Gastrointestinal perforations by ingested foreign bodies: A preoperative diagnostic flowchart-based experience. A case series report.

BACKGROUND: Gastrointestinal tract perforation is the most harmful complication of Foreign Body (FB) ingestion, besides diagnostic delay adversely affects the outcome. This paper aims to present our preoperative diagnostic flowchart and describe the surgical management in a Tunisian center. METHODS: A retrospective review of 48 patients with gastrointestinal perforation by ingested FB treated in the surgery department of Jendouba Hospital. January 2010-December 2020. RESULTS: 48 patients were treated for gastrointestinal tract perforation induced by FB ingestion. The mean age was 56.6 years. The sex ratio was 2/1. Acute abdominal pain was reported in all the patients. 35 patients had abdominal X-ray that showed a FB in 12 cases. CT scan was performed in 38 patients and identified the FB in 28 cases. Postoperative proofreading has identified a preoperative missed diagnosis of FB perforation in 5 cases, all before applying the diagnostic flowchart. All patients underwent open surgery after a median time of 7.12 h. This duration decreased after applying the flowchart (8.21 h versus 5.6 h). 33 patients had a terminal ileum perforation. Enterectomy was performed in 33 patients. Postoperatively, there was one abdominal abscess, one pulmonary embolism, one refractory septic choc, and one wound abscess. The median hospital stay was 6.35 days. The mortality rate was 6.25%. All patients managed with enterostomy had their stoma closed after 3-5 months. CONCLUSIONS: The challenge of gastrointestinal perforation due to FB ingestion is accurate diagnosis and early management. A standardized initial assessment based on a diagnostic flowchart is helpful to achieve this goal and improve outcomes.

A rare case of prostate tuberculosis after holmium laser enucleation of the prostate.

Prostatic tuberculosis is considered to be a rare disease. It is usually associated with nonspecific symptoms and is detected incidentally after prostatic histological analysis. We report the case of a 60-year-old man suffering from acute urinary retention with an estimated 90 g prostate who underwent Holmium laser enucleation of the prostate. The diagnosis of prostate tuberculosis was histological based on the analysis of prostate enucleation chips. The clinical course was favourable under anti-tuberculous drugs.

A bladder stone surrounding a foreign body: A rare case.

Intra-vesical foreign bodies can be of variable nature and etiology, their introduction can be voluntary or not. The motivations most frequently associated with the presence of foreign bodies within the bladder are of a sexual or erotic nature. Various objects have been inserted into the bladder and many patients fail to remove them themselves and are very embarrassed to seek medical advice, which is the origin of a clinical picture which is most often atypical which occurs in a patient particular terrain.

The management of appendicular abscesses in a Tunisian Tertiary Care Hospital.

BACKGROUND: This study aims to describe the epidemiological, clinical, and radiological features of appendicular abscesses, compare the different approaches, and assess the safety and utility of laparoscopy in its management. METHODS: This descriptive retrospective study was carried out over 3 years extending from January 2017 to December 2019, reporting 150 appendicular abscesses cases. Data were collected from the register of the general surgery department B of the Rabta hospital. Cases with appendicular abscess were included. Files concerning patients with early appendicitis, non-appendicular abscesses or generalized appendicular peritonitis were excluded. Data were analysed with Statistical Package for the Social Sciences (SPSS) software. In univariate analysis, we used the chi2 test, the Fischer test, the Student t test. The factors retained by the univariate analysis were introduced into a logistic regression model. The significance level was set to 0.05. RESULTS: The mean age was 40.51 years. The gender ratio in patients with appendicular abscesses was M:F 1.94:1. Pain in the right iliac fossa associated with fever was the most common symptom (78% of cases). Clinical examination showed tenderness in the right iliac fossa in 38% of cases, rebound and guarding were found in 77 patients (51.3%), and a palpable mass was noted in 4 cases (4.2%). Imaging was done to confirm diagnosis; 46 patients underwent ultrasonogram and this confirmed the diagnosis in 26 patients (56%), while among the 71 patients who underwent CT abdomen confirmatory diagnosis was made in 65 patients (91.55%). An appendectomy was performed in 148 patients (98.6%) via laparoscopic approach in 94 patients, open Mac burney procedure in 32 cases (21.3%) and midline incision in 24 cases (16%). Two patients had an ileocecal resection. The appendix was most commonly located retrocecally (55.3%) in our cohort. The laparoscopic approach was performed in 94 patients (62.6%), and we had to convert in 44 patients due to dissection difficulties (46.8%). Among patients who underwent laparascopic approach 7 had developed peritonitis.. There were only 2 deaths. The mortality rate was 0,013%. The median duration of outpatient followup was 6 months (4-24 weeks) and was uneventful. CONCLUSION: Appendicular abscess is a disease of young adults more common in men. Location of the appendix in our case series was mostly retroceacal. Laparoscopy was associated with good outcomes; peritonitis was uncommon and mortality was rare. The laparoscopic approach is a safe surgical technique for treating appendicular abscess and it can be considered as the routine approach for this condition In developing countries with limited technical resources, laparoscopy guarantees the absence of recurrence, reduces healthcare costs and decreases the risk of treating a severe disease conservatively.

