Wael Rebai

Genetic variability and haplotypes of Echinococcus isolates from Tunisia

BACKGROUNDnThe species/genotypes of Echinococcus infecting a range of intermediate, canid and human hosts were examined as well as the intraspecific variation and population structure of Echinococcus granulosus sensu lato (s.l.) within these hosts.nnnMETHODSnA total of 174 Echinococcus isolates from humans and ungulate intermediate hosts and adult tapeworms from dogs and jackals were used. Genomic DNA was used to amplify a fragment within a mitochondrial gene and a nuclear gene, coding for cytochrome c oxidase subunit 1 (cox1; 828 bp) and elongation factor 1-alpha (ef1a; 656 bp), respectively.nnnRESULTSnE. granulosus sensu stricto was identified from all host species examined, E. canadensis (G6) in a camel and, for the first time, fertile cysts of E. granulosus (s.s.) and E. equinus in equids (donkeys) and E. granulosus (s.s.) from wild boars and goats. Considerable genetic variation was seen only for the cox1 sequences of E. granulosus (s.s.). The pairwise fixation index (Fst) for cox1 E. granulosus (s.s.) sequences from donkeys was high and was statistically significant compared with that of E. granulosus populations from other intermediate hosts. A single haplotype (EqTu01) was identified for the cox1 nucleotide sequences of E. equinus.nnnCONCLUSIONSnThe role of donkeys in the epidemiology of echinococcosis in Tunisia requires further investigation.

Cystic echinococcosis in Tunisia: analysis of hydatid cysts that have been surgically removed from patients.

Abstract Echinococcosis/hydatidosis caused by Echinococcus granulosus has a widespread distribution in the human population of Tunisia, particularly in the north–west and centre–west of the country. In a recent study, the morphological features, fertility and viability of hydatid cysts that had been excised from patients in Tunis were explored, and the E. granulosus strain or genotype involved in each case was identified from morphology of the protoscolex hooks and the results of molecular genotyping. The hepatic cysts investigated came from 41 patients [31 women and 10 men, with a mean (S.E.) age of 43.41 (14.25) years] who were treated for cystic echinococcosis, by surgery but rarely with chemotherapy, at the La Rabta Hospital in Tunis, in the 12 months ending in June 2008. Most (56%) of these patients originated from rural areas in endemic governorates. Of the 60 hepatic cysts that were studied, 38.3% were located in the right lobe of the liver and 35.0% each involved both hepatic lobes. Almost a third (31.7%) of the excised cysts were degenerating, with the rest considered viable and either multivesicular (38.3%) or univesicular (30.0%). Almost all (93.3%) of the cysts were categorized as fertile, with a mean protoscolex viability of 21.8%. Protoscolex viability was relatively high in the viable univesicular cysts with a visible cyst wall and in the multivesicular and multiseptate cysts with daughter cysts, and lowest in the cysts that appeared to be solid calcified masses. The observed variation in protoscolex viability with cyst type, in cysts excised from patients before any chemotherapy, supports the cyst classification recommended by the World Health Organization but could also be compatible with the imaging-based Gharbi classification. The results of the molecular genotyping showed that all 23 cysts investigated (which came from 20 of the patients) were caused by E. granulosus of the G1 genotype (also known as the sheep or sheep–dog strain).

Left-sided gallbladder: An incidental finding on laparoscopic cholecystectomy

Transposition of the gallbladder to the left side without situs inversus viscerum is rare. These gallbladders are situated under the left lobe of the liver between Segment III and IV or on Segment III to the left of the falciform ligament. This is a report of a 50-year-old woman who was admitted to our department with a history of pain in her right upper abdomen. The physical examination showed tenderness in the right upper quadrant of the abdomen without a Murphys sign. Abdominal ultrasonography showed gall bladder stones without dilatation of the bile ducts. The patient underwent a laparoscopic cholecystectomy using the French position and four ports positioned as usual. We discovered a left-sided gallbladder located on the left of the round ligament. The gallbladder was excised as usual. Intraoperative cholangiogram showed neither dilatation of the bile ducts nor associated congenital anomalies of the biliary tree. The patient was discharged on the first postoperative day. Because routine preoperative examinations may not detect the anomaly, the latter may take surgeons by surprise during laparoscopy. Awareness of the unpredictable confluence of the cystic duct into the common bile duct and selective use of intraoperative cholangiography both contributed to the safe laparoscopic management of this unusual problem.

