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Background: The accessory spleen is a congenital defect with an additional splenic tissue to the native spleen due to an incomplete fusion of splenic masses during the embryologic period. The preoperative diagnosis is usually mistaken for a retroperitoneal neoplasm. The aim of the present manuscript is to highlight the diagnostic difficulties of a retroperitoneal spleen. Case presentation: A 41-year-old woman was admitted to the surgical department for an abdominal mass discovered by auto palpation associated with a left lower quadrant pain. The computed tomographic scan showed a heterogeneous and partially necrotic retroperitoneal mass located along the left primitive iliac vessels. Arterial supply to the mass arose from the aorta and the left iliac vessel. The spleen was normal. MRI examination showed a left retroperitoneal heterogeneous and necrotic mass, surrounding the iliac vessels extended from the aortic to the left iliac bifurcation, hyper vascularized at the arterial time with a peripheral capsule intensely enhanced, and there were two other lateroaortic vascularized masses. The patient underwent laparotomy resection of the retroperitoneal mass. The examination of the specimen concluded to an accessory spleen. The postoperative course was uneventful. Conclusion: An accessory spleen on the retroperitoneal position is extremely uncommon. Preoperative diagnosis is still challenging. The main misdiagnosis is neoplastic disease.

Clinical presentation of liver hydatidosis can vary from asymptomatic forms to lethal complications. We report herein a rare case of a 27-year-old male from a rural Tunisian region who presented with large-abundance haematemesis, haemodynamic instability, and marked biological data of hypersplenism. Endoscopy showed bleeding esophageal varicose veins that were ligated. Abdominal ultrasound concluded the presence of three type CE2 hydatic liver cysts causing portal cavernoma with signs of portal hypertension. Despite resuscitation, the patient died of massive rebleeding leading to haemorrhagic shock. Hepatic hydatid cyst should be considered as an indirect cause of gastrointestinal bleeding in endemic countries. Early abdominal ultrasound in varicose haemorrhage is essential in orienting the diagnosis.

INTRODUCTION: Pneumatosis cystoid intestinalis (PCI) is a rare disease reported in the literature affecting 0.03% of the population. It has a variety of causes and its manifestation may change widely. In the acute complicated form of pneumatosis intestinalis, management is challenging for physicians and surgeons. CASE PRESENTATION: We present a case of a 60-year-old patient who was admitted to our surgical department with a symptomatology suggestive of small bowel occlusion. Computed tomography demonstrated ileal volvulus associated with parietal signs suffering and pneumoperitoneum. An emergent exploratory laparoscopy followed by conversion was performed demonstrating segmental ileal pneumatosis intestinalis secondary to a small bowel volvulus due to an inflammatory appendix wrapping around the distal ileum. Detorsion, retrograde draining, and appendectomy were performed. DISCUSSION: PCI is an uncommon disease, affecting 0.03% of the population. It is usually presenting as a marginal finding resulting from various gastrointestinal pathologies. This case is exceedingly rare in the literature, featured by the ileal volvulus due to appendicitis.CONCLUSION: This work emphasizes the importance of surgical procedures in the management of symptomatic pneumatosis intestinalis.

Background: Ambulatory surgery is defined as surgery without an overnight hospital stay, which allows the patient to return home on the same day of admission after the surgical procedure. It is increasing countinuously in the world because of its several advantages. This study aimed to describe the experience of our department in outpatient hernia surgery, evaluate its feasibility and safety, and determine the predictive factors for failure of this surgery. Results: We collected 1294 patients. One thousand twenty patients underwent groin hernia repair (GHR). The failure rate of ambulatory management of GHR was 3.7%: 31 patients (3%) had an unplanned admission (UA) and 7 patients (0.7%) had an unplanned rehospitalisation (UR). Morbidity rate was 2.4% (24 patients) and mortality rate was zero. In multivariate analysis, we did not identify any variable predicting discharge failure in the GHR group. Two hundred and seventy-four patients underwent ventral hernia repair (VHR). The failure rate of ambulatory management of VHR was 5.5%: 11 patients (4%) had a UA and 4 patients (1.5%) had an UR. Morbidity rate was 3.6% (10 patients) and the mortality rate was zero. In multivariate analysis, we did not identify any variable predicting discharge failure in the VHR group. Conclusions: Our study data suggest that ambulatory hernia surgery is feasible and safe in well-selected patients. The development of this practice would allow for better management of eligible patients and would offer many economic and organisational advantages to healthcare structures.

