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Resume Objectifs de l’etude Evaluer les effets de la chirurgie bariatrique sur les parametres anthropometriques et metaboliques chez des sujets tunisiens obeses morbides. Methodes Il s’agit d’une etude retrospective qui a inclus 47 sujets ayant une obesite morbide et qui ont beneficie d’une chirurgie bariatrique entre 2004 et 2012. L’âge moyen etait de 36,5 ± 8,9 ans et le sex-ratio de 0,08. Les donnees cliniques et paracliniques pre et post-operatoires ont ete relevees a partir des dossiers medicaux des patients. Resultats La perte moyenne de l’excedent ponderal (PEP) etait de 50,6 % [17,9–99,8]. Le taux d’echec (PEP Conclusion Notre etude a prouve l’efficacite de la chirurgie bariatrique chez nos patients obeses morbides dans l’obtention d’une PEP significative et dans la remission des comorbidites.

Les tumeurs pseudopapillaires et solides du pancréas (TPPS) sont des tumeurs épithéliales rares. Dans la plupart des cas, il s’agit de tumeurs survenant chez la femme jeune dans la deuxième ou la troisième décennie de la vie. La survie après résection primaire approche 90% à 5 ans. Nous rapportons le cas d’une jeune patiente de la vingtaine qui présente une tumeur pseudopapillaire et solide du pancréas découverte devant des douleurs abdominales sans perturbations des bilans biologiques. La tomodensitométrie (TDM), l'imagerie par résonance magnétique (IRM) et l'échographie endoscopique ont révélé une masse bien limitée se développant au dépend de l'isthme pancréatique. L'exérèse complète de la tumeur a été réalisée. L’examen anatomopathologique confirmait le diagnostic de tumeur pseudopapillaire et solide du pancréas. En conclusion, les tumeurs pseudopapillaires et solides du pancréas doivent être évoquées comme un des diagnostics différentiels de toute masse pancréatique en particulier chez les jeunes femmes. L'exérèse chirurgicale procure un bon pronostic.

The surgery is required in more than 80% of patients with Crohn's disease (CD). Studies before confirm the specific genetic variation of CD in the Tunisian population compared with the others ethnic groups.This article aims to study the epidemiological, anatomical and therapeutic principles of surgical forms of CD in a cohort of Tunisian patients.We report a retrospective study from January 1998 to September 2010 that studied 226 patients originated only from Tunisia (in North Africa), operated on for MC. We had been interested in epidemiological, anatomical, clinical, therapeutic, topographic progression of the disease, the procedure and the postoperative follow-up.The median age was 33 years. The average time between the onset of the disease and the surgical procedure was 31 months. The diagnosis of CD was established preoperatively in 213 patients (94%). The diagnosis was made intraoperatively because of an acute complication in 5 cases (2.2%) and postoperatively in 8 cases (3.5%). The most common location was the ileocecal junction in 184 cases (81.4%). Achieving the most common was the mixed form (stricture and fistula) in 123 cases (54.4%). Operative mortality was 0.04% (n = 1). Specific morbidity was 8.4% (n = 19). In long term, a surgical recurrence was noted in 17 patients (7.5%). In multivariate analysis the independent risk factors for surgical recurrence were: smooking (p = 0.012, ORs = 3.57) and post-operative medical treatment (p = 0.05, ORs = 2.6).Achieving stenosing and fistulizing the ileocecal junction is the most frequent surgical form in Crohn's disease. Our series is unique for a lower rate of the postoperative recurrence (7.5%).

Anorectal malformations are congenital anomalies ranging from simple perineal fistulas to complex malformations. They are usually treated inchildhood, and exceptionally in adult. We herein report the case of a 22 years aged patient and relate the diagnosis difficulties and therapeuticoptions. She consulted for anal imperforation discovered since birth. Initially, His parents refused the surgical management. It was an analimperforation with a vestibular fistula. The patient was operated by a low approach. She had a disconnection of the recto-vestibular fistula,dissection of the anal canal and a perineal posterior transposition. Postoperative course was uneventful. The evaluation of continence usingKelly's score found good Functional result.

