Julien Jarry

Delayed colo-anal anastomosis is an alternative to prophylactic diverting stoma after total mesorectal excision for middle and low rectal carcinomas.

BACKGROUND After total mesorectal excision (TME), a low colorectal or colo-anal anastomosis is usually performed. A prophylactic covering stoma is often used, especially for patients receiving neoadjuvant chemo-radiotherapy. However, morbidity is high, mainly due to anastomotic leakage. METHODS From May 2000 to October 2008, patients with middle or low rectal cancer who underwent a trans-anal pull-through procedure after TME were prospectively recorded. No covering stoma was performed in these patients. However, they all underwent a delayed colo-anal anastomosis (DCA), which was performed 6 days following the TME, on average. Both the surgical technique and follow-up were standardised. Patients with T3, T4 and/or N+ cancers were given preoperative radiotherapy. A retrospective analysis was done to assess post-operative mortality, morbidity, and oncologic and functional results. RESULTS One hundred consecutive patients with rectal tumours at a median distance of 5 cm from the anal verge underwent DCA after TME. The 5-year overall and disease-free survival rates were 81% and 66%, respectively. The post-operative mortality rate was 3% and the overall post-operative morbidity rate was 36%, with only 3 anastomotic leakages. After two years, 73% of the patients had good functional outcomes. CONCLUSION The trans-anal pull-through procedure after TME, followed by DCA seems to be a safe and efficient sphincter-preserving procedure to treat patients with middle or low rectal cancer while avoiding a prophylactic, diverting stoma.

A Rare Cause of Ascites

Question: A 40-year-old man was hospitalized for severe abdominal pain and vomiting. He had been undergoing treatment for asthma since childhood. Physical examination revealed generalized distention with tenderness all over the abdomen. Rectal examination was normal. Laboratory investigations revealed a total peripheral white cell count of 10.8 10 9 /L with 34% eosinophils. Other laboratory studies were within normal ranges. An abdominal x-ray displayed multiple air‐fluid levels in the small intestine. Abdominal computed tomography showed moderate ascites, noticeable wall thickening, and dilatation of the upper intestinal tract (Figure A and B). Upper endoscopy showed a nonspecific gastroduodenal and jejunal inflammation. Colonoscopy and random biopsies from the colon were normal. A series of biopsies of the duodenal and jejunal mucosal layer revealed inflammation with moderate eosinophilic infiltration and an absence of parasitic infiltration or Crohn’s disease. An ascites puncture was performed that showed a sterile exudative peritoneal effusion with up to 95% eosinophils. Stool samples were examined twice, and no ova or parasites were found. What is your diagnosis?

An Uncommon Surgical Disease

A woman in her 50s was hospitalized for a painful anal mass. She had a history of hypertension and depression and was receiving omeprazole and paroxetine. The mass had appeared 2 days before presentation and was associated with vomiting. Additionally, the patient had not passed stools or had intestinal gas for 2 days. On physical examination, the mass was exteriorized through the anal canal. It was covered by hypoxemic rectal mucosa, but no digestive lumen could be identified inside the mass (Figure 1). Furthermore, the patient had a distended abdomen, absent bowel sounds, and no tenderness to palpation. No abdominal scar was visible, and no groin hernia was palpable. Her blood pressure was 160/80 mm Hg and her temperature was 37.8°C. Results of complete blood cell count, coagulation tests, and basic chemistry panel were all within normal limits. An abdominal radiograph showed several air-fluid levels without pneumoperitoneum, confirming an intestinal occlusion. Figure 1. View of the mass exteriorized through the anus.

Role of laparoscopic distal pancreatectomy for solid pseudopapillary tumor.

Results of this study suggest that laparoscopy may offer an alternative to open surgery in the treatment of solid pseudopapillary tumors of the pancreas.

Appendicitis: When there is more than meets the eye.

Acute appendicitis is the most frequent emergency in gastrointestinal surgery. Obstruction of the appendiceal lumen appears to be one of the most common physiologic mechanisms for the development of acute appendicitis. Once obstructed, the dilatation of the lumen causes ischemia and necrosis of the wall. The most common organisms involved in appendicitis are Escherichia coli, Peptostreptococcus, Bacillus fragilis and Pseudomonas. Rarely, Actinomyces is involved in this process. In this case report, we report a case of actinomycosis of the appendix vermiformis occurring in a 19-year-old male with no predisposing factors. Along with a review of the literature, we will define the risk factors, clinical characteristics, diagnostic methods, and treatment of actinomycosis.