Lymphangiomatous endothelial cyst of the adrenal gland: A case report.

Cystic adrenal tumors are rare with an incidence of approximately 0.06% in the general population. Four main histological types are distinguished: Endothelial cysts of lymphangiomatous or angiomatous origin, pseudocysts, epithelial cysts and cysts of parasitic origin. Surgery is recommended for signs of complications, suspicion of malignancy and large size. In other cases, simple surveillance can be proposed. We report here a case of a lymphangiomatous endothelial cyst of the adrenal gland. The objective is to recall the clinical characteristics and to specify the diagnostic contribution of imaging as well as the therapeutic modalities of this entity.

Cystic renal oncocytoma: A rare case report.

Cystic renal lesions are extremely common. The major clinical concern is differentiating simple renal cysts from complex cysts to assess the risk of malignancy. The Bosniak classification of renal cystic tumors is employed to distinguish benign cysts from potential malignant cysts. Benign renal tumors can be rarely encountered in Bosniak type 4 cysts. Herein, we report a case of 56-year-old female with a single right mediorenal solid-cystic mass classified bosniak 4. An open surgery was planned: There was a 2-cm-sized cystic tumor, mediorenal, in contact with the hilum. A lumpectomy was performed. Anatomopathological examination revealed a cystic oncocytoma.

Renal cell carcinoma in children, report of a new case.

Renal cell carcinoma (RCC) is rare in children and is usually found in late children. We present a case of a 14 year-old boy who presented with right lumbar pain. CT-scan showed a tumor in the upper pole of the right kidney measuring 15 cm. He underwent radical nephrectomy and histopathologic examination revealed RCC. No adjuvant therapy was given. After three years and half, there is no evidence of recurrence.

Urachal mucinous cystadenoma: An exceptional entity.

Urachal villous adenoma is a rare entity. We aimed to share a case of a giant villous adenoma that was treated surgically. Surgery was uneventful and flow up was normal.

The deceitful diagnosis of gallbladder volvulus: A case report.

INTRODUCTION AND IMPORTANCE: The gallbladder volvulus is a rare but life-threatening condition characterized by an axial torsion of the gallbladder along the cystic pedicle, causing gallbladder ischemia and necrosis. This paper aims to present and discuss a rare case of gallbladder volvulus. This case report has been reported in line with the SCARE criteria 2020 [1]. CASE PRESENTATION: We report the case of a 90-year-old female patient who presented to the emergency room with sharp right upper abdominal quadrant pain of acute onset associated with vomiting, evolving for the last 12 h. She had no fever nor jaundice. Her body mass index (BMI) was 22. She had kyphosis, and scoliosis. Physical examination found tenderness with a palpable mass in the right upper abdominal quadrant. Laboratory test results showed leukocytosis at 11600 /mL and a high C-reactive protein rate at 40 mg/L revealed acute calculous cholecystitis features. However, emergency laparotomy was performed and discovered a gallbladder volvulus. A detorsion and cholecystectomy were performed with a good outcome. CLINICAL DISCUSSION: The preoperative diagnosis of gallbladder volvulus is difficult due to its misleading clinical presentation mimicking acute cholecystitis. The presence of the three highly suggestive triad clinical signs should encourage the radiologist to search for a gallbladder with a horizontal orientation and located outside its anatomical fossa connected to the liver by a conical structure corresponding to the twisted pedicle in ultrasonography. Unlike ordinary acute cholecystitis, which may sometimes tolerate an initial conservative medical treatment, gallbladder volvulus management is always an emergency cholecystectomy. CONCLUSION: Despite the clinical similarities with the classical acute calculous cholecystitis, gallbladder volvulus is more likely to result in fatal outcome. Therefore, a high level of clinical suspicion is necessary to save lives.

