Idiopathic megacaecum: clinical features and diagnostic approach.

Congenital megacaecum is a rare entity and difficult to diagnose. The pathogenesis of this malformation is not well known since there are very few cases reported in the literature. The purpose of this observation is to describe the functional signs that may suggest this rare diagnosis and the means to confirm it. We report the case of a 22-year-old young man, who complained of constipation associated with pelvic pain in the form of gravitational pull exacerbated by standing, sitting and going down the stairs. However, symptoms seemed to be relieved by supine positions. The radiological investigations concluded that the megacaecum dipped into the pelvis, but there was no evidence of mechanical or functional obstruction distally. The treatment consisted of a laparoscopic right colectomy. The postoperative course was uneventful. The megacaecum is rare and poorly understood. The abdominal pain is directly related to fecal stasis, which increases the pressure on cecal colonic segment and this in turn causes a pull on the mesentery. The entero-MRI is valuable in the diagnosis so as to eliminate other causes of chronic abdominal pain.

Prognostic factors in gastric carcinoma after R0 resection with DII lymph node dissection. Tunisian experience.

BACKGROUND: Curative resection with adequate lymph node dissection is the treatment of choice for gastric cancer. AIM: To determine the prognostic factors after R0 resection with DII lymph node dissection. METHODS: We retrospectively assessed 126 patients who underwent R0 resection with DII lymph node dissection for gastric cancer (excluding the upper third of the stomach) in a single institution between 1991 and 2006 with median follow-up of 38.5 months (6 - 219). Prognostic factors were assessed by Cox proportional hazard model. RESULTS: There were 45 women and 81 men. The median age was 60 years (21 - 87). Four patients died (3.2 %). Postoperative hospital morbidity was 16.7 %. The pathologic review of the slides revealed that 50% of the tumors were stage T3 (63 cases). The median number of lymph node removed was 11 (8-40), 50% were involved. Five and 10 years survival rates were respectively 56.9 % and 40.2 %. In multivariable analysis, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were found to be independent prognosis factors. CONCLUSION: After R0 resection with DII lymphadenectomy, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were independent predictive factors for survival.

Surgical management of intra-abdominal cystic lymphangioma. Report of 20 cases.

BACKGROUND: Cystic lymphangioma (CL) is a benign rare malformation of lymphatic vessels. Its discovery in adults is rare. Although it can affect any organ, the common forms found in adults are mesenteric and/or retroperitoneal CL. This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma in adults. METHODS: We report a retrospective study from January 1998 to September 2010 concerning 20 patients who underwent surgical removal of a CL. We were interested in discovering the clinical, biological, and radiological characteristics of CL. The localization, size, and number of cysts have been reported, as well as the surgical intervention used and the postoperative immediate and late complications. RESULTS: The median age was 46 years. Abdominal pain was the main symptom and was found in 15 patients (75%). Physical examination revealed an abdominal mass in 12 patients (60%). In four patients (20%), the cystic lymphangioma was incidental. Abdominal ultrasound and abdominal CT scan helped to highlight 22 cystic masses. CL diagnosis was established preoperatively in 13 patients (65%). Six patients (30%) were operated with a diagnosis other than CL. The diagnosis was made intraoperatively in one case (5%). Only two patients (10%) were operated on in emergency: one due to an infected CL and the other was CL complicated with intracystic hemorrhage. A laparotomy in 13 cases (65%) was the surgical approach used, whereas 7 cases (35%) benefited from a laparoscopy. No conversion was noted. The majority of the patients, 18 cases (90%), received a total cystectomy. Only two patients (10%) had recurrences of which only one was reoperated. CONCLUSIONS: The diagnosis of CL often is facilitated by means of modern imaging; however, other diagnoses may be discussed, particularly hydatid disease endemic areas. If symptomatic lesions or complications arise, complete surgical excision, when possible without major sacrifice, seems to be the best therapeutic option to reduce the risk of recurrence.

[Anatomic variations of the hepatic artery : a study of 33 cases and review]. / Variations anatomiques de l'artère hépatique et applications pratiques: a propos de 33 cas et revue de la littérature.

BACKGROUND: The hepatic artery is prone to numerous anatomic variations dictated by certain variables of the organogenesis. Aim : To research study the anatomic variations of the hepatic artery as well as their implications within surgical practice. METHODS: Study of a post-mortem series of 33 cases of dissection of the hepatic pedicle with fresh corpses (deaths amounting no longer than 24 hours), carried out in conditions that are quite close to those met with the living ones. RESULTS: The common hepatic artery was divided at the foot of the hepatic pedicle into a gastro duodenal artery and into a proper hepatic artery in 94% of the cases. In 6% of the cases, we noticed a three level change, a branching of the average hepatic artery into a gastro duodenal artery, a right hepatic artery and a left hepatic artery. The proper hepatic artery represented the pedicle segment of the hepatic artery in 94% of the cases. In 36% of the cases, the liver was irrigated by two hepatic arteries. In 12% of the cases, there was the matter of the right hepatic artery, branch of the mesenteric artery. In 24% of the cases, there was the matter of the left hepatic artery branch of the left gastric artery. CONCLUSION: The perfect knowledge in preoperative and preoperative stages of the anatomic variations of the hepatic pedicle is quite essential. Actually, the lack of knowledge of these variations exposes to the risk of certain complications which are sometimes deadly during hepatic transplants, pancreatic surgery, cholecystectomies, through laroscopic way as well as in the treatment of gastro-esophagus surging.