Acinar cell carcinoma of the pancreas: A rare tumor with a particular clinical and paraclinical presentation

Acinar cell carcinoma (ACC) of the pancreas is a rare tumor with an extremely low incidence rate. While the number of reported patients with ACC is relatively small, a long-term survival rate has been noted in patients with neuroendocrine differentiation. A 39-year-old woman visited our emergency department for upper gastrointestinal bleeding. Endoscopy indicated extrinsic compression of the posterior body of the stomach, together with a large, 10-cm, central ulcer covered with necrotic tissue. Abdominal computed tomography (CT) indicated a lesion that involved the whole of the pancreas, with a fistula in the stomach, which was suspected of being a degenerative intraductal papillary mucinous tumor of the pancreas. Magnetic resonance imaging (MRI) of the pancreas was performed, and the results further strengthened our suspicions by demonstrating the presence of cystic lesions and tumor buds. A total duodenopancreatectomy, including total splenectomy and gastrectomy, was performed, along with two independent Roux-en-Y anastomoses (one esojejunal and one hepaticojejunal). The tumor also had a wide opening in the stomach. The patients postoperative course was marked by partial thrombosis of the portal vein, which was treated medically. Histopathological examination provided evidence of pancreatic ACC. The diagnosis of ACC should be considered in the presence of cutaneous lesions, which were absent in the case of our patient, and colonoscopy is also highly desirable because of the various forms associated with familial adenomatous polyposis. The prognosis, which includes a 5-year survival rate of 45%, in the population with an R0 resection is better than that for ductular adenocarcinoma, thus prompting the more aggressive management of this type of tumor.

Mucocele of Appendiceal Stump - an Atypical Presentation and a Diagnostic Dilemma

Abstract Background: Appendiceal mucocele is a well-recognised entity that can present in a variety of clinical syndromes or can occur as an incidental surgical finding. The term mucocele is inherently imprecise and inclusive of both benign and malignant lesions. Mucocele of the appendiceal stump is a rare entity. Aim: We present a case of an appendiceal stump mucocele caused by a mucinous cystadenoma clinically presented as a giant retroperitoneal mass. Diagnosis was made postoperatively, after pathological study of the surgical sample. Case report: The case of a 54-year-old woman, with a previous appendectomy, suffering from a painful mass in the right lower quadrant of the abdomen, is reported. Imaging showed a large cystic structure at the base of the caecum. Surgery revealed a 13 x 5.5 cm retroperitoneal cystic mass, which was excised together with the appendiceal remnant. Pathological diagnosis was that of a mucocele arising from the appendiceal stump due to the development of a benign mucinous cystadenoma. The patient was discharged on the fourth post-operative day after an uneventful recovery. Conclusion: Mucocele of the appendiceal stump is a rare entity. In spite of extensive pre-operative investigations, preoperative diagnosis may still remain elusive and may only be made at the time of surgery.

Mature teratoma of the pancreas diagnosed by fine-needle aspiration

A 41-year-old female patient, presented with recurrent epigastric pain of 2 years duration. Physical examination revealed a 15-cm epigastric mass that was mobile and tender on palpation. Abdominal ultrasound revealed a 20-cm hypoechoic mass, containing multiple hyperechoic structures. The exact origin of the mass could not be clearly defined. CT scan of the abdomen revealed a well-circumscribed voluminous cystic mass measuring approximately 25 cm in size, with heterogeneous content. After the administration of contrast material, no enhancement of the mass

Abdominal Metastasis of a Parosteal Osteosarcoma of the Femur: an Unusual Cause of Large-Bowel Obstruction

