IntroductionSitus inversus is an uncommon anomaly. Situs inversus viscerum can be either total or partial. Total situs inversus, also termed as mirror image dextrocardia, is characterized by a heart on the right side of the midline while the liver and the gall bladder are on the left side. Patients are usually asymptomatic and have a normal lifespan. The exact etiology is unknown but an autosomal recessive mode of inheritance has been speculated. The first case of perforated duodenal ulcer with situs inversus was reported in 1986; here, we report the second case of this nature in the medical literature.Case presentationA 22-year-old Pakistani man presented with severe epigastric and left hypochondrial pain. Examination and investigations (chest X-ray and ultrasonography) confirm peritonitis in a case of situs inversus totalis. On exploratory laparotomy, a diagnosis of situs inversus totalis with perforated duodenal ulcer was confirmed. Graham's patch closure of the duodenal ulcer was performed with absorbable sutures, and a thorough peritoneal lavage was also performed; an incidental appendectomy was also performed to avoid further diagnostic problems. Our patient had an uneventful recovery.ConclusionsA diagnostic dilemma arises whenever abdominal pathology occurs in patients with situs inversus. Although an uncommon anomaly, to choose a proper surgical incision site for abdominal exploration pre-operative recognition of the condition is important.

Background/Aim:The role of laparoscopic appendectomy is still not well defined in the literature. This study was conducted to evaluate the feasibility of laparoscopic appendectomy at a university hospital in a developing country.Patients and Methods:Patients undergoing laparoscopic appendectomy (LA) from August 2002 to August 2006 were identified. For each case, a control was selected from patients undergoing open appendectomy (OA) during the same year by systematic sampling. The groups were compared in terms of duration of surgery, requirement of narcotic analgesia, length of hospital stay, postoperative complications and the overall cost for each patient.Results:A total of 68 patients underwent laparoscopic appendectomy during the study period. Median duration of surgery was 82 minutes in LA group and 70 minutes in OA group (P < 0.001). Forty-five patients in LA group and 64 in OA group required narcotic analgesia (P < 0.001). Median length of hospital stay (P = 0.672) and postoperative complications (P = 0.779) were comparable in both groups. Median cost of hospital stay was Pakistani Rupees (PKR) 47121/in LA group and PKR 39318/in OA group, the difference being significant (P = 0.001).Conclusions:Laparoscopic appendectomy is feasible in developing countries with similar postoperative outcome and less requirement of narcotic analgesia. The duration of surgery and overall cost were significantly higher and efforts should be made to develop expertise and reduce operative time with resultant decrease in cost. Development of standardized protocols for discharge of patients from the hospital after LA may further reduce the cost and benefit patients in developing countries.

IntroductionPhytobezoars are concretions of poorly digested fruit and vegetable fibers found in the alimentary tract. Previous gastric resection, gastrojejunostomy, or pyloroplasty predispose people to bezoar formation. Small-bowel bezoars normally come from the stomach, and primary small-bowel bezoars are very rare. They are seen only in patients with underlying small-bowel diseases such as diverticula, strictures, or tumors. Primary small-bowel bezoars almost always present as intestinal obstructions, although it is a very rare cause, being responsible for less than 3% of all small-bowel obstructions in one series. Jejunal diverticula are rare, with an incidence of less than 0.5%. They are usually asymptomatic pseudodiverticula of pulsion type, and complications are reported in 10% to 30% of patients. A phytobezoar in a jejunal diverticulum is an extremely rare presentation.Case presentationA 78-year-old Pakistani man presented to our clinic with small-bowel obstruction. Upon exploration, we found a primary small-bowel bezoar originating in a jejunal diverticulum and causing jejunal obstruction. Resection and anastomosis of the jejunal segment harboring the diverticulum was performed, and our patient had an uneventful recovery.ConclusionPrimary small-bowel bezoars are very rare but must be kept in mind as a possible cause of small-bowel obstruction.

Background/Aims:Although laparoscopic cholecystectomy (LC) has become the procedure of choice for cholelithiasis in the general population, many consider cirrhosis as a relative or absolute contraindication for laparoscopic surgery. The aim of this study was to confirm the safety of LC in cirrhotic patients in our set-up.Materials and Methods:This is a retrospective case series including all the patients with cirrhosis who underwent LC for gallstones from January 2000 to December 2006 at our institution. Data were analyzed for Child class, indication for surgery, hospital stay, and procedure-related morbidity and mortality. Results are given as mean ± standard deviation.Results:Thirty patients, including 21 females (median age: 42 years) underwent LC during the study period. There was no operative mortality. Twenty-four patients belonged to Child class A and 6 belonged to Child class B. Mean operative time was 80 ± 26 min. There was no incidence of bile duct injury, but two patients (6.7%) required conversion to open procedure. Mean hospital stay was 3 ± 2.7 days. Postoperative morbidity was observed in seven patients, including postoperative deterioration of liver function in 2, worsening of ascites in 2 and pneumonia, and port-site infection in 1. Two patients had significant drop in hemoglobin requiring blood transfusion.Conclusions:Cirrhosis is not a contraindication for LC and it can be performed safely in compensated cirrhotic patients with acceptable morbidity and mortality.

BackgroundBrucellosis incidence has declined in developped countries, nevertheless it remains endemic in certains regions. Spondylodiscitis is the most frequent localisation of brucellosis infections complications, ranging from 30% to 85% according to cases series.ObjectivesThe aim of our study is to report the clinical and bacteriological features of this disease as well as its therapeutic profile.MethodsRetrospective study witch included medical records of patients treated for brucellar spondylodiscitis during the fifteen past years (2000–2014).ResultsNineteen cases were collected (12 males/ 7 females). Mean age was 52 years [rang 36 to 75]. All patients had at least a risk factor: exposed occupation in 6 cases, and unpastorized milk consumption in 12 cases). The following symtoms were observed: inflammatory back pain (14 cases), inflammatory dorsal pain (4 cases), raduculalgia with neurological signs were (1 cases), weight loss (13 cases), fever (14 cases), night sweating (4 cases), C Reactive protein was increased in 2 cases. Lymphopenia was noted in 1 case. Wright serology was positive in all cases. Standard X-ray showed narrowing in disc space in 5 cases, endplate destuction in 9 cases and bone condensation in 3 cases. MRI performed in 14 cases, showed Low signal on T1 weighted images and high signal on T2 weighted images of the vertebral bodies and intervertebral disc. Moreover it revealed epidural extension (5 cases) abcess formation (2 cases) and psoas abcess (6 cases). All patients were treated by association of antibiotics (doxycicline and rifampicin) for 2 to 3 months. Evolution was farorable with resolution of pain, normalization of biological inflammation and slow radiologic reconstruction in 10 cases. For one patient treatment was prolongated to one year due to the persistance of an epiduritis in the follow-up MRI.ConclusionsPrognosis of brucellar spondylodiscitis seems good under appropriate treatment. Nevertheless primary prevention is still necessary especially in countries where brucellosis is endemic.Disclosure of InterestNone declared