Pneumoretroperitoneum, bilateral pneumothorax and emphysema following endoscopic biliary sphincterotomy

We report a case of pneumothorax, subcutaneous emphysema and pneumoretroperitoneum after an endoscopic sphincterotomy. A 40-yr-old woman presented with dyspnea immediately after she had undergone an endoscopic retrograde cholangiopancreatogram for a residual stone in common bile duct. On arrival to our hospital, she complained about severe dyspnea and on examination subcutaneous emphysema was discovered. A CT scan was conducted and showed a right-sided pneumothorax, a pneumoretroperitoneum in the peritoneal cavity. We recommended to the patient an immediate laparotomic exploration. We discovered a duodenal perforation in which we sutured it with accompanying pyloric exclusion, double truncular vagotomy and gastroenteroanastomosis. Endoscopic retrograde cholangiopancreatogram (ERCP) is a popular procedure for biliary and pancreatic diseases, but it can cause severe complications such as intestinal perforation. Besides perforations, air can spread through the abdominal cavity, retroperitoneum, mediastinum, and the soft tissues of the neck, eventually causing pneumothorax. Early recognition and appropriate management is crucial for optimal results.

[Primary and isolated phrenic hydatid cyst in Tunisia]

The hydatid cyst of the diaphragm is defined as the development of a hydatid cyst in the diaphragm muscle. The purpose of this study is to identify the specific pathogenic, clinical and therapeutic aspects of this hydatid cyst. It is important to confirm the diagnosis of the location before surgery. We report the case of a patient aged 40 years, in whom the diagnosis of hydatid cyst of the diaphragm was made incidentally in the course of a gastric stromal tumour. The patient was operated by a midline laparotomy. Resection of the protruding dome of hydatid cyst of the diaphragm was carried out along with total gastrectomy. The postoperative course was uneventful. After 12 months, the results were negative. The diagnosis of hydatid cyst of the diaphragm is based on the thoraco-abdominal CT scan. The treatment is surgical based on the topographic features of the cyst.

Pancreaticojejunostomy vs. pancreaticogastrostomy following pancreaticoduodenectomy: results of comparative study

AIM

Several techniques have been proposed for reconstructing pancreatico-digestive continuity, which the first goal is reducing the rate of pancreatic leakage after pancreaticoduodenectomy. Only a limited number studies have been carried out. Our objective is to compare the results of pancreaticojejunostomy versus pancreaticogastrostomy following pancreaticoduodenectomy.

METHODS

This is a retrospective and comparative study about 80 patients who underwent pancreaticoduodenectomy. These patients were divided into two groups: pancreaticojejunostomy (group PJ) and pancreaticogastrostomy (group PG).

RESULTS

The PJ group included 39 patients, while 41 patients were included in the PG group. There were no differences between the two groups concerning: patients' demographics, risk factors, indication, mean duration of surgery, texture of pancreatic tissue, need for intraoperative blood transfusion and postoperative prophylactic octreotide. Overall, the mortality postoperative rate was 7.5% (N.=6), the incidence of surgical complications was 50% (51.3% in PJ, 48.8% in PG; P=0.823, not significant). Pancreatic fistula was the most frequent complication, occurring in 17.5% of patients (25.6% in PJ and 9.8% in PG; P=0.062, almost significant). 7.7% of patients who underwent PJ and 14.6% of patients who underwent PG required a second surgical intervention (P=0.326, not significant). There were no differences between the two groups PG and PJ concerning: Postoperative hemorrhage (P=0.63), biliary fistula (P=0.09), acute pancreatitis (P=0.95), delayed gastric emptying (P=0.33). The mean postoperative hospitalisation period stay was similar in both groups (P=0.63)

CONCLUSION

There were not any significant differences between the two groups in the overall postoperative complication rate, the incidence of postoperative haemorrhage, biliary fistula, acute pancreatitis, and delayed.

[Complicated sigmoid tumor: perforated amebiasis]

Amoeboma is an inflammatory mass of the colon. It can be an inaugural symptom and thus pose the problem of differential diagnosis with colon cancer. The purpose of this report is to describe the case of a 43-year-old patient who presented with acute abdomen. Physical examination revealed a perforated circumferential mass in the sigmoid colon. Based on a presumptive diagnosis of colonic cancer complicated by perforation, segmental colectomy was performed. Histological examination of the surgical specimen demonstrated colonic amoeboma. The patient was treated using metronidazole. Although rare, amoeboma must be considered in differential diagnosis of cancer of any colonic mass.