Abstract Background: Parosteal osteosarcoma is a rare, well-differentiated, predominantly fibro-osseous variant of osteosarcoma. It is regarded as a distinct form of osteosarcoma with better prognosis than conventional osteosarcoma. Aim: We report an unusual case of abdominal mass recurrence of parosteal osteosarcoma of the left distal femur treated eight years previously with wide resection, hip disarticulation and chemotherapy, which presented as an acute abdomen: we discuss the clinical outcomes of this rare entity. Case presentation: We present a 54-year-old patient with low-grade parosteal osteosarcoma of the left distal femur. Left total hip disarticulation was indicated after several local relapses of the tumour following extensive resection and chemotherapy. Eight years later, he presented with an acute large bowel obstruction secondary to a compression of the large bowel by an abdominal mass. Abdominal computed tomography showed a large abdominal calcified mass with dilated large bowel loops. During laparotomy, the mass was unresectable. So, the patient underwent emergent colostomy of diversion. Biopsy of the lesion yielded grade III parosteal osteosarcoma material. The patient received adjuvant chemotherapy, but the response was poor: six months later, the patient presented with a peristomal mass and two pulmonary metastases. Conclusion: Abdominal recurrence of parosteal osteosarcoma of the distal femur eight years after definitive surgery is rare. This case emphasises the importance of the long-term follow-up of patients with parosteal osteosarcoma.

Résultats de la chirurgie laparoscopique pour la hernie de l’aine: l’expérience Tunisienne

La hernie de laine de ladulte reste une affection fréquente en chirurgie digestive. De nombreuses techniques de réparation ont été décrites à ce jour dont les procédés laparoscopiques. Deux méthodes furent rapidement adoptées par les différents praticiens pour le traitement chirurgical des hernies de laine par laparoscopie: la méthode laparoscopique totalement extra péritonéale (TEP) et la méthode laparoscopique transpéritonéale (TAPP). Le but était détudier la faisabilité de la cure de hernie de laine par cœlioscopie et de décrire ses résultats du point de vue récidive herniaire et douleur post opératoire. Ce travail était une étude rétrospective, uni centrique, et transversale, portant sur des patients opérés par des chirurgiens du service de chirurgie A La Rabta pour hernie de laine par voie laparoscopique, sur une période de 8 ans allant de janvier 2006 à décembre 2013. Le principal critère de jugement était la récidive herniaire. La douleur post opératoire et les complications étaient les critères de jugement secondaires. Nous avons colligés 104 hernies chez 92 patients respectant les critères dinclusion de notre étude. La moyenne dâge de nos patients était de 48 Ans (19-83). Lapproche TAPP était la plus utilisée: 94 cas (90%) TAPP contre 10 cas TEP. Aucune complication per opératoires na été signalée. Le taux de conversion de notre série était nul. La mortalité opératoire était aussi nulle. La morbidité postopératoire était de 5% (5 patients). Elle était à type dhématome dans 3 cas et de sérum dans 2 cas. La durée moyenne dhospitalisation était de 1.2 jours (1-4jours). Le séjour post opératoire navait pas dépassé 2 jours chez 94% des patients. Seulement 2 patients avaient présenté une récidive. Les douleurs chroniques postopératoires étaient notées chez seulement 3 patients. Notre étude a montré que la cure de hernie de laine par laparoscopie a apporté un confort considérable à nos patients en ce qui concerne les phénomènes douloureux, les durées dhospitalisation et darrêt de travail. Les résultats obtenus dans cette série sont bons et conformes aux résultats déjà publiés dans la littérature. Ceci nous encourage à poursuivre lutilisation de ces techniques et à contrôler nos résultats à plus long terme.

Intraductal Papillary Mucinous Carcinoma of the Pancreas Associated With Pancreas Divisum: A Very Rare Entity

Pancreas divisum (PD) is a common congenital anomaly of the pancreas, which results from an abnormal fusion between the ventral and dorsal pancreatic ducts during fetal development. Association with Intraductal papillary mucinous neoplasm (IPMN) is extremely rare. The treatment of this entity will depend both on the malignant potential of IPMN and on the symptoms related to pancreas divisum. We report a rare case of Intraductal papillary mucinous carcinoma of the pancreas associated with pancreas divisum, one of the most difficult situations which the surgeon can be confronted to in his practice.