: Malignant tumors of the small bowel are rare. The jejunum, ileum, and duodenum represent the most common sites of intestinal leiomyosarcoma (LMS). Herein, we present a case of a 65-year-old patient having ileal LMS successfully treated with surgical resection. PRESENTATION OF CASE: A 65-year-old patient, with no comorbidities, presented with chronic and paroxysmal abdominal pain. Upper endoscopy and colonoscopy showed no abnormalities. Thoracoabdominal computed tomography (CT) revealed an ileal lobulated, heterogeneously enhancing solid mass measuring 6 cm. Laparotomy was performed. Findings showed a lobulated ileal mass. We made an enlarged ileal resection with end-to-end anastomosis. The postoperative course was uneventful. Histology and IHC stains concluded into ileal LMS. No relapse of the disease was noted during the 4-month follow-up. CLINICAL DISCUSSION: Ileal LMS is a rare tumor originating from the smooth muscle cells within the muscularis mucosa or muscularis propria. CT colonography (CTC) and magnetic resonance enterography (MRE) represent good options to aid the diagnosis. Histologically, LMS often has a comparable morphological appearance to GISTs. IHC is essential to differentiate those tumors. Surgery is the only curative treatment. The prognosis is poor knowing that those tumors are discovered at advanced stages. CONCLUSION: Ileal LMS is a rare tumor originating from the smooth muscle cells. It has a comparable morphological appearance to GISTs. Immunohistochemistry is essential to confirm the diagnosis. Surgery is the only curative treatment. The prognosis is poor.

Myxofibrosarcoma of the abdominal wall : A case report and literature review.

INTRODUCTION: Myxofibrosarcoma (MFS) is a subtype of soft tissue sarcoma characterized by diffuse infiltration patterns. Myxofibrosarcoma arises often in extremities. Its occurrence in the abdominal wall is extremely rare. Herein, we present here a case of high-grade MFS of the abdominal wall discovered in a 58-year-old woman complaining of an abdominal mass. PRESENTATION OF CASE: This report illustrates the case of a female who presented a mass in the right lower quadrant of the abdomen. Abdominal computed tomography (CT) scan revealed a well-circumcised, heterogeneous soft tissue mass. We performed a wide margin excision of the mass. Histology concluded in myxofibrosarcoma of the abdominal wall. Adjuvant radiotherapy was performed. CLINICAL DISCUSSION: We reported successful surgical treatment for myxofibrosarcoma of the abdominal wall. To our knowledge, this is the second report in English literature. MFS is a subtype of soft tissue sarcoma with a locally infiltrative behavior. To ensure the best curative treatment, It is important to excise the tumor with wide margins. Knowing that MFS has a propensity for local recurrence (16 to 57 %), adjuvant radiotherapy has emerged as an efficient treatment for improving local control. The role of chemotherapy is controversial and has not shown effects on survival. CONCLUSION: Myxofibrosarcoma is a connective tissue neoplasm. Its occurrence in the abdominal wall is extremely rare. Surgical treatment with large negative margins is the cornerstone of the treatment. Adjuvant radiotherapy is essential in preventing local recurrences.

Should acute cholecystitis be operated in the 24 h following symptom onset? A retrospective cohort study.

BACKGROUND: Early laparoscopic cholecystectomy is the gold standard for management of acute cholecystitis (AC). Nevertheless, the definition used for early phase remained unclear. We aimed to compare the clinical outcome and cost of immediate (patients undergoing laparoscopic cholecystectomy within 24 h following symptom onset) versus early laparoscopic cholecystectomy (patients managed 25-72 h following symptom onset) for acute cholecystitis. METHODS: A retrospective analysis was performed. The outcomes of 143 patients undergoing laparoscopic cholecystectomy within 24 h (ICG) were compared to 350 patients managed 25-72 h following symptom onset (ECG) for acute cholecystitis. RESULTS: There were significantly more diabetic patients in the early laparoscopic group (ECG). All other characteristics were comparable (demographic, clinical, biologic and ultrasonographic characteristics) between the two groups. The rate of conversion to open surgery was significantly higher in the ECG. Overall postoperative morbidity and specific morbidity did not differ significantly between the groups. Total hospital stay was longer in the ECG. Direct medical costs were higher in the ECG. CONCLUSIONS: Laparoscopic cholecystectomy, for acute cholecystitis, during the first 24 h of onset of symptoms, significantly reduced conversion to open surgery and total hospital stay without increasing postoperative complications.

Could the Tokyo guidelines on the management of acute cholecystitis be adopted in developing countries? Experience of one center.