[Distribution of surgical hydatidosis in Tunisia, results of 2001-2005 study and trends between 1977 and 2005]

We have performed an exhaustive retrospective study in all surgical wards (54 services in 35 hospitals) which usually carry out surgical treatment of hydatic cysts in the country, covering the period between January 2001 and December 2005, in order to determine the annual surgical incidence of human cystic hydatidosis in Tunisia. A total of 6249 surgical interventions were recorded during the period 2001-2005. The highest proportion was recorded in the hospitals of Tunis District (42.9%). The service of thoracic surgery from Ariana hospital occupies the first rank (95%). The yearly incidence rate varies between 11 and 13.6 per 100,000. Calculated over the 5 years period, the incidence rate is 63.2 per 100,000 inhabitants, which means an average yearly incidence rate of 12.6 per 100,000 [12.28-12.99]. Governorates of the North West and the Western Central regions of the country are the most endemic area with an average annual incidence rates varying between 19.2 and 33.9 per 100,000, which is at least once and half higher than the national level. After 30 years (1977-2005), the average annual incidence rate slightly dropped, from 15 to 12.6 per 100,000, proving that such zoonosis remains a problem of public health in Tunisia. In order, to control in more or less short term this heavy burden disease and public health expenditure, the only efficient way is the prevention of the diseases with a mass treatment campaign of dogs, principal host of the parasite.

Abdominal metastasis of a parosteal osteosarcoma of the femur: an unusual cause of large-bowel obstruction

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.

Mucocele of appendiceal stump--an atypical presentation and a diagnostic dilemma

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.

[Primary hydatid cyst of the pancreas: Diagnosis and surgical procedures. Report of three cases]

The pancreas is an uncommon site of a hydatid cyst, even in countries where echinococcal disease is endemic. We report three cases of primary hydatid cysts of the pancreas revealed by abdominal pain. The diagnosis was based on ultrasound and CT-scan, which showed a cystic mass in the tail of the pancreas in the two first cases. In the third case, the diagnosis was determined preoperatively and a pancreatic fistula was found in the head of the pancreas during peroperative cholangiography. The echinococcal immunological test (Elisa) was positive in all cases. Surgical treatment included resection of the prominent lump in two patients and a cystogastric anastomosis in the third. Based on these three cases and a study of the literature, the difficulties of diagnosing this rare disease and the surgical procedures are discussed.

[Subcutaneous hydatid cyst. Case report of an exceptional location]

Primary subcutaneous cyst hydatid disease is an exceptional entity. We report a new case involving a 70-year-old woman hospitalized for a subcutaneous mass in the hypogastric area with no local inflammatory signs. Radiological examination was consistent with a partially calcified subcutaneous cyst in the hypogastric area. Complete surgical resection of the mass was performed with uneventful postoperative recovery. Histopathological examination of the surgical specimen demonstrated multivesicular hydatid cyst.

[A previously unreported late complication of Finney strictureplasty]

We report the case of a 23 year old woman, treated for Crohn's disease for 11 years. She was operated on for multiple obstructing jejuno-ileal strictures using strictureplasty technique. Nine stricturoplasties of Heineke-Mikulicz type and one Finney type were performed without immediate postoperative complication. The patient received Imurel(R) and remained in remission for 15 months. Peritonitis due to a perforation of the Finney strictureplasty required re-operation; an ileostomy was performed. Such a late complication of a strictureplasty has not previously been reported in the literature. Although this complication was severe, the indication for this procedure in the surgical management of Crohn's complications should not be modified.

[Subcutaneous rupture of hydatid cyst of liver: dealing with a rare observation]

Hydatid cyst of liver is a parasitosis of endemic proportions in Tunisia. The purpose of this report is to describe a case involving subcutaneous rupture of a hydatid cyst of liver in a 41-year-old patient. Diagnosis was established by ultrasonography and CT-scan. The patient underwent surgical treatment and recovered uneventfully. Subcutaneous rupture remains an uncommon complication. This is only the second case reported in the literature up to now.

[Pseudotumoral gastric amyloidosis]

INTRODUCTION

Localized gastric amyloidosis is rare. It should be considered in differentiation of gastric tumors, in which biopsy is the only means to confirm the diagnosis.