Ileo-cecal resection is the most performed procedure in Cohn’s disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn’s disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach. The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt’s fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis. This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn’s disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %. We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn’s disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.

Resume Introduction L’approche laparoscopique est devenue le gold standard dans le traitement chirurgical de la maladie de Crohn. Le but de cette etude est de comparer les deux voies d’abord : cœlio-assistee et classique pour la realisation de la resection ileocaecale pour maladie de Crohn. Materiel et methodes De 1998 a 2010, nous avons mene une etude retrospective, comparative et non randomisee d’une base de donnees recueillie de facon prospective. Cent vingt-neuf patients ont ete divises en deux groupes : le groupe « cœlio-assiste » (groupe L ; n = 64) et le groupe « classique » (groupe C ; n = 65). Il n’y avait pas de difference entre les deux groupes en ce qui concerne les caracteristiques preoperatoires des patients. La morbidite postoperatoire a ete evaluee en se basant sur la classification de Clavien et Dindo. Resultats Cent dix-sept patients (90,7 %) avaient des suites operatoires simples. Au moins une complication etait presente en postoperatoire chez 12 patients : quatre (3,1 %) etaient de grade I, six (4,7 %) de grade II et deux (1,6 %) de grade III. La mortalite etait nulle (grade V). Le temps operatoire etait plus long dans le groupe L par rapport au groupe C (p Conclusion L’abord cœlio-assiste de la resection ileocaecale faite pour maladie de Crohn est sur et efficace dans la plupart des cas et permet d’assurer une rehabilitation precoce.

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.

Cystic lymphangioma (CL) is a benign rare malformation of lymphatic vessels. Its discovery in adults is rare. Although it can affect any organ, the common forms found in adults are mesenteric and/or retroperitoneal CL. This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma in adults. We report a retrospective study from January 1998 to September 2010 concerning 20 patients who underwent surgical removal of a CL. We were interested in discovering the clinical, biological, and radiological characteristics of CL. The localization, size, and number of cysts have been reported, as well as the surgical intervention used and the postoperative immediate and late complications. The median age was 46 years. Abdominal pain was the main symptom and was found in 15 patients (75%). Physical examination revealed an abdominal mass in 12 patients (60%). In four patients (20%), the cystic lymphangioma was incidental. Abdominal ultrasound and abdominal CT scan helped to highlight 22 cystic masses. CL diagnosis was established preoperatively in 13 patients (65%). Six patients (30%) were operated with a diagnosis other than CL. The diagnosis was made intraoperatively in one case (5%). Only two patients (10%) were operated on in emergency: one due to an infected CL and the other was CL complicated with intracystic hemorrhage. A laparotomy in 13 cases (65%) was the surgical approach used, whereas 7 cases (35%) benefited from a laparoscopy. No conversion was noted. The majority of the patients, 18 cases (90%), received a total cystectomy. Only two patients (10%) had recurrences of which only one was reoperated. The diagnosis of CL often is facilitated by means of modern imaging; however, other diagnoses may be discussed, particularly hydatid disease endemic areas. If symptomatic lesions or complications arise, complete surgical excision, when possible without major sacrifice, seems to be the best therapeutic option to reduce the risk of recurrence.

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).

Pylephlebitis, also called suppurative endophlebitis of the portal vein, is a rare potentially life-threatening acute abdominal complication of an intra-abdominal inflammatory process. Only early recognition substantially reduces the catastrophic mortality. As its clinical picture is fairly nonspecific, radiological findings, while not pathognomonic, are of great use in early diagnosis and management of these patients. We report a rare case of pylephlebitis with no identified intraperitoneal septic process in a 75-year-old man. Diagnosis was suspected on imaging features and confirmed with percutaneous transhepatic needle puncture. Thereafter, a drainage catheter was placed into the intrahepatic portal system. After a transient clinical improvement during the three following days, the drainage stopped and the patient developed a septic shock requiring transfer to intensive care but he died approximately 24 h later.