Monolobar Caroli's disease.

Carolis disease (CD) is defined as the segmental dilatation of the intrahepatic bile ducts, which is generally diffuse throughout the liver, but may occasionally involve a single lobe, most commonly the left.1 We report the case of a 78-year-old male with recurrent cholangitis due to left monolobar CD. A preoperative diagnosis was made using MR cholangiography and the patient underwent a left hepatectomy. Macroscopic examination of the resected specimen revealed cystic dilatations of the intrahepatic bile ducts and intrahepatic lithiasis. Histologically, there was no evidence of malignancy. Liver resection is the treatment of choice for localized forms of CD, eliminating the potential for cholangiocarcinoma. Figure 1 Operative view: Cystic dilatation of the intrahepatic bile ducts in the left lobe with intrahepatic lithiasis (arrow)

Right-sided intra-thoracic kidney associated to Bochdalek hernia in an adult patient

Diaphragmatic hernia of Bochdalek (BH) and intra-thoracic kidney (IK) are both rare congenital, developmental anomalies. In some extremly rare occasion, these two congenital anomalies can be associated in the same patient. The kidney typically exits the retroperitoneal space through the foramen of Bochdalek. The majority of IK and BH are discovered incidentally. A conservative approach can be proposed in asymptomatic cases. In this report, the case of a 35-year-old man presenting with 1-week of acute abdominal pain is presented. Chest radiography revealed a posterior mass in the right hemithorax, which was later confirmed by chest computed tomography and magnetic resonance imaging to be a congenital IK associated with a BH.

A Fishy Nodule

Question: A 65-yearold patient presented with a painful epigastric mass. It had been diagnosed as a hematoma after a blunt abdominal trauma 3 months prior. Since then, the mass remained and continued to cause the patient pain. Past medical history included chronic alcohol consumption and benign prostatic hyperplasia. Upon physical examination, e was determined to have a hard, irregular mass in the epigastric area associated with an ulcerated, 1.5 cm large nodule of the umbilicus Figure A). Laboratory tests revealed a mild anemia (10 g/dL) with a low prothrombin time (63%) and a total bilirubinemia of 26 mg/L. is serum alpha-fetoprotein concentration was 16.8 ng/mL. Thoracoabdominopelvic computed tomographic (CT) was performed. It evealed a 12 7-cm solid mass in the epigastric region associated with a hypertrophy of the left hepatic lobe (Figure B). What is your diagnosis? the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

A fish bone-related hepatic abscess

We report an unusual case of pyogenic, hepatic abscess caused by fish bone penetration of the duodenum in a 68-year-old woman. The fish bone had migrated into the liver through the duodenal wall. The patient was initially admitted to our emergency room with abdominal pain, fever, and asthenia. A contrastenhanced abdominal coputed tomography (CT) scan showed a hepatic abscess in relation with a straight, foreign body, which had entered through the duodenal wall. Surgery was necessary to remove the foreign body, which was identified as a fish bone. The patients recovery was uneventful and she was discharged on postoperative day 10. This case is discussed together with the data collected by a medline-based extensive review of the literature.

Right postoperative pleural effusion following laparoscopic appendicectomies: a case series

Pleural effusion is not a commonly reported complication of appendicectomy. In our experience, we have performed all forms of appendicitis by laparoscopy (n = 217) since August 2006. We report three consecutive cases of right postoperative pleural effusion, all of which occurred during the immediate postoperative course of a laparoscopic appendicectomy. All three patients presented a perforated appendicitis. The right postoperative pleural effusions seem to be linked to the laparoscopic approach, and can be explained by the cumulative effects of peritoneal lavage, pneumoperitoneum and Trendelenburg position. The first two cases were managed medically by intravenous antibiotic therapy. The third patient required a pleural drainage by thoracoscopy. Surgeons should be aware of this complication when operating perforated appendicitis by the laparoscopic method.