Lamine Hamzaoui

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.

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.

Cutaneous Large B Cell Lymphoma Involving the Duodenum and the Bile Duct: a Case Report

A 63-year-old male patient presented a huge indolent tumor (60 cm in diameter), with peripheral annular erythematous and pigmented reinforcement on the back next to the left shoulder, evolving for 1 year and ignored by the patient (Fig. 1). A skin biopsy was performed 3 months before admission and histologic examination showed dense diffuse lymphocytic infiltrate of centroblasts and immunoblasts. An immunohistochemical analysis showed positivity of CD20 and Bcl-2 and negativity of the other markers: MUM-1, and Bcl-6, CD30, and EpsteinBarr virus stains including Epstein-Barr encoded RNA. A primary cutaneous B cell lymphoma (PCBCL) leg type was initially established. Chemotherapy was indicated but the patient did not consult and he presented with a 2-week history of progressive obstructive jaundice and abdominal pain without fever. Physical examination showed jaundice and a palpable gallbladder but no hepatosplenomegaly or peripheral lymph nodes. His right upper abdomen was tender to palpation. Laboratory findings confirmed cholestasis with elevated levels of direct bilirubin, alkaline phosphatase, and gammaglutamyl-transpeptidase, associatedwith a moderate cytolysis. Prothrombin time was normal. The cancer antigen 19-9 level was mildly elevated. Lactate dehydrogenase level was normal. Abdominal ultrasound showed dilation of the intrahepatic and common bile ducts with an enlarged gallbladder without evidence of an obstacle on the bile ducts. Abdominal CTscan and magnetic resonance cholangiopancreatography (MRCP) revealed dilatation of the proximal common bile duct (CBD) and both intrahepatic bile ducts, a narrowing of the distal common bile duct with no masses in the liver and no lymphadenopathy (Fig. 2). Pancreatic duct was also dilated. Lateral duodenoscopy showed an ulcer of the second portion of the duodenum away from the papilla; biopsies were performed. Histological examination with immunohistochemistry revealed a large B cell-type malignant lymphoma. Endoscopic retrograde cholangiopancreatography (ERCP) and cholangiography confirmed the stricture and showed a narrowed segment in the inferior part of the CBD, with proximal dilatation (Fig. 3). After endoscopic papillotomy, cytological and biopsy tests were performed and a plastic stent was placed for drainage. Histological examination with immunochemistry showed a large B cell-type lymphoma (Fig. 4). A * Lamine Hamzaoui lamine015@yahoo.fr

Inflammatory pseudotumor of the liver

La Presse Medicale - In Press.Proof corrected by the author Available online since jeudi 28 juillet 2016

Metastatic Squamous Cell Carcinoma of the Stomach

Primary squamous cell carcinoma of the stomach is very rare. Its pathogenesis is unclear and the treatment strategy is controversial. We report an agressive primary squamous cell carcinoma of the stomach with liver and lung metastases in a 55-year-old man. The patient presented with a 1-month history of abdominal pain, vomiting and weight loss. Abdominal ultrasound revealed multiple liver metastases. Endoscopic examination showed two tumour masses on the fundus of the stomach. Biopsy of the lesions revealed squamous cell carcinoma of the stomach. Chest x-ray showed multiple large pulmonary nodules highly suggestive of pulmonary metastases. The patient died ten days after he was admitted because of progression of the tumour and before any therapeutic decision.