Summary Phytobezoars are a rare cause of acute bowel obstruction. The purpose of this work was to identify the predisposing factors and diagnostic difficulties of this rare entity. Material and methods This was a retrospective study including all cases of small-bowel obstruction secondary to phytobezoars observed between April 2001 and August 2007. The diagnosis of bezoars was established by surgical exploration or by computed tomography (CT). Results During the study period, 375 patients were hospitalized at our institution with a diagnosis of bowel obstruction that, in 15 (4%) cases, was secondary to phytobezoars. The average patient age was 55 years, with a gender ratio of 1.7, favoring men. The predisposing factors were gastroduodenal surgery for peptic ulcer in nine patients, and excessive consumption of prickly pears (cactus figs) in 12. The diagnosis was established by CT scans in three patients, who were successfully treated with gastric aspiration, thereby avoiding surgery. Laparotomy was performed in 12 patients to allow digital fragmentation of the bezoar, which was then washed into the colon. There were no postoperative deaths and morbidity was about 13%. Conclusion An abdominal CT scan should be obtained for patients with small-bowel obstruction. This examination offers a precise diagnosis of bezoars, reducing the number of unnecessary surgical procedures, and helping to guide the approach if surgery is needed.

Resume La fistule enterotubaire est une complication rare de la maladie de Crohn. Le diagnostic preoperatoire de cette entite est exceptionnel. Nous rapportons un nouveau cas de cette complication suspecte par la tomodensitometrie et confirme par l’hysterosalpingographie et le transit du grele. Il s’agit d’une femme âgee de 50 ans, connue porteuse d’une maladie de Crohn depuis deux ans, hospitalisee actuellement pour une stenose symptomatique de la derniere anse ileale avec decouverte fortuite lors des explorations (tomodensitometrie, transit du grele) d’une fistule enterotubaire droite. Le traitement a consiste en une resection ileocaecale associee a une salpingectomie avec des suites operatoires simples.

Resume La localisation pancreatique du kyste hydatique est exceptionnelle, meme dans les pays ou la maladie hydatique sevit a l’etat endemique. Nous rapportons trois observations de kyste hydatique du pancreas revelees par des douleurs abdominales. Le diagnostic etait porte sur les donnees de l’echographie et du scanner abdominal qui objectivaient une masse kystique a paroi propre de la queue du pancreas pour les deux premiers cas. Le troisieme kyste a ete decouvert en peroperatoire avec, a la cholangiographie peroperatoire, une large fistule wirsungokystique. La serologie hydatique (Elisa) etait positive dans tous les cas. Le traitement chirurgical a consiste en une resection du dome saillant dans deux cas et en une anastomose kystogastrique pour le troisieme cas. A travers ces trois observations et une revue de la litterature, nous discutons les difficultes diagnostiques et les modalites du traitement chirurgical de cette localisation rare du kyste hydatique.

Summary Introduction Internal hernias are a rare cause of acute intestinal obstruction. Herniation through the falciform ligament is rare and often diagnosed only during surgery. Abdominal computed tomography (CT), performed on an emergency basis, can help to diagnose this obstruction before surgery and select a therapeutic approach. Case A 60-year-old man was hospitalized on an emergency basis for symptoms that had been developing for 3 days, including tympanites and epigastric pain (torsion), associated with vomiting and the cessation of both feces and flatus. Abdominal radiography showed multiple levels of air-fluid levels in the small bowel, some projecting towards the liver area, as well as the presence of a flat intestinal loop continuous with a distended small-bowel segment. Abdominal CT suggested a diagnosis of small-bowel herniation and obstruction, very probably through the falciform ligament. The patient then underwent emergency surgery after a brief resuscitation. Intraoperative exploration confirmed the diagnosis of internal hernia through the falciform ligament. The postoperative course was without problems. Discussion Abdominal CT is the examination of choice in cases of a “new” acute intestinal obstruction. It makes it possible to diagnose the mechanism of the occlusion and especially the cause, especially for an internal hernia through the falciform ligament. It thus guides the choice of emergency surgical procedure and of appropriate approach. Once diagnosed, emergency surgery is essential to free the intestinal loop, with or without intestinal resection as a function of vitality.

