C-reactive protein is a predictive factor for complications after incisional hernia repair using a biological mesh

The introduction of biological or absorbable synthetic meshes has provided an alternative to conventional repair for incisional hernia. The ability to predict the development of complications after hernia surgery is important, as it guides surgical planning and patient management. This retrospective study assessed whether the postoperative C-reactive protein (CRP) level can predict complications after incisional hernia repair using biological mesh reinforcement. Patients who underwent incisional hernia repair surgery using biological meshes between February 2009 and February 2015 were screened for study inclusion. Patients included in the study were divided into two groups: those with and without postoperative complications. The two groups were analysed based on sex, surgical operation, length of intensive care unit stay (ICU), complications and mortality. Laboratory values, including white blood cell (WBC) count and CRP levels, were determined preoperatively and up to postoperative day (POD) 10. Postoperative complications requiring further management occurred in 32 of the 60 patients (53.3%). Among 47 patients, the mean CRP and WBC levels were 6.6 mg/L and 9.073 G/L in the group without complications vs. 141.0 mg/L, 16.704 G/L in the group with complications (p < 0.001). Patients with complications also had a longer ICU stay (10.1 vs. 0.6 days, p < 0.0001). A cut-off was 101 mg/L and offered 80.00% sensitivity (IC 61.43% to 92.29) and 95.24% specificity (76.18% to 99.88%) for postoperative complication. The rate of postoperative complications before POD10 was 95% in the group with CRP > 100 mg/L vs. 46% in the group with CRP < 100 mg/L (p = 0.000372). A high postoperative CRP level (> 100 mg/L) up to POD10 may serve as a predictor of postoperative complications in patients undergoing incisional hernia using biological meshes.

Bile Duct Injury During Cholecystectomy: Necessity to Learn How to Do and Interpret Intraoperative Cholangiography

Introduction: Biliary duct injury (BDI) is a serious complication during cholecystectomy. Perioperative cholangiography (POC) has recently been generating interest in order to prevent BDI. However, the current literature (including randomized controlled trials) cannot conclude whether POC is protective or not against the risk of BDI. The aim of our study was to investigate whether POC could demonstrate earlier BDI and which criteria are required to make that diagnosis.

Methods: We performed a retrospective study between 2005 and 2018 in our French tertiary referral center, which included all patients who had presented following BDI during cholecystectomy.

Results: Twenty-two patients were included. Nine patients had POC, whereas 13 did not. When executed, POC was interpreted as normal for three patients and abnormal for six. In this latter group, only two cases had a BDI diagnosed intraoperatively. In other cases, the interpretation was not adequate.

Conclusion: BDIs are rare but may reduce patients' quality of life. Our study highlights the surgeon's responsibility to learn how to perform and interpret POC in order to diagnose and manage BDIs and potentially avoid catastrophic consequences.

Correlations of the rectus abdominis muscle anatomy with anthropometric measurements

PURPOSE

The anterior abdominal muscle wall has a strong aesthetic connotation, primarily because of the classical anatomical description of the rectus abdominis muscle in the collective consciousness. However, the morphological reality of the general population considerably deviates from this description. Therefore, we investigated the anthropometric characteristics correlated with the anatomy of the rectus abdominis muscle.

METHODS

We performed a computed tomography scan anatomical study of recti abdominis muscles in 86 patients with no history of abdominal surgery. We noted the transverse and anteroposterior measurements of the rectus abdominis muscle, the transverse measurement of the linea alba, and the cutaneous and muscular abdominal perimeters. We compared these morphological elements with anthropometric data (sex, age, weight, height, and body mass index [BMI]).

RESULTS

BMI was positively correlated with cutaneous abdominal perimeter (r = 0.89, p < 0.001) and muscular abdominal perimeter (r = 0.7, p < 0.001). The correlation of BMI with cutaneous abdominal perimeter was not influenced by sex (r = 0.90 and r = 0.89 in men and women, respectively). The correlation of BMI with muscular abdominal perimeter was greater in men than in women (r = 0.80 vs. r = 0.75). The muscular abdominal perimeter was more strongly correlated with the transverse measurement of the rectus abdominis muscle in men than in women (r = 0.75 vs. r = 0.59). The muscular abdominal perimeter was more strongly correlated with the linea alba in women than in men (r = 0.51 vs. r = 0.31).