CASE REPORT

A 56-year old male patient presented dysphagia and vomiting. A plastic linitis was suggested by endoscopic ultrasonography. Total gastrectomy and clearance of perigastric lymph nodes were performed. The postoperative pathological diagnosis determined the lesion to be localized gastric amyloidosis and no malignant tumor was found. No sign of recurrence has been found one year after surgical resection.

DISCUSSION

Currently, surgical resection of pathological tissue and circumambient lymph nodes may be a preferable therapeutic strategy for the localized amyloidosis to prevent possible complications.

Tumeur intracanalaire papillaire mucineuse du pancréas dégénérée et fistulisée dans l'estomac, le duodénum, et le côlon

We report a case of intraductal papillary mucinous tumor of the pancreas (IPMT) degenerated and fistulized into the stomach, the duodenum and the colon. Diagnoses of malignancy and fistulization were proven preoperatively. Pancreaticoduodenectomy extended to the body was performed. Pathological examination revealed a malignant IPMT with an invasive component. Of the 3 fistulizations tracts, both gastric and duodenal ones were malignant. To our knowledge, this is the first reported case of IPMT with colonic fistulization. Twelve months later, the patient is alive without signs of recurrence.

[Gastric amyloidosis mimicking malignancy. A case report]

Amyloidosis is an abnormal extracellular deposition of insoluble proteins, which is associated with an involvement of the gastrointestinal tract in 50 to 70% of cases. In primary amyloidosis (light chain amyloidosis), localized gastric involvement is a rare finding which can mimic malignancy. We report the case of a 56-year-old man, admitted with upper digestive outlet obstruction. Linitis plastica with lymph node involvement was suspected by gastroscopy, barium meal and endoscopic ultrasonography but was not confirmed by gastric biopsies. The patient was treated with total gastrectomy with lymph node dissection. Pathological examination demonstrated gastric and lymph nodes amyloidosis and no malignant tumor was found. The patient died 9 months later from cardiac failure due to amyloidosis.

[Laparoscopic cholecystectomy in a patient with situs inversus]

Laparoscopic cholecystectomy is the standard approach to manage symptomatic gallbladder stones. However, only twelve patients with total situs invertus have been previously reported in the literature. We report a new case of a 58-year-old patient hospitalized for acute pain of the left hypochondrium with fever. The diagnosis of acute cholecystitis with situs inversus totalis was made following clinical examination and radiological investigations. Laparoscopic cholecystectomy was subsequently performed through a modification of the technique to adapt to the mirror image anatomy.

[Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas. A case report]

Undifferentiated carcinoma with osteoclast-like giant cells is a rare pancreatic neoplasm, with a possible cystic pattern, includes an adenocarcinoma component and giant cell mimicking osteoclastic bone tumor. We report the case of a 72-year woman admitted for jaundice and epigastric pain. Abdominal ultrasound and computed tomography scan revealed a 6 x 5 cm cystic and solid tumor of the pancreatic head with both bile duct and pancreatic duct dilatation. A pancreaticoduodenectomy was performed and pathologic examination revealed an undifferentiated carcinoma with osteoclast-like giant cells of the pancreatic head. The patient was alive and disease-free with a 18-month follow-up.

[Primary hydatid cyst of adrenal gland. Report of two cases]

Primary hydatid cyst of adrenal gland is still an exceptional localization. The adrenal gland is an uncommon site even in our country in which echinococcal disease is endemic. We report two cases of primary hydatid cyst of adrenal gland presented with isolated abdominal pain. The diagnosis was based on CT-scan, which showed a cystic mass of respectively the right and left adrenal gland with a calcified wall. The echinococcal immunologic test (Elisa) was positive in one case. The surgical treatment consisted on a total resection of the cyst, without rupture of the cystic wall and preserving the gland. The diagnosis was confirmed on the macroscopic examination of the resected pieces. In the first case the cyst was multilocular filled with daughter cysts and in the second case the cyst was unilocular filled with hydatid membrane and clear fluid. In the two cases, the postoperative course was uneventful. No recurrence had occurred respectively after 24 months and 36 months of follow up.

Retrovesical hydatid disease: a clinical study of 27 cases

OBJECTIVES

We report our experience with 27 cases of retrovesical hydatid cysts (RVHC) and discuss the pathogenesis, diagnosis and treatment of this hydatid location.