Introduction: Solitary tuberculosis of the upper gastrointestinal tract is a rare pathology that usually mimics the clinical and radiological features of malignant tumors. A gastric subepithelial tumor is usually detected during diagnostic endoscopy. Stomach tuberculosis, in particular, can appear as a subepithelial tumor of the stomach wall. Several cases of gastric tuberculosis imitating subepithelial tumor gastric have been reported recently. Case report: We describe a case of a Patient with tuberculous lymphadenitis that mimics the submucosal gastric tumor. A 52-year-old female was admitted to our department; endoscopy revealed a submucosal compression or anterior submucosal lesion, erosive anterior gastropathy, and a fistulous orifice located in the bulb. The patient was diagnosed with a gastric tumor and Endoscopic ultrasound demonstrated a rounded antral lesion, hypoechogenic, not vascularized, that is distant from the gastric wall whose 5 layers appear of normal aspect. The patient was operated on for exploratory laparotomy. the biopsy was sent for frozen section examination that concluded to tuberculous intraperitoneal lymphadenitis. The patient received anti-tuberculosis treatment.Conclusion: Abdominal lymphadenitis tuberculosis is an uncommon situation which presents a dilemma for clinicians, as a great mimicker for a long list of differential diagnoses.

Introduction Splenic artery aneurysms are a rare arterial disease. They are considered as the most common visceral artery aneurysms and found mostly in multiparous women and patients with portal hypertension. Case presentation We present a case of an unruptured SAA of the hilum in a 58-year-old woman, with vague abdominal pain, treated by open splenectomy. Discussion Splenic artery aneurysms are often difficult to diagnose due to their vague or asymptomatic forms. However, they present a high risk of rupture that may cause fatal hemorrhage and death. Symptomatic artery aneurysms or SAA, larger than 20 mm and aneurysms in pregnant or in women of childbearing age are indications for surgery because of the increased risk of rupture in these patients’ groups. As known generally, the treatment of SAA has been surgical ligation of the splenic artery, ligation of the aneurysm or aneurysmectomy with or without splenectomy, depending on the aneurysm location. There are other percutaneous interventional procedures. Conclusion A multidisciplinary discussion is an important step in choosing the optimal treatment for visceral aneurysms. Surgical approaches should take place especially in cases where splenic perfusion is seriously threatened., Highlights • Splenic artery aneurysms are a rare arterial disease, They are often difficult to diagnose due to their vague or asymptomatic forms. • Their Management depends on their size, location, and presenting symptoms. • Conventional surgery has not lost of its efficiency and indications, especially in hemodynamic emergencies, unexperienced surgeons or surgical history of laparotomy.

Background: Erector spinae plane (ESP) block is a recently described interfacial block, and since 2016, studies have shown that it is a safe technique related to the lower risk of neurovascular and pleural injury comparing to epidural or paravertebral blockade. The application of ESP block in abdominal surgery is relatively limited to case reports and small population studies, which is why we believe every new case of its application should be a valuable contribution. Case presentation: With this present case, we explored the efficacy of bilateral ESP block as a post-operative analgesia technique for liver hydatid surgery on a 56-year-old patient. Ultrasound-guided bilateral ESP block was applied at T7 level, while the patient was awake before general anaesthesia induction. The local anaesthetic used was 20 mL ropivacaine (0.375%) and 2 mg dexamethasone on each side. After recovery from anaesthesia, she reported mild pain (visual analogue score of 5 on effort). After 12 hours post-operatively, she received only one dose of paracetamol 1 g considered as rescue analgesic. She did not experience nausea and vomiting episodes. We noted a sensory block extending from T4 to T10. Conclusion: To our knowledge, it may be the first adult bilateral single-shot case report for this specific procedure. This technique appears to be safe and effective on post-operative analgesia for this type of surgery; however, prospective studies comparing ESP block to other techniques are needed.

