Presentation with perforation of the terminal ileum and acute limb ischemia in Crohn's disease: A case report.

INTRODUCTION AND IMPORTANCE: Crohn's disease is a chronic inflammatory bowel disease with complex pathophysiology and multiple complications, some of which can be fatal. We report herein the management of an unusual case of Crohn's disease revealed by two life-threatening complications. CASE PRESENTATION: A 59-year-old patient presented with an acute abdominal pain evolving for one day with a clinical presentation in favor of peritonitis by perforation of the last ileal loop and acute limb ischemia. At emergency laparotomy, we found a fecal peritonitis by perforation of the last ileal loop. The patient underwent an ileo-caecal resection with rifle barrel ileo-colostomy associated with embolectomy using a Fogarty catheter of the femoral artery. Pathological examination of the specimen showed an aspect consistent with an ileo-caecal Crohn's disease and blood clot embolus of the femoral artery. Postoperative course was uneventful and the patient was kept in remission with immunosuppressants. DISCUSSION: Several complications may arise during the evolution of the disease. However, Life-threatening complication scarcely inaugurate crohn's disease like in our patient. Free perforation of the small intestine in crohn's disease occurs rarely, which makes its statistical study difficult. Risk factors for perforation are still poorly identified. Patients diagnosed with crohn's disease have a higher risk of thromboembolic complications. Indeed, there is an association between the activity of the disease and thromboembolic events. In our case, the severity of the clinical presentation as well as its inaugural character are unique. CONCLUSION: The management of inaugural two uncommon acute conditions in Crohn's disease is challenging.

[Outcomes of laparoscopic surgery for groin hernia repair: our experience in Tunisia]. / Résultats de la chirurgie laparoscopique pour la hernie de l'aine: l'expérience Tunisienne.

Groin hernia in adults is a frequent affection in digestive surgery. Many repair techniques have been described to date, including laparoscopic surgery. Two methods are quickly adopted by the various practitioners for the surgical treatment of groin hernia using laparoscopy: laparoscopic totally extra-peritoneal (TEP) technique and laparoscopic transperitoneal inguinal hernia repair (TAPP). This study focused on the feasibility of groin hernia repair using coelioscopy, aiming to describe its outcomes in terms of recurrence and postoperative pain. We conducted a single-center, retrospective and cross-sectional study of patients who had undergone laparoscopic surgery for groin hernia repair in the Department of Surgery at La Rabta Hospital over a period of 8 years, from January 2006 to December 2013. The main evaluation criterion was hernia recurrence. Postoperative pain and complications were the secondary criteria of judgment. We collected data from 92 patients with 104 hernias, respecting the inclusion criteria in our study. The average age of patients was 48 years (19-83). TAPP was the most used technique: 94 TAPP (90%) versus 10 TEP. No intraoperative complication was reported. Conversion rate was 0. Operative mortality was also 0. Postoperative morbidity was 5% (5 patients). It included hematoma in 3 cases and serum in 2 cases. The mean lenght of stay in hospital was 1.2 days (1-4 days). Postoperative length of stay didn't exceed 2 days in 94% of patients. Only 2 patients had a recurrence. Postoperative chronic pain was reported only in 3 patients. Our study shows that laparoscopic surgery for groin hernia repair gives considerable comfort to our patients with regard to pain, length of stay in hospital and cessation of work. Outcomes are good and consistent with the results already published in the literature. This encourages surgeons to use these techniques and to monitor longer term outcomes.

[Solid pseudo-papillary tumor of the pancreas]. / Tumeur pseudo papillaire et solide du pancréas.

Solid pseudo-papillary tumors of the pancreas (SPTP) are rare epithelial tumors. In most cases, they occur in young woman in the second or the third decades of life. Survival after primary resection is approximatively 90% at 5 years. We report the case of a 20-year old female patient with solid pseudo-papillary tumor of the pancreas detected given the onset of abdominal pain without laboratory tests' disturbances. CT scan, MRI and endoscopic ultrasound showed well-defined mass in the pancreatic isthmus. Complete tumor resection was performed. Anatomo-pathological examination confirmed the diagnosis of solid pseudo-papillary tumor of the pancreas. Solid pseudo-papillary tumor of the pancreas should be included in the differential diagnosis of any pancreatic mass, in particular among young women. Surgical resection is associated with a good prognosis.

