Intraluminal Duodenal Diverticulum: A Rare Cause of Chronic Epigastric Pain.

Despite its first identification in 1885, intraluminal duodenal diverticulum remains a rare entity and only a few case reports are found in the literature. Its diagnosis is almost always delayed due to the lack of specific symptoms and to the very vague presentation consisting of mild epigastric discomfort. However, with the aid of new diagnostic modalities and imaging, it has become easier to diagnose this entity when its symptoms persist. Finally, it can remain undiagnosed in asymptomatic patients.

Total or Subtotal Colectomy with Primary Anastomosis for Occlusive Left Colon Cancer: A Safe, Acceptable and Applicable Procedure.

INTRODUCTION: Occlusive left colon cancer is a major emergency setting in colon cancer with high morbidity and mortality rates. Different surgical treatment exist since there is no clear guidelines for the best treatment. We have conducted this retrospective study in order to evaluate the safety, morbidity, and bowel movement status of the operated patients. METHODS: One-hundred and one left occlusive colon cancer patients were operated of total or subtotal colon resection with primary anastomosis from March 2000 till March 2017 in Hotel Dieu de France hospital. We analyzed the sex ratio, age, caecum condition, tumor localization, number of synchronous adenoma and adenocarcinoma, Dukes stage, major complications and the number of stools per day at 3 and 12 months after surgery. RESULTS: Mean hospital stay was 7.8 days. Thirteen complications were observed in 11 (10.9%) patients, in which one (1%) patient had splenectomy for severe hemorrhage. Six synchronous adenocarcinoma and 40 adenoma with dysplasia were diagnosed on pathology specimens proximal to occlusion site. Caecum laceration was found in 33 (32.6%) of cases. No patient had anastomotic leak. After 12 months of surgery, the average bowel movement was 2 stools per day. CONCLUSION: Our study showed that treating occlusive left colon cancer with total or subtotal colectomy with primary anastomosis is a safe procedure, with a good bowel movement status and presents the advantage to resect an important number of synchronous tumors and adenomas proximal to the occlusion site.

Sporadic colon cancer in Lebanon: A clinicopathological study.

Colon cancer is a heavy public health burden. No data has been previously published on colon cancer epidemiology in Lebanon. The objective of this study was to report the clinical and pathological features of surgically operated colon cancer. From July 2005 to July 2012, 187 sporadic colonic tumors were operated in Hotel-Dieu de France Hospital (Beirut, Lebanon). Demographic, clinical, pathological and staging data was collected. The male: female sex ratio was 1.3 and the mean age at diagnosis was 66.0 years. Most tumors occurred at the right colon (54.0%). Histologically, conventional adenocarcinoma had the biggest proportion (88.2%), followed by mucinous adenocarcinoma (9.1%). Most cases operated belonged to stages II, III or IV, leaving only 8.0% of the cases in stage I. Some characteristics were similar to western countries like the predominance of right tumors while others were similar to developing countries like the sex ratio and the high proportion of stage IV tumors at diagnosis. This study reports for the first time in the middle-eastern populations a clinico-pathological analysis of surgically operated colon cancer.

Unusual etiology of epigastric pain.

BACKGROUND: Epigastric pain is a common presenting complaint encountered in urgent care settings. Although peptic, biliary, and pancreatic pathologies are the most frequent findings, other rare diagnoses also can be found. OBJECTIVES: We report an unusual case of acute epigastric pain in which abdominal ultrasound was of great support in revealing the diagnosis. CASE REPORT: A 64-year-old man presented to the Emergency Department after rapid onset of acute epigastric pain. Abdominal ultrasound showed a multi-cystic heterogeneous mass between the stomach and the liver. Abdominal computed tomography scan confirmed the gastric origin of the mass and showed torsion signs. Urgent laparotomy was performed with tumor excision. The diagnosis of pedunculated exophytic gastric stromal tumor was made and long-term follow-up was arranged. CONCLUSIONS: Acute presentation revealed the presence of the tumor, which was excised surgically.

The impact of obesity on surgical outcome after pancreaticoduodenectomy.