Gastro-intestinal stromal tumors (GIST) are the most common mesenchymal gastrointestinal tumors. The Gastric location represents 60% of cases [1,2]. Complete surgical excision remains the treatment of reference for the localized forms. This surgery can be made by laparoscopy when the lesion's size doesn't exceed 5 cm. Some principles must e respected: a mono-block complete surgical resection, with healthy margins and without effraction. This technique will be reserved for trained teams and for selected cases according to the size and location. We herein try to explain the surgical laparoscopic excision of gastric stromal tumors explaining .

Peritoneal tuberculosis and carcinomatosis are the most frequent etiologies of exsudative ascitis and require rapid diagnosis and treatment. The purpose of this study has been to evaluate the predictive value of clinical and complementary data for the etiologic diagnosis of exsudative ascites and to assess the results of laparoscopic surgery.We report a prospective long-term study conducted over 10 years, having included all cases of exsudative ascites of unidentified etiology. We excluded patients with a history of anterior laparotomy and patients having a contraindication for laparoscopic surgery. Clinical signs, results of the cytochemical and bacteriological exam of the ascetic liquid and findings from radiological exams and endoscopic investigations were noted. Open laparoscopic exploration noted the macroscopic aspect and many peritoneal biopsies were obtained as well as a liver biopsy when possible. Statistical analysis was performed with SPSS10.0 software. The degree of statistical significance was set for P0.05.We included 90 cases of isolated exsudative ascites. There were 59 cases of tuberculosis and 31 of carcinomatosis. Mean patient age was 47 years with a sex ratio of 0.5. Bowel transit disorders were significantly in favor of a carcinomatosis (P=0.04) while fever and nocturnal sweats were suggestive of tuberculosis (P=0.04) but in both instances, the positive predictive value (PPV) of these two signs was weak, respectively 29% and 43%. Relative to chemical and cytologic study of ascitic fluid, hemorrhagic fluid, low white cell count, low lymphocyte differential and presence of atypical cells were significantly linked with the carcinomatosis (P=0.01) but with a PPV85%. Radiological exams were not very contributive for the etiologic diagnosis. The laparoscopic peritoneal aspect was typical of tuberculosis in 90% of proved cases and in 29% of carcinomatosis cases, underlying the importance of peritoneal biopsies for histological study. Hepatic tuberculosis was associated with peritoneal localisation in 48% of cases. We had no surgical mortality and the morbidity was about 1%.Etiological diagnosis of exsudative ascitis remains difficult to establish. Peritoneal biopsies under videolaparoscopy are currently the "gold standard" for diagnosis.

Crohn's disease (CD) is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. aim: To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula (EVF) during the CD. methods: We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. results: The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted.Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term.

Gastrointestinal bleeding from a pancreatic pseudocyst is a rare condition that is diagnostically and therapeutically challenging. A 78-year-old woman with a history of acute pancreatitis due to gallstones was hospitalized for abdominal pain and gastrointestinal bleeding. Gastroscopy revealed blood extruding from the papilla of Vater. A computed tomography scan revealed hemorrhage into a pancreatic pseudocyst. The patient was successfully treated by coil embolization.

Suppurative pylephlebitis is a rare condition with a significant mortality rate, ranging from 50% to 80%. We report a case of suppurative pylephlebitis complicating acute pancreatitis treated by percutaneous drainage in a 40-year-old woman. The patient had an uneventful recovery.

