[Microcystic serous pancreatic cystadenoma]. / Cystadénome séreux microkystique du pancréas.

BACKGROUND: The pancreatic cystic serous neoplasms are divided into two categories: benign serous cystadenoma (SCA) and malignant serous cystadenocarcinoma. Furthermore, based on the macroscopic appearances, SCAs are subdivided into serous microcystic adenomas (SMAs) and serous oligocystic or macrocystic adenomas. AIM: Report of a new case of SMA in which we emphasize on the diagnostic difficulties encountered against such tumor despite its relatively radiological easiness compared to the other variants. CASE REPORT: We report the case of 84 year-old-woman with a microcystic serous cystadenoma of the pancreas which was identified on pathologic examination of the surgical specimen, after unconclusive abdominal ultrasound and computed tomography (CT)- scan. CONCLUSION: This case describes this rare entity and emphasizes that the diagnosis of such entity is still based on pathological examination after tumor removal.

[Intraductal papillary mucinous tumor of the pancreas mimicking pancreatic pseudocyst]. / Une Tumeur Intracanalaire Papillaire et Mucineuse du Pancreas Simulant un Faux Kyste du Pancreas.

BACKGROUND: Most of pancreatic cysts are in fact pseudocysts. Only 10 to 20% are real cystic tumors. Intraductal papillary mucinous tumors of the pancreas represent nearly 15% of them. AIM: To illustrate, by an observation, the difficulties to diagnose a cystic tumor of the pancreas. CASE REPORT: We report the case of a 55 year old woman complaining of epigastric pain for one month with an elevated pancreatic enzymes level. Ultrasonography and computed tomography scan showed two cystic formations measuring 6 and 7 cm localized respectively in the head and the body of the pancreas. The diagnosis of pancreatic pseudocysts was maintained. The appearance of a jaundice made us think about a pseudocyst's compression of the common bile duct. A cysto-gastric anastomosis was made. The recurrence of the jaundice associated to diabetes and a general state deterioration led to the practice of magnetic resonance cholangiopancreatography. It revealed an intraductal papillary mucinous tumor of the pancreas affecting secondary ducts. The presence of a peritoneal carcinosis led to therapeutic abstention. CONCLUSION: The diagnosis of intraductal papillary mucinous tumor of the pancreas must be referred to in case of pancreatic cystic tumor without extrapancreatic necrosis. This kind of tumor can simulate a pancreatic pseudocyst.

[Laparascopic cholecystectomy on a previously operated abdomen]. / Les choléystectomies sous coelioscopie sur abdomen cicatriciel.

BACKGROUND: Laparoscopic cholecystectomy is the "gold standard" reference treatment of gall bladder stones. Laparoscopy is still contra-indicated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. AIM: This study aimed to assess outcomes of laparoscopic cholecystectomy on a scarred abdomen. METHODS: We have carried out a retrospective study on a number of consecutive patients operated between the first januar 2000 and 31 december 2006, who underwent laparoscopic cholecystectomy with previous abdominal surgery (one or several) during this period, laparoscopic cholecystectomy was performed on 2281 patients, including 233 patients who had at least one abdominal scar (10%). We have noted on the records of these patients all the data relating to the epidemiological, clinical and therapeutical aspects. We have worked out a descriptive analysis of the series and we have thus studied the rate of operative and post-operative complications, the rate of conversion, the duration of the operation and the duration of post-operative stay. Then we have compared two groups of patients, those with an upper abdominal surgery: group 1 (G1) and those with lower abdominal surgery: group 2 (G2). RESULTS: The groups consist of 200 women and 33 men aged on average 13.8 +/- 49.6 years. The indication for cholecystectomy was a symptomatic cholelithiasis in 78% of cases (n = 181), an acute cholecystitis in 22% of cases. The adhesions were believed numerous or very numerous in only 46 patients (20%). Four patients had interventional adverse events: a small intestine injury, a choledoch injury, a gastric injury and a least known colic injury. The rate of open conversion was 2.1%. Post-operative complication was 2.1%. The evolution was satisfactory in all cases. Mean operating time was 50 minutes (15-230). Mean post operative stay was one day (1-29 days). When comparing the above mentioned two groups of patients (G1: 45 patients and G 2: 188 patients), we can conclude that the first group (G1) is made up of more male patients aged over 60 years (p < 10-3). It also appears that the existence of an upper umbilical scar is correlated to a greater number of adhesions (p < 10-3), an increased risk of operative complications (p = 0.01), a greater conversion rate (p < 10-4), a prolonged operating time (p < 10-3) and a longer stay (p = 0.017). On the other hand, post-operative complications was similar in group 1 and 2. CONCLUSION: Previous abdominal operations, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a higher rate of adhesions, an increased risk of operative complications, a greater conversion rate, a prolonged operating time and longer stay.