PURPOSE: The Tokyo guidelines for diagnostic criteria and severity assessment of acute cholecystitis (AC), published in 2007, recommend early laparoscopic cholecystectomy (ELC) be done as soon as possible after the onset of symptoms. We conducted this study to analyze the changes in the therapeutic strategy for AC in a surgical center in Tunisia after the Tokyo guidelines were published. METHODS: Between January, 2005 and January, 2013, 649 patients underwent cholecystectomy for AC at the Department of Surgery, Mohamed Tahar Maamouri Hospital in Nabeul, Tunisia. The study period was subdivided into before (n = 192) and after (n = 457) the publication of the Tokyo guidelines, that is, prior to and including 2007, and from 2008 onward, respectively. We reviewed patient records retrospectively to collect demographic data, biochemical data, radiological findings, and postoperative outcomes. All these factors were compared between the groups. RESULTS: The duration of symptoms before surgery was significantly longer before 2008 (p = 0.018). ELC was significantly more frequent after 2008 (p = 0.001). Laparoscopic surgery was converted to open surgery in 16.1 % of patients before 2008 vs. 7.8 % of patients after 2008 (p = 0.02). There were no significant differences in bile duct injury or postoperative complications between the groups. The length of preoperative, postoperative, and total hospital stay was longer before 2008. CONCLUSIONS: ELC is a safe and effective therapeutic strategy for AC. The Tokyo guidelines resulted in a significant increase in the number of ELCs being performed and significantly reduced preoperative and total hospital stay without increasing intra- and postoperative complications. Importantly, ELC reduced medical costs, which is crucial for a country with limited resources, such as Tunisia.

Surgery for Colorectal Cancer in Elderly Patients: How Could We Improve Early Outcomes ?

BACKGROUND: Age is one of the causes behind the undertreatment of elderly colorectal cancer patients. The increase of mortality among elderly colorectal cancer (CRC) patients is due to competing causes of death occurring in the early post operative period. The purpose of this study was to evaluate the risk factors for post operative mortality and morbidity among elderly CRC patients. MATERIALS AND METHODS: A retrospective descriptive chart review was performed on consecutive patients older than 70 y with CRC. We have collected data of 124 patients who were admitted from January 2001 to January 2010. Demographic characteristics, operative and postoperative informations were retrospectively analysed. RESULTS: Early postoperative morbidity, operation related to morbidity and mortality were observed in 44 (35.5%), 9 (7.3%) and 20 (16.1%) cases, respectively. No other factors but ASA score (p = 0.002 and 0.005 in univariate and multivariate analyses, respectively) and emergency operations (p<0.001 and 10(-3) in univariate and multivariate analyses, respectively), were found to be risk factors of mortality. The results of multivariate analyses indicated that anaemia (p=0.021) and rectal cancer (p=0.015) had significant impact on the risk of anastomotic leakage. On the other hand, diabetes mellitus and rectal cancer were indicators that correlated with the width of hospitalization. CONCLUSION: Elderly CRC patients should no longer be undertreated only because of their age. They should be exposed to more aggressive management than they are currently receiving. Careful preoperative evaluation, followed by medical optimization and planning of perioperative care could improve outcomes of colorectal surgery for elderly patients.

Clinico-Pathological Caracteristics, Therapeutic Features and Post-operative Course of Colorectal Cancer in Elderly Patients.

STATEMENT OF PROBLEM: Colorectal cancer is predominantly a disease of elderly people and is a major cause of morbidity and mortality in the elderly population. The geriatric colorectal population is a very heterogeneous group, including patients with excellent health status and others with comorbid conditions, functional dependency, and limited life expectancy. On the other hand, the effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved post-operative life expectancy or at least one that is not diminished by the surgery. MATERIALS AND METHODS: This work is a descriptive study of a retrospective cohort, based on administrative databases, of all patients with colorectal cancer diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, stage of cancer, type of treatment received, post-operative complications and cause of post-operative death. We compared differences between an elderly group (Group A) (age >75 years) and a group of patients below 75 years (Group B). RESULTS: We found that elderly patients with colorectal cancer were more likely to be operated in emergent conditions, had more non-specific complications and more post-operative mortality than patients below 75 years. On the other hand, tumours stages, tumours characteristics and post-operative specific morbidity have been proved to be similar, both in Group A and Group B patients. CONCLUSION: These results suggest that surgery is feasible and can be safe for patients above 75 years, but it needs much more evaluation of comorbidities, pre- and post-operative intensive care to avoid post-operative non-specific complications.

Appendiceal GIST: report of an exceptional case and review of the literature.

Gastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only eight cases has been described in the literature, most of which have been of the benign type. We report a new case of an appendiceal GIST in a 75-year-old man. The tumor was discovered when the patient presented with acute appendiceacal peritonitis. Preoperative diagnosis of appendiceal GIST was rarely done as tumors were usually associated with appendicitis-like symptoms.

Retroportal lamina or mesopancreas? Lessons learned by anatomical and histological study of thirty three cadaveric dissections.