Curative resection with adequate lymph node dissection is the treatment of choice for gastric cancer.To determine the prognostic factors after R0 resection with DII lymph node dissection.We retrospectively assessed 126 patients who underwent R0 resection with DII lymph node dissection for gastric cancer (excluding the upper third of the stomach) in a single institution between 1991 and 2006 with median follow-up of 38.5 months (6 - 219). Prognostic factors were assessed by Cox proportional hazard model.There were 45 women and 81 men. The median age was 60 years (21 - 87). Four patients died (3.2 %). Postoperative hospital morbidity was 16.7 %. The pathologic review of the slides revealed that 50% of the tumors were stage T3 (63 cases). The median number of lymph node removed was 11 (8-40), 50% were involved. Five and 10 years survival rates were respectively 56.9 % and 40.2 %. In multivariable analysis, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were found to be independent prognosis factors.After R0 resection with DII lymphadenectomy, depth of wall invasion, lymph node involvement and more than 15 retrieved lymph nodes were independent predictive factors for survival.

Liposarcoma is the most frequent histopathological variety of the retroperitoneum, surgery is the gold standard for treatment.We report, retrospectively over 7 years (2000-2006), 5 cases (four men and one woman, the mean age was 48 years) of giant retroperitoneal liposarcomas and study their clinical characteristics intra operatively findings and course evolution. None of our patients had a percutaneous biopsy of his tumour. Surgery was indicated to all patients. Resection was performed in 4 cases (we performed a bloc resection in three cases and a simple tumour resection in one case), and in one case, abstention was decided. None of patients had an adjuvant therapy Three of the patients still alive after the follow up of 2, 3 and 4 years.Retroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach including multiple resections for recurrences. Based on the ability of the patient to tolerate the procedure, surgery is suggested to evaluate resectability of the tumor. We must take into consideration whether prolonged survival will be attained and tumor removal will result in palliation of symptoms.

Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection.To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP).35 patients underwent DP during a 10-year period (2000- 2009). Informations regarding diagnosis, operative details, and perioperative morbidity and mortality were collected. Nine risk factors were examined.Indications for DP included primary pancreatic disease (n=23; 66 %) and non-pancreatic disease (n = 12; 34 %). Postoperative morbidity rate was 43 % and none patient died. No patients required a reoperation. Pancreatic fistula was occurred in 11 patients (31 %). On univariate analysis, incidence of pancreatic fistula rate was not significantly associated with these risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, additional procedures, intra operative bleeding and texture of pancreatic parenchyma. We observed significant statistical difference between male and female, 47 % of females experienced a pancreatic fistula, while 17 % males developed a pancreatic leakage (p =0.05). The role of the technique of pancreatic stump closure in the development of pancreatic leak remains unclear because of the few number of patients on who we used stapler.The rate of pancreatic fistula after left pancreatectomy is 31 %. The female was identified as a risk factor for occurrence of pancreatic fistula after left pancreatectomy. The role implicated in the use of a mechanical claw for the treatment of pancreatic stump requires a larger number of patients to conclude. The body mass index has not been studied in our series.

An infected urachal cyst is an uncommon finding in adults.To report a case of a sigmoid- urachal- cutaneous fistula.A 51 years old adult male presented with fecaloid leaking from rupture of an infected urachal cyst. Definitive management consisted of resection of the urachus with a bladder cuff, along with removal of the affected bowel segments.Colo-urachal-cutaneous fistula is a rare condition; its management is rather complex.

Intra ductal papillary mucinous tumors of pancreas are rare and are characterized by a risk of malignant transformation.To clarify their clinical presentation and the performance of different imaging examinations to determine their benign or malignant and achieve their staging.We report three cases of degenerate intra ductal papillary mucinous tumors of pancreas. The combination of CT, the pancreato- MRI and duodenoscopy has led to the diagnosis in all cases. A pancreaticoduodenectomy were performed in two cases.The various imaging techniques allow better detection and analysis of the tumor including the evaluation criteria of degeneration. The treatment of these lesions is still surgery.

