Houcine Maghrebi

Adult intussusceptions: Clinical presentation, diagnosis and therapeutic management

Highlights • This is a rare entity. Its treatment still difficult because of controversy regarding the diagnosis and the optimal management.• We tried to present our experience with 8 adult intussusceptions cases followed by a review of the literature in order to analyze the cause, clinical features, diagnosis, and management of this rare pathology.• It was a retrospective study, But it is very interesting with clear results and excellent figures which may guide surgeons who encounter this problem.• I am hoping that you have received everything as required and that the reviewing process finds the manuscript acceptable for publication in the journal. Please accept again dear professor our most humble greetings.

Les facteurs prédictifs de récidive du kyste hydatique du foie : l’expérience tunisienne

Cystic echinococcosis is a public health problem. Surgery represents the basic treatment and the surgeon is regularly faced with the choice of the appropriate surgical procedure (radical versus conservative surgical approach). The conservative procedure is safe and easy but can lead to a recurrence in the site of residual cavity. The aim of this study was to evaluate the predictive factors of the recurrence of hepatic hydatid cysts, to optimize surgical management and to implement preventive measures. The current retrospective study included 391 patients with hepatic hydatid cysts operated at our institution from 1996 to 2006. The diagnosis of recurrence was suspected by radiological survey and confirmed at laparotomy. The univariate study of predictive factors of recurrence was based on the Fisher test and the multivariate one on the logistic regression model. The recurrence rate reached 12% in our study with an average period of 50 months. Univariate analysis showed that the predictive factors of recurrence were: the rural origin of patients, the voluminous cysts larger than 7 cm, and unilocular hydatid cyst. Multivariate analysis showed that only voluminous cysts and unilocular ones were the predictive factors of recurrence. The unilocular and voluminous hydatid cysts represent the cysts that relapse frequently because of their immunogenic character and the presence of exocysts in the pericysts. This is very important for the therapeutic strategy the main aim of which is to prevent the recurrence.

Lymphangiome kystique intra-péritonéal et maladie de Crohn: à propos d’une association exceptionnelle

Cystic lymphangioma is a rare benign malformative tumor of the lymphatic vessels which may occur in various locations. Intra-abdominal cystic lymphangioma is less frequent than cervicoaxillary cystic lymphangioma. Clinical presentation is polymorphic. Diagnosis is based on imaging data but it requires histological confirmation. Surgery is the gold standard treatment. We here report a rare case of acquired intraperitoneal cystic lymphangioma secondary to subtotal colectomy in a female patient with severe evolutive Crohns disease treated with anti-TNF alpha. The patient presented with irreducible right painful paramedian mass with no impulse on coughing, suggesting the diagnosis of strangulated eventration within a surgical scar from midline laparotomy. She underwent emergency surgery. Surgical exploration showed multi-cystic intraperitoneal mass protrunding through the right paramedian eventration. Anatomo-pathological examination helped to confirm the diagnosis of cystic lymphangioma. Postoperatively, the mass was punctured twice to evacuate the fluid, because of incomplete surgical resection. This is the first reported case of cystic lymphangioma in a patient under anti-TNF alpha. It could be caused by disruption of the immune system and more specifically of the lymphocyte population. This association has not hitherto been established and experimental studies are necessary to accept or refuse this hypothesis.

Giant transverse colon diverticulum

La Presse Medicale - In Press.Proof corrected by the author Available online since mercredi 31 janvier 2018

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.

