Hadj Omar El Malki

Rupture intrapéritonéale du kyste hydatique du foie

Resume La rupture kystique represente Ia principale complication du kyste hydatique du foie et interesse 15 a 40 % des kystes. Dans de 2 a 7 % des cas le kyste hydatique du foie se rompt dans la grande cavite peritoneale. La survenue d’une peritonite encapsulante secondaire a la rupture du kyste hydatique du foie n’a ete decrite, a notre connaissance, qu’une seule fois. Nous rapportons l’observation d’une patiente de 43 ans chez qui le diagnostic de rupture peritoneale d’un kyste hydatique du foie est fait apres 3 mois. La malade etait mise sous traitement medical a base d’albendazole (10 mg/kg/j). Deux mois apres le debut de ce traitement, la malade etait operee. On a decouvert d’une peritonite encapsulante. Les differents prelevements realises pour etude parasitologique etaient negatifs. Le geste chirurgical a consiste en un lavage a l’eau oxygenee de la coque fibreuse de la peritonite encapsulante et un drainage sans aucune dissection. L’evolution a ete satisfaisante sous traitement par l’albendazole pendant 14 mois. Actuellement, elle est en bonne sante sans recidive et sans trouble du transit avec un recul de 2 ans. Nous pensons que l’albendazole est tres efficace dans le traitement de la maladie hydatique a condition de l’administrer de facon continue le plus longtemps possible. La survenue d’une peritonite encapsulante est heureusement une situation exceptionnelle dont la prise en charge chirurgicale est tres delicate.

Surgery in Intra-abdominal Ruptured Hydatid Cyst

In a recent original article, Derici et al. reported an interesting study on 17 hydatid disease cases with a rupture in the peritoneum [1]. We think that some points regarding hydatid rupture need to be made clear. We would like to underline that urgent surgery should be minimized after diagnosing hydatid cyst rupture. It is well established that liver hydatid cyst rupture incidence represents 15%–40% of all cases, and 2%–7% of cysts can become perforated in the peritoneum [2]. In this situation, the rupture requires emergency care because allergic reactions or anaphylactic shock may develop in up to 25% of the cases [1]. In their report, Derici et al. did not mention their 17 patients’ hemodynamic status or body temperature. Nor did they specify whether the patients had jaundice or peritonitis with or without sepsis. Hydatid cyst rupture itself, does not compel us to initiate emergency operation unless the patient’s clinical status requires immediate action. Thus we believe it is important to report the patients’ clinical and biological status. It is also important to discuss the time from onset of symptoms to emergency unit consulting and operation. Cholangitis, sepsis, acute abdomen status, intraperitoneal bile leak, extensive inflammatory reaction, and shock as consequence of or associated with rupture(trauma) are all reasons for urgent surgery. However, if the patient is not suffering from a critical illness, the operation can be postponed to a better moment. Albendazole may play an interesting role in the management of patients with hydatid cyst rupture [2] by neutralizing liquid parasitological activity from the cyst. Another possible side effect is sclerosing peritonitis [2], in which case percutaneous drainage of the intraperitoneal fluid could be performed. Peritoneal fibrosis reaction and albendazole could prevent new hydatid cyst formation from floating daughter cysts. Although, hydatid disease is often asymptomatic, it can sometimes cause difficult complications that can lead to death. More studies are needed to clarify the mechanisms that control the allergic phenomena produced by hydatid disease [3]. After liver hydatid cyst intaperitoneal rupture, mortality rate climbs to 6% and morbidity averages 20%– 35% [4].

Acute abdominal compartment syndrome complicating a colonoscopic perforation: a case report

IntroductionA perforation occurring during colonoscopy is an extremely rare complication that may be difficult to diagnose. It can be responsible for acute abdominal compartment syndrome, a potentially lethal complex pathological state in which an acute increase in intra-abdominal pressure may provoke the failure of several organ systems.Case presentationWe report a case of acute abdominal compartment syndrome after perforation of the bowel during a colonoscopy in a 60-year-old North African man with rectal cancer, resulting in respiratory distress, cyanosis and cardiac arrest. Our patient was treated by needle decompression after the failure of cardiopulmonary resuscitation. An emergency laparotomy with anterior resection, including the perforated sigmoid colon, was then performed followed by immediate anastomosis. Our patient remains alive and free of disease three years later.ConclusionAcute abdominal compartment syndrome is a rare disease that may occasionally occur after a colonoscopic perforation. It should be kept in mind during colonoscopy, especially considering its simple salvage treatment.

