[Digestive stomas: which professional impact?] / Les stomies digestives: quel impact professionnel?

INTRODUCTION: digestive stomas result from a certain number of surgical interventions. They may be temporary or definitive. The patient with stoma has potentially damaging physical and psychological problems. Therefore patient´s adaptation to the changes and acceptance of this temporary or permanent situation is essential. This study aims to assess the impact of intestinal stomas on patients´ quality of life and professional life. METHODS: we conducted a retrospective study from January 2010 to December 2014. During the study period, 115 patients had intestinal stomas. Among these patients, sixty were of working age, had a fixed employment and had resumed their work; they made up the study population. Data were collected using a specific questionnaire: the Short Form-36 (SF-36) health questionnaire conducted in the post-operative period. RESULTS: the average score for the overall quality of life for patients with stoma was 41. Forty patients had poor quality of life with a score SF-36 less than 50. Our study showed that patients with stoma experienced difficulties at work. Forty-eight patients reported discomfort directly linked to stoma during their professional activities. The causes mentioned were physical in 6 cases and psychological in 3 cases. Six patients were moved into more adapted working positions. CONCLUSION: the management of patients with digestive stomas should aim to an adequate social and professional reintegration. This can only be done by involving the occupational physician, the psychologist, the stoma therapist and the associations.

[Unexpected discovery of isolated osteochondroma in the pubic symphysis]. / Ostéochondrome solitaire de la symphyse pubienne de découverte fortuite.

Osteochondroma is the most common benign bone tumor. It usually affects the metaphyses of the long bones, in particular around the knee and the proximal humerus. It very rarely affects the pubic symphysis, usually with an atypical symptomatology. We here report the case of a 35-year old man in whom osteochondroma in the pubic symphysis encroaching on the iliopubic branch was fortuitously discovered. Radiological examinations as well as macroscopic and histological examination confirmed the diagnosis and the absence of signs of malignancy.

A disconcerting false gastric diverticulum mimicking malignancy.

Gastric diverticula are the most uncommon form of gastrointestinal diverticula. They can either be of true or false type with different pathogenesis. They may be very challenging to diagnose as symptoms are nonspecific and imaging can simulate a malignant lesion. We report an unusual case of pre-pyloric diverticulum in a 69-year-old man, leading to severe gastric obstruction with a poor general condition. As subsequent endoscopy and imaging were alarming and couldn't exclude malignancy, the patient underwent an antrectomy. The final diagnosis was made on pathological examination. We discuss, through this case, the clinical and pathological features of gastric diverticula with an emphasis on the pathogenesis of this rare entity and the risk of a malignant transformation.

Predictive factors for histological response to neo-adjuvant treatment in rectal cancers.

INTRODUCTION: The complete histological response represents the goal of neo-adjuvant treatment of locally advanced rectal cancer. This objective is a real challenge requiring the research of predictive factors for this response, from the perspective of targeted therapeutic strategies. The results of the various studies focused on these predictive factors are discordant. AIM: To seek a correlation between 7 prognostic factors tested in pre-therapy and the histological response to neo-adjuvant treatment. METHODS: A retrospective study involving 44 patients with locally advanced rectal adenocarcinoma who received neo-adjuvant radiotherapy or radiochemotherapy. The 7 prognostic factors studied were clinical (age and sex), radiological (tumor size and parietal invasion) and histological (histological grade, vascular and nerve invasion) features. The complete histological response was defined by Bateman's tumor grade m-RCRG 1 and the absence of lymph node metastases. RESULTS: A complete histological response was observed in 25% of cases (n = 11). In multivariate analysis, age> 60 years (OR: 1.14 and p = 0.028), male sex (OR: 21 and p = 0.045) and radiological wall invasion exceeding the subserosa (OR: 11 , 5 and p = 0.008) were significantly associated with the histological response. In contrast, none of the 3 histological factors tested were correlated with this response's intensity. CONCLUSION: Age, gender, and pre-therapeutic parietal invasion could be used to select "good" and "poor" responders to neo-adjuvant treatment in locally advanced rectal cancers.

Resected colorectal cancer liver metastases : Prognostic study about 110 patients.