An aggressive course of de novo ulcerative colitis after renal transplantation: colonic adenocarcinoma with choriocarcinomatous differentiation.

AIM: A rare case of colonic carcinoma arising in de novo ulcerative colitis after renal transplantation in a 42-year-old woman is reported. CASE: Clinically, the patient presented ulcerative colitis 8 years after renal transplantation, developed colonic cancer with liver metastasis 2 years later and died one month post operatively. Histologically, the removed tumor was composed of two distinctive elements consisting of adenocarcinoma and choriocarcinoma. The metastatic foci in the liver were composed exclusively of choriocarcinoma. Identification as choriocarcinoma was made on the basis of typical histological appearance, immunohistochemical demonstration of human chorionic gonadotropin (hCG) in the tumor cells and the high serum hCG level, unrelated to trophoblastic disease. In this report, pathogenesis is briefly discussed and clinical conditions are reviewed. CONCLUSION: In conclusion, the issue of de novo UC after organ transplantation is still a matter of debate. Further investigations are necessary to understand the tumorogenesis of colorectal cancer in de novo UC after renal transplantation,

[Hydatid cysts of the pancreas, report of two cases]. / Kyste hydatique du pancréas: propos de deux observations.

BACKGROUND: Hydatid cyst of the pancreas is a rare affection with a frequency less than one percent of the various sites of hydatid disease. AIM: We report two cases of hydatid cyst of the pancreas. CASE 1: A 49 year old woman with a history of laparotomy for liver and peritoneal hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 3 cm in size. Surgical treatment consisted in a resection of the protruding dome with uneventful postoperative course. CASE 2: A 45 year old man who underwent laparotomy four years ago for hepatic hydatid cyst was admitted with recurrent liver and peritoneal hydatid disease associated with a head pancreatic cyst of 4 cm in size. At laparotomy it was a head pancreatic hydatid cyst without duct pancreatic lesion. The treatment consisted in the resection of the protruding dome. The postoperative evolution was simple. CONCLUSION: Hydatid cyst of the pancreas is rare. If associated with another hydatid localization, the diagnosis is generally easy. It can however be more difficult if the pancreatic localization is isolated. In most cases, resection of the protruding dome is sufficient.

Squamous cell carcinoma arising in Verneuil's disease.

BACKGROUND: Verneuil's disease or hidradenitis suppurativa is a chronic suppurative, and cicatricial inflammatory disease, mainly affecting apocrine-bearing area of the skin. Squamous cell carcinoma is an uncommon but a frightening complication of hidradenitis suppurativa. AIM: To report a new case of squamous cell carcinoma arising in Verneuil's disease. CASE REPORT: We reported a case of 60 year old man with a 30 years history of hidradenitis suppurativa in which squamous cell carcinoma arise. A wide surgical excision removing the tumour and leaving a large defect was performed. The patient had a well recovery, wounds healed well by primary intention. No recurrence observed at 18 months of follow up. CONCLUSION: Squamous cell carcinoma is an uncommon complication of hidradenitis suppurativa. Surgical excision represents also the treatment of choice.

[Myofibroblastic tumor of the great omentum]. / Tumeur inflammatoire myofibroblastique du grand épiploon.

BACKGROUND: Myofibroblastic tumors are a spindle cell lesion of indeterminate malignant potential. Abdominal location was rare. AIM: We report a case of an unusual location of myofibroblastic tumors in the great omuntum. CASE REPORT: A 63-year-old women presented with a one year of isolated left hypochondrium pain. Physical examination was normal. CT scan of the abdomen showed a multicystic and a multilocular building-up of the great omentum suggestive of a peritoneal haemolymphagioma. Besides, at the MRI, this lesion showed up with threefold component: cystic, plump and fibrous, all leading towards a myofibroblastic tumor. At laparotomy, there was already a 10 cm diameter cystic tumor of the great omentum, composed of numerous cystic sockets, all filled with a thick brunish substance. A total resection of the great omentum was done, thus taking away the whole tumor. The histological examination confirms the diagnosis of myofibroblastic tumor of great omentum.. Post operative evolution was uneventful. One year later there were no signs of recurrence. CONCLUSION: Myofibroblastic tumors of the great omentum are rare. The diagnosis is often confirmed by careful microscopic examination or immunohistochemical markers. Treatment consists on a complete surgical resection and life-time follow-up is needed because the risk of recurrence.