An uncommon event in the natural course of Crohn's disease is the spontaneous perforation. It's the most serious intestinal complication.To report the incidence of this complication and to discuss the mechanism of the perforation.We report, retrospectively, 4 cases (3 men and one woman; median age: 30 years) of peritonitis complicating Crohn's disease and study their clinical characteristics intra operatively findings and course evolution. Steroid therapy was administrated to all patients before the perforation. The perforation sites are on the ileum in three cases and on the jejunum in one case. The treatment consists in a resection of the perforated intestine with stoma in all cases.Perforation in Crohn's disease is a rare event. The exact mechanism of the perforation is still unknown and many hypotheses are presented.

SummaryTransposition 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 Murphy's 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.

To study the value of the CT scan in the diagnosis of internal herniation and to evaluate its performance comparing its features to preoperative data.We report 3 cases of patients with internal hernias (two men and one woman whose age is 23, 45 and 60 years) hospitalised in emergency for a small bowel obstruction. There were no previous abdominal surgeries or trauma, The three patients underwent CT scan. Signs of tranmesenteric hernias and hernia through the falciform ligament were diagnosed preoperatively and confirmed at laparotomy.The internal hernia is rare cause of small bowel obstruction. The CT scan is an important way to make diagnosis and to choose the surgical strategy.

The peri-pancreatic sporadic gastrinoma represents a paradigm of digestive endocrinology. It was originally an abnormal secretion of gastrin fits the syndrome Zollinger-Ellison.The objective of our work is to clarify the diagnostic strategy and therapeutic conduct of gastrinoma.We report the case of a patient aged 42 years, hospitalized for bleeding duodenal ulcer, revealed a Zollinger-Ellison syndrome. The different explorations have shown that it was a primitive péripancréatique sporadic gastrinoma. In surgery, we discover a rétropancréatique tumor associated to a stenosis post-bulbar ulcer. It was conducted a enucleation of the tumor with vagotomie troncular and gastroenteroanastomosis. The forecast was favourable with normalization of the values of gastrinémie.The sporadic gastrinoma is rare, its emphasis is increasingly being facilitated by the technology of modern medical imaging, belonging to a polyendocrinopathie must be systematic search. Treatment of pancreatic gastrinoma is multidisciplinary. Surgery is the only cure for this disease.

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 patient's 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.

the purpose of this study was to determine the epidemiological and clinical behaviour of the superficial adenocarcinoma of the stomach, to clarify its pathological characteristics, its therapy and prognosis.Over a period of 14 years (1990-2004), 16 patients were operated for a superficial gastric adenocarcinoma among 155 gastric cancers treated during the same period in the service of general surgery "A" La Rabta.The superficial gastric adenocarcinoma represented 10.3% of our series. The mean age was 59 years, 8 men and 8 women. Two patients were followed for a chronic stomach ulcer, a patient is followed for Biermer anaemia and another one for Menetrier disease. Among these cancers, 12 were intra mucosal and 4 invaded the submucousa. Lymph node involvement was present only in one case. The cancer was located in the antrum in 8 cases and was multifocal in 3 cases. One patient died in postoperative case because of a medical cause. The 5-year-overall survival was 65,6%. The recurrence had interested only one patient.the superficial gastric adenocarcinoma is rare. The follow up of precancerous states allows its diagnosis. The treatment is based on the gastric resection associated to the D1-type lymph node clearance. The multifocal character imposes a surveillance of the remaining gastric stump.