Background While the incidence of gastric cancer has decreased worldwide in recent decades, the incidence of poorly cohesive carcinoma (PCC) is rising. The prognostic significance of gastric PCC remains a subject of debate. Objective To analyze the prognosis of gastric PCC in a Tunisian cohort. Methods A total of 122 gastric adenocarcinoma patients who underwent curative gastrectomy from 2001 to 2014 at Habib Thameur hospital in Tunis, Tunisia were included. The clinicopathological parameters and prognosis of PCC were analyzed in comparison with non PCC (NPCC). Results Sixty one patients (50%) presented PCC. Patients were younger in PCC group (p = 0,001). There was no difference in sex distribution between the two groups. PCC was more likely to be stage T4 (55.7% vs 34.4%; p = 0.033), N3 (67.8% vs 30%; p < 0.001) and have a higher metastatic lymph node ratio (p < 0.001). Hepatic metastases were more frequent in NPCC group (p = 0.031) whereas peritoneal carcinomatosis was more common in PCC group (p = 0.004). Perineural invasion was more frequent in PCC group (p = 0.001). Resection margins were more often positive in PCC group (31.1% vs 9.8%; p = 0.004). There was no difference in recurrence rate between the 2 groups (p = 0.348). The 5-year survival was similar in the NPCC and PCC (respectively 43% vs 23 %; p = 0.247). Survival rates were also comparable in early stage (100% vs 80% respectively for PCC and NPCC; p = 0.527) as well as for advanced stage (16% vs 35% respectively for PCC and NPCC; p = 0.538). PCC was not a prognostic factor for survival. Interestingly, advanced age, adjacent structures invasion, positive resection margins were specific prognostic factors for PCC. Conclusion In our study PCC was not a prognostic factor for survival. Advanced age, adjacent structures invasion and positive resection margins were specific prognostic features for this histological subtype., Biological sciences; Health sciences; Pathology; Abdominal surgery; Cancer surgery; Gastric cancer, Poorly cohesive carcinoma, Prognosis, Survival.

Clinical presentation of liver hydatidosis can vary from asymptomatic forms to lethal complications. We report a rare case of a 27-year-old male from a rural Tunisian region who presented with large-abundance haematemesis, haemodynamic instability, and marked biological signs of hypersplenism. Endoscopy showed bleeding esophageal varicose veins that were ligated. Abdominal ultrasound concluded the presence of three type CE2 hydatic liver cysts causing portal cavernoma with signs of portal hypertension. Despite resuscitation, the patient died of massive rebleeding leading to haemorrhagic shock. Hepatic hydatid cyst should be considered as an indirect cause of gastrointestinal bleeding in endemic countries. Early abdominal ultrasound in varicose haemorrhage is essential in orienting the diagnosis.

Pneumatosis cystoid intestinalis is a rare disease reported in the literature affecting 0.03% of the population. It has a variety of causes and its manifestation may change widely. It usually presents as a marginal finding resulting from various gastrointestinal pathologies. In the acute complicated form of pneumatosis intestinalis, management is challenging for physicians and surgeons. We present a case of a 60-year-old patient who was admitted to our surgical department with a symptomatology suggestive of small bowel occlusion. Computed tomography demonstrated ileal volvulus associated with parietal signs suffering and pneumoperitoneum. An emergent exploratory laparoscopy followed by conversion was performed demonstrating segmental ileal pneumatosis intestinalis secondary to a small bowel volvulus due to an inflammatory appendix wrapping around the distal ileum. Further, detorsion, retrograde draining, and appendectomy were performed because there were no signs of necrosis and the appendix was pathological. The postoperative course was uneventful. This case is exceedingly rare in the literature, because it was featured by the ileal volvulus due to appendicitis.This case report emphasizes the importance of surgical procedures in the management of symptomatic pneumatosis intestinalis.