[Acute peritonitis complicating Crohn's disease: epidemiologic and physiopathological characteristics]. / Peritomite aigue generalisee compliquant une maladie de Crohn: aspects epidemiologiques et physiopathologiques.

BACKGROUND: An uncommon event in the natural course of Crohn's disease is the spontaneous perforation. It's the most serious intestinal complication. AIM: To report the incidence of this complication and to discuss the mechanism of the perforation. OBSERVATIONS: We report, retrospectively, 4 cases (3 men and one woman; median age: 30 years) of peritonitis complicating Crohn's disease and study their clinical characteristics intra operatively findings and course evolution. Steroid therapy was administrated to all patients before the perforation. The perforation sites are on the ileum in three cases and on the jejunum in one case. The treatment consists in a resection of the perforated intestine with stoma in all cases. CONCLUSION: Perforation in Crohn's disease is a rare event. The exact mechanism of the perforation is still unknown and many hypotheses are presented.

[Tomodensitometric diagnosis of internal herniation: report of 3 cases]. / Apport de l'enteroscanner dans le diagnostic pre operatoire des hernies internes: a propos de 3 cas.

AIMS: To study the value of the CT scan in the diagnosis of internal herniation and to evaluate its performance comparing its features to preoperative data. CASES: We report 3 cases of patients with internal hernias (two men and one woman whose age is 23, 45 and 60 years) hospitalised in emergency for a small bowel obstruction. There were no previous abdominal surgeries or trauma, The three patients underwent CT scan. Signs of tranmesenteric hernias and hernia through the falciform ligament were diagnosed preoperatively and confirmed at laparotomy. CONCLUSION: The internal hernia is rare cause of small bowel obstruction. The CT scan is an important way to make diagnosis and to choose the surgical strategy.

Pseudoaneurysm of the splenic artery presenting with gastrointestinal bleeding.

Gastrointestinal bleeding from a pancreatic pseudocyst is a rare condition that is diagnostically and therapeutically challenging. A 78-year-old woman with a history of acute pancreatitis due to gallstones was hospitalized for abdominal pain and gastrointestinal bleeding. Gastroscopy revealed blood extruding from the papilla of Vater. A computed tomography scan revealed hemorrhage into a pancreatic pseudocyst. The patient was successfully treated by coil embolization.

[Gastric volvulus: diagnosis and management]. / Volvulus gastrique: diagnostic et prise en charge thérapeutique.

Gastric volvulus is defined as an abnormal rotation of all or part of the stomach around one of its axes. It is a diagnostic emergency and therapeutic challenge because in acute forms it may lead to gastric strangulation with a high risk of ischemia and necrosis. Organoaxial and mesentericoaxial volvulus are distinguished according to the direction of rotation. The most common cause of gastric volvulus is hiatal hernia, but the principal predisposing factor is ligamentous laxity. The diagnosis is suspected when erect chest radiograph images show a high air-fluid level in the chest. Moreover a barium swallow is essential to confirm the diagnosis. Nonetheless, a computed tomography (CT) scan now provides a comprehensive description of the thoracic lesion, including stomach vitality. Gastric volvulus requires surgical treatment, specifically volvulus reduction, reintegration of the stomach into the abdominal cavity in cases of intrathoracic migration, and correction of causal factors. Resection of the hernial sac and the role of gastropexy for preventing recurrence remain controversial. Advances in laparoscopic surgery have made possible a laparoscopic approach to most cases of chronic gastric volvulus.