CONTEXT: The effect of obesity on surgical outcome is becoming an increasingly relevant issue given the growing rate of obesity worldwide. OBJECTIVE: To investigate the specific impact of obesity on pancreaticoduodenectomy. DESIGN: A retrospective comparative study of a prospectively maintained database was carried out to investigate the specific impact of obesity on the technical aspects and postoperative outcome of pancreaticoduodenectomy. PATIENTS: Between 1999 and 2006, 92 consecutive patients underwent pancreaticoduodenectomy using a standardized technique. The study population was subdivided according to the presence or absence of obesity. RESULTS: Nineteen (20.7%) patients were obese and 73 (79.3%) patients were non-obese. The two groups were comparable in terms of demographics, American Society of Anesthesiology (ASA) score as well as nature and type of pancreatico-digestive anastomosis. The rate of clinically relevant pancreatic fistula (36.8% vs. 15.1%; P=0.050) and hospital stay (23.1+/-13.9 vs. 17.0+/-8.0 days; P=0.015) were significantly increased in obese vs. non-obese patients, respectively. Pancreatic fistula was responsible for one-half of the deaths (2/4) and two ruptured pseudoaneurysms. The incidence of the other procedure-related and general postoperative complications were not significantly different between the two groups. Intrapancreatic fat was increased in 10 obese patients (52.6%) and correlated positively both with BMI (P=0.001) and with the occurrence of pancreatic fistula (P=0.003). CONCLUSION: Obese patients are at increased risk for developing pancreatic fistula after pancreaticoduodenectomy. Special surgical caution as well as vigilant postoperative monitoring are therefore recommended in obese patients.

Is therapy with calcium and vitamin D and parathyroid autotransplantation useful in total thyroidectomy for preventing hypocalcemia?

BACKGROUND: Routine calcium and vitamin D administration and routine autotransplantation of parathyroid glands can prevent hypocalcemia after total thyroidectomy. METHODS: Routine autotransplantation of 1 or more parathyroid glands and oral calcium and vitamin D supplementation was used in 252 patients. RESULTS: One, 2, or 3 parathyroid glands were autotransplanted in 223, 27, and 2 patients, respectively. Routine oral calcium and vitamin D was administered in postoperative period in all patients. Postoperative hypocalcemia occurred in 17%, of whom 1.6% had minor symptoms related to hypocalcemia. No patient developed permanent hypocalcemia during the follow-up period. The postoperative stay was 1 day in 93.6% of the cases. The incidence of postoperative hypocalcemia and hospital stay was higher in patients who underwent autotransplantation of more than 1 parathyroid gland. CONCLUSIONS: Routine oral calcium and vitamin D supplementation and autotransplantation of at least 1 parathyroid gland effectively reduced symptomatic hypocalcemia and permanent hypoparathyroidism in total thyroidectomy.

[Subtotal or total colectomy as surgical treatment of left-sided occlusive colon cancer]. / Place de la colectomie subtotale ou totale dans le traitement en urgence des cancers du côlon gauche et du sigmoïde en occlusion.

INTRODUCTION: The treatment of acutely obstructed carcinoma of the left colon and sigmoid still represents a matter of controversy. The aim of this study was to assess retrospectively the results of its management by emergency subtotal or total colectomy with primary anastomosis. MATERIALS AND RESULTS: Sixty-seven patients were reviewed. There were 42 males and 25 females. The mean age was 70.5 years (range: 26-87 years). Mean operative time was 210 minutes. There were five synchronous colon carcinomas (7.5%) and 23 (343%) synchronous tubulous and tubulo-villous adenomas. No death was noted in the series. Ten postoperative complications (15%) occurred in nine patients including one postoperative peritonitis without evidence of anastomotic leak, one alithiasic cholecystitis, one evisceration and two intra-abdominal abscesses. The mean hospital stay was 11.4 days. Fifty-eight patients were assessed at three and twelve months for functional results. No fecal incontinence was encountered. The mean number of bowel movements per 24 hours was 3.2 at three months and 2 at twelve months. All patients were satisfied with their quality of life. Twelve patients (20.7%) occasionally needed anti-diarrheic medications. CONCLUSION: Urgent subtotal or total colectomy with primary anastomosis is a safe and efficient procedure in the management of acutely obstructed neoplasm of the left colon. It allows to treat in one stage the cancer and the obstruction, bearing no mortality, acceptable morbidity and satisfactory postoperative functional results.

[Colorectal cancer in young patients: presentation, clinicopathological characteristics and outcome]. / Le cancer colorectal du sujet jeune: présentation, caractéristiques clinicopathologiques et pronostic.