Background Tuberculosis (TB) is a common endemic disease in Tunisia. Abdominal location is rare. Early diagnosis of abdominal TB remains difficult due to its non-specific clinical presentations. The aim of our study is to highlight the characteristics of the different presentations, to characterize tools contributing to a positive preoperative diagnosis, and finally to assess the role of surgery in the management of this entity. Materials and methods A retrospective review from 2005 to 2015 identified 90 cases of confirmed abdominal TB managed in the Department of General Surgery of the Habib Thameur Hospital. The diagnosis was established by histopathology examination for all cases. This study was approved by the ethical committee. Results The mean age of the patient was 44.13 years with a sex ratio (M/F) of 0.34. We collected 56 cases of peritoneal TB, 12 cases of abdominal lymph node TB, 10 cases of intestinal TB, four cases of hepatic TB, and two cases of gallbladder's TB. For six patients, an association of many localizations was noted. The diagnosis was suspected on clinical, biological, and morphological arguments, but the confirmation was always made by surgical exploration and pathological examination of removed specimens. Surgical management was urgent in complicated cases (13.3%). Laparoscopy was performed in 71 cases (78.9%). Laparoscopic features of peritoneal TB were specific and always confirmed by histological examination. Conclusion Despite the wide range of examination available for the preoperative exploration of abdominal TB, diagnosis is usually late and difficult. TB is a medical condition. However, surgical exploration is frequently needed in the management.

Solitary tuberculosis of the upper gastrointestinal tract is a rare pathology that usually mimics the clinical and radiological features of malignant tumors. A gastric subepithelial tumor is usually detected during diagnostic endoscopy. Stomach tuberculosis, in particular, can appear as a subepithelial tumor of the stomach wall. Several cases of gastric tuberculosis imitating subepithelial gastric tumors have been reported recently. We describe the case of a patient with tuberculous lymphadenitis that mimics a submucosal gastric tumor. A 52-year-old female was admitted to our surgical department for epigastric pain and weight loss. Endoscopy was inconclusive; it revealed either a submucosal compression or an anterior submucosal lesion with erosive anterior gastropathy and a fistulous orifice located in the bulb. The patient was diagnosed with a gastric tumor and an endoscopic ultrasound demonstrated a rounded hypoechogenic antral lesion that was not vascularized and was distant from the gastric wall, whose five layers appeared of a normal aspect. The patient underwent an exploratory laparotomy. A biopsy was sent intraoperatively for frozen section examination, and concluded that the diagnosis was tuberculous intraperitoneal lymphadenitis. The patient received anti-tuberculosis treatment. This case demonstrates that gastric tuberculosis remains a challenging diagnosis.

Background Since the advent of immunohistochemistry for the diagnosis of stromal tumours, the incidence of leiomyosarcomas has significantly decreased. Nowadays, gastric leiomyosarcoma is an exceptionally rare tumour. We report the second case in the English literature of gastric leiomyosarcoma revealed with massive bleeding and hemodynamic instability and diagnostic pitfalls that we encountered. Case presentation A 63-year-old woman, with 2 years’ history of dizziness and weakness probably related to an anaemic syndrome, presented to the emergency room with hematemesis, melena and hemodynamic instability. On examination, she had conjunctival pallor with reduced general condition, blood pressure of 90/45 mmHg and a pulse between 110 and 120 beats per minute. On digital rectal examination, she had melena. Laboratory blood tests revealed a haemoglobin level at 38 g/L. The patient was admitted to the intensive care department. After initial resuscitation, transfusion and intravenous Omeprazole continuous infusion, her condition was stabilized. She underwent upper gastrointestinal endoscopy showing a tumour of the cardia, protruding in the lumen with mucosal ulceration and clots in the stomach. Biopsies were taken. Histological examination showed interlacing bundles of spindle cells, ill-defined cell borders, elongated hyperchromatic nuclei with marked pleomorphism and paranuclear vacuolization. Immunohistochemistry showed positivity for Vimentine, a strong and diffuse immunoreactivity for smooth muscle actin (SMA). Immunoreactivities for KIT and DOG1 were doubtful. Computed tomography scan revealed a seven-cm tumour of the cardia, without adenopathy or liver metastasis. The patient underwent laparotomy. A total gastrectomy was performed without lymphadenectomy. Post-operative course was uneventful. Histological examination of the tumour specimen found the same features as preoperative biopsies with negative margins. We solicited a second opinion of an expert in a reference centre for sarcomas in France, who confirmed the diagnosis of a high grade gastric leiomyosarcoma. Conclusion Gastric leiomyosarcoma is a rare tumour. Diagnosis is based on histological examination with immunohistochemistry, which could be sometimes confusing like in our case. The validation of a pathological expert is recommended.