[Internal herniation through the falciform ligament revealed by acute intestinal obstruction]. / Hernie interne du ligament falciforme révélée par une occlusion intestinale aiguë

INTRODUCTION: Internal hernias are a rare cause of acute intestinal obstruction. Herniation through the falciform ligament is rare and often diagnosed only during surgery. Abdominal computed tomography (CT), performed on an emergency basis, can help to diagnose this obstruction before surgery and select a therapeutic approach. CASE: A 60-year-old man was hospitalized on an emergency basis for symptoms that had been developing for 3 days, including tympanites and epigastric pain (torsion), associated with vomiting and the cessation of both feces and flatus. Abdominal radiography showed multiple levels of air-fluid levels in the small bowel, some projecting towards the liver area, as well as the presence of a flat intestinal loop continuous with a distended small-bowel segment. Abdominal CT suggested a diagnosis of small-bowel herniation and obstruction, very probably through the falciform ligament. The patient then underwent emergency surgery after a brief resuscitation. Intraoperative exploration confirmed the diagnosis of internal hernia through the falciform ligament. The postoperative course was without problems. DISCUSSION: Abdominal CT is the examination of choice in cases of a "new" acute intestinal obstruction. It makes it possible to diagnose the mechanism of the occlusion and especially the cause, especially for an internal hernia through the falciform ligament. It thus guides the choice of emergency surgical procedure and of appropriate approach. Once diagnosed, emergency surgery is essential to free the intestinal loop, with or without intestinal resection as a function of vitality.

Budd-Chiari syndrome secondary to hepatic echinococcosis.

OBJECTIVES: Hydatid cyst of liver is a parasitosis which is an endemic state in Tunisia and is a very rare cause of Budd-Chiari syndrome. The purpose of this study was to report the clinical features, radiological investigations and therapeutic management. PATIENTS AND METHODS: A retrospective analysis of 12 patients who underwent surgery for Budd-Chiari syndrome secondary to hepatic echinococcosis between January 1990 and December 2004 was performed. RESULTS: The series included ten females and two males with a mean age of 36 years. Budd-Chiari syndrome was subacute in 75% of cases. Ultrasound showed a compression of hepatic veins by cysts with a mean diameter of 13 cm situated in at least two hepatic segments. US Doppler and CT-scan of the liver provided the diagnosis in all cases. Laparotomy was performed in all cases. Operative mortality was 8% and morbidity 66% due to biliary fistula and deep abscess formation. Hepatic vein outflow was successfully re-established in four patients. CONCLUSION: Budd-Chiari syndrome is a rare but severe complication of hydatid cyst of the liver. Early diagnosis is necessary to improve prognosis.

Role of laparoscopic surgery in the etiologic diagnosis of exsudative ascites: a prospective study of 90 cases.

PURPOSE: Peritoneal tuberculosis and carcinomatosis are the most frequent etiologies of exsudative ascitis and require rapid diagnosis and treatment. The purpose of this study has been to evaluate the predictive value of clinical and complementary data for the etiologic diagnosis of exsudative ascites and to assess the results of laparoscopic surgery. MATERIAL AND METHODS: We report a prospective long-term study conducted over 10 years, having included all cases of exsudative ascites of unidentified etiology. We excluded patients with a history of anterior laparotomy and patients having a contraindication for laparoscopic surgery. Clinical signs, results of the cytochemical and bacteriological exam of the ascetic liquid and findings from radiological exams and endoscopic investigations were noted. Open laparoscopic exploration noted the macroscopic aspect and many peritoneal biopsies were obtained as well as a liver biopsy when possible. Statistical analysis was performed with SPSS10.0 software. The degree of statistical significance was set for P<0.05. RESULTS: We included 90 cases of isolated exsudative ascites. There were 59 cases of tuberculosis and 31 of carcinomatosis. Mean patient age was 47 years with a sex ratio of 0.5. Bowel transit disorders were significantly in favor of a carcinomatosis (P=0.04) while fever and nocturnal sweats were suggestive of tuberculosis (P=0.04) but in both instances, the positive predictive value (PPV) of these two signs was weak, respectively 29% and 43%. Relative to chemical and cytologic study of ascitic fluid, hemorrhagic fluid, low white cell count, low lymphocyte differential and presence of atypical cells were significantly linked with the carcinomatosis (P=0.01) but with a PPV<85%. Radiological exams were not very contributive for the etiologic diagnosis. The laparoscopic peritoneal aspect was typical of tuberculosis in 90% of proved cases and in 29% of carcinomatosis cases, underlying the importance of peritoneal biopsies for histological study. Hepatic tuberculosis was associated with peritoneal localisation in 48% of cases. We had no surgical mortality and the morbidity was about 1%. CONCLUSION: Etiological diagnosis of exsudative ascitis remains difficult to establish. Peritoneal biopsies under videolaparoscopy are currently the "gold standard" for diagnosis.

[Chemo-laparoscopic treatment of hydatic cyst of the liver myth or reality! Preliminary results of 27 cases]. / Traitement médico-laparoscopique du kyste hydatique du foie mythe ou realité! Résultats préliminaires à propos de 27 cas.

The laparoscopic treatment of hydatic cyst of the liver is at present codified. These last years, several progresses were obtained in the laparoscopic approach of hydatic cyst by avoiding the risk of preoperative hydatic peritoneal scattering. The aim of this study is to evaluate the effect of Albendazole given before a laparoscopic management of the hydatic cyst of the liver.