CONCLUSION

The anatomy of the anterior abdominal wall correlated with anthropometric data, including BMI. Rectus abdominis muscles and linea alba structures differed between men and women.

Identification of risk factors for morbidity and mortality after Hartmann's reversal surgery - a retrospective study from two French centers

Hartmann’s reversal procedures are often fraught with complications or failure to recover. This being a fact, it is often difficult to select patients with the optimal indications for a reversal. The post-recovery morbidity and mortality rates in the literature are heterogeneous between 0.8 and 44%. The identification of predictive risk factors of failure of such interventions would therefore be very useful to help the practitioner in his approach. Given these elements, it was important to us to analyze the practice of two French university hospitals in order to highlight such risk factors and to allow surgeons to select the best therapeutic strategy. We performed a bicentric observational retrospective study between 2010 and 2015 that studied the characteristics of patients who had undergone Hartmann surgery and were subsequently reestablished. The aim of the study was to identify factors influencing morbidity and postoperative mortality of Hartmann’s reversal. Primary outcome was complications within the first 90 postoperative days. 240 patients were studied of which 60.4% were men. The mean age was 69.48 years. The median time to reversal was 8 months. 79.17% of patients were operated as emergency cases where the indication was a diverticular complication (39.17%). Seventy patients (29.2%) underwent a reversal and approximately 43% of these had complications within the first 90 postoperative days. The mean age of these seventy patients was 61.3 years old and 65.7% were males. None of them benefited from a reversal in the first three months. We identified some risk factors for morbidity such as pre-operative low albuminemia (p = 0.005) and moderate renal impairment (p = 0.019). However, chronic corticosteroid use (p = 0.004), moderate renal insufficiency (p = 0.014) and coronary artery disease (p = 0.014) seem to favour the development of anastomotic fistula, which is itself, a risk factor for mortality (p = 0.007). Our study highlights an important rate of complications including significant anastomotic fistula after Hartmann’s reversal. Precarious nutritional status and cardiovascular comorbidities should clearly lead us to reconsider the surgical indication for continuity restoration.

Long-term survival after surgery of pancreatic primary squamous cell carcinoma: A case report and literature review

Pancreatic primary squamous cell carcinoma is rarer and no optimal treatment has been validated according to the tumor stage. The surgical resection was the only curative option. The radiotherapy or chemotherapy was performed for the other cases.

What is the cost of endoscopic submucosal dissection (ESD)? A medico-economic study

Introduction

Endoscopic submucosal dissection (ESD) is the gold-standard treatment for superficial lesions of the digestive tract. No medico-economic study has been conducted in Europe.

Material and methods

A monocentric study was conducted including all patients undergoing ESD between January 2015 and December 2017. The global cost of hospital stays was measured by microcosting, and revenue was based on the diagnosis-related group (DRG) system. The primary objective was to assess the cost/revenue balance. A medico-economic comparison with surgery was performed as a secondary outcome.

Results

A total of 193 patients were prospectively included. The cost per procedure was €3463.79, subtracted from a €2726.84 revenue, with a deficit of -€736.96 per stay. Presence of comorbidities/complications increasing DRG value was the only predictive factor for a positive budgetary balance in a multivariate analysis (odds ratio 49.21, 95% confidence interval 11.3-214.25, p < 0.0001). In comparison with surgery, ESD was associated with shorter length of stay (11 vs 2 days; p < 0.0001) and lower morbidity (28% vs 14%; p = 0.061), lower cost (€8960 vs €1770; p < 0.0001).

Conclusion

The ESD cost/revenue balance is negative in 80% of cases. Given the benefits of ESD in terms of patient morbidity and financial savings compared with surgery, the implementation of a specific ESD reimbursement is warranted.

Stepwise management of hepatocellular carcinoma associated with Abernethy syndrome

Patients with congenital agenesis of the portal vein may develop hepatocellular tumors due to enhanced arterial blood flow. These tumors may be benign (FNH, adenomas) or malignant (hepatoblastoma, HCC). Liver resection can be proposed, and preoperative arterial embolization may decrease blood loss during surgery. Liver transplantation with PV reconstruction is also an option.