Actinomycose digestive: Trois cas et revue de la litérature

Resume L’actinomycose est une affection chronique suppurative. Elle est causee par une bacterie anaerobie, le plus souvent Actinomyces israelii. Les localisations cervicales et thoraciques sont les plus frequentes. L’actinomycose digestive est rare et peut simuler un cancer conduisant a une intervention chirurgicale avec resection. Nous rapportons trois observations d’actinomycose abdominale. Il s’agissait d’une localisation colique dans deux cas et d’une localisation hepatique dans un cas. Tous les malades ont ete operes. Le diagnostic d’actinomycose a ete pose en post-operatoire dans les trois cas. L’evolution a ete favorable sous traitement medical. Ces observations illustrent les difficultes diagnostiques de cette maladie rare et meconnue dont le traitement est essentiellement medical reposant sur une penicillinotherapie prolongee.

Feasibility and safety of laparoscopic adrenalectomy for large tumours

Abstract Objective: To verify the feasibility and safety of laparoscopic adrenalectomy for large tumours, as since it was described, the laparoscopic approach for adrenalectomy has become the ‘gold standard’ for small tumours and for large and non-malignant adrenal tumours many studies have reported acceptable results. Patients and methods: This is a retrospective study from a general surgery department from January 2006 to December 2013 including 45 patients (56 laparoscopic adrenalectomies). We divided patients into two groups according to tumour size: <5 or ⩾5 cm, we compared demographic data and peri- and postoperative outcomes. Results: There was no statistical difference between the two groups for conversion rate (3.7% vs 11.7% P = 0.32), postoperative complications (14% vs 12%, P = 0.4), postoperative length of hospital stay (5 vs 6 days P = 0.43) or mortality (3.5% vs 0% P = 0.99). The only statistical difference was the operating time, at a mean (SD) 155 (60) vs 247 (71) min (P < 0.001). Conclusion: Laparoscopic adrenalectomy for large tumours needs more time but appears to be safe and feasible when performed by experienced surgeons.

Laparoscopic approach for liver hydatid cyst: primum no nocer.

To the Editor: We have read with great interest the article by Tai et al,1 reporting an encouraging study about laparoscopic management of liver hydatid cyst (LHC). The purpose of this study was to report a series of patients with 60 LHC, totally managed by laparoscopic approach. Indeed, surgical management of LHC remains the mainstay treatment in endemic areas,2 and we agree that laparoscopic approach may represent an attractive option offering all the advantage of laparoscopic surgery. However, additional specifications should be made to this report. First, both selection and exclusion criteria to this study were hard to guess as they were cited in discussion paragraph instead of being reported in materials and methods section. Actually, a more precise description of the 3 groups’ demographics, according to the WHO classification of the cysts, their locations, and sizes, would help to draw a better profile of patients undergoing each laparoscopic approach. Morevoer, 8 of the 17 (47%) patients who underwent laparoscopic cystectomy had multiple cysts. They may not be the best candidates for this approach because of high risk of spillage (11.7%; 2/17) and specially high risk of cystic relapses (hazards ratio: 3.8).3,4 In addition, cystic spillage is one of the most identified risk factor of peritoneal hydatid recurrences.5 Second, both CE1 and CE5 stages according to the WHO classification were included in this study; authors did not mention if CE1 stages could not be managed by PAIR, which remains the recommended option with similar results and less hospital stay.6 Furthermore, CE5 stage has no surgical indication according to the WHO recommendations of LHC management7,8 and therefore, authors should specify this exceptional indication to surgery. Third, authors would be more helpful by specifying how they proceed to the aspiration of all cystic content and daughter vesicles using a 10mm suction, as technically it is very hard, even in laparotomy, and usually it may demand high power suction and higher diameter to avoid cystic spillage, in order to reduce local recurrence.9 The use of specific laparoscopic cannulas seems to facilitate and ensure the aspiration of all contents and daughter cysts,10 whereas the extraction of remaining cystic wall should be protected in a plastic bag. Fourth, this study is one of the largest series of laparoscopic pericystectomy for LHC; more details about surgical techniques are required, such as the management of liver resection bed, the use of liver mobilization or anterior approach, and the practice of intraoperative ultrasound for the location of other cyst, as in the figure 1 showing the hydatid cyst located at segment VI. It also shows a cystic formation at segment IV (biliary cyst? LHC?). Peroperative ultrasonography would help to confirm the diagnosis and change the surgical approach. The use of 30-degree optical device may also help to better explore the cystic cavity, looking for biliocystic communications. Moreover, removing drainage at the second or third day may be, in our opinion, early to detect biliary fistulas. Finally, the unique recurrence occurred in the laparoscopic cystectomy group; however, authors did not mention if it was peritoneal recurrence (which can be explained by the high risk of spillage in this technique) or a liver recurrence. In such a case, the location of the recurrence (resection site or the rest of the liver) may be good to mention. We do agree with Tai and colleagues, concerning the fact that laparoscopic treatment of liver hydatid cyst is effective in selected patients. However, this approach should be more radical (laparoscopic pericystectomy of liver resection) than conservative (partial cystectomy), knowing the poor prognosis of this benign disease when surgery fails. The reason why in laparoscopic approach of LHC, Primum No Nocer.