UNLABELLED: Previous studies have emphasized the increasing incidence of colorectal cancer (CCR) among young adults and suggest that they may have more aggressive disease and worse five-year survivals than their older counterparts. PURPOSE: Describe the profile of sporadic colorectal cancer in young patients focusing on its prevalence, clinicopathological characteristics, prognostic and survival factors. METHODS: Three hundred and twenty-five CCR patients were divided in two groups : G1 < 45 years and G2 > 45 years. RESULTS: 13.2% of patients were less than 45 years old. A family history of a first-degree relative with colorectal cancer was more frequent in young patients: 44.1% vs 18.2% (p = 0.025). A significant delay in seeking medical care was noted in G1 patients: 29.7 weeks vs 18.6 weeks (p = 0.01). A trend to have more aggressive stages III and IV at presentation was observed among young patients: 55.8% vs 48.6% (p = 0.8). Mucin-producing tumors were more frequently observed in G1 group: 41.9% vs 12% (p = 0.000). Mean survival was 76.9 months in G1 group and 91.7 months in G2 group (p = NS). Five-year survival was 52% in G1 group and 58% in G2 group (p = 0.6). Stage for stage comparison was not significant in determining survival. The only independent factors were delay in consultation, right location of the tumor, peritoneal carcinomatosis, and the need for chemotherapy. CONCLUSION: This study confirms that colorectal cancer in young patients is frequent. Despite more frequent occurrence of mucin-producing tumors, age is not by itself a worse outcome predictor.

[Retroperitoneal cystic lymphangiomas in adults: four case reports and review of the literature]. / Lymphangiome kystique rétropéritoneal de l'adulte: a propos de 4 cas et revue de la littérature.

Retroperitoneal location of cystic lymphangiomas in adult patients is rare. Their clinical presentation is not specific. Magnetic resonance imaging is the best radiological exam for the diagnosis. These tumors must be distinguished from mesenteric cysts which are more frequent and can degenerate. The authors report four cases of retroperitoneal cystic lymphangioma with a literature review.

Enlarged parathyroid glands discovered in normocalcemic patients during thyroid surgery.

BACKGROUND: This is a retrospective study analyzing data of normocalcemic patients with enlarged parathyroid glands discovered during thyroid surgery and comparing it with data of patients operated on for proved primary hyperparathyroidism. METHODS: The records of patients with enlarged parathyroid glands (group 1) and those with primary hyperparathyroidism (group 2) were reviewed. RESULTS: There were 11 patients in group 1 and 123 patients in group 2. Enlarged parathyroid glands identified at thyroid surgery were lighter and developed in younger patients. Biochemistry and pathology revealed that these were less hyperfunctioning. Sex, number of diseased glands per patient, and cell type were not statistically different between the 2 groups. CONCLUSIONS: Enlarged parathyroid glands discovered at the time of surgery are mildly hyperfunctioning. They may represent an early pathologic stage responsible for overt primary hyperparathyroidism. We recommend removal of enlarged parathyroid glands found during thyroid operation in normocalcemic patients as long as at least 1 normal parathyroid gland remains.

One hundred liver resections: improved outcome in a tertiary care center in Lebanon.

BACKGROUND: Recent reports highlight the reduced mortality and morbidity rates of liver resection in the last decades. The authors report on the surgical techniques and perioperative management that have yielded a low mortality and morbidity rates. METHODS: One hundred consecutive liver resections carried out from 1997 to 2005 were reviewed. Data were collected retrospectively. RESULTS: The indications for liver resection were malignant tumors in 73%. Major liver resection was performed in 52%. Overall, 42.5% of liver resections were performed without vascular clamping and 57% of liver resections were performed without blood transfusions. There was no intraoperative death and the overall mortality rate was 1%. The major complications rate was 28% and was related to the extent of resection. The mean length of hospital stay was 12 days. CONCLUSION: The current series shows that with accurate preoperative evaluation, standardization of the surgical technique, appropriate use of vascular clamping method, and vigilant postoperative monitoring, an in-hospital mortality of 1% was achieved in a series where more than 50% of patients underwent a major hepatectomy.

Extra-adrenal composite pheochromocytoma-ganglioneuroma.

Composite tumors containing pheochromocytoma and ganglioneuroma are rare tumors typically arising in the adrenal glands. Very few were reported outside of the adrenals. We present the case of a middle-aged woman with a retroperitoneal mass that was discovered when she complained of local signs of compression and systemic signs of catecholamine hypersecretion. On pathology the mass was composed of large polygonal and pleomorphic cells arranged in nests characteristic of pheochromocytoma that were mixed with clusters of mature ganglion cells and bundles of spindle cells characteristic of ganglioneuroma. The histological features were benign, but due to its invasion of the inferior vena cava and of the right renal artery, we had concerns about the malignant potential of the pheochromocytoma component, which is extremely rare in these composite tumors.

Prevalence and risk factors for primary hyperparathyroidism in hyperthyroid patients.