INTRODUCTION: The prognosis of hepatic metastases in colorectal cancers is constantly being improved at the cost of multidisciplinary care, allowing each patient to have an adapted strategy. The prognostic factors make it possible to recognize patients needing further treatment after resection and closer monitoring. OBJECTIVE: The aim of our study was to conduct a prognostic study to identify factors influencing survival at 5 years for patients operated of colorectal liver metastases. METHODS: This is a retrospective study conducted over a period of 10 years (2005-2015). All patients operated for liver metastasis of colorectal cancers were included. The primary endpoint was overall survival. Secondary endpoints were recurrence-free survival and operative morbidity and mortality. The proportions were compared by the Chi 2 test. The survival curves were established according to the Kaplan-Meier method and the comparison of the curves according to the Logrank test. A univariate and then multivariate Cox model was used to determine prognostic factors. The significance level was set at 0.05. RESULTS: Overall survival of our patients at 3 and 5 years was 49% and 32% respectively. Recurrence-free survival was 21% at 3 years and 15% at 5 years. In multivariate analysis, the hepatic resection margin <1 mm and the number of hepatic metastases ≥3 were independent factors correlated with survival. CONCLUSIONS: colorectal liver metastases surgery improves patient survival. Some factors need to be sought to adapt care strategies.

Extracapsular involvement in nodal metastasis as a prognostic factor in colorectal cancer.

BACKGROUND: Extracapsular extension of nodal metastasis has recently emerged as an important prognostic factor in different malignancies. In colorectal cancer (CRC), only a limited number of studies have been published and its prognostic value has not yet been completely established. AIMS: To assess the incidence of extracapsular invasion (ECI) in lymph node (LN) metastasis in colorectal adenocarcinoma and to investigate the correlation between this parameter and other clinico-pathological factors.  Furthermore, its effect on overall and disease free survival were evaluated. METHODS: Seventy-five patients who underwent colorectal resection for adenocarcinoma with node metastasis were included in this study. Extracapsular invasion was evaluated by two pathologists. Associations between clinicopathologic factors, survival, and the nodal findings were evaluated. The 2009 pTNM staging of CRC was used. RESULTS: Extracapsular invasion was identified in 45 patients (60 %). Average follow-up time was 25 months. Extracapsular invasion was correlated with pT stage> pT2 (p=0,015), pN stage > pN1 (p= 0,014), distant metastasis at diagnosis (p=0,005) and later (p=0,01) and with local recurrences (p=0,0001). Univariate analysis indicated that ECI tends to decrease overall survival but not significantly.  Multivariate analysis showed that age and synchronic metastasis were independent prognostic factors (HR = 2,03 and 2,24; p= 0,039 and 0,012 respectively). Patients with ECI had a significantly worse five-year disease-free survival than ECI-negative groups. CONCLUSION: In patients with CRC, ECI in regional LNs would reflect an aggressive behavior. It would therefore be useful to include this parameter in standardized pathologic reports and future staging systems.

[Post traumatic anterior abdominal wall hernia]. / Hernie post traumatique de la paroi abdominale antérieure.

Post traumatic anterior abdominal wall hernia can be ignored in emergency settings. We here report the case of a 32-year-old patient with a BMI of 30 kg/m2, suffering from anterior abdominal wall hernia as a result of a road accident. This lesion wasn't detected during clinical examination. Abdominal tomodensitometry showed a defect of 8 cm in the anterior abdominal wall. The patient underwent surgery during which a musculoaponeurotic defect of 12 cm was detected. The repair was carried out using interrupted suture. The postoperative course was marked by a secondarily infected skin necrosis. The evolution was satisfactory after directed cicatrization. At 3 months postoperatively the patient was doing well with a healed wound and a strong abdominal wall.

[Primary renal carcinoid metastasizing to distant sites 12 years after the initial diagnosis]. / Carcinoïde primitif du rein métastasant après 12 ans.

Primary renal cancinoids are rare, with one hundred cases reported in the literature. Histologically, it is a well-differentiated tumor which shares a morphological pattern similar to that seen in carcinoids identified at other anatomic locations. We report a case of a 45-year-old man with primitive renal carcinoid, with diagnosis made after the detection of liver metastases. The tumour was peculiar given its tubulopapillary architecture, wrongly suggesting a diagnosis of papillary renal carcinoma. This diagnosis was revised 12 years after, following the appearance of other liver, bone and lung metastases.

Surgical treatment of Crohn's disease: indications, results and predictive factors of recurrence and morbidity.

