Hassen Touinsi

Meckel's diverticulum: an exceptional cause of vesicoenteric fistula: case report and literature review

Meckels diverticulum is the most common congenital malformation of the gastrointestinal tract. It can cause complications in the form of ulceration, hemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae as noted in six previously reported cases. 66-year-old woman was presented with an enterovesical fistula. Exploratory laparotomy revealed a vesico-diverticular fistula resulting from a perforated Meckel′s diverticulum. Pathologic examination revealed that the diverticulum did not contain ectopic gastric or pancreatic tissue. The patient underwent a diverticulectomy and had an uneventful postoperative course. Unlike four of the six previously reported cases, our patient had no coexisting bowel or bladder disease occurring with her vesico-diverticular fistula. Conclusion: This is only the third reported case of a vesico-diverticular fistula resulting from a perforated Meckel′s diverticulum that did not contain ectopic tissue.

Retroportal lamina or mesopancreas? Lessons learned by anatomical and histological study of thirty three cadaveric dissections

OBJECTIVE AND BACKGROUND Despite its importance in pancreatic head carcinoma, the retroportal lamina is still under studied, with only two anatomical cadaveric dissections in the English literature, with recent controversies about the concept of a mesopancreas. METHODS Resection of the mesopancreas was performed in 33 fresh cadavers. The pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated. RESULTS The retroportal lamina is roughly rectangular in shape. Its dimensions are: height 6.2 cm (5-8), 2.5 cm wide (1.5-4). It contains a right hepatic artery arising from the superior mesenteric artery in 13.3% of cases. Microscopic examination revealed areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatics and capillaries. However, fibrous sheath and fascia were not found around these structures. CONCLUSION A right hepatic artery arising from the superior mesenteric artery is a frequent anatomic variation. Surgeons must be aware of this to ensure the integrity of the hepatic artery blood supply in patients treated by pancreaticoduodenectomy. Despite controversy about the reality of the mesopancreas (postulated in analogy to the mesorectum), because of the absence of fibrous sheath or fascia, its complete removal in pancreatic head carcinoma is feasible by a subadventitial dissection of the superior mesenteric artery which can be considered as the real limit of the mesopancreas.

Angiocholite aiguë : mode de révélation d’un carcinome épidermoïde pur de la vésicule biliaire

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Iatrogenic colorectal Kaposi sarcoma complicating a refractory ulcerative colitis in a human immunodeficiency negative-virus patient

Kaposi sarcoma is a mesenchymal tumor associated to a human herpes virus-8. It often occurs in human immunodeficiency virus-positive subjects. Colorectal localization is rare. We report the case of a colorectal Kaposi sarcoma complicating a refractory ulcerative colitis treated with surgery after the failure of immunomodulator therapy in a human immunodeficiency virus-negative heterosexual man.

Appendiceal GIST: report of an exceptional case and review of the literature.

Gastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only eight cases has been described in the literature, most of which have been of the benign type. We report a new case of an appendiceal GIST in a 75-year-old man. The tumor was discovered when the patient presented with acute appendiceacal peritonitis. Preoperative diagnosis of appendiceal GIST was rarely done as tumors were usually associated with appendicitis-like symptoms.

Surgery for Colorectal Cancer in Elderly Patients: How Could We Improve Early Outcomes ?

BACKGROUND Age is one of the causes behind the undertreatment of elderly colorectal cancer patients. The increase of mortality among elderly colorectal cancer (CRC) patients is due to competing causes of death occurring in the early post operative period. The purpose of this study was to evaluate the risk factors for post operative mortality and morbidity among elderly CRC patients. MATERIALS AND METHODS A retrospective descriptive chart review was performed on consecutive patients older than 70 y with CRC. We have collected data of 124 patients who were admitted from January 2001 to January 2010. Demographic characteristics, operative and postoperative informations were retrospectively analysed. RESULTS Early postoperative morbidity, operation related to morbidity and mortality were observed in 44 (35.5%), 9 (7.3%) and 20 (16.1%) cases, respectively. No other factors but ASA score (p = 0.002 and 0.005 in univariate and multivariate analyses, respectively) and emergency operations (p<0.001 and 10(-3) in univariate and multivariate analyses, respectively), were found to be risk factors of mortality. The results of multivariate analyses indicated that anaemia (p=0.021) and rectal cancer (p=0.015) had significant impact on the risk of anastomotic leakage. On the other hand, diabetes mellitus and rectal cancer were indicators that correlated with the width of hospitalization. CONCLUSION Elderly CRC patients should no longer be undertreated only because of their age. They should be exposed to more aggressive management than they are currently receiving. Careful preoperative evaluation, followed by medical optimization and planning of perioperative care could improve outcomes of colorectal surgery for elderly patients.