Surgical management of primary crohn's disease. descriptive study about 226 patients.

BACKGROUND: The surgery is required in more than 80% of patients with Crohn's disease (CD). Studies before confirm the specific genetic variation of CD in the Tunisian population compared with the others ethnic groups. AIM: This article aims to study the epidemiological, anatomical and therapeutic principles of surgical forms of CD in a cohort of Tunisian patients. METHODS: We report a retrospective study from January 1998 to September 2010 that studied 226 patients originated only from Tunisia (in North Africa), operated on for MC. We had been interested in epidemiological, anatomical, clinical, therapeutic, topographic progression of the disease, the procedure and the postoperative follow-up. RESULTS: The median age was 33 years. The average time between the onset of the disease and the surgical procedure was 31 months. The diagnosis of CD was established preoperatively in 213 patients (94%). The diagnosis was made intraoperatively because of an acute complication in 5 cases (2.2%) and postoperatively in 8 cases (3.5%). The most common location was the ileocecal junction in 184 cases (81.4%). Achieving the most common was the mixed form (stricture and fistula) in 123 cases (54.4%). Operative mortality was 0.04% (n = 1). Specific morbidity was 8.4% (n = 19). In long term, a surgical recurrence was noted in 17 patients (7.5%). In multivariate analysis the independent risk factors for surgical recurrence were: smooking (p = 0.012, ORs = 3.57) and post-operative medical treatment (p = 0.05, ORs = 2.6). CONCLUSIONS: Achieving stenosing and fistulizing the ileocecal junction is the most frequent surgical form in Crohn's disease. Our series is unique for a lower rate of the postoperative recurrence (7.5%).

Anal imperforation in adults: Diagnostic difficulties and therapeutic options.

Anorectal malformations are congenital anomalies ranging from simple perineal fistulas to complex malformations. They are usually treated inchildhood, and exceptionally in adult. We herein report the case of a 22 years aged patient and relate the diagnosis difficulties and therapeuticoptions. She consulted for anal imperforation discovered since birth. Initially, His parents refused the surgical management. It was an analimperforation with a vestibular fistula. The patient was operated by a low approach. She had a disconnection of the recto-vestibular fistula,dissection of the anal canal and a perineal posterior transposition. Postoperative course was uneventful. The evaluation of continence usingKelly's score found good Functional result.

Laparoscopic resection of gastric stromal tumors.

Gastro-intestinal stromal tumors (GIST) are the most common mesenchymal gastrointestinal tumors. The Gastric location represents 60% of cases [1,2]. Complete surgical excision remains the treatment of reference for the localized forms. This surgery can be made by laparoscopy when the lesion's size doesn't exceed 5 cm. Some principles must e respected: a mono-block complete surgical resection, with healthy margins and without effraction. This technique will be reserved for trained teams and for selected cases according to the size and location. We herein try to explain the surgical laparoscopic excision of gastric stromal tumors explaining .

Laparoscopic ileo-cecal resection: the total retro-mesenteric approach.

BACKGROUND: Ileo-cecal resection is the most performed procedure in Cohn's disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn's disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach. METHOD: The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt's fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis. RESULTS: This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn's disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %. CONCLUSION: We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn's disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.

[Surgical management of entero-vesical fistulas in Crohn's disease]. / Traitement chirurgical des fistules entéro-vésicales secondaires à la maladie de Crohn.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. aim: To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula (EVF) during the CD. methods: We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. results: The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted. CONCLUSION: Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term.

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.

[The Caroli's disease. Report of 16 cases]. / La maladie de caroli. A propos de 16 cas.

