Pancreaticojejunostomy vs. pancreaticogastrostomy following pancreaticoduodenectomy: results of comparative study.

AIM: Several techniques have been proposed for reconstructing pancreatico-digestive continuity, which the first goal is reducing the rate of pancreatic leakage after pancreaticoduodenectomy. Only a limited number studies have been carried out. Our objective is to compare the results of pancreaticojejunostomy versus pancreaticogastrostomy following pancreaticoduodenectomy. METHODS: This is a retrospective and comparative study about 80 patients who underwent pancreaticoduodenectomy. These patients were divided into two groups: pancreaticojejunostomy (group PJ) and pancreaticogastrostomy (group PG). RESULTS: The PJ group included 39 patients, while 41 patients were included in the PG group. There were no differences between the two groups concerning: patients' demographics, risk factors, indication, mean duration of surgery, texture of pancreatic tissue, need for intraoperative blood transfusion and postoperative prophylactic octreotide. Overall, the mortality postoperative rate was 7.5% (N.=6), the incidence of surgical complications was 50% (51.3% in PJ, 48.8% in PG; P=0.823, not significant). Pancreatic fistula was the most frequent complication, occurring in 17.5% of patients (25.6% in PJ and 9.8% in PG; P=0.062, almost significant). 7.7% of patients who underwent PJ and 14.6% of patients who underwent PG required a second surgical intervention (P=0.326, not significant). There were no differences between the two groups PG and PJ concerning: Postoperative hemorrhage (P=0.63), biliary fistula (P=0.09), acute pancreatitis (P=0.95), delayed gastric emptying (P=0.33). The mean postoperative hospitalisation period stay was similar in both groups (P=0.63) CONCLUSION: There were not any significant differences between the two groups in the overall postoperative complication rate, the incidence of postoperative haemorrhage, biliary fistula, acute pancreatitis, and delayed.

Paratesticular Liposarcoma: what is the best Therapeutic Strategy?

Introduction: Liposarcomas are neoplasms of mesodermal origin derived from adipose tissue and correspond to 10-14of all soft tissue sarcomas. Paratesticular liposarcoma is very rare. Case report: We report a 60-year old man who presented with a left testicular tumor 20 cm in diameter. Initial incisional biopsy was reported as fibromatosis. Chest and abdominal CT scan did not show distant metastases. Through an inguinal incision orchidectomy with homolateral inguinal node dissection was performed. Histopathological examination showed a paratesticular myxoid liposarcoma. Adjuvant radiotherapy without chemotherapy was administered. The patient remains well at 11 months followup; with no evidence of recurrence. Conclusion: Complete surgical extirpation reduces the risk of local recurrence. Neoadjuvant chemotherapy or radiotherapy may reduce the tumor size; thus facilitating complete excision

[Complicated sigmoid tumor: perforated amebiasis]. / Une tumeur sigmoïdienne compliquée: amoebome perforé.

Amoeboma is an inflammatory mass of the colon. It can be an inaugural symptom and thus pose the problem of differential diagnosis with colon cancer. The purpose of this report is to describe the case of a 43-year-old patient who presented with acute abdomen. Physical examination revealed a perforated circumferential mass in the sigmoid colon. Based on a presumptive diagnosis of colonic cancer complicated by perforation, segmental colectomy was performed. Histological examination of the surgical specimen demonstrated colonic amoeboma. The patient was treated using metronidazole. Although rare, amoeboma must be considered in differential diagnosis of cancer of any colonic mass.

Leiomyosarcome du rein: a propos d'un cas

Le leiomyosarcome du rein est une tumeur rare. Les auteurs ont rapporte l'observation d'un homme age de 45 ans; chez lequel le diagnostic d'une tumeur retroperitoenale gauche a ete pose lors de l'exploration de douleurs du flanc gauche associees a une alteration de l'etat general et ce par l'imagerie (Echographie et scanner abdominal). La laparotomie exploratrice avait conclu a une tumeur renale gauche localement evoluee; une nephrectomie elargie a ete realisee et l'histologie etait en faveur d'un leiomyosarcome renal. Une recidive locale a ete diagnostiquee apres un recul de 6 mois. Apres une nouvelle laparotomie; l'abstention etait de mise devant le caractere evolue de la recidive. Le but de cette observation est double. Le premier; est la necessite de faire un diagnostic precoce; afin d'intervenir sur une tumeur de petite taille; plus accessible a la chirurgie. Le second; est de discuter la place du traitement adjuvant; qui pourrait reduire le risque de recidive precoce

Mucocele of appendiceal stump--an atypical presentation and a diagnostic dilemma.