Retroperitoneal necrotizing fasciitis with gas gangrene, caused by perforated caecal diverticulitis.

Dear Editor, Necrotizing fasciitis is a relatively rare but rapidly spreading necrotizing infection of the subcutaneous tissues. It is caused by rapid proliferation of microorganisms [1]. Retroperitoneal necrotizing fasciitis is extremely rare, with very few cases reported in the literature. It is a life-threatening soft tissue infection which requires aggressive, early surgical management. The precise aetiology of necrotizing fasciitis is unclear in many cases. To the best of our knowledge, this case is only the second case reported of retroperitoneal gas gangrene, caused by caecal diverticulitis with perforation [2]. A 38-year-old man, with no previous medical history, presented to the emergency department with the chief complaints of fever, multiple episodes of non-bilious vomiting over the last 8 days, and severe right loin pain for the last 5 days. On examination, he had a pulse rate of 120 beats/minute and temperature of 38.3 °C. On physical examination, tenderness in the right lower quadrant and lumbar area was noted. Bowel sounds were reduced. There was diffuse oedema of the skin with marked erythema and heat in the area of the skin of the right loin. Subcutaneous crepitus was present. Investigations revealed a raised white blood cell count (WBC; 24,900 cells/mm). Blood sugar level, urea, creatinine, and urine microscopic examination and culture results were all normal. A presumed diagnosis of necrotizing fasciitis was made, and the patient commenced on intravenous antibiotics, resuscitated with intravenous fluids. The patient was evaluated by computed tomography (CT) scan, which revealed a retroperitoneal abscess and necrotizing fasciitis limited to the retroperitoneum with retroperitoneal emphysema; the necrotizing fasciitis is also present in the subcutaneous tissues. During exploratory laparotomy, a spreading retroperitoneal phlegmon with extensive necrosis of the retroperitoneum and a secondary peritonitis were found. The exploration revealed a 2cm perforation in the posterior wall of the caecum. The tissue planes in the retroperitoneal space were friable and loose, allowing free separation with finger dissection. Foul odour, gas, crepitation, and a brown, turbid fluid were present. The patient underwent right hemicolectomy, debridement of the retroperitoneal tissues with an ileocolostomy, and placement of a corrugated retroperitoneal drain and a pelvic tube drain. Fluid cultures developed Escherichia coli sensitive to cefoperazone. The same antibiotics were continued postoperatively. Fever and inflammation were alleviated by treatment with antibiotics, and discharge of pus from the retroperitoneal cavity persisted at 2 weeks after surgery. The patient was discharged from the hospital 18 days after his initial surgery. Pathology revealed a solitary diverticulum of the caecum, with a surrounding inflammatory response and perforation. Restoration of intestinal continuity was performed 3 months later (ileotransverse anastomosis). At 1 year after surgery, the patient is doing well, and there has been no evidence of recurrent infection. Retroperitoneal necrotizing fasciitis with gas gangrene is a life-threatening disease that needs prompt recognition, M. Bouassida (*) :B. Mroua :O. Belghith :M. M. Mighri : H. Touinsi Department of Surgery, Mohamed Tahar Maamouri Hospital, Faculty of Medicine of Tunis, Tunis El Manar University, 8000Mrazga, Nabeul, Tunisia e-mail: bouassidamahdi@yahoo.fr

Clinico-Pathological Caracteristics, Therapeutic Features and Post-operative Course of Colorectal Cancer in Elderly Patients.