BACKGROUND: Caroli's disease is a congenital dilatation of the intrahepatic biliary duct. AIM: To analyse and discuss diagnostic and therapeutics difficulties through 16 patients with Caroli's disease. METHODS: Between January 1990 and September 2010, 16 patients underwent surgical procedure for Caroli's disease. Data recorded for each patient included clinical symptoms, biologic findings, previous biliary procedures, and the presenting symptoms. The distribution of the biliary lesions, the surgical procedure and the postoperative outcomes and follow up were detailed. RESULTS: The mean age was 55 years. The mean interval between the first symptoms and diagnosis was 27 months. Five of 16 patients had undergone 12 surgical or endoscopic procedures prior to liver resection. Before the definitive diagnosis, 9 patients presented 15 episodes of acute cholangitis. The diagnosis was established preoperatively in 13 cases, 5 among them underwent previous biliary surgical procedures. The diagnosis was documented peroperatively in 2 cases and postoperatively in 1 case. The distribution of the biliary lesions was monolobar in 13 and bilobar in 3 patients. 13 patients underwent liver resection, in two cases we perfomed biliojejunostomy and the last one had endoscopic sphincterotomy. There was no mortality and the overall postoperative morbidity is about 43%. The follow-up shows that 12 patients still alive with a mean follow up for 53 months, from whom only one patient have intrahépepatic lithiasis. CONCLUSION: The clinical course of Caroli's disease is often complicated by recurrent episodes of angiocholitis and requires iterative surgery. The hepatectomy witch prevented septic complications and degenerescence is possible only in a restricted number of patients.

Left-sided gallbladder: an incidental finding on laparoscopic cholecystectomy.

Transposition of the gallbladder to the left side without situs inversus viscerum is rare. These gallbladders are situated under the left lobe of the liver between Segment III and IV or on Segment III to the left of the falciform ligament. This is a report of a 50-year-old woman who was admitted to our department with a history of pain in her right upper abdomen. The physical examination showed tenderness in the right upper quadrant of the abdomen without a Murphy's sign. Abdominal ultrasonography showed gall bladder stones without dilatation of the bile ducts. The patient underwent a laparoscopic cholecystectomy using the French position and four ports positioned as usual. We discovered a left-sided gallbladder located on the left of the round ligament. The gallbladder was excised as usual. Intraoperative cholangiogram showed neither dilatation of the bile ducts nor associated congenital anomalies of the biliary tree. The patient was discharged on the first postoperative day. Because routine preoperative examinations may not detect the anomaly, the latter may take surgeons by surprise during laparoscopy. Awareness of the unpredictable confluence of the cystic duct into the common bile duct and selective use of intraoperative cholangiography both contributed to the safe laparoscopic management of this unusual problem.

Giant retroperitoneal liposarcoma. Report of 5 cases.

BACKGROUND: Liposarcoma is the most frequent histopathological variety of the retroperitoneum, surgery is the gold standard for treatment. CLINICAL SERIES: We report, retrospectively over 7 years (2000-2006), 5 cases (four men and one woman, the mean age was 48 years) of giant retroperitoneal liposarcomas and study their clinical characteristics intra operatively findings and course evolution. None of our patients had a percutaneous biopsy of his tumour. Surgery was indicated to all patients. Resection was performed in 4 cases (we performed a bloc resection in three cases and a simple tumour resection in one case), and in one case, abstention was decided. None of patients had an adjuvant therapy Three of the patients still alive after the follow up of 2, 3 and 4 years. CONCLUSION: Retroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach including multiple resections for recurrences. Based on the ability of the patient to tolerate the procedure, surgery is suggested to evaluate resectability of the tumor. We must take into consideration whether prolonged survival will be attained and tumor removal will result in palliation of symptoms.

Risk factors associated with pancreatic fistula after distal pancreatectomy.

BACKGROUND: Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. AIM: To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP). METHODS: 35 patients underwent DP during a 10-year period (2000- 2009). Informations regarding diagnosis, operative details, and perioperative morbidity and mortality were collected. Nine risk factors were examined. RESULTS: Indications for DP included primary pancreatic disease (n=23; 66 %) and non-pancreatic disease (n = 12; 34 %). Postoperative morbidity rate was 43 % and none patient died. No patients required a reoperation. Pancreatic fistula was occurred in 11 patients (31 %). On univariate analysis, incidence of pancreatic fistula rate was not significantly associated with these risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, additional procedures, intra operative bleeding and texture of pancreatic parenchyma. We observed significant statistical difference between male and female, 47 % of females experienced a pancreatic fistula, while 17 % males developed a pancreatic leakage (p =0.05). The role of the technique of pancreatic stump closure in the development of pancreatic leak remains unclear because of the few number of patients on who we used stapler. CONCLUSION: The rate of pancreatic fistula after left pancreatectomy is 31 %. The female was identified as a risk factor for occurrence of pancreatic fistula after left pancreatectomy. The role implicated in the use of a mechanical claw for the treatment of pancreatic stump requires a larger number of patients to conclude. The body mass index has not been studied in our series.