Introduction: Unintentional post-operative open abdominal wall (UPOAW) is a postoperative complication that consists of the early separation of the fascial layer after a primary closure of a laparotomy incision. This complication is associated with great morbidity and mortality. In this article, we studied the frequency of some of these known factors in our series and we briefly discussed the management of this complication.Methods: It was a monocentric retrospective and descriptive study. We enrolled patients with UPOAW, admitted in the department of surgery in Habib Thameur hospital in Tunis (Tunisia), between January 2010 and December 2015.We did not include traumatic patients. We excluded patients with missing data from medical records.Results: The study was conducted on fifteen patients. Eight out of fifteen were men. Patients were aged between 41 and 76 years, with a mean age of 66.6 ± 11.4 years. In the past medical history, chronic obstructive pulmonary disease was noted in three patients, cirrhosis in three patients, diabetes in one patient and a history for laparotomy in one patient. Eight out of fifteen underwent emergent surgeries. Two out of these eight patients had haemodynamic instability throughout surgery. In the postoperative course, coughing was noted in three patients, abdominal distension from ileus in three patients, vigorous postoperative ventilation in two patients and vomiting in one patient. UPOAW was diagnosed between postoperative day zero and postoperative day twenty-one, with a mean time of diagnosis of 10.1 ± 6.6. All patients had immediate closure of the fascial layer. The surgeon used retro-fascial polyglactin mesh in three patients. Relaxing incisions were used in 5 patients. Morbidity after reoperation was 46.7 % (7/15) and mortality was 33.3 % (5/15).Conclusion: UPOAW is a serious complication with high morbidity and mortality. Many factors can contribute to this complication. Every visceral surgeon is confronted with this problem at some point of his carrier and should apply the adequate treatment to his patients depending on his decision and experience. Strong level of evidence is needed to establish clear guidelines for the management of this heterogenous complication.

Collision tumors of adenocarcinoma and MALT (Mucosa-associated lymphoid tissue) lymphoma are often rare findings of resection specimens of gastric carcinomas. The fact that these two histological lesions are contiguous may suggest a common oncogene. As it is widely known, Helicobacter pylori (H. pylori) plays a leading role in gastric oncogenesis. Could it be responsible for these tumors? As of today, the exact mechanism is still unclear. However, some histological findings may suggest that H. pylori promotes the formation of MALT lymphoma which increases the risk of carcinomatous changes. Prognosis of collision tumors is tightly linked to the carcinoma lesion, which is generally poor due to diagnostic delay. Large scale strategies to eradicate H. pylori and detect early lesions could reduce the mortality of this disease.

La Presse Medicale - In Press.Proof corrected by the author Available online since mardi 16 aout 2016

Background Gastroduodenalartery (GDA) pseudo-aneurysms are very rare. Their clinical importance lies in the eventuality of rupture, causing bleeding and ultimately exsanguination. Case presentation We report the case of a man, with prior history of biliary surgery, presenting with haemobilia secondary to a rupture of GDA pseudo-aneurysm eroding the main bile duct. The patient was treated with coil embolization. This technique is considered to be safe. However, on the long term, some complications may occur. In our case, the patient presented with cholangitis subsequent to coil migration in the lower bile duct. This situation was managed using endoscopic retrograde cholangiopancreatography (ERCP) allowing coil extraction with favorable evolution. Conclusions GDA pseudo-aneurysms are very rare. Bleeding, secondary to the rupture of these lesions, is a serious complication that could lead to death. Diagnosis and treatment of ruptured GDA pseudo-aneurysms rely on angiography. This method is considered to be safe. Cholangitis secondary to coil migration in the main bile duct is exceedingly rare,but remains an eventuality that physicians should be cognizant of.

Key points Spigelian hernias represent 1–2% of all abdominal wall hernias. The pathogenesis often involves a dehiscence of the transverse and internal oblique muscle aponeurosis. The diagnosis is made by physical examination; but sometimes it is complicated by obesity. The risk of strangulation is important and can reach 30%. The abdominal CT scan is helpful in the description of hernia's topography and sometimes in diagnostic confirmation. The treatment is surgical. The rate of recurrence after direct closure is considerable. Synthetic mesh repair seems to be a more adequate alternative. The advent of laparoscopy has improved the management of these hernias.

