Wissem Triki

Facteurs thérapeutiques affectant la cicatrisation au cours des gangrènes du périné

Fournier gangrene is a rare and severe necrotizing fasciitis. It is burdened with high morbi-mortality, requiring early and massive medical and surgical management. Initial treatment is based on patients resuscitation associated with surgical debridement. Subsequently, the main challenge is the healing process and its possible sequelae. Several therapeutic approaches are currently available to improve and accelerate the healing process. We conducted a retrospective study of 20 cases. The median age of our patients was 56 years. The study included 16 men and 7 women. Comorbidity was present in 15 patients. Antibiotic therapy was administered in all cases, with a median duration of 15 days. All patients underwent surgery. Iterative reviews were necessary in all patients, who needed, on average, 3 dressing changes. Colostomy was performed in 6 cases. Hyperbaric oxygen therapy was performed in 4 cases. Vacuum assisted closure was performed in 1 case. Soft tissue coverage was necessary in 2 cases. The mean duration of healing was 15 days with oxygen therapy versus 24 days in the absence of this treatment. The mean duration of hospitalization was 20 days. Four patients died. Healing process without sequelae is a therapeutic challenge. Despite the addition of new therapeutic approaches, outcomes are not satisfactory. However, multidisciplinary approach associated with oxygen therapy and vacuum assisted closure might improve patients outcomes.

Ciliated Foregut Cyst of Gallbladder: A Little Known Entity

Ciliated foregut cysts are rare masses that develop from the tissues which remain from embryological foregut development. In the literature, a few cases have been described in various organs so far. The solitary cysts are characterized by ciliated pseudostratified columnar epithelium. They are usually located above the diaphragm but they can also arise in relation to the liver, gallbladder and pancreas. Although rare, there is a risk of development of squamous cell carcinoma from these cysts that typically bear benign features. Prognosis following the development of carcinoma is poor. Congenital gallbladder cysts are detected rather rarely. The diagnosis is suspected on imaging. Treatment using a laparoscopic surgical method is the first preference.

Management of Complicated Hydatid Cyst in Pregnancy. A Multicenter Study

BackgroundThe hepatic hydatid cyst is a major public health concern in endemic areas. It presents a therapeutic challenge when it occurs in pregnant women and exposes the mother and the fetus to a high mortality risk in the case of complications. The main complication is communication with the biliary tree, which fortunately is rare.MethodsA multi-center retrospective study was conducted spanning 7 years, from January 2009 to December 2015. In 17 departments of surgery across Tunisia, 24 cases were identified of pregnant women who were treated for complicated hepatic hydatid cyst. The data on their treatment and outcome were retrieved from the medical records.ResultsThe age range of the 24 patients was 23 to 40 years, median 30 years. The median gestational age was 15 weeks (range 5 to 29 weeks).The patients complained of a variety of symptoms, mainly abdominal pain (87.5%), fever (50%), jaundice (50%) and vomiting (21%). The laboratory examination showed leukocytosis (54.2%), cholestasis (41.7%), elevated liver enzymes (12%), and positive blood culture (6%). On abdominal ultrasound (U/S), dilatation of the common bile duct was observed in 41% of the cases, dilatation of the intra-hepatic bile ducts in 50%, and hydatid material in the duct in 12% of the cases. Most of the cysts were located in the right lobe of the liver, in the hepatic dome. All of the patients were treated surgically, by one of three types of intervention: Largot intervention (18 cases), internal transfistulary drainage (4 cases), and the Perdromo procedure (2 cases). Postoperative follow-up was complication-free for 20 patients. In the remaining four, complications included: purulent retention (1 case), biliary fistula (2 cases), pneumonia (1 case). There was no maternal death. A tocolytic agent was administered to 16 women and 21 had a live full-term birth. One spontaneous miscarriage and 2 neonatal deaths occurred.ConclusionsComplicated hydatid cyst in pregnancy is a serious condition which can be life-threatening for the mother and the fetus. The treatment is surgical, and patient management requires close collaboration between the surgeon, the anesthesiologist and the obstetrician-gynecologist.

Spontaneous rupture of the common hepatic duct associated with acute pancreatitis: a case report

BackgroundRupture of the common bile duct is a life-threatening condition, usually observed after a trauma or in association with choledocholithiasis or an obstructive tumor of the bile duct. However, a spontaneous rupture of the common bile duct is a rare entity.Case presentationWe report a new observation of a spontaneous rupture of the common bile duct, associated with biliary peritonitis and pancreatitis, in a 15-year-old North African girl. Etiological aspects, specificities of clinical presentation, means of diagnosis, as well as surgical and perioperative management are discussed.ConclusionsThe diagnosis of spontaneous rupture of the common bile duct is a challenge for both radiologist and surgeon. Beyond the difficulty of diagnosis, which requires radiological exploration, management of the subsequent biliary peritonitis involves urgent surgery, life-supporting measures, and close monitoring.

