A. Makni

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.

Laparoscopic-assisted versus conventional ileocolectomy for primary Crohn's disease: results of a comparative study.

INTRODUCTION The laparoscopic approach is becoming the gold standard in the surgical treatment of primary Crohns disease. The aim of this study was to compare laparoscopic-assisted and open ileocolic resection for primary Crohns disease. METHODS We conducted a non-randomized, comparative, retrospective analysis of a prospective database from 1998 to 2010. The remaining 129 patients were divided into two groups: laparoscopic-assisted group (Group L; n=64) and conventional group (Group C; n=65). There were no differences between the two groups as regards preoperative patient characteristics. Complications were graded according to the Clavien-Dindo classification. RESULTS One hundred and seventeen (90.7%) patients had no complications. Out of 12 patients (9.3%) with complications, four (3.1%) had Grade I, six (4.7%) had Grade II and two (1.6%) had Grade III. There were no postoperative deaths (Grade V). Operating time was longer in Group L compared with Group C (P<0.001). Bowel function returned more quickly in the laparoscopic group in terms of return of bowel movements (P=0.018) and resumption of a regular diet (P=0.06). The mean length of stay was significantly shorter in the laparoscopic group (P=0.001). The mean follow-up was 26 months in Group L versus 34 months in Group C (P=0.06). During follow-up, six patients presented with small bowel obstruction in Group C, which was not statistically different from Group L (3 patients) (P=0.25). During the follow-up period, there have been no recurrences of Crohns disease in the laparoscopic group while 11 patients (16.9%) have developed a recurrence in the conventional group (P=0.001). CONCLUSION Laparoscopic-assisted ileocolectomy for primary Crohns disease of the terminal ileum and/or cecum is safe and successful in most cases. Laparoscopic surgery for Crohns disease should be considered as the preferred operative approach for primary resections.

Mature teratoma of the pancreas diagnosed by fine-needle aspiration

A 41-year-old female patient, presented with recurrent epigastric pain of 2 years duration. Physical examination revealed a 15-cm epigastric mass that was mobile and tender on palpation. Abdominal ultrasound revealed a 20-cm hypoechoic mass, containing multiple hyperechoic structures. The exact origin of the mass could not be clearly defined. CT scan of the abdomen revealed a well-circumscribed voluminous cystic mass measuring approximately 25 cm in size, with heterogeneous content. After the administration of contrast material, no enhancement of the mass

Abdominal Metastasis of a Parosteal Osteosarcoma of the Femur: an Unusual Cause of Large-Bowel Obstruction

Abstract 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.

Kyste hydatique primitif et isolé du diaphragme en Tunisie

The hydatid cyst of the diaphragm is defined as the development of a hydatid cyst in the diaphragm muscle. The purpose of this study is to identify the specific pathogenic, clinical and therapeutic aspects of this hydatid cyst. It is important to confirm the diagnosis of the location before surgery. We report the case of a patient aged 40 years, in whom the diagnosis of hydatid cyst of the diaphragm was made incidentally in the course of a gastric stromal tumour. The patient was operated by a midline laparotomy. Resection of the protruding dome of hydatid cyst of the diaphragm was carried out along with total gastrectomy. The postoperative course was uneventful. After 12 months, the results were negative. The diagnosis of hydatid cyst of the diaphragm is based on the thoraco-abdominal CT scan. The treatment is surgical based on the topographic features of the cyst.

Pancreatic mucinous cystadenoma doubly complicated by acute pancreatitis and retroperitoneal rupture

Mucinous cystadenomas are the most frequent cystic benign tumors of the pancreas. They are characterized by a malignant potential. Acute pancreatitis is their most common complication. This manuscript reports a unique complication of mucinous cystadenomas of the pancreas: retroperitoneal rupture associated to acute pancreatitis. After resuscitation, the patient underwent surgery. A cystic mass of the pancreas tail with retroperitoneal rupture was found. Splenopancreatectomy was performed. Outcomes were straightforward. After 3 years of follow-up, no signs of recurrence are highlighted.

Cystadénome mucineux pancréatique doublement compliqué de pancréatite aigüe et de rupture dans le rétro-péritoine