[Analysis of antibiotics as a curative measure in four hospital units]. / Analyse de la prescription antibiotique a visee curative en milieu chirurgical et en reanimation.

In order to analyse the methods of curative prescription of antibiotics in four units of hospitalization of the hospital Charles Nicolle of Tunis, a descriptive study of prescriptions was carried out during the first five months of year 2001. On the whole, 165 prescriptions delivered to patients were included in the study. The average age of the patients was 44 years, the sex ratio of 1.45 and the average duration of 15.1 days. Approximately two thirds of the initially probabilist prescriptions were not documented secondarily. Those secondarily documented (n = 51) were essentially related to nosocomial pneumonias and septicaemias (29 and 10 prescriptions). The two germs most frequently isolated during nosocomial pneumonias were Acinetobacter baumannii and, Pseudomonas aeruginosa (17 and 8 strains). Only imipenem, netilmicin and colistin remain active on A. baumannii. The bitherapy was the most used treatment (87.5%). It was generally an association beta-lactamin-aminosid (52.9%). The average cost of a documented prescription varied from 943,6 to 1184,9 TD (Tunisian Dinars) according as the prescription were secondarily documented or not.

[Analysis of knowledge attitudes and practices of health care workers facing blood exposure accidents in a general surgery service]. / Analyse des connaissances attitudes et pratiques du personnel soignant face aux accidents d'exposition au sang en chirurgie generale.

In order to assess the degree of knowledge, attitudes and the personnel's practices exercising in a service of general surgery of the hospital Charles Nicolle of Tunis, concerning blood exposure accidents, we did a transverse survey during the month of January of the year 2002. A questionnaire has been addressed to 114 people while using the technique of the direct interview. The middle age of investigated is 35.7 years. The sex ratio is 0.7. Only the 2/3 declare have been vaccinated against the B hepatitis. The results show a good knowledge of the exposure risk to a communicable disease by blood (95.6%), but less good for the risk of contamination by the three viruses HBV, HCV and HIV. The resheathing of needles, considered like gesture to risk, is underestimated by 71.2% of investigated. The majority of investigated declare to know universal precaution principles (85.8%). However, to the maximum 4 measures only on the 10 advisable have been mentioned by investigated. The conduct to hold in case of blood exposure accident seems insufficiently known by our sample. It is represented, in 78.8% of cases, in the application of disinfectants Betadine type or alcohol iodized, whereas the practice of a serology to the patient source is ignored completely. 75% of investigated having had a blood exposure accident lasting the last 12 months (n = 44) didn't declare their blood exposure accident and only 11.4% declare to have undergone cares. Actions of information and formation, to the intention of the whole of the personnel of the service, on risks incurred by the nursing, gestures and procedures to risk, the universal precaution respect, the conduct to hold in case of a blood exposure accident, the interest of the declaration and the interest of the vaccination against the B hepatitis, are primordial.

[Predictive factors of morbidity and mortality after surgery in the elderly]. / Facteurs prédictifs de morbidité et de mortalité de la chirurgie du vieillard.

UNLABELLED: The aim of the study was to determine prognostic factors of post operative morbidity and mortality for patients aged 80 years and older. We compared two groups of patients aged 80 and over operated to determine predictive factors of morbidity and mortality: group of patients who presented post operative complication within 30 days after surgery and group of patients without any complication. Comparison of the two groups for global morbidity using univariate analysis showed only one prognostic factor: surgery of diabetic foot (p = 0.034). Predictive factors of mortality according to univariate analysis were: pre-operative shock (p = 0.001), abdominal wall pathology (p = 0.027), gastric or duodenal ulcer diseases (p = 0.011) and global morbidity (p = 0.006). After logistic regression, only pre-operative shock was an independent predictive factor of mortality (p = 0.0023). CONCLUSION: Risk for morbidity after surgery in the elderly 80 years and over is linked with type of surgery and not with soil. Likewise, risk for mortality is linked with advanced stage of disease that is presence of pre-operative shock and not with soil.

[Acute pancreatitis due to lupus]. / La pancréatite aiguë lupique.