Duodenal diverticulitis: a difficult clinical problem

A duodenal diverticulum is a pouch attached to the duodenum which may be present in 20% of the population. Although they are common entities, symptoms caused by duodenal diverticula are relatively rare and complications such as diverticulitis remain a difficult clinical problem. Nonoperative management has emerged as a safe, practical alternative to surgery in selected patient. We present a rare case of duodenal diverticulitis and its successful conservative management. A 57-year-old man was admitted to the Emergency Department with a 4-day history of epigastric and right upper quadrant pain. The patient claimed a six month history of abdominal pain and weight loss. Physical examination shows fever and tenderness of the epigastric and right upper quadrant. Laboratory tests revealed an elevated leukocyte count with normal liver tests, lipase level. Abdominal X-ray showed no intra-peritoneal free air. Computer tomography of the abdomen reveals an infected duodenal diverticulum with infiltration of neighboring fat. The patient was admitted to the acute care surgical service for a conservative management: nasogastric suction, bowel rest, intravenous antibiotic therapy, parenteral nutrition with a close clinical observation. The patient improved and was discharged on hospital day 10 without complications.

Jejunogastric intussusception: shall we think about it?

1. Tayaran A, Abdulrasool H, Bui HT. Paracaecal hernia: a case report on the evolving role of laparoscopy. Int. J. Surg. Case Rep. 2017; 32: 29–31. 2. Jang EJ, Cho SH, Kim DD. A case of small bowel obstruction due to a paracecal hernia. J. Korean Soc. Coloproctol. 2011 Feb; 27: 41–3. 3. Bass J Jr, Longley BJ. Paracecal hernia: case report and review of the literature. Am. Surg. 1976; 42: 285–8. 4. Ogami T, Honjo H, Kusanagi H. Pericecal hernia manifesting as a small bowel obstruction successfully treated with laparoscopic surgery. J. Surg. Case Rep. 2016; 2016: rjw020. 5. Kleyman S, Ashraf S, Daniel S, Ananthan D, Sanni A, Khan F. Pericecal hernia: a rare form of internal hernias. J. Surg. Case Rep. 2013; 2013: rjs021.

Idiopathic megacaecum: Clinical features and diagnostic approach

Congenital megacaecum is a rare entity and difficult to diagnose. The pathogenesis of this malformation is not well known since there are very few cases reported in the literature. The purpose of this observation is to describe the functional signs that may suggest this rare diagnosis and the means to confirm it. We report the case of a 22-year-old young man, who complained of constipation associated with pelvic pain in the form of gravitational pull exacerbated by standing, sitting and going down the stairs. However, symptoms seemed to be relieved by supine positions. The radiological investigations concluded that the megacaecum dipped into the pelvis, but there was no evidence of mechanical or functional obstruction distally. The treatment consisted of a laparoscopic right colectomy. The postoperative course was uneventful. The megacaecum is rare and poorly understood. The abdominal pain is directly related to fecal stasis, which increases the pressure on cecal colonic segment and this in turn causes a pull on the mesentery. The entero-MRI is valuable in the diagnosis so as to eliminate other causes of chronic abdominal pain.

Les facteurs prédictifs de récidive du kyste hydatique du foie : l’expérience tunisienne@@@Recurrence of hydatid cyst of liver: predictive factors: Tunisian experience

Cystic echinococcosis is a public health problem. Surgery represents the basic treatment and the surgeon is regularly faced with the choice of the appropriate surgical procedure (radical versus conservative surgical approach). The conservative procedure is safe and easy but can lead to a recurrence in the site of residual cavity. The aim of this study was to evaluate the predictive factors of the recurrence of hepatic hydatid cysts, to optimize surgical management and to implement preventive measures. The current retrospective study included 391 patients with hepatic hydatid cysts operated at our institution from 1996 to 2006. The diagnosis of recurrence was suspected by radiological survey and confirmed at laparotomy. The univariate study of predictive factors of recurrence was based on the Fisher test and the multivariate one on the logistic regression model. The recurrence rate reached 12% in our study with an average period of 50 months. Univariate analysis showed that the predictive factors of recurrence were: the rural origin of patients, the voluminous cysts larger than 7 cm, and unilocular hydatid cyst. Multivariate analysis showed that only voluminous cysts and unilocular ones were the predictive factors of recurrence. The unilocular and voluminous hydatid cysts represent the cysts that relapse frequently because of their immunogenic character and the presence of exocysts in the pericysts. This is very important for the therapeutic strategy the main aim of which is to prevent the recurrence.