BACKGROUND: Appendiceal mucocele is a well-recognised entity that can present in a variety of clinical syndromes or can occur as an incidental surgical finding. The term mucocele is inherently imprecise and inclusive of both benign and malignant lesions. Mucocele of the appendiceal stump is a rare entity. AIM: We present a case of an appendiceal stump mucocele caused by a mucinous cystadenoma clinically presented as a giant retroperitoneal mass. Diagnosis was made postoperatively, after pathological study of the surgical sample. CASE REPORT: The case of a 54-year-old woman, with a previous appendectomy, suffering from a painful mass in the right lower quadrant of the abdomen, is reported. Imaging showed a large cystic structure at the base of the caecum. Surgery revealed a 13 x 5.5 cm retroperitoneal cystic mass, which was excised together with the appendiceal remnant. Pathological diagnosis was that of a mucocele arising from the appendiceal stump due to the development of a benign mucinous cystadenoma. The patient was discharged on the fourth post-operative day after an uneventful recovery. CONCLUSION: Mucocele of the appendiceal stump is a rare entity. In spite of extensive pre-operative investigations, preoperative diagnosis may still remain elusive and may only be made at the time of surgery.

Abdominal metastasis of a parosteal osteosarcoma of the femur: an unusual cause of large-bowel obstruction.

BACKGROUND: Parosteal osteosarcoma is a rare, well-differentiated, predominantly fibro-osseous variant of osteosarcoma. It is regarded as a distinct form of osteosarcoma with better prognosis than conventional osteosarcoma. AIM: We report an unusual case of abdominal mass recurrence of parosteal osteosarcoma of the left distal femur treated eight years previously with wide resection, hip disarticulation and chemotherapy, which presented as an acute abdomen: we discuss the clinical outcomes of this rare entity. CASE PRESENTATION: We present a 54-year-old patient with low-grade parosteal osteosarcoma of the left distal femur. Left total hip disarticulation was indicated after several local relapses of the tumour following extensive resection and chemotherapy. Eight years later, he presented with an acute large bowel obstruction secondary to a compression of the large bowel by an abdominal mass. Abdominal computed tomography showed a large abdominal calcified mass with dilated large bowel loops. During laparotomy, the mass was unresectable. So, the patient underwent emergent colostomy of diversion. Biopsy of the lesion yielded grade III parosteal osteosarcoma material. The patient received adjuvant chemotherapy, but the response was poor: six months later, the patient presented with a peristomal mass and two pulmonary metastases. CONCLUSION: Abdominal recurrence of parosteal osteosarcoma of the distal femur eight years after definitive surgery is rare. This case emphasises the importance of the long-term follow-up of patients with parosteal osteosarcoma.

Cystic echinococcosis in Tunisia: analysis of hydatid cysts that have been surgically removed from patients.

Echinococcosis/hydatidosis caused by Echinococcus granulosus has a widespread distribution in the human population of Tunisia, particularly in the north-west and centre-west of the country. In a recent study, the morphological features, fertility and viability of hydatid cysts that had been excised from patients in Tunis were explored, and the E. granulosus strain or genotype involved in each case was identified from morphology of the protoscolex hooks and the results of molecular genotyping. The hepatic cysts investigated came from 41 patients [31 women and 10 men, with a mean (S.E.) age of 43.41 (14.25) years] who were treated for cystic echinococcosis, by surgery but rarely with chemotherapy, at the La Rabta Hospital in Tunis, in the 12 months ending in June 2008. Most (56%) of these patients originated from rural areas in endemic governorates. Of the 60 hepatic cysts that were studied, 38.3% were located in the right lobe of the liver and 35.0% each involved both hepatic lobes. Almost a third (31.7%) of the excised cysts were degenerating, with the rest considered viable and either multivesicular (38.3%) or univesicular (30.0%). Almost all (93.3%) of the cysts were categorized as fertile, with a mean protoscolex viability of 21.8%. Protoscolex viability was relatively high in the viable univesicular cysts with a visible cyst wall and in the multivesicular and multiseptate cysts with daughter cysts, and lowest in the cysts that appeared to be solid calcified masses. The observed variation in protoscolex viability with cyst type, in cysts excised from patients before any chemotherapy, supports the cyst classification recommended by the World Health Organization but could also be compatible with the imaging-based 'Gharbi' classification. The results of the molecular genotyping showed that all 23 cysts investigated (which came from 20 of the patients) were caused by E. granulosus of the G1 genotype (also known as the 'sheep' or 'sheep-dog' strain).