Sclerosing encapsulating peritonitis (SEP) is a very rare entity characterized by encasement of small intestine by a fibrocollagenous membrane. It is divided into primary (idiopathic) which is named as abdominal cocoon and secondary forms. The preoperative diagnosis is difficult and most cases are diagnosed intraoperatively. A conservative treatment approach is the most suitable management strategy in asymptomatic idiopathic SEP. In this paper, we aimed to present a case of idiopathic SEP revealed by intestinal obstruction.

Background: Cancers of the small bowel are rare. Diagnosis is late and difficult because of the lack of specific signs. Treatment is surgical. Prognosis is usually poor and depends on the histological type of tumor. Aim of Study: To specify the epidemiological, clinical and therapeutic characteristics of small bowel primary cancers in order to improve their prognosis. Material and Methods: This is a retrospective study about 20 cases of malignant tumors of the small bowel, collected in the department of general surgery of Habib Thameur Hospital in Tunis (Tunisia), from January 1994 through June 2011. Results: Our series involved 11 women and 9 men aged 62 on average (range: 44 - 80 years). In 45% of cases, the diagnosis was made in a patient rushed to hospital with clinical features of acute generalized peritonitis (66% of all surgical emergencies). Intestinal transit was performed in 5 patients only. Ultrasound abdominal examination was performed in 11 patients. Abdominal CT scan was performed in 7 patients, but the results were conclusive in 4 cases only (57%). Small bowel scanning was done in 5 patients only, but led to a positive diagnosis in all of them. All of our patients underwent surgery. Tumors of the small bowel were histologically divided as follows: carcinoid tumor (8 cases), leiomyosarcoma (7 cases), giant B-cell lymphoma (2 cases), malignant stromal tumor (2 cases) and malignant myxoid schwannoma (1 case). Malignant tumors of the small bowel most commonly arise in the ileum (60%) followed by the jejunum (35%). As for the long-term course, there was a recurrence at one year of a leiomyosarcoma and two recurrences of stromal tumors associated with liver metastases. Conclusion: Small bowel cancers are rare. Time to consultation is long and diagnosis is difficult and late due to the absence of typical presentation. Treatment is surgical and progression depends essentially on histological findings.

Spigelian hernias represent 1-2% of all abdominal wall hernias. The pathogenesis often involves a dehiscence of the transverse and internal oblique muscle aponeurosis. The diagnosis is made by physical examination; but sometimes it is complicated by obesity. The risk of strangulation is important and can reach 30%. The abdominal CT scan is helpful in the description of hernia's topography and sometimes in diagnostic confirmation. The treatment is surgical. The rate of recurrence after direct closure is considerable. Synthetic mesh repair seems to be a more adequate alternative. The advent of laparoscopy has improved the management of these hernias.

Acute mesenteric ischemia is a surgical emergency that requires a quick diagnosis and therapeutic care. Without treatment, the outcome is towards intestinal infarction whose prognosis remains grim.To look for predictive factors of mortality of this disease.We retrospectively reviewed the clinical data of patients hospitalized between January 2000 and December 2008 for acute mesenteric ischemia. Univariate and multivariate analysis of factors that could influence mortality was conducted.26 patients, predominantly male, were included. The mean age was 60 years. These patients were cared for on average 4 days after the onset of symptoms. The diagnosis was made pre-operatively in 9 patients, by CT scan in 8 patients and by Doppler ultrasound in 1 patient. The cause of AMI was arterial thrombosis in 19 cases, venous thrombosis in 4 cases and non occlusive mesenteric ischemia in 3 cases. 25 patients were operated on emergency 24 times by a laparotomy and one time by a laparoscopy. The surgery consisted in bowel resection in 15 patients; an abstention was decided in one case of venous mesenteric ischemia and in 9 cases where necrosis affected all small bowels. Revascularization of the superior mesenteric artery was associated in 4 cases. Outcome was simple in 8 patients. The mortality rate was 69%, death occurred in a period of J0 to J90 after surgery. This rate wasn't influenced by age or sex. It was higher in patients with preoperative collapse (p = 0.02) and having an expansive bowel necrosis (p=.0001). The prognosis is better in cases of venous infarction with a mortality rate of zero.Prognosis of acute mesenteric ischemia depends on the aetiology and the quickness of treatment. It is directly linked to the extension of intestinal infarction. An urgent and multidisciplinary care is necessary.