Rupture of hydatid cyst in the digestive tract is a rare complication even in endemic areas.Authors report a case of a hydatid cyst of the left hepatic lobe ruptured in the duodenumwas discovered at the occasion of epigastric pain and vomiting. Ct-scan revealed presence of air in a calcified hydatid cyst of the left liver lobe and a fistulous tract between the cyst and the duodenum. Endoscopy confirmed the diagnosis by the visualisation of a fistulous orifice of the anterior aspect of the first duodenum with a protrusion of hydatid membrane. Patient was treated surgically and had a partial cysto-pericystectomy and suture of duodenum.

the purpose of this work is to study the pathological features and the outcome of lymphoid stroma gastric carcinoma and its relation with Epstein-Bar Virus (EBV) and the imortance of the EBV serology in detection of early reccurence.between january 1990 and december 2004, 155 patients underwent gastric resection for gastric carcinoma. Nine of them had lymphoid stroma gastric carcinoma. Over all survival as well as disease free survival were determined. Detection of reccurence was based on clinical exam and on findings yielded by endoscopy, radiological exams and EBV serology. A comprison of survival rate of patients beteween current gastric carcinoma and those with lymphoid stroma gatsric carcinoma was done using the Log Rank test.the patients (7 men and 2 women) had a mean age of 61 years (41 to 82). The tumor was in the antrum in 4 cases, in the body of the stomach in 3 cases and in the cardia in 2 cases. The mean tumor size was 8 cm with deep invasion of the stomach wall in 5 cases and ganglionnary invasion in 6 cases out of 9. EBV was detected in all patients by in situ hybridation. Post operative morbidity and mortality were nil. Global survival and disease free survival were, respectively, 53.3% and 65.6% in lymphoid stroma gatsric carcinoma, and 43.4% and 63.5% for current gatsric carcinoma. Three patients died of a reccurent disease after 6, 30 and 33 months. The remaing 6 patients didn't have signs of reccurence.lymphoid stroma gastric carcinoma is a bulky, local disease. In our patients, it was always associated with EBV. Over all survival was better than survival of current gastric carcinoma, although there was no significance. EBV serology can be an effective screening procedure of reccurence.

Summary Objectives Hydatid cyst of liver is a parasitosis which is an endemic state in Tunisia and is a very rare cause of Budd-Chiari syndrome. The purpose of this study was to report the clinical features, radiological investigations and therapeutic management. Patients and methods A retrospective analysis of 12 patients who underwent surgery for Budd-Chiari syndrome secondary to hepatic echinococcosis between January 1990 and December 2004 was performed. Results The series included ten females and two males with a mean age of 36 years. Budd-Chiari syndrome was subacute in 75% of cases. Ultrasound showed a compression of hepatic veins by cysts with a mean diameter of 13 cm situated in at least two hepatic segments. US Doppler and CT-scan of the liver provided the diagnosis in all cases. Laparotomy was performed in all cases. Operative mortality was 8% and morbidity 66% due to biliary fistula and deep abscess formation. Hepatic vein outflow was successfully re-established in four patients. Conclusion Budd-Chiari syndrome is a rare but severe complication of hydatid cyst of the liver. Early diagnosis is necessary to improve prognosis.

The aim was to evaluate the reliability and safety of laparoscopic ileocecal resection for Crohn's disease and to report our preliminary results.A retrospective analysis of 20 patients undergoing a laparoscopic ileocecal resection for Crohn's disease was carried out between November 2003 and June 2005. First of all, we defined the inclusions and exclusions criteria which allowed us to select the patients who would be resected laparoscopically. Fistulizing disease, emergent surgery (perforation, occlusion), large mass and patients with previous laparotomy were excluded. Duration of operation, rate of conversion, complications and time from discharge from hospital were evaluated.Median operation time was 160 min. Conversion to laparotomy was needed in three cases. There was no death. Minor complications occured in 2 patients. Median postoperative time for discharge was 5 days.These preliminary results indicate that laparoscopic ileocecal resection is a feasible and safe alternative in patient with Crohn's disease offering many advantages thanks to a strict patient selection.