[Serological markers, viral RNA and genotype of hepatitis delta virus in HBs antigen positive Tunisian patients]. / Marqueurs sérologiques, ARN viral et génotype du virus de l'hépatite delta chez des patients tunisiens antigène HBs positifs.

OBJECTIVE: This study had for aim to study the serological and molecular patterns of hepatitis delta infection in Tunisian patients. DESIGN: Our study was carried out in 215 HBs antigen positive patients, including 176 asymptomatic carriers originated from regions of variable hepatitis B virus (HBV) endemicities, and 39 hepatitis B chronic patients with delta positive serology. Delta antigen, delta antibodies and HBe antigen were investigated for all patients; detection and genotyping of hepatitis delta virus (HDV) RNA and detection of HBV DNA were conducted in the second group patients. RESULTS: Twelve patients (6.8%) out of 176 asymptomatic carriers had HDV positive serology. Delta prevalence was relatively more elevated in regions of high HBV endemicity than on those with moderate or weak endemicity. The mean age of patients was 5 years higher in the delta positive subjects than in the global population. For hepatitis B chronic patients with delta positive serology, HDV RNA was detected in 53.8% of cases; HBV-HDV co-replication was observed in 38.4% of cases. Genotype 1 was found for one of the amplified samples. CONCLUSIONS: The results of our study enrich the limited data on HDV prevalence in Tunisia and on the molecular epidemiology of circulating isolates.

[Primary hydatid cyst of the psoas muscle: description of 9 cases in Tunisia and review of the literature]. / Kyste hydatique primitif du psoas: 9 cas tunisiens et revue de la littérature.

The psoas muscle is an uncommon location for hydatid cyst accounting for only 1 to 3% of cases. The purpose of this report is to describe the epidemiologic, clinical, paraclinical, and therapeutic features of primary hydatid cyst of the psoas muscle. A retrospective study conducted in Surgery Department A at the Rabta Hospital in Tunisia compiled a total of 9 cases of primary hydatid cyst of the psoas muscle treated between 1980 and 2006. There were 6 men and 3 women with a mean age of 42.8 years. Symptomatology was nonspecific with pain in 6 cases. Discovery was coincidental in two cases. Clinical examination detected a mass in the presents of an abdominal mass in 7 cases. Radiologic findings (ultrasound and/or CT scan) confirmed diagnosis in 8 cases. In one case a mistaken diagnosis of psoas muscle abscess was made in a patient with an infected hydatid cyst. Serological tests were performed in 4 cases and were positive in 3. All patients underwent surgical treatment. The extraperitoneal approach (Leriche) was used in 7 cases and the transperitoneal approach via median laparotomy in 2. In all cases the surgical procedure consisted of partial cystectomy leaving a part of the pericystic against neurovascular structures. There was no operative mortality. The only postoperative complication was urinary infection in one patient. Mean follow-up was 2.5 years. One local recurrence was observed 4 years after surgical treatment and required reoperation.

A report of 15 cases of small-bowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties.

UNLABELLED: Phytobezoars are a rare cause of acute bowel obstruction. The purpose of this work was to identify the predisposing factors and diagnostic difficulties of this rare entity. MATERIAL AND METHODS: This was a retrospective study including all cases of small-bowel obstruction secondary to phytobezoars observed between April 2001 and August 2007. The diagnosis of bezoars was established by surgical exploration or by computed tomography (CT). RESULTS: During the study period, 375 patients were hospitalized at our institution with a diagnosis of bowel obstruction that, in 15 (4%) cases, was secondary to phytobezoars. The average patient age was 55 years, with a gender ratio of 1.7, favoring men. The predisposing factors were gastroduodenal surgery for peptic ulcer in nine patients, and excessive consumption of prickly pears (cactus figs) in 12. The diagnosis was established by CT scans in three patients, who were successfully treated with gastric aspiration, thereby avoiding surgery. Laparotomy was performed in 12 patients to allow digital fragmentation of the bezoar, which was then washed into the colon. There were no postoperative deaths and morbidity was about 13%. CONCLUSION: An abdominal CT scan should be obtained for patients with small-bowel obstruction. This examination offers a precise diagnosis of bezoars, reducing the number of unnecessary surgical procedures, and helping to guide the approach if surgery is needed.

[Radiologic diagnosis of enterosalpingeal fistula complicating Crohn's disease]. / Diagnostic radiologique d'une fistule entérotubaire compliquant une maladie de Crohn.