BACKGROUND: Crohn's disease management represents a major problem in gastroenterology and general surgery because it affects young subjects and has a major impact on their quality of life. The aims of our study were to identify the indications for surgery in Crohn's disease, the results and the complications of surgery in our series, and to identify possible predictive factors of recurrence and postoperative morbidity. METHODS: A retrospective descriptive study including 38 cases of patients with Crohn's disease who underwent surgical treatment in the department of surgery in Mongi Slim Hospital, during the period between January 1992 and December 2011 was performed. RESULTS: The occurrence of stenosis was the most common indication for surgical treatment in Crohn's disease in our series, and ileocecal resection was the most performed surgery. Twenty six patients (58%) received maintenance therapy after surgery. Twenty two patients relapsed and 13 had surgical management for recurrence. In univariate analysis, predictive factors of post operative morbidity in our study were leukocytosis, penetrating phenotype and intraabdominal sepsis. Ileocecal location was the only factor that significantly improved the incidence of recurrence. In multivariate analysis, only penetrating phenotype was a predictive factor or post operative morbidity. CONCLUSION: Despite the development of medical treatment, surgical treatment keeps large indications for the management of complications of Crohn's disease. The surgery should be an alternative to immunosuppressive therapy. Currently, prevention postoperative recurrence is well codified, reducing the risk of complications.

Percutaneous treatment versus hepatic resection for the treatment of small hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma is the first liver tumor worldwide. Therefore, it is a matter of debate whether surgical treatment or percutaneous treatment should be preferred for the treatment of patients with small hepatocellular carcinoma. The aim of our study was to compare the long-term outcome and the survival between surgically and percutaneously treated small hepatocellular carcinomas. MATERIAL AND METHODS: A retrospective study was performed in the department of hepatology during a period of 2009-2012. The study included all patients carrying small hepatocellular carcinoma which were divided in: group 1 including patients who underwent surgical treatment, and group 2 including patients who underwent percutaneous treatment. RESULTS: Among the 63 patients who were diagnosed for hepatocellular carcinoma, 28 carried a small hepatocellular carcinoma with a mean age of 63 years and sex-ratio of 0.64. Etiology of cirrhosis was viral in 96% cases. Surgical treatment (hepatic resection) was performed in 54% cases while percutaneous treatment was proposed for 46%: radiofrequency ablation in 69% and alcoholic injection in 31%. No major complications for both surgical and percutaneous treatment occurred in our study. The corresponding 6 months and 1- year overall survival rates for the surgical resection group and the percutaneous treatment group were 100%, 100%, 20%, and 52%, respectively (p=0,04). The disease free survival were not significantly different. CONCLUSION: Our results showed the efficacy and safety of percutaneous ablation treatments (radiofrequency ablation and ethanol injection) in patients with small hepatocellular carcinoma.

Solid pseudopapillary tumor of the pancreas with concomitant Bochdalek's hernia. The first reported case.

BACKGROUND: Solid pseudopapillary tumors of the pancreas are rare. The diagnosis is difficult because of its clinical and radiological polymorphism. It was described in the literature that this entity can be associated with congenital malformation. We report an exceptional case associating solid pseudopapillary tumor of the pancreas to Bochdalek's hernia. CASE REPORT: A 31 year-old woman presented with abdominal pain. Radiological findings (ultrasound, CT scan, MRI) showed a heterogeneous mass evoking a stromal tumor of duodenal origin associated to a hernia through the foramen of Bochdalek. The patient underwent tumorectomy without lymphadenectomy with a hernia repair. Pathology report confirmed the diagnosis of solid pseudopapillary tumor of the pancreas. The 3-years follow- up was uneventful. CONCLUSION: Solid pseudopapillary tumor of the pancreas is a rare benign tumor with a good prognosis after resection. Recognition of the association of congenital malformation with solid pseudopapillary tumor of the pancreas is useful as it could have implications on the diagnosis and treatment.

Autoimmune pancreatitis. A report of 5 cases from Tunisia: diagnostic challenge.

BACKGROUND: In this study, we aimed to review retrospectively the records of 5 patients who were treated in our hospital and to review the current approaches in diagnosis and management of autoimmune pancreatitis (AIP). METHODS: The series of patients diagnosed with AIP during the last seven years (January 2006 - August 2012) was the basis of this study. All records were retrieved and analyzed. The diagnosis of AIP was established on the basis of imaging studies, serology, cytology and response to treatment. RESULTS: Five patients were diagnosed with AIP pancreatitis during this 7-years period. Four of the 5 patients were males. The most common presenting symptom was abdominal pain (4/5). Two patients with the preliminary diagnosis of pancreatic mass underwent surgery. Histological analysis of the surgical resection did not reveal any malignancy. During the follow-up, one of them has developed Crohn's disease and Sjogren syndrome. One of the patients had obstructive jaundice and abdominal pain for several months. Abdominal contrast enhanced computed tomography (CECT) suggested the diagnosis of AIP, cholangitis with renal atrophy and retroperitoneal fibrosis. He was started on steroids to which he responded dramatically. One patient had been diagnosed as primary sclerosing cholangitis few months earlier on the basis of abdominal CECT features showing a dominant stricture in the common bile duct. During the follow-up, the diagnosis of AIP was suspected and finally established on the basis of repeated magnetic resonance imaging (MRI). The last patient had history of acute pancreatitis, obstructive jaundice and abdominal pain for 3 months. An abdominal CECT suggested autoimmune pancreatitis which was confirmed by MRCP. He was started later on steroids to which he responded significantly. IgG4 was done in all cases, high in four patients. CONCLUSION: AIP is a disease with increasing incidence and characterized by lymphoplasmacytic cells infiltration and fibrosis. It is necessary to evaluate patients in terms of AIP serologically to avoid wrong diagnosis and the morbidity of surgery.