Mucinous cystadenomas are benign tumors with malignant potential. They are often revealed by non-specific abdominal pain, jaundice or an episode of acute pancreatitis. We here report an exceptional case of mucinous cystadenoma doubly complicated by acute pancreatitis and retroperitoneal rupture. The study involved a 30-year old non-weighted female patient, presenting with epigastric pain associated with left hypochondrium evolving over the last three months and which had intensified without fever or jaundice in the last 3 days. Clinical examination showed impingement on palpation of the epigastrium and of the left hypochondrium. There was no palpable mass. Laboratory tests were without abnormalities, except for lipasemia that was 8-times the upper normal. Abdominal CT scan showed bi-loculated cystic mass in the pancreas tail, measuring 111 mm * 73 mm, with a thin wall and a fluid content, associated with an infiltration of the left perirenal fascia. MRI (Panel A) showed mucinous cystadenoma with retroperitoneal rupture. The caudal portion of the main pancreatic duct was slightly dilated and communicated with the pancreatic cyst. The patient underwent surgery via bi-sub-costal approach. A cystic mass in the pancreas tail with retroperitoneal rupture associated with acute pancreatitis (outflow of necrotic content from left anterior prerenal space) was found. Caudal splenopancreatectomy was performed (Panel B). The postoperative course was uneventful. The anatomo-pathological examination of the surgical specimen showed pancreatic mucinous cystadenoma with low-grade dysplasia.

Kyste hydatique primitif et isolé du diaphragme en Tunisie Primary and isolated phrenic hydatid cyst in Tunisia

The hydatid cyst of the diaphragm is defined as the development of a hydatid cyst in the diaphragm muscle. The purpose of this study is to identify the specific pathogenic, clinical and therapeutic aspects of this hydatid cyst. It is important to confirm the diagnosis of the location before surgery. We report the case of a patient aged 40 years, in whom the diagnosis of hydatid cyst of the diaphragm was made incidentally in the course of a gastric stromal tumour. The patient was operated by a midline laparotomy. Resection of the protruding dome of hydatid cyst of the diaphragm was carried out along with total gastrectomy. The postoperative course was uneventful. After 12 months, the results were negative. The diagnosis of hydatid cyst of the diaphragm is based on the thoraco-abdominal CT scan. The treatment is surgical based on the topographic features of the cyst.

Lettre à la rédactionPseudo obstruction duodénaleDuodenal pseudo obstruction

Homme âgé de 22 ans, issu d’un mariage consanguin de premier degré, a été hospitalisé pour douleurs abdominales et vomissements. Le patient présentait depuis cinq mois des douleurs de l’hypochondre droit associées à des vomissements alimentaires et bilieux. L’interrogatoire a noté la notion de syndromes subocclusifs spontanément résolutifs, d’infections urinaires récidivantes et d’un amaigrissement par autorestriction alimentaire. À l’examen physique, le patient était maigre et présentait une dysmorphie faciale avec un hypertélorisme, une obliquité antimongoloïde, des fentes palpébrales et une micro-ophtalmie droite. L’examen ophtalmologique a mis en évidence au niveau de l’œil droit une microcornée, un nystagmus et l’absence de perception lumineuse. L’œil gauche était normal. La fibroscopie digestive haute a mis en évidence un aspect d’endobrachyœsophage s’étendant de façon circonférentielle à partir du cardia sur une hauteur de 10 cm environ. Le bulbe était normal et le duodénum était dilaté contenant du liquide de stase empêchant toute exploration. Les biopsies œsophagiennes ont confirmé le diagnostic d’endobrachyœsophage avec présence de métaplasie intestinale étendue. Le transit œsogastroduodénal a montré la présence d’une importante dilatation duodénale sans obstacle organique d’aval. Le diagnostic retenu en préopératoire était celui d’un diverticule géant du duodénum. Le patient a été opéré après aspiration gastrique. L’exploration peropératoire a mis en évidence une dilatation s e m t i

Pseudo obstruction duodénale

Homme âgé de 22 ans, issu d’un mariage consanguin de premier degré, a été hospitalisé pour douleurs abdominales et vomissements. Le patient présentait depuis cinq mois des douleurs de l’hypochondre droit associées à des vomissements alimentaires et bilieux. L’interrogatoire a noté la notion de syndromes subocclusifs spontanément résolutifs, d’infections urinaires récidivantes et d’un amaigrissement par autorestriction alimentaire. À l’examen physique, le patient était maigre et présentait une dysmorphie faciale avec un hypertélorisme, une obliquité antimongoloïde, des fentes palpébrales et une micro-ophtalmie droite. L’examen ophtalmologique a mis en évidence au niveau de l’œil droit une microcornée, un nystagmus et l’absence de perception lumineuse. L’œil gauche était normal. La fibroscopie digestive haute a mis en évidence un aspect d’endobrachyœsophage s’étendant de façon circonférentielle à partir du cardia sur une hauteur de 10 cm environ. Le bulbe était normal et le duodénum était dilaté contenant du liquide de stase empêchant toute exploration. Les biopsies œsophagiennes ont confirmé le diagnostic d’endobrachyœsophage avec présence de métaplasie intestinale étendue. Le transit œsogastroduodénal a montré la présence d’une importante dilatation duodénale sans obstacle organique d’aval. Le diagnostic retenu en préopératoire était celui d’un diverticule géant du duodénum. Le patient a été opéré après aspiration gastrique. L’exploration peropératoire a mis en évidence une dilatation s e m t i