Gallbladder adenomyomatosis: Diagnosis and management.

INTRODUCTION: Gallbladder adenomyomatosis is a benign acquired gallbladder disease. It can mimic cancer on radiological findings, leading to a diagnostic dilemma. The management and prognosis of these two gallbladder anomalies are entirely different. Therefore, it is essential to recognize the pathognomonic features of gallbladder adenomyomatosis is in order to accurately diagnose this pathology. This paper presents two encountered cases of gallbladder adenomyomatosis is, their diagnostic modalities as well as the algorithmic approach of their management. These two-case reports have been reported in line with the SCARE Criteria 2020 [1]. PRESENTATION OF CASE: Patient-1 was symptomatic. He was explored by an abdominal ultrasound picturing gallbladder wall thickening while the biopsy showed pleomorphic proliferation of inflammatory cells. An examination of the liver with MRI was indicated, showing diffuse parietal thickening with multiple cystic pockets. He underwent laparoscopic cholecystectomy with simple operative follow-up. Patient 2 was asymptomatic, a staging CT scan of acute pancreatitis revealed focal mural thinking of the gallbladder wall. A liver MRI showed an intramural cystic formation in the vesicular fundus. Given the inconclusive imaging results, laparoscopic cholecystectomy was performed. Histological examination confirmed the diagnosis of GA. DISCUSSION: Adenomyomatosis is usually asymptomatic. Imaging can confirm the diagnosis of gallbladder adenomyomatosis without the need for invasive procedures such as vesicular biopsy. Histologic examination can also confirm the diagnosis when cholecystectomy is done. High resolution ultra-sound is the most efficient radiological examination. Laparoscopic cholecystectomy is the gold standard for symptomatic GA or radiological suspicion of a gallbladder cancer. CONCLUSION: The practitioner should always consider gallbladder carcinoma before confirming the GA, as they share the same features but with a far worse prognosis. The likelihood of malignancy depends on radiological characteristics. In the case of inconclusive findings, cholecystectomy is justified.

Mitrofanoff external continent urinary diversion in the management of bladder exstrophy-epispadias complex in adolescents.

Despite theadvancements in surgical reconstructive techniques for bladder exstrophy-epispadias complex, urinary incontinence represents a major problem that affects the quality of life. Bladder augmentation associated to Mitrofanoff external continent urinary diversion (ECUD) constitute for some surgeon the best solution for the management of bladder exstrophyallowing to achieve continence and to preserve renal function.

Giant primary hydatid cyst of the adrenal gland: A rare case report.

Hydatid disease (HD) is a parasitic endemic zoononis in Tunisia, caused by the larval stage of Echinococcus Granulosus (EG). Adrenal glands are an uncommon and rare location for hydatid cysts, even in endemic areas, and primary adrenal cysts are exceptional. Herein, we report a rare case of 46-year-old man with primary giant adrenal hydatid cyst complicated by inferior vena cava thrombosis. The patient was successfully treated with an open adrenalectomy, with prophylactic albendazole therapy pre and postoperatively.

Intrarenal foreign body after PCNL procedure: A rare complication.

The use of LASER for lithotripsy has not only improved PCNL results, but also reported complications related to laser's use. We report a case of severed guide wire after PCNL.

Emphysematous prostatitis: A case report.