Relationship between MDM2 and p53 alterations in colorectal cancer and their involvement and prognostic value in the Tunisian population.

BACKGROUND: The prevalence of p53 mutations in colorectal cancer could reach 90%. The most important regulator of this protein that was identified originally was the Murine Double Minute2 (MDM2) oncoprotein, by which the levels of p53 were fixed through an autoregulatory feedback loop. In cancer cases, the overexpression of MDM2 deregulates this feedback, and the signaling pathway between MDM2 and p53 is blocked. MATERIALS AND METHODS: We genotyped 167 patients and 167 healthy blood donors to determinate the mutational status of MDM2 and p53. Immunohistochemical analysis was performed on tumor and normal mucosa. RESULTS: The MDM2 polymorphism study showed a higher distribution of MDM2 SNP309 in tumors compared with healthy controls. At the same time, the majority of samples with SNP309 indicated a positive expression of MDM2 protein in the tumor. In this case, we found a first significant association between p53 expression and the single-strand conformational polymorphism analysis and a second association between the MDM2 polymorphism and p53 mutation. Moreover, the nuclear overexpression of MDM2 and SNP309 was significantly related to a higher mortality rate. CONCLUSIONS: In this work we wanted to highlight the role, which is becoming increasingly important, of MDM2. In fact, we conclude that the effects of MDM2 SNP309 may be considered a valuable prognostic marker to predict poor outcome for Tunisian patients with colorectal cancer.

Toxic megacolon complicating a first course of Crohn's disease: about two cases.

Toxic megacolon is a rare and serious complication of Crohn's disease. Because of the associated high morbidity and mortality, early recognition and management of toxic megacolon is important. Through two cases of toxic megacolon complicating Crohn's disease, we assessed the clinical, radiologic and therapeutic characteristics of this complication. A 35-year-old man presented a first course of Crohn's disease treated with corticosteroid. He exhibited sudden severe abdominal pain and distension with shock. A plain abdominal radiography revealed toxic megacolon. He underwent medical therapy, but symptoms not relieved. The patient underwent subtotal colectomy with ileostomy. The resected specimen confirmed the diagnosis. Recovery of digestive continuity was performed. Endoscopic evaluation six months later did not shown recurrence. A 57-year-old man presented with severe acute colitis inaugurating Crohn's disease, was treated with corticosteroid and antibiotics. He exhibited signs of general peritonitis. Computed tomographic examination revealed toxic megacolon with free perforation, showing prominent dilation of the transverse colon and linear pneumatosis. The patient underwent emergent subtotal colectomy and ileostomy. The final histological patterns were consisting with diagnosis of Crohn's disease associated with cytomegalovirus infection. The patient underwent antiviral therapy during 15 days. Because of the high risk of postoperative recurrence, he underwent immunosuppressive therapy. Recovery of digestive continuity was performed successfully. Toxic megacolon in Crohn's disease is a serious turning of this disease. We underscore the importance of early diagnosis of toxic megacolon and rapid surgical intervention if improvement is not observed on medical therapy.

Impact of MDM2 polymorphism: increased risk of developing colorectal cancer and a poor prognosis in the Tunisian population.