Acute esophageal necrosis: A new case

Acute esophageal necrosis is an uncommon clinical entity. It is diagnosed with upper gastrointestinal endoscopy with the presence of strikingly black necrotic esophagus. Very often no definite etiology is identified, even though a large list of potential associations has been postulated. His treatment is primarily medical. A high mortality is usually related to the underlying medical co-morbidities and diseases. We report a case of acute esophageal necrosis occurring in a patient undergoing Fournier’s gangrene intervention.

Syndrome de la pince mésentérique primitif : cause rare de la sténose digestive haute chez l’adulte

La Presse Medicale - In Press.Proof corrected by the author Available online since vendredi 26 fevrier 2016

Laparoscopic approach in an incarcerated femoral hernia, with the ipsilateral fallopian tube as a single content

The right fallopian tube as a single content of an incarcerated femoral hernia is an uncommon condition. Due to its extreme rarity, preoperative misdiagnosis is frequent.Femoral hernias are more frequent among women. The strangulation rate is higher than in the other groin hernias. Thus, femoral hernias are usually operated on and diagnosed in an emergency setting which leads to higher postoperative morbidity and mortality.The main aim is to verify the vitality of the contents of the hernia sac. In the absence of ischaemic signs, the contents can be safely reduced back into the abdominal cavity. Otherwise, resection is inevitable. The authors report the case of a 20-year-old patient presenting an incarcerated femoral hernia containing the ipsilateral fallopian tube. At laparoscopic exploration, the fallopian tube was seen to be contained within the sac, without the ovary which was in the abdominal cavity. After checking out the vitality of the fallopian tube, it was reduced back into the pelvis. A resection of the hernia sac with a suture of the neck was performed. Postoperative recovery was uneventful and the patient was discharged on the second day following surgery. The patient was informed of the risk of an ectopic pregnancy that could prove fatal due to incarceration of the fallopian tube. To our knowledge, this is the sixth case to be reported in the literature, and the first time a laparoscopic approach has been used in such a case. Diagnostic and therapeutic aspects of this rare condition will be discussed, along with a review of previous reported cases.

An inflammatory pseudotumour of the head of the pancreas - A rare pancreatic tumour

Aim-backgroundAn inflammatory pseudotumour is an uncommon lesion originally described in the respiratory tract. It is currently established that it can occur in a variety of locations, including the pancreas. The aetiology is still not defined. Histological features include inflammatory and other mesenchymal cells without signs of malignancy.CaseThe authors report a case of an inflammatory pseudotumour arising from the head of the pancreas in a 74-year-old male patient. Due to local extension of the tumour, a resection of the tumour was not performed. The patient underwent a double diversion with a hepaticojejunal anastomosis and gastroileal bypass. A strict 4-year follow-up period did not reveal any signs of malignancy or local invasion.ConclusionInflammatory pseudotumour of the pancreas is a rare tumour that is very difficult to diagnose preoperatively. Surgical resection is the first option, in order to obtain histological confirmation of an IMT (inflammatory myofibroblastic tumour) and to resolve the symptoms.

Factors affecting prognosis after curative surgical treatment of gastric cancer

Background: Gastric cancer is a cancer with a poor prognosis. Surgery with adequate lymph node dissection is the only potentially curative treatment for gastric cancer. The aim of this work is to determine the prognostic factors after curative resection for gastric cancer.Patients and Methods: We retrospectively assessed 66 patients who underwent operation for gastric cancer (excluding the eso gastric junction cancer) in a single institution between 2001 and 2015. Results: There were 25 women and 40 men. The median age was 60 years (21–87). Four patients died (6.1%). A total gastrectomy was performed in 35 cases, and a subtotal gastrectomy was performed in 30 cases. The type of lymphadenectomy was D2 lymphadenectomy in 35 cases and D2 without spl énectomy in 30 cases. The pathologic review of the slides revealed that the tumors were stage T3–T4 in 49 cases. The median number of lymph node removed was 14. Median survival rate was 34 months. The median follow-up was 24 months. In multivariate analysis, the location in the fundus, lymph nodes involvement, and involvement of located organs were associated with poor prognosis. Conclusion: After R0 resection with DII lymphadenectomy, fundus location, lymph node Involvement, and involvement of organs were independent predictive factors for survival.

Difficultés diagnostiques et thérapeutiques de l’actinomycose abdominale : à propos d’une observation chez une patiente tunisienne

The Abdominal Actinomycosis (AA) is a rare and often unrecognised suppurative chronic illness. The diagnosis is difficult. It can have a variety of clinical manifestations and can mimic a malignancy. Its established by histology of surgical biopsy. We report a case of a 58 years old woman admitted to our institution for a pain of the right iliac fossa with a mass. The diagnosis was established after surgical intervention and histological examination. The treatment was surgical resection and antibiotherapy by amoxcillin during 6 months. The primary diagnosis of abdominal pelvic actinomycosis is difficult. All organs and anatomic structures of the abdomen can be involved. Even with extensive infection, combined operative and antibiotic therapy allows cure in most cases.