Enterosalpingeal fistula is a rare complication of Crohn's disease which is rarely diagnosed preoperatively. We describe a new case of this complication suspected by CT scan and confirmed by hysterosalpingogram and contrast from the ileum. This case is about a 50-year-old woman suffering from ileal Crohn's disease diagnosed two years previously and actually complicated by stenosis and entero-salpingeal fistula. The treatment consisted on resection of the ileocaecal region with salpingectomy. Postoperative course was uneventful.

Kyste hydatique primitif du psoas : 9 cas tunisiens et revue de la litterature

Le muscle psoas est une localisation exceptionnelle du kyste hydatique ne representant que 1 a 3des cas. Le but de ce travail est d'etudier les caracteristiques epidemio- logiques; cliniques; paracliniques et therapeutiques de cette entite. Notre etude est retrospective consecutive portant sur 9 cas de kystes hydatiques primitifs du psoas colliges entre 1980 et 2006 dans le service de chirurgie A de l'Hopital La Rabta. Il s'agissait de 6 hommes et 3 femmes dont l'age moyen etait de 42;8 ans. La symptomatologie etait atypique dominee par les douleurs retrouvees dans 6 cas. La decouverte etait fortuite dans deux cas. L'examen physique retrouvait une masse du flanc dans 7 cas. Le diagnostic etait confirme par la radiologie (echographie et/ou tomodensitometrie) dans 8 cas. Dans 1 cas; le diagnostic d'abces du psoas etait pose a tort chez un patient porteur d'un kyste hydatique infecte. La serologie hydatique pratiquee dans 4 cas etait positive dans 3 cas. Tous les patients etaient operes. La voie d'abord etait extra peritoneale (Leriche) dans 7 cas et transperitoneale a travers une laparotomie mediane dans 2 cas. Le geste a consiste dans tous les cas en une kystectomie partielle laissant une calotte de perikyste contre les elements vasculo-nerveux. La mortalite etait nulle. Un seul patient s'est complique en postoperatoire d'une infection urinaire. Le suivi moyen etait de 2;5 ans. Au cours de la surveillance postoperatoire; une seule recidive locale etait diagnostiquee a 4 ans postoperatoire ayant necessite une nouvelle intervention

[Subcutaneous hydatid cyst. Case report of an exceptional location]. / Kyste hydatique sous-cutané: à propos d'une localisation exceptionnelle.

Primary subcutaneous cyst hydatid disease is an exceptional entity. We report a new case involving a 70-year-old woman hospitalized for a subcutaneous mass in the hypogastric area with no local inflammatory signs. Radiological examination was consistent with a partially calcified subcutaneous cyst in the hypogastric area. Complete surgical resection of the mass was performed with uneventful postoperative recovery. Histopathological examination of the surgical specimen demonstrated multivesicular hydatid cyst.

[Unopened colostomy in colorectal surgery: a renewal interest?]. / La colostomie à ouverture potentielle en chirurgie colorectale: un regain d'intérêt?

INTRODUCTION: Anastomotic leak or disruption is a grave complication of colorectal surgery. Protection of an at-risk anastomosis by an upstream open diverting colostomy (OC) reduces this gravity. An unopened upstream loop colostomy is a surgical alternative which may diminish the unpleasant consequences of an open colostomy while maintaining the option of diversion in case of need. The aim of this study is to report the results of this approach and to define its indications. MATERIAL AND METHODS: [corrected] We report a retrospective series of 34 cases of unopened diverting loop colostomy to protect an at-risk colorectal anastomosis. Indications for this procedure were stool-laden bowel (59%), low serum albumin (11.5%), local inflammation (11.5%), and very low placed anastomosis (17.5%). RESULTS: The loop colostomy was eventually opened after surgery in six cases because of anastomotic leakage diagnosed clinically and/or detected by water soluble contrast opacification which was performed routinely on the sixth post-operative day. In all six cases, there was no need for an urgent surgical intervention. In 28 cases, the anastomosis healed without complication and the exteriorized loop was returned to the abdominal cavity seven days after the initial surgery. This was a short, simple procedure with an average operating time of ten minutes. Average hospital stay after returning the unopened colostomy to the abdomen was two days. CONCLUSION: Unopened loop colostomy offers the advantages of protection of a colorectal anastomosis without proper morbidity or mortality, shorter hospitalization, and improved psychological comfort for the patient. It's principal indication is to minimize the risks related to leakage from an at-risk colorectal anastomosis.