Hichem Jerraya

Insulinoma with focal hepatic lesions: malignant insulinoma?

Insulinoma is a rare tumour that is malignant in only 10% of cases. We report a case of insulinoma in a 59-year-old woman, associated with focal liver lesions, which raised the suspicion of malignancy of a pancreatic tumour. Enucleation of the insulinoma was performed with wedge resection of one hepatic nodule. Pathological examination indicated that the pancreatic tumour was compatible with insulinoma whereas the hepatic lesion was related to focal nodular hyperplasia. This clinical case highlights the need for histopathological proof of malignancy before selecting therapeutic strategies for insulinomas.

Giant primary hydatid cyst of retroperitoneum.

A 62‐year‐old woman operated on for perforated peptic ulcer 18 years ago by laparoscopic approach complained of right‐sided abdominal pain and heaviness for 1 year. She denied any fever or jaundice and there were no disorders of the transit. The physical exam found a dense, painless mass occupying the whole right side of the abdomen. The rest of the physical exam was unremarkable. Routine laboratory tests were normal. Computed tomography showed a large retroperitoneal multilocular cystic mass of 33 × 20 cm with no contrast enhancement that extended from the pelvis to the right upper quadrant of the abdomen displacing the right kidney medially with dilatation of the pyelocalyceal cavities. The mass also displaced to the left of the inferior vena cava and the bowel loops whereas liver was displaced superiorly without signs of hepatic invasion (Fig. 1). The characteristic image of daughter cysts that appears as cysts within a cyst evoked the hydatid origin of the cyst. Through a midline incision, the hydatid cyst was completely aspirated after its isolation from the rest of the abdominal cavity using gauze swabs soaked by scolicidal solution in order to avoid dissemination of hydatid material. As complete pericystectomy as possible was performed leaving only small pieces of pericyst when dissection was difficult. The post‐operative course was uneventful and no recurrence was observed after 1 year of follow‐up. Primary retroperitoneal cystic masses represent a rare condition. They include several entities with completely different prognoses such as cystic lymphangioma and pseudomyxoma retroperitonei. Diagnosis is mainly based on a detailed analysis of the imaging findings. Retroperitoneal cystic masses other than hydatid cysts can present a multicystic appearance but in no way the image of daughter cysts that is highly suggestive of the hydatid disease. The primary retroperitoneal location of hydatid cyst is a very uncommon condition even in endemic areas. Despite the benign nature of hydatid disease, its retroperitoneal location can reach extensive sizes with mass effect on adjacent organs as in our case, simulating malignant lesions.

Mesenteric Panniculitis: An Unusual Cause of Epigastric Pain.

A 63-year-old man with history of diabetes, arterial hypertension and duodenal ulcer treated medically seven years ago, complained of epigastric pain which arose suddenly, five days before admission, with mid-back radiation. This abdominal pain was not associated with fever or vomiting. The physical examination found a temperature at 37.5°C and tenderness in the periumbilical and the epigastric area. Laboratory tests showed normal range of white blood cell count (5140/mm3) and slightly high rate of C-reactive protein (46 mg/L). The haemoglobin level was 97 g/L and the serum lipase levels were 1.5 times upper limit of normal. Abdominal ultrasound showed uncomplicated gallstones and a normal aspect of the pancreatic head. Upper gastrointestinal endoscopy revealed multiple superficial ulcerations of small sizes at the initial portion of the duodenum. Abdominal computed tomography (CT) showed densification of the mesenteric fat which was well limited and which extended from the root of the mesentery to the periumbilical region with preservation of normal fat density around the mesenteric vessels [Table/Fig-1]. The pancreas appeared normal. These CT findings were compatible with mesenteric panniculitis. [Table/Fig-1]: Abdominal CT image showing well limited densification of the mesenteric fat or ‘misty mesentery’ (bold white arrows), with preservation of normal fat density around the mesenteric vessels or ‘fat halo’ sign (thin white ... Laparoscopic cholecystectomy was performed. Intraoperatively, the root of the mesentery had a thickened and fibrous appearance [Table/Fig-2]. Mesenteric biopsy was performed. The postoperative course was uneventful. Microscopic examination showed chronic inflammation and mesenteric fat necrosis. [Table/Fig-2]: Intraoperative findings showing the thickened and fibrous appearance of the root of mesentery (black arrow) Mesenteric panniculitis is a nonspecific inflammatory process affecting the fatty tissue at the root of the mesentery [1]. The exact aetiology remains unknown [2]. Most patients do not show symptoms. Elsewhere, the most commonly seen symptoms are abdominal pain, which is usually localized in the central region or on the upper quadrants, and abdominal mass [3]. The diagnosis is more often suspected on the basis of CT findings [4]. The regional increase in mesenteric fat density or ‘misty mesentery’ [4] is a non-specific feature on abdominal CT which can be due to the infiltration of the mesentery by fluid or fibrous tissue. It can also be due to infiltration by inflammatory cells as in acute pancreatitis or by neoplastic cells (lymphoma and primary mesenteric neoplasma) [4]. Typical imaging signs which led to diagnosis in this case included a left-sided distribution [2], the ‘fat halo’ sign [4] which refers to the preservation of normal fat density around the mesenteric vessels and the ‘tumoural pseudocapsule’ sign [4] which refers to a peripheral band limiting the mesenteric mass . The abdominal CT strongly suggests the diagnosis, but confirmation is made by the histological examination which excludes an underlying infection or malignancy [1]. Only symptomatic patients may be treated by corticosteroids or immunosuppressive agents but spontaneous regression of symptoms is possible [1]. In conclusion, mesenteric panniculitis is a rare disease that can simulate an acute abdomen. The medical practitioner should consider this diagnosis and recognize specific signs on abdominal CT especially since the treatment are usually nonsurgical.

Jejunal Diverticulitis: A Challenging Diagnosis

Jejunal diverticulitis is an uncommon condition, characterized by unspecific symptoms which may lead to delayed diagnosis and high risk of mortality. Computed tomography can be very useful for early diagnosis. We reported a case of 42-old-woman who presented with acute abdomen due to jejunal diverticulitis. The diagnosis was strongly suspected preoperatively by computed tomography but other entities such as perforated neoplasms and foreign body perforation couldn’t be formally eliminated. By laparoscopic approach, the diagnosis remained uncertain. In view of diseased jejunal segment, it was decided for bowel resection followed by a side to side anastomosis. Post operative course was uneventful and the pathological analysis was consistent with the diagnosis of jejunal diverticulitis.

Laparoscopic treatment of intestinal obstruction caused by an uncommon congenital band.

Congenital bands represent a rare cause of small bowel obstruction. We report a case of intestinal obstruction caused by an uncommon form of congenital band in a 16-year-old girl. The diagnosis was strongly evoked preoperatively by CT scan and the intestinal obstruction was successfully treated using a laparoscopic approach.