Gallbladder agenesis is a rare malformation, that can lead to an unnecessary and dangerous surgery. We report a case of gallbladder agenesis in a 27-year-old woman who had a right upper abdominal pain described as intermittent without fever neither jaundice during 1 year and half. The Physical examination was normal. The abdominal ultrasound examination revealed the absence of gallbladder. The MRI-cholangiography confirmed the agenesis of gallbladder. Using this case report, we will try to remember outcome particularities of this bile duct malformation.

Internal hernias are a rare cause of acute intestinal obstruction. Herniation through the falciform ligament is rare and often diagnosed only during surgery. Abdominal computed tomography (CT), performed on an emergency basis, can help to diagnose this obstruction before surgery and select a therapeutic approach.A 60-year-old man was hospitalized on an emergency basis for symptoms that had been developing for 3 days, including tympanites and epigastric pain (torsion), associated with vomiting and the cessation of both feces and flatus. Abdominal radiography showed multiple levels of air-fluid levels in the small bowel, some projecting towards the liver area, as well as the presence of a flat intestinal loop continuous with a distended small-bowel segment. Abdominal CT suggested a diagnosis of small-bowel herniation and obstruction, very probably through the falciform ligament. The patient then underwent emergency surgery after a brief resuscitation. Intraoperative exploration confirmed the diagnosis of internal hernia through the falciform ligament. The postoperative course was without problems.Abdominal CT is the examination of choice in cases of a "new" acute intestinal obstruction. It makes it possible to diagnose the mechanism of the occlusion and especially the cause, especially for an internal hernia through the falciform ligament. It thus guides the choice of emergency surgical procedure and of appropriate approach. Once diagnosed, emergency surgery is essential to free the intestinal loop, with or without intestinal resection as a function of vitality.

To evaluate the epidemiological clinical features and herapeutic results of gastrointestinal stromal tumour (GIST).This retrospective study concerned 25 cases of gastrointestinal stromal tumour from January 1993 to December 2002. All patients have been operated and the diagnosis of GIST has been confirmed by histological and immunohistochemical study of pieces of resection or biopsies.Population include II men and 13 women with a mean age of 64 years. Symptomatology was dominated by abdominal pain (54% of cases) and the digestive haemorrhage (46% of cases). A palpable mass has been found in 29% of cases. The tumour was gastric in 17 cases, small intestinal in 6 cases, colic in 1 case and rectal in 1 case. A double gastric localization and small intestinal was found in 1 case. The mean tumour size was 8 cm (1 to 30 cm). A tumour resection has been achieved in 23 cases (96%), extended to neighbourhood organs in 2 cases. The morbidity was 12.5% and there was no operative mortality. Histologically, tumour was of low grade in 10 cases, high grade in 10 cases and unclassified in 5 cases. With a median follow up of 27 months (2 to 108), we observed 4 cases of loco-regional recurrence. Overall survival at 2 years was 74% for the whole population and 35% for the high grade. Independent prognostic factors recovered were the degree of malignancy (p = 0.01) and the local recurrence (p = 0.01).The treatment of the GIST is surgical. lymphadenectomy is superfluous. The new oral chemotherapies that inhibits Tyrosine Kinase seems to be promising.

The laparoscopic treatment of hydatic cyst of the liver is at present codified. These last years, several progresses were obtained in the laparoscopic approach of hydatic cyst by avoiding the risk of preoperative hydatic peritoneal scattering. The aim of this study is to evaluate the effect of Albendazole given before a laparoscopic management of the hydatic cyst of the liver.

Solid cystic papillary tumors of the pancreas are rare. This tumors were seen in young women. They have distinct clinicopathologic characteristics. Their prognosis is excellent because of their low grad of malignancy. The tumor was encapsulated and have favorable prognosis after complete surgical resection. We report one case of solid cystic papillary tumor of the pancreas occuring in female patient who are 20 years old. This observation have been a pre operative morphologic and ultrastructural study (CT, Ctscan, EE, IRM and immunohistochemistry study) who permetted to elaborate diagnosis.