Thierry Peycru

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.

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.