MATERIALS AND METHODS

We retrospectively reviewed the clinical files of 27 patients with RVHC admitted to our institution from January 1984 to December 2000.

RESULTS

The predominant presenting symptom was burning micturition (13 cases). Physical examination revealed a pelvic mass in 17 patients. Preoperative diagnosis was based upon ultrasonography, intravenous pyelography, and serology tests. CT was performed in 10 patients. We noticed that RVHC can be subdivided into two categories: those that develop mainly in the peritoneal cavity (intraperitoneal type; 18 cases), and those that develop mainly in the confined pelvic cavity (subperitoneal type; 9 cases) and are more liable to induce ureteral compression and more difficult to approach surgically. One patient died before operation. Twenty-six patients were operated and had either a total (9 cases) or partial pericystectomy (17 cases). Four patients underwent closure of cystovesical fistulas. Two patients had ureteral reimplantation. Postoperatively, 1 patient died with septic shock and 1 was reoperated for peritonitis. Mean postoperative hospital stay was 8 days.

CONCLUSIONS

The preoperative diagnosis of RVHC is based mainly on ultrasonography. Open surgery is the treatment of choice.

[Right paraduodenal hernia: a case report]

Paraduodenal hernia is a rare etiology of intestinal obstruction. Its preoperative diagnosis can only be made by a well-performed upper gastrointestinal series. We report a case of a 19 years old man with abdominal pains and recurrent Koenig's syndromes. The upper gastrointestinal series and CT scan showed a right paraduodenal hernia. we reviewed the anatomy. physiopathology, symptoms and radiographic criteria for the diagnosis of the paraduodenal hernia.

[Ménétrier disease associated with a gastric adenocarcinoma. Apropos of 2 cases]

Two new cases of Menetrier's disease with gastric adenocarcinoma in two men aged 62 and 81 years, respectively, are reported. In both cases, the diagnosis was established by histologic examination of the operative specimen. Emphasis is placed on diagnostic difficulties and on the risk of malignant transformation of Menetrier's disease, which should be viewed as a precancerous gastric lesion.

[Value of ultrasonics in differential diagnosis of pseudotumor hydatid cyst of the liver and other solid hepatic masses (prospective study)]

A prospective study in 88 consecutive patients with solid hepatic mass was performed to determine the value of ultrasound in the diagnosis of pseudo-tumoral hydatid cyst. Ultrasonography systematically searched 5 evocative signs: hypoechoic spiral, peripheric hypoechoic rim surrounded by an echoic border, daughter cysts, hyperechoic areas with shadowing and/or enhancement of back-wall echos. Diagnosis of pseudo-tumoral hydatid cyst was based upon the association of, at least, 2 signs. The sensitivity of echography was 92.3% and the specificity was 98.3%. Furthermore this study allow us to propose a new, more accurate, definition of the hydatid spiral. However, serologic tests were found to be of little interest.

[Pseudotumoral abdominal cysto-steato-necrosis: an unusual etiology]

We report an unusual case of subcutaneous pseudo-neoplastic focal fat necrosis in a woman with a Mersilen plate placed outside the abdominal wall muscles. To our knowledge, this association has not been previously reported in the radiologic literature. The differential diagnosis using ultrasound and computerized tomography is discussed.

[Rupture of a hydatid cyst of the liver into the peritoneal cavity. Value of computed tomography]

The authors report one case of a intraperitoneal rupture of an hydatic cyst. The diagnosis of rupture was performed pre-operatively by tomodensitometry which has demonstrated the rupture and an intraperitoneal epanchement.

[Cystic lymphangioma of the spleen. An exceptional site]

The authors report a case of cystic lymphangiomatosis of the spleen. Study of this case and a review of the literature confirm the rarity of this site and problems of differential diagnosis with hydatid disease. Treatment remains surgical and the prognosis is good.

[Abdominal actinomycosis: a rare complication of gastric surgery? Apropos of a case]

One case of abdominal actinomycosis is reported which was detected in a diabetic patient three years after surgery for duodenal peptic ulcer. Gastric actinomycosis is very rare and is usually discovered during surgery for gastric mass. The role of surgery as a predisposing condition to infection is discussed. The diagnosis rely on the characterization of the bacteria in cultures from a discharging wall fistula and on histopathologic examination which reveals the characteristic actinomycotic granules.