Among digestive clinical presentations of systemic lupus erythematosus, acute pancreatitis remains a serious affection with very poor prognosis. To date, pathogenesis is still unclear. We report two cases of fatal acute pancreatitis related to systemic lupus erythematosus.

Trauma of an ectopic kidney. A case report.

Ectopic kidney is a rare pathology. It is usually misknown and often revealed by a complication. We report a case of a 30-year-old male patient who presented in emergency with a right thoraco-abdominal trauma and a benign head trauma. Injury evaluation revealed a right ectopic pelvic kidney with a grade IV laceration. Furthermore, there was a hepatic contusion in the sixth segment and a fracture of the ninth, tenth and eleventh right ribs. Therapeutic attitude consisted on a successful conservative and nonoperative treatment for both lesions. CT scan is of utmost importance in diagnosis. Management is the same as for normally positioned kidney.

Neuroendocrine tumours of the digestive tract report of two cases and literature review.

Neuroendocrine tumors (NET) of the digestive system are rare. They comprise only 1% of all the tumors of the gastrointestinal tract. The aim of this study is to report two cases of exceptional localization of non secretary neuroendocrine tumors. Their difficulty in diagnosis, treatment and controversy in chemotherapy merit their study in depth. These are two patients that were treated in the department of general surgery (Beau Séjour) in Charles Nicolle Hospital for non secretary (NET) of the pancreas and stomach. The first was presented as a painless epigastria mass with frequent diarrhea. The second was presented as a painful mass in the left hypochondriac area without any other symptoms. Biochemical evaluation confirmed their non secretary properties. Surgery remains the first line of treatment. It was possible for the gastric, but not for the pancreatic tumor. Both were very advanced and had metastasis. Histopathological evaluation and immunohistochemical study using the method of peroxydase antiperoxydase (PAP) complexes for some special monoclonal antibodies confirmed the diagnosis. Chemotherapy of both cases was mal tolerated and was discussed in details.

[Stomach perforation: an unusual complication of gastric bezoars]. / La perforation de l'estomac: une complication rare du bézoard gastrique.

Bezoars are concretions of stagnant swallowed material in digestive tract. The most frequent are trichobezoars made of hair and phytobezoars composed of undigestible fruits and vegetables fibers. We report a case of a 24-year-old female patient who presented in emergency with an acute peritonitis due to a gastric perforation on bezoars. Gastrotomy, extraction of bezoars, gastric stitching and peritoneal lavage were performed. Post operative period was uneventful. A new careful interrogation into the patient's previous habits found glue-eating custom during the four last years.

[Prognostic study of liver abscess]. / Etude pronostique des abcès du foie.

The objective of this work is to study factors of prognostic of mortality of abscesses of the liver. We have treated between 1990 and 2000 in our service, 38 patient for abscess of the liver. The symptoms are dominated by the pain of the right hypochondria (37 cases) and the fever (34 cases). An unique abscess has been recovered in 25 cases. Some multiple localizations have been observed in 12 cases. 21 patients have been operated. The bacteriological study at all patients revealed the presence of germ in 27 cases. In 6 cases, there were two germs. It was a bacillus negative gram in 26 cases and a cocci positive gram in 7 cases. Six complications have been observed at the operated patients. In 5 cases, it was a septic shock having leads to the death. After survey univariate and multivariate the only factor of bad prognostic recovered is the septic shock. The aetiology was identified in only 9 cases; it was abscess cholangiotis.

[Acute cytomegalovirus colitis after bone marrow transplantation]. / Colite aiguë grave à cytomégalovirus après greffe de moëlle osseuse.

Cytomegalovirus infection of the digestive tract is rare and particularly severe after transplantation. Colon is the most often affected part of the digestive tube. We present the case of acute cytomegalovirus colitis that occurred five months after a bone marrow transplantation. An emergency subtotal colectomy with sigmoidostomy and ileostomy was performed followed six weeks later by an ileorectal anastomosis. The pathologic specimen showed cytomegalovirus inclusion bodies proving the diagnosis.

[Small bowel neurofibromatosis in Von Recklinghausen's disease. A rare cause of emergency surgery]. / Les neurofibromes du grele au cours de la maladie de von Recklinghausen. Une cause rare d'urgence chirurgicale.

Two cases of small bowel neurofibromatosis in patients with Von Recklinghausen's disease are reported. Diagnosis of small bowel neurofibromatosis was made on the occasion of a complication for the two cases. We insist on the difficulty of diagnosis as well as in presence or not of complications. Treatment of these most often benign tumours remains surgical based on a segmental small bowel resection.