Chemotherapy outcome predictive effectiveness by the Oncogramme: pilot trial on stage-IV colorectal cancer

Background

Colorectal cancer (CRC) remains a major public concern. While conventional chemotherapeutic regimens have proved useful against advanced/metastatic diseases, progresses are to be made to effectively cure the large portion of patients not benefiting from these treatments. One direction to improve response rates is to develop chemosensitivity and resistance assays (CSRAs) efficiently assisting clinicians in treatment selection process, an already long preoccupation of oncologists and researchers. Several methods have been described to this day, none achieving yet sufficient reliability for recommended use in the clinical routine.

Methods

We led a pilot study on 19 metastatic CRC patients evaluating capacity of the Oncogramme, a standardized process using tumor ex vivo models, to provide chemosensitivity profiles and predict clinical outcome of patients receiving standard CRC chemotherapeutics. Oncogramme responses were categorized according to the method of percentiles to assess sensitivity, specificity and concordance.

Results

We report from a primary analysis a success rate of 97.4 %, a very good sensitivity (84.6 %), a below-average specificity (33.3 %), along with a global agreement of 63.6 % and a concordance between Oncogramme results and patients’ responses (Kappa coefficient) of 0.193. A supplementary analysis, focusing on CRC patients with no treatment switch over a longer time course, demonstrated improvement in specificity and concordance.

Conclusions

Results establish feasibility and usefulness of the Oncogramme, prelude to a larger-scale trial. Advantages and drawbacks of the procedure are discussed, as well as the place of CSRAs within the future arsenal of methods available to clinicians to individualize treatments and improve patient prognosis.

Trial registration: ClinicalTrials.gov database, registration number: NCT02305368

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-0765-4) contains supplementary material, which is available to authorized users.

Anatomical study of the clavicle: endomedullary morphology

BACKGROUND

The treatment of clavicle fractures remains controversial. The objective of this study was to investigate the possibility of clavicular intramedullary fixation by nailing through an anatomic study combined with CT scan studies.

METHODS

For the anatomic study, 20 clavicles of donated bodies to science (10 men, 10 women, 10 right, 10 left) were used. We measured the length of the clavicle, lateral epiphysis diameter, mean diaphysis diameter, medial epiphysis diameter, lateral width, lateral radius of curvature, medial width and medial radius of curvature. Intramedullary cavity diameter (anteroposterior and superoinferior) and calibration were measured by CT scan study on 20 clavicles.

RESULTS

Average length was 152 mm for men and 140 mm for women. The anteroposterior curvature was most pronounced. The medullary canal had a gradually decreasing size from the distal portion to the middle segment, but never disappeared.

CONCLUSION

Evaluation of morphological data can clarify the specifications of an intramedullary nail: flexibility of the nail to match clavicle curvature and a locking system to ensure primary stability. Intramedullary fixation by nailing in displaced fractures of the middle portion of the clavicle is a minimally invasive surgical technique, with excellent functional and cosmetic results.

Long-term results of mesocaval shunts with polytetrafluoroethylene grafts

Despite the introduction of new procedures such as pharmacologic reduction of portal pressure and endoscopic sclerotherapy, the role of surgery in portal hypertension must be reconsidered. The aim of this retrospective study was to evaluate the long-term results of mesocaval interposition shunting in the treatment of recurrent variceal bleeding after sclerotherapy failure or in patients with intractable ascites in whom optimal medical treatments failed. Over a 20-year period, 85 patients (66 men and 19 women; mean age, 53.96 +/- 11.57 years) underwent a mesocaval interposition shunt procedure. Sixty-six patients had recurrent variceal bleeding, and 19 patients had refractory ascites. The underlying etiology of portal hypertension was alcoholic cirrhosis (n = 69), posthepatitis cirrhosis (n = 10), cryptogenic cirrhosis (n = 3), primary biliary cirrhosis (n = 2), and Budd-Chiari syndrome (n = 1). Thirty-one patients were in Child-Pugh grade A, 34 were in grade B, and 20 were in grade C. The mean diameter of the graft was 11.85 +/- 1.53 mm (range, 10-14 mm). Overall, in-hospital mortality was 10.5% (9 of 85 patients). There were 3 postoperative recurrences of variceal hemorrhage and 5 recurrent bleeds during the follow-up. The overall incidence of shunt thrombosis of this series was 10.5%. The total incidence of encephalopathy was 10.5%. Intraoperative gradient pressure measurements before and after shunt showed satisfactory pressure reduction (16.90 +/- 5.32 to 5.12 +/- 2.50/ mmHg; P < 0.0001). The mean follow-up period was 26.09 +/- 25.3 (range, 1-90) months. Nine patients (10.5%) later received liver transplants, with time intervals ranging from 2 months to 5 years. The actuarial survival rate was 92% at 1 year and 75% at 5 years. In our series, the interposition mesocaval shunt seems to be an effective procedure for the control of complications of portal hypertension in cirrhotic patients with good long-term results. Moreover, the procedure can be considered as a solution of choice in patients who are current liver transplant candidates, leaving the hepatic hilus intact.