Gastric heterotopia is a rare congenital lesion, described everywhere in the body, but involves predominantly the digestive tract. Diagnosis is based on histologic examination and requires the presence of gastric mucosa, especially fundic. This diagnosis is usually easy, but sometimes it can be misinterpreted as gastric metapalsia . This latter is an acquired and frequent lesion of the gastrointestinal tract.To determine the relationship between this affection and the other digestive malformations, to describe the clinical characteristics and the evolution of this lesion and to discuss the differential diagnosis particularly the gastric metaplasia.Twelve cases of gastric heterotopia were diagnosed over a 12-year period at Habib Thameur Hospital. Clinical data was obtained and all the slides were reviewed.Nine cases were found in Meckel's diverticulum (75%), one case in intestinal duplication, one case in the esophagus and another in the gallbladder. The mean age of patients at diagnosis was 16 years with a peak of incidence at the first decade of life. Intestinal obstruction and digestive bleeding were the most presenting features. Heterotopic gastric mucosa complicates other congenital anomalies such as common mesentery, vestigial polyp of the liver, appendiceal agenesis and heterotopic pancreas. Differential diagnosis consists in gastric metaplasia was found extensively in a patient with Crohn's disease associated with Meckel's diverticulum.Gastric heterotopia is frequently associated with congenital anomalies especially with Meckel's diverticulum and digestive duplication. Diagnosis relies on histology, mainly on finding heterotopic fundic glands in normal organizational structure. Sometimes, differentiating between gastric heterotopia and gastric metaplasia requires clinical confrontation.

the purpose of our trial is to evaluate the impact of the intravenous perfusion of magnesium on the morphin consumption and on the controle of the stress neuro-endocrin and metabolic reaction in major digestive surgery.prospective, randomized, double blinded study versus placebo.Including 42 ASA I patients, scheduled for major digestive surgery, randomized into two groups : Magnesium, receiving a bolus of magnesium sulfate; 50 mg/kg, followed by a continuous perfusion; 10 mg/kg/h for the 24 postoperative hours. The control group received the same volume of an isotonic saline solution.Postoperative analgesia was assured by morphin PCA. The patients were evaluated by the pain visual analogic scale (VAs), the total dose of morphine consumed and the evolution of the biological markers of stress (glycemia, cortisol, ATH, prolactine and IL6) during the first 24 postoperative hours. Hemodynamic and respiratory parameters, side effects and patient satisfaction were recorded.the total dose of morphine consumed during the first 24 postoperative hours,was equivalent in the two groups (44,49+/-6,4 vs 45,26+/-9,1 mg; p= 0,59).the initial pain VAS means were equivalent (68 mm +/- 15 vs 71 mm+/-14). Ulterior pain VAS means, after morphin titration then with PCA were also equivalent and less to 40 mm. the global amplitude and the evolution of the stress markers evaluated by the surface under curbs were comparable in the two groups, despite a magnesemia twice higher than the normal values in the magnesium group.the satisfaction and the incidence of side effects were similar.association of magnesium to morphin PCA does not help to reduce morphin consumption, and does not affect the control of the stress reaction in major digestive surgery.

The objective of this study is to evaluate the feasibility, efficacy and safety of laparoscopic repair for perforated duodenal ulcer.One hundred and sixty patients were treated by coelioscopic procedure for a perforated duodenal ulcer. The procedure consists on a suture of perforated ulcer associated with a peritoneal lavage. A medical treatment of Helicobacter pylori associated with an inhibitor of the protons pomp was conducted.The coelioscopic procedure permitted to confirm the diagnostic of perforated duodenal ulcer in all cases. A simple suture of the ulcer was done in 155 cases. The conversion was compulsory in 5 cases, because of difficulties of the peritoneal lavage in 2 cases, a bleeding associated with perforation of the ulcer in one case and associated stenosis in 2 cases. Mean duration was 90 min (extremes 50 - 120 min). Complications occur in 3,1%. They were post - operative peritonitis in 3 cases and duodenal fistulae in 2 cases. All patients were reviewed at 16 months. A recurrence, either clinical or endoscopic occurs in 4 cases because of no adhesion to medical treatment.Coelioscopic treatment of perforated duodenal ulcer is a safe and efficacy method. It permits to avoid potential septic and parietal complications of laparotomy. The actual efficacy of medical treatment mustn't allow place to the radical treatment of ulcerous illness.