STATEMENT OF PROBLEM Colorectal cancer is predominantly a disease of elderly people and is a major cause of morbidity and mortality in the elderly population. The geriatric colorectal population is a very heterogeneous group, including patients with excellent health status and others with comorbid conditions, functional dependency, and limited life expectancy. On the other hand, the effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved post-operative life expectancy or at least one that is not diminished by the surgery. MATERIALS AND METHODS This work is a descriptive study of a retrospective cohort, based on administrative databases, of all patients with colorectal cancer diagnosed or treated in our institution. We extracted data on sociodemographic characteristics, comorbidity, type of cancer, stage of cancer, type of treatment received, post-operative complications and cause of post-operative death. We compared differences between an elderly group (Group A) (age >75 years) and a group of patients below 75 years (Group B). RESULTS We found that elderly patients with colorectal cancer were more likely to be operated in emergent conditions, had more non-specific complications and more post-operative mortality than patients below 75 years. On the other hand, tumours stages, tumours characteristics and post-operative specific morbidity have been proved to be similar, both in Group A and Group B patients. CONCLUSION These results suggest that surgery is feasible and can be safe for patients above 75 years, but it needs much more evaluation of comorbidities, pre- and post-operative intensive care to avoid post-operative non-specific complications.

Giant adrenal cavernous hemangioma in a patient with familial adenomatous polyposis

Adrenal hemangioma is an uncommon benign vascular tumor that is often discovered incidentally. It has never been reported in association with familial adenomatous polyposis. We report a case of a 60-year old man with a history of familial adenomatous polyposis, in whom a huge retroperitoneal cyst of 18x17 cm was discovered during routine radiologic evaluation. Because of the impossibility of ruling out the presence of malignancy, surgical cystectomy was performed, associated to a scheduled total colectomy. Pathological examination revealed that the cyst corresponded to an adrenal cavernous hemangioma. Colonic adenomas did not show signs of degeneration. Screening for adenomatous polyposis coli (APC) gene mutation was not carried out. As familial adenomatous polyposis is known to involve a variety of extracolonic manifestations, this finding raises the suspicion of a possible variant of this syndrome including adrenal hemangioma. An extensive study based on a larger patient series with genetic exploration is necessary.

Balloon dilatation in patients with gastric outlet obstruction related to peptic ulcer disease.

BACKGROUND AND STUDY AIMS Gastric outlet obstruction (GOO) is a rare complication of peptic ulcer disease (PUD). The endoscopic balloon dilatation (EBD) associated with medical treatment of Helicobacter pylori is a successful method in the management of pyloric stenosis. The aim of this study was to describe epidemiological, clinical, and endoscopic characteristics of GOO related to PUD and to evaluate the effectiveness, safety, and outcome of EBD. PATIENTS AND METHODS In a retrospective study of patients seen between 1999 and 2009 with symptoms of GOO secondary to PUD, pyloro-bulbar stenosis was confirmed by endoscopic examination. Balloon dilatation was performed when obstruction persisted after treatment with double-dose proton-pump inhibitor (PPI) intravenously for 7-10days. The H. pylori status was assessed with histology, and eradication therapy was prescribed for infection. RESULTS A total of 45 consecutive patients (38 males, 7 females median age, 51.9years; range, 20-58years) with symptoms of GOO secondary to PUD underwent EBD. Median follow-up time of the 45 patients was 32months (range, 4-126months). The immediate success rate of the procedure was 95.5%. Clinical remission was noted in 84.4% of the patients. Remission without relapse was observed in 55.8%, 30months after the dilatation. Pyloric stenosis relapsed in 15 patients (39.5%) after a median period of 22.9months. The dilatation was complicated in three patients (6.7%, two perforations and one bleeding). A total of 13 patients (29%) underwent surgery. H. pylori was found to be positive in 97.7% of the patients, and was eradicated in 78.4% of them. Smoking and failure of H. pylori eradication were associated with the relapse of the stenosis. CONCLUSION EBD is a simple, effective, and safe therapy for the GOO related to PUD, producing short- and long-term remission.