[Acute intestinal strangulation after Scarpa's triangle cow horn injury]

A 52 year-old man, treated by neuroleptic drugs, presented with a cow horn injury in the right Scarpa's triangle. The surgical management found no injury of femoral vessels. Surgical hemostasis of superficial vessels was performed. An ileal strangulation appeared three days later. At laparotomy, we found an internal parietal wound. Here we explain the mechanism of this strangulation.

[The Alzheimer's disease or the fall of the neocortical empire at the age of nonsense]

If we observe the evolution of the Alzheimer's disease of a premature entorhinal stage at an evolved stage of the neocortex, the succession of the confusions of the simple mnesic complaint in the aphasia, praxia, gnosia, visual, psychological and comportemental difficulties testify of the extension of the lesions in the neocortical structures. This neocortical regression seems to take the inverse road of the phylo- and ontogenetic evolution, where this hegemonic neocerebral cortex - which had grown again on the borders of the archeocortical and paleocortical barbarian empire - sees itself dispossessed of its conquests and gives free rein to these ancestral structures. We could compare the Alzheimer's disease with the fall of the neocortical empire at the age of nonsense.

[Ewing sarcoma of the mesocolon]

This case-report studies the clinical, radiological, anatomopatholo-gical and therapeutic aspects of peripheral primitive neuroectodermal tumours (PNET). PNET are neoplasms with a similar histology to tumours in the Ewing family. Diagnosis requires histopathology, immunohistochemistry and cytogenetic studies. To our knowledge, this rare tumour has never been reported in the mesocolon (our case). The treatment, which is usually similar to that for Ewing's sarcoma is complex and has not yet been codified, which is another difficult aspect of this disease with a poor prognosis.

Platelet-activating factor in cirrhotic liver and hepatocellular carcinoma

AIM: Platelet-activating factor (PAF) is a pro-inflammatory and angiogenic lipid mediator. Here we aimed to investigate levels of PAF, lyso-PAF (the PAF precursor), phospholipase A₂ (PLA₂, the enzymatic activity generating lyso-PAF), acetylhydrolase activity (AHA, the PAF degrading enzyme) and PAF receptor (PAF-R) transcripts in cirrhotic liver and hepatocellular carcinoma (HCC).

METHODS: Twenty-nine patients with HCC were enrolled in this study. Cirrhosis was present in fourteen patients and seven had no liver disease. Tissue PAF levels were investigated by a platelet-aggregation assay. Lyso-PAF was assessed after its chemical acetylation into PAF. AHA was determined by degradation of [³H]-PAF. PLA₂ levels were assessed by EIA. PAF-R transcripts were investigated using RT-PCR.

RESULTS: Elevated amounts of PAF and PAF-R transcripts 1 (leukocyte-type) were found in cirrhotic tissues as compared with non-cirrhotic ones. Higher amounts of PAF and PAF-R transcripts 1 and 2 (tissue-type) were found in HCC tissues as compared with non-tumor tissues. PLA₂, lyso-PAF and AHA levels were not changed in cirrhotic tissues and HCC.

CONCLUSION: While the role of PAF is currently unknown in liver physiology, this study suggests its potential involvement in the inflammatory network found in the cirrhotic liver and in the angiogenic response during HCC.