Response to the Comment: Surgery of Liver Hydatid Cyst’s Recurrence is Always More Difficult

Dear editor, We read with great interest the Letter to the Editor: Comments on the article about recurrence after surgical management of liver hydatid cyst by Enver Zerem et al. regarding our manuscript published in the Journal of Gastrointestinal Surgery. We first want to thank you for allowing us to answer this letter to the editor and to explain our point of view. Surgery remains the treatment of choice of liver hydatid cyst (LHC).Our rate of 8.5% of WTC recurrence is not high, it is an average rate of recurrence in all surgical studies ranging from to 4.5% to 30%. This rate may be explained by the fact that our center is a tertiary center which receives patients from all over the country with no selection of patients as reported in previous papers. Our series is a retrospective study of all LHCs surgically managed in our department. At the opposite, in the Zerem study performing ultrasound-guided puncture, aspiration, injection, and reaspiration (PAIR) method in the management of highly selected patients with types I and III Gharbi’s classification LHC, it is possible to assess this very low rate of recurrence, excluding initially complicated cysts. The diagnosis of LHC recurrence was assessed preoperatively during routine surveillance ultrasonography and then confirmed by a 6-month control ultrasonography associated with an abdominal CT scan showing either the same image or the worsening of the lesion. In doubtful cases, fine needle aspiration was performed to confirm the diagnosis. During surgery, after covering and isolating the area, the cyst was incised at its most accessible part and all its content was aspirated. We insured a total removal of germinative membrane with forceps which definitely proved the real nature of the recurrence and eliminated any other differential diagnosis (residual cavity or biliary collection) even for the 16% of Gharbi’s type I of LHC. Surgery for recurrences is always more difficult due to structural and anatomical modifications. Based on these general conclusions, we can easily imagine that the development of LHC recurrence may be perturbed and may escape the rule of 2 cm per year process. This may explain our 80% rate of cysts with a diameter greater than 10 cm. Moreover, new cysts can arise in free hepatic parenchyma but merge with old residual cavities, which can enhance the diameter of these new cysts. Finally, some small cysts may be unapparent at the first surgery and have fully the time to grow and to appear as a recurrence. Indeed, the use of Albendazole perioperatively can help to lower this rate of recurrence, but in Morocco, it was only recently introduced during these last 4 years. This factor was analyzed in univariate analysis, but we H. O. El Malki (*) :A. Souadka :B. Zakri :Y. El Mejdoubi : R. Mohsine : L. Ifrine :A. Belkouchi Surgery Departement “A”, Ibn Sina Hospital, BP 2151, Sale, Bab Chaâfa, Sale-Maroc, Rabat, Morocco e-mail: oelmalki@hotmail.fr