BACKGROUND: Coexistence of hyperthyroidism and primary hyperparathyroidism may be more prevalent than previously recognized. We report 13 cases of concomitant occurrence of both diseases to estimate their combined prevalence and its factors. METHODS: Ninety-six unselected patients admitted for elective hyperthyroidism surgery were retrospectively included. Eighty-three patients were initially seen for hyperthyroidism with normocalcemia (group 1), and 13 patients were initially seen for hyperthyroidism with associated primary hyperparathyroidism (group 2). Patients' characteristics, examinations, and pathology reports were reviewed. Risk factors were identified using a logistic regression model. RESULTS: The prevalence of concomitant hyperparathyroidism was 13.5%. No patients manifested hypercalcemia in the absence of organic parathyroid disease. Eleven patients had a parathyroid adenoma, and two patients had parathyroid hyperplasia. Group 2 patients were older (median 61 vs 43 years, p = .006). Thyroid-stimulating hormone levels were more depressed in group 2 (median 0.01 vs 0.032 UI/L, p = .034). On multivariate analysis, age was the unique factor significantly different between groups (odds ratio, 1.05; 95% confidence interval, 1.008-1.098; p = .020). CONCLUSIONS: Hypercalcemia in patients with hyperthyroidism, particularly older patients, should warrant a thorough investigation for concomitant primary hyperparathyroidism that would dictate a combined thyroidectomy and parathyroidectomy.

Existence and anatomic distribution of double parathyroid adenoma.

BACKGROUND: Double parathyroid adenomas occur in 2% to 15% of primary hyperparathyroidism cases, but the very existence of double adenomas has been controversial. This study was conducted to evaluate the clinical significance and anatomic distribution of parathyroid double adenomas. STUDY DESIGN: Mono-institutional retrospective study of the medical records of 183 unselected consecutive patients who underwent intervention for primary hyperparathyroidism between 1996 and 2003. RESULTS: A total of 14 (7.65%) patients were found to have double parathyroid adenomas. Intraoperative parathyroid hormone (PTH) levels were measured in every case. Two enlarged parathyroid glands were identified in four possible configurations: two both superior, one both inferior, two both right, three both left, two right superior and left inferior, and three left superior and right inferior. There was a preferential crossed bilateral distribution of double adenomas. In all patients, intraoperative PTH levels dropped by at least 50% from baseline after removal of both abnormal parathyroid glands. In this series, no patient developed persistent hypoparathyroidism or had recurrent laryngeal nerve injuries or neck hematoma. All patients remained normocalcemic 9 to 96 months postoperatively. One patient had persistently elevated PTH values with normal serum calcium levels. CONCLUSION: The drop in intraoperative PTH levels and maintenance of normocalcemia postoperatively confirm previous reports that double adenomas do exist and are not simply missed cases of four-gland hyperplasia. There was a preferential crossed bilateral distribution of double adenomas in this series.

Use of fine-needle aspiration cytology and frozen section in the management of nodular goiters.

BACKGROUND: This study evaluates the role of frozen section (FS) in surgical decisions for nodular thyroid disease when a preoperative fine-needle aspiration cytology (FNAC) is available. MATERIAL AND METHOD: The charts of 113 patients who underwent thyroidectomy for nodular goiter were reviewed. Each patient underwent FNAC, FS, or both. Results were compared with the final pathologic examination to evaluate their effectiveness in predicting malignancy. RESULTS: The sensitivity and specificity of FNAC alone (49 patients) were 73% and 93.5%, respectively, and of FS (111 patients) 68% and 99%, respectively. The result of fine-needle aspiration cytology was: benign (n = 8), malignant (n = 13), indeterminate (n = 25), and nondiagnostic (n = 3). All cases diagnosed as benign on FNAC were benign on final pathology, but of the six FS performed in these cases, four were benign and two were suspect. Of the 13 FNAC that were interpreted as malignant, 11 and 10 proved to be malignant on final pathology and FS, respectively. The 25 indeterminate cases on FNAC were on final pathology benign (n = 21) and malignant (n = 4) and on frozen section were benign (n = 12), malignant (n = 2), and suspect (n = 11). CONCLUSION: When results of FNAC are interpreted as benign or malignant, FS is of little value, because it does not change the extension of thyroidectomy. FS proved useful in determining the extent of thyroidectomy only when results of the FNAC were suspect or atypical.

Perforation of the rectum and colon during barium enema examination. Report of four cases.

BACKGROUND: The barium enema examination (BEE) is an important diagnostic study and considered to be safe without adverse effects. Perforation of the bowel is rare but is the most frequent complication of BEE and can be life-threatening. STUDY DESIGN: We report four cases of barium extravasation due to BEE treated at our institution, three rectal perforations and one perforation in the descending colon. RESULTS: The four patients underwent surgery because signs of peritonitis developed. Two of them recovered and two died from multiple organ failure. CONCLUSION: Perforation of the colon and rectum during BEE constitutes a surgical emergency in most cases. Prompt recognition and management are vital in decreasing morbidity and mortality.