[Hepatic haemangioendothelioma: case report and review of literature]

A 37 year old-woman complained about persistant pain of right abdominal quadrant. We discovered many hepatic lesions. Histology revealed benign processus. Evolution was marked by peritoneal carcinomatosis. After reexamination of histology we discovered hepatic haemangioendothelioma. The patient died 18 month after diagnosis although chemotherapy.

[Inferior mesenteric arteriovenous fistulas. Report of a case]

We report a case of postoperative inferior mesenteric arteriovenous fistula. Arteriovenous fistula represents a rare disease. Symptoms are due to portal hypertension and distal ischemy. Treatment of these fistulas is embolization. Surgery is possible by ligature or excision of the fistula because vascularisation is obtained by Riolan arcade and hypogastric artery.

Les volvulus du cæcum

The cecum is the second most common site of colonic volvulus after the sigmoid. The mechanism is torsion or hyperflexion of the enlarged, poorly-fixed, and hypermobile cecum. It presents clinically as an acute bowel obstruction with strangulation. Diagnosis can be made by plain abdominal X-ray in more than half the cases on the basis of cecal distention (with a classical "teardrop" or "comma" appearance), proximal small bowel distention with air-fluid levels, and a gasless distal colon. Barium enema shows lack of filling of the cecum, often with a "beaked" termination of the column of contrast. CT images are pathognomonic when they reveal a cecal "vortex". After surgical reduction of the torsion, ileo-cecal resection is usually the best therapeutic alternative. Cecopexy may be aDDrouriate in older and debilitated Datients if there is no concomitant cecal necrosis.

[Aberrant pancreas: report of five cases]

We herein report five cases of heterotopic pancreas localized on common bile duct, gastric antrum, duodenum (two cases including one with cystic dystrophy), and jejunum. The choledocal localization was revealed by jaundice. The duodenal localization with cystic, diagnosed by endoscopic ultrasound, was revealed by onsets of acute pancreatitis. All localizations were treated by resection: antrectomy, bowel resection, and pancreaticoduodenectomy. Postoperative course was uneventful. Review of the literature shows that, even in uncomplicated cases, resection is usually performed.

Diverticule géant du côlon sigmoïde fistulisé dans le jejunum

An 80-year-old woman with sigmoïd diverticula was treated by corticosteroid for Horton disease. She presented abdominal pain, and abdominal mass in left iliac fossa. Radiological examinations revealed a colo-jejunal fistula. At laparotomy it was a giant diverticulum of colon sigmoid with fistula in the jejunum. The pathogeny of giant diverticulum and the role of corticosteroid are discussed.

[Apropos of a case of bilateral axillary supernumerary breasts]

We herein report a case of axillary localization of supernumerary breast. It is a matter of axillary bilateral masses mistaken as lipoma at clinical examination and ultrasonography. We here explain this confusion between lipoma and supernumerary breast. The aim of this work is to specify clinical characters of an axillary mass that must lead to suspect a supernumerary breast.

Right hepatectomies without vascular clamping: report of 87 cases

BACKGROUND/PURPOSE

Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping.

METHODS

From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 +/- 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava).

RESULTS

There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 +/- 2.7 units. The mean operative length was 280 +/- 60 min and the mean hospital stay was 12.8 +/- 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week.

CONCLUSIONS

In our experience with major liver resections, vascular clamping is not necessary.

À propos d’un cas de sagittalisation des voies biliaires droites

The authors report a case of right liver atrophy. This rare anomaly was suspected during post-operative period on abnormalities of cholangiogram. This biliary tract anomaly was diagnosed by CT scan. This congenital abnormality may be associated with biliary tract abnormalities, portal hypertension and other congenital abnormalities.

Hepatocarcinoma with congenital agenesis of the portal vein

The association of congenital absence of the portal vein and hepatocellular carcinoma has been described, but is rare. It is most frequently discovered fortuitously in children. The absence of intrahepatic portal circulation may predispose to the development of hepatocarcinoma.

Laparoscopic liver resection of benign liver tumors

OBJECTIVE

The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting.

BACKGROUND

Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors.

METHODS

A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome.

RESULTS

From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD.

CONCLUSIONS

Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

Development of colonic stenosis following severe acute pancreatitis

BACKGROUND

Colonic necrosis after acute pancreatitis is rare. When it does occur, it is commonly due to ischaemia or inflammation and may necessitate early colonic resection.