We report the case of a 48-year-old man with ischemic stroke, diabetes and chronic renal failure admitted for fever with LUTS associated with nausea and vomiting.The physical examination showed a depressible abdomen, painful prostate on digital rectal examination.A biological inflammatory syndrome with diabetic ketoacidosis.The abdominopelvic CT scan confirmed the diagnosis by the presence of gas in the prostate,and the CBUE was positive for Enterobacter cloacae.The patient was treated with appropriate antibiotic therapy with transrectal aspiration of the prostate collection,but the evolution was marked by the worsening of the patient's condition leading to his death after two weeks of treatment.

[Urolithiasis of the kidney transplanted patient in south Tunisia: A 17-year experience]. / La lithiase urinaire du transplanté rénal dans le sud tunisien : expérience de 17 ans.

INTRODUCTION: Urolithiasis in a kidney transplanted patient is an uncommon but complex urological complication. Its potential severity comes from its occurrence on a solitary kidney and on a field of immunosuppression. The aim of our study is to assess the incidence, characteristics and course of urolithiasis in our series. METHODS: A retrospective study was performed. We included kidney transplanted patients between November 2002 and November 2019 and presenting lithiasis during their follow-up. Clinical, biological and radiological data were collected as well as lithiasis disease related data. The management of and patient's evolution were also specified. RESULTS: Seven of 416 kidney transplanted patients developed lithiasis during their follow-up with an incidence of 1.6 %. The mean age at lithiasis diagnosis was 36.5 years [24-55 years], the sex ratio was 1.3. They developed stones after mean follow-up of 67 months [4-168 months]. The stones' size varied from 2 to 18mm. Treatment was alkalisation in 3 cases, extracorporeal lithotripsy in 2 cases, a double J stent in 3 cases and pyelolithotomy in 2 cases. Four patients had multiple treatments. Three patients had 1 residual stone during evolution (7mm average diameter), 1 microlithiasis, 1 lost to follow-up after treatment and only 2 (out of 7) were "stone free". Furthermore, lithiasis didn't damage the graft survival after a median follow-up of 62 months post-treatment. CONCLUSION: Urolithiasis in the kidney transplanted patient requires an adapted multidisciplinary management. Its skill is a challenge for both the nephrologist and urologist.

A case of an isolated hydatid cyst in the right kidney.

Isolated renal hydatid cyst is rare. Preoperative diagnosis may be difficult because clinical, biochemical and radiologic findings can not eliminate the diagnosis of renal cancer in its cystic form. Open surgery is traditionally the gold standard.

Laparoscopic treatment of a cystic pheochromocytoma of 6cms: A challenging case.

Cystic pheochromocytoma is a very rare entity.Preoperative diagnosis is difficult because clinical, biochemical and radiologic findings are usually not consistent with a pheochromocytoma.Open surgery is traditionally the gold standard to avoid cyst rupture.we present a case of a 6 cm cystic pheochromocytoma treated by laparoscopy.

Cancer on cryptorchid testis revealing a Persistent Müllerian Duct Syndrome: A rare case.

The persistence of Müllerian derivatives syndrome or PDMS is a rare form of male pseudohermaphrodism. Its association to ectopic testicular cancer is even rarer. Because of its rarity it is difficult to diagnose preoperatively. We present a case of a cancer on cryptorchid testis revealing a persistent Müllerian duct syndrome.

Brain Metastasis of Pheochromocytoma: Diagnostic and Therapeutic Challenge.

BACKGROUND: Pheochromocytoma brain metastasis is extremely rare. Few cases have been reported in the literature. Therefore, diagnosis and effective treatment of these lesions are difficult. CASE DESCRIPTION: Here, we report the case of 29-year-old woman, who was operated on for a right adrenal pheochromocytoma. Fourteen months later, a posterior fossa tumor was diagnosed. Radiologic findings mimicked an extra-axial lesion. The radiologic differential diagnosis was difficult even using magnetic resonance imaging spectroscopy. The patient was operated on through a retrosigmoid approach. Local recurrence occurred 6 months after first surgery. The patient died 1 month later, despite a second operation. CONCLUSIONS: Although the occurrence of brain metastases in pheochromocytoma is not prevalent, patients presenting with suggestive features need to be carefully considered. Magnetic resonance imaging can help in differential diagnosis with a primary brain tumor. There are no established guidelines for the treatment of pheochromocytoma brain metastasis, for which the prognosis remains dismal, despite effective surgery.