OBJECTIVE AND BACKGROUND: Despite its importance in pancreatic head carcinoma, the retroportal lamina is still under studied, with only two anatomical cadaveric dissections in the English literature, with recent controversies about the concept of a mesopancreas. METHODS: Resection of the mesopancreas was performed in 33 fresh cadavers. The pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated. RESULTS: The retroportal lamina is roughly rectangular in shape. Its dimensions are: height 6.2 cm (5-8), 2.5 cm wide (1.5-4). It contains a right hepatic artery arising from the superior mesenteric artery in 13.3% of cases. Microscopic examination revealed areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatics and capillaries. However, fibrous sheath and fascia were not found around these structures. CONCLUSION: A right hepatic artery arising from the superior mesenteric artery is a frequent anatomic variation. Surgeons must be aware of this to ensure the integrity of the hepatic artery blood supply in patients treated by pancreaticoduodenectomy. Despite controversy about the reality of the mesopancreas (postulated in analogy to the mesorectum), because of the absence of fibrous sheath or fascia, its complete removal in pancreatic head carcinoma is feasible by a subadventitial dissection of the superior mesenteric artery which can be considered as the real limit of the mesopancreas.

Meckel's diverticulum: an exceptional cause of vesicoenteric fistula: case report and literature review.

UNLABELLED: Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract. It can cause complications in the form of ulceration, hemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae as noted in six previously reported cases. 66-year-old woman was presented with an enterovesical fistula. Exploratory laparotomy revealed a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum. Pathologic examination revealed that the diverticulum did not contain ectopic gastric or pancreatic tissue. The patient underwent a diverticulectomy and had an uneventful postoperative course. Unlike four of the six previously reported cases, our patient had no coexisting bowel or bladder disease occurring with her vesico-diverticular fistula. CONCLUSION: This is only the third reported case of a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum that did not contain ectopic tissue.

Histopathologic characteristics and short-term outcomes of colorectal cancer in young Tunisian patients: one center's experience.

INTRODUCTION: Colorectal carcinoma (CRC) is generally a disease of persons older than 40 years. Concerning younger patients, controversies still exist regarding features and prognosis of CRC. We performed this study to characterise CRC in young patients (≤ 40 years) as well as to evaluate short-term outcome in comparison with older patients (>40 years) with CRC. METHODS: Clinical and histopathological parameters of 40 patients aged 40 years or less were compared with 240 patients aged more than 40 years. RESULTS: In young patients, the minority suffered from hereditary cancer syndromes (0.4%). Furthermore, up to 87% of young patients denied any cancers in their families. Compared with older patients, young patients had more mucinous adenocarcinomas (32.5% vs. 11.5%; p=0.02), more venous invasion (p=0.021), more perineural invasion (p=0.028). For grading (p=0.42), lymphatic invasion (p=0.17) and tumor sites (p=0.46), no significant differences between young and older patients were found. Young patients had less post operative morbidity (p=0.039), less post operative mortality (0.029). Young and older patients had the same overall 1-year survival rates (p=0.24), and the same cancer-related 1-year survival rates (p=0.1). CONCLUSION: Tunisian patients present with colorectal cancer at a more advanced stage of the disease at younger ages compared to developed countries. The early detection of CRC followed by a sufficient oncologic treatment is crucial regardless of age. It is mandatory for all patients with suspicious symptoms to undergo early adequate diagnoses.

A wandering spleen presenting as a hypogastric mass: case report.

Wandering spleen is a rare condition characterized by the absence or underdevelopment of one or all of the ligaments that hold the spleen in its normal position in the left upper quadrant of the abdomen. It is an uncommon clinical entity that mainly affects children. Among adults it most frequently affects women of reproductive age, in whom acquired laxity of the splenic ligaments is usually the cause. Patients with a wandering spleen may be asymptomatic, present with a movable mass in the abdomen, or have chronic or intermittent abdominal pain because of partial torsion and spontaneous detorsion of the spleen. A 26-year-old woman was admitted to our hospital with vomiting and abdominal pain. Abdominal examination revealed a large ovoid hypogastric mass. A CT scan showed a wandering spleen in the hypogastric region. Exploratory laparotomy revealed an ischemic spleen. A total splenectomy was performed.

Solid pseudopapillary neoplasm of the pancreas in an old man: age does not matter.

Solid pseudopapillary tumor (SPN) of the pancreas is a rare tumor, but has favorable prognosis. It is typically observed in young women. Only few cases have been reported in young men. We report the observation of a 73-year-old man presented with a palpable mass in the left upper abdomen. CT scan showed 10 cm mass at the tail of the pancreas. This mass had mixed cystic and solid components. The patient underwent a distal pancreatectomy and splenectomy. SPN of the pancreas was diagnosed based on histopathological features. The patient recovered uneventfully and didn't receive adjuvant therapy. A CT scan performed 16 months postoperatively showed no evidence of disease recurrence. Although SPN of the pancreas is typically observed in young women, the diagnosis should not be discounted in old male patients. Male patients and those with old age, atypical histopathology and incomplete resection may have a higher risk of recurrence and death, deserving particular attention.