INTRODUCTION: MDM2 was originally identified as an oncoprotein that binds to p53 and inhibits p53-mediated transactivation. Scientists have described functional single-nucleotide polymorphisms (SNP) in the MDM2 gene. They showed that the genotype of SNP 309 induces an increase in the level of MDM2 protein, which causes attenuation of the p53 pathway. In this study, we sought to investigate whether this polymorphism was related to risk of colorectal cancer and whether there were relationships between SNP 309 and protein expression or clinicopathological variables in Tunisian patients. MATERIALS AND METHODS: To investigate the effect of this polymorphism in colorectal cancer pathogenesis, we genotyped 167 patients and 167 blood donors. Immunohistochemistry was performed on normal mucosa and tumor. RESULTS: The rates of MDM2 genotypes were 6.6% for wild-type (T/T) and 93.4% for the SNP 309 polymorphic genotype (T/G and G/G) in patients and 38.3 and 61.7% in controls, respectively. There were significant differences in the frequencies of genotypes between patients and controls (P<0.01). We did not find any relationship between genotypes and clinicopathological features of patients, except in the case of the nonmucinous histological subtype (P=0.001). Moreover, we found that patients with the wild-type genotype (T/T) had significantly more favorable clinical outcome than did patients with the SNP 309 genotype (T/G, G/G) (P=0.005). In addition, we found an association between positive expression of p53 and polymorphic genotypes of MDM2 (T/G, G/G) (P=0.037). There was a significant association between tumoral immunostaning and MDM2 polymorphism (P=0.01). CONCLUSION: Our results suggest that the MDM2 polymorphism is significantly associated with colorectal cancer risk and may provide useful prognostic information for Tunisian patients with colorectal cancer.

Pseudotumoral autoimmune pancreatitis mimicking a pancreatic cancer: a very difficult disease to diagnose.

Autoimmune pancreatitis (AIP) is a rare disorder, although the exact prevalence is still unkown. It is a type of pancreatitis that is presumed to have an autoimmune aetiology, and is currently diagnosed based on a combination of 5 criteria. However, in this day and age, some patients with AIP are likely to be resected for the suspicion of malignancy. The authors report a case of pseudo-tumoral autoimmune pancreatitis, reviewing some literature about it and underlining the difficulty in the diagnosis. A 56-year-old patient was referred to our unit for upper abdominal pain. In his past medical history we note mellitus diabetes. The clinical examination was unremarkable. Laboratory data showed no abnormal values. Upper endoscopy showed antral gastritis. Transabdominal ultrasonography showed a hepatic steatosis and 5 angiomas. No computed tomography scan was made. Magnetic resonance imaging (MRI) showed 5 angiomas and a lesion of 20×20 mm of the pancreatic tail with decreased signal intensity on T1-weighted MR images, increased signal intensity on T2-weighted MR images. Due to concerns of pancreatic malignancy, the patient underwent open distal spleno-pancreatectomy. Histolo gical analysis of the resected specimen revealed no malignancy. Postoperatively, immunoglobulin G fraction 4 was slightly above of the upper limit of the normal range. After corticotherapy the patient is getting better. This case underlines the difficulties still encountered in the diagnosis of AIP. It has been frequently misdiagnosed as pancreatic cancer and caused unnecessary resection. In order to avoid unnecessary resections for an otherwise benign and easily treatable condition, it is urgent to refine diagnostic criteria and to reach an international consensus.

[Treatment of primary and secondary malignant tumor of the liver. Opinion of the surgeon]. / Le traitement des tumeurs malignes primitives et secondaires du foie. Le point de vue du chirurgien.

Hepatocellular carcinoma is the most frequent primitive cancer of the liver. This tumor mainly develops in cirrhotic liver that is a true precancerous state. Treatment can be surgical or not surgical. Orthotopic liver transplantation is the only treatment that definitively address both the metachronous occurrence risk of hepatocellular carcinoma and the underlying disease. Liver metastases from colorectal carcinomas are the most frequent secondary tumors. Only complete resection offers the potential for curative treatment of these metastases.

[Intestinal T cell lymphoma in coeliac disease. A case report]. / Lymphome t du grêle sur maladie coeliaque. A propos d'un cas.

Primary intestinal T-cell lymphomas account for about 5% of all primary gastrointestinal lymphomas and are mostly associated with coeliac disease. Intestinal lymphomas are usually discovered during the 4th to 5th decade and constitute an exceptional complication of coeliac disease. This lymphoma is generally a high grade pleomorphic cell lymphoma with large cells. Our case concerned a 30 year old woman with a history of coeliac disease who developed a gastro-enteromesenteric lymphoma. Anatomopathological and immunohistochemical analysis showed an enteropathy associated T-cell lymphoma. We suggest that patients with coeliac disease unresponsive to a gluten free diet or with deteriorating clinical condition be investigated for complications such as enteropathy associated T-cell lymphoma. It is also important to avoid this complication by detecting asymptomatic form of coeliac disease that needs a gluten-free diet.