CASE OUTLINE

A 72-year-old man developed colonic necrosis 6 weeks after severe acute pancreatitis. CT scan revealed a bulky mass near the left colon. Barium enema and colonoscopy revealed stenosis of the left colonic flexure, and this segment of bowel was successfully resected.

DISCUSSION

Severe acute pancreatitis must be recognised as a cause of colonic ischaemia and necrosis. The possible pathogenic mechanisms include severe local inflammation and an ischaemic process. This complication is associated with a very poor prognosis despite surgical intervention, but a timely resection may prevent further problems.

Laparoscopic liver resection of benign liver tumors

OBJECTIVE

The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting.

BACKGROUND

Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors.

METHODS

A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome.

RESULTS

From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD.

CONCLUSIONS

Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

[Intrathyroid metastases from kidney cancers: two case reports]

The thyroid metastasis are under estimated in clinical practice because they are in the vast majority of cases "silent". Over than 50% of clinically apparent metastatic lesions are due to kidney carcinomas. We report two cases of thyroid metastasis from clear-cell renal carcinoma occurred 3 years and 8 years after nephrectomies. The previous history of any type of carcinoma should suggest a possibility of metastasis for every thyroid nodules. Fine-needle aspiration cytology is recommended by some authors. Finally, clear-cell carcinoma metastases seem to have a propensity to occur in abnormal thyroid tissue and further study could be interesting.

[Mesenteric-portal confluence aneurysm]

The authors take interest in the portal aneurysm about the observation of a 52 year-old woman with an echographic lesion in the head of the pancreas. Radiological examination was done with abdominal CT and MRI. Because of no accurate diagnosis, an explorative laparotomy was done and showed an aneurysm at the junction of the portal and superior mesenteric veins. These lesions are rare: they can be acquired particularly with underlying hepatocellular diseases and portal hypertension; they can be congenital due to an incomplete obliteration of the right vitelline vein. If asymptomatic, only a close surveillance must be proposed.

[Perforated juxta-papillary duodenal diverticula: two cases]

Perforation of juxta-ampullary duodenal diverticula, occurring spontaneously or after abdominal trauma, is a severe condition. Diagnosis is difficult to establish and is based on tomodensitometry, which is the most reliable diagnostic tool. Treatment consists in diverticulectomy that can be associated with drainage of the duodenum or anastomosis between digestive and biliary tract. We report two cases of perforated juxta-ampullary duodenal diverticula. Perforation was spontaneous in one case and complicated a blunt abdominal trauma in the other case.

[Duodenal duplication: pathologic anatomy and embryogenesis. Case report in an adult]

Duodenal duplication is a rare congenital entity and less than 100 cases have thus far been reported in the literature. This was first described by Sanger in 1880. By definition, they are located in or adjacent to the wall part of the gastrointestinal tract, have smooth muscle in 2 layers and are lined by alimentary tract mucosa. With the case report of a 18 year-old patient with pancreatitis, we expose modern imaging procedure and surgical management. Although the exact etiology of enteric duplications is not known, the two main hypothesis are dysembryogenesis and dysorganogenesis.

Rupture of mesenteric artery branch aneurysm

We describe a case of ruptured mesenteric artery branch aneurysm. Since it is characterized by nonspecific clinical manifestations, aneurysm in this uncommon location is usually diagnosed following complications. Definitive diagnosis requires Doppler ultrasound followed by arteriography. The purpose of this report is to describe the pitfalls of diagnosis and define an appropriate management strategy. Unlike abdominal aortic aneurysm, isolated aneurysms of the superior mesenteric artery (SMA) branches are rare. Most cases are diagnosed after the occurrence of complications. Early diagnosis would be useful, since the natural course can be tragic without timely treatment. In this report, we describe one case of ruptured mesenteric artery branch aneurysm and review the literature for relevant data on the circumstances of discovery, methods of investigation, and appropriate management of these lesions.

[Composite, non-resorbable parietal prosthesis with polyethylene terephtalate-polyurethane (HI-TEX PARP NT): prevention of intraperitoneal adhesions. Experimental study in rabbits]

The authors report an experimental study in the rabbit with a new composite non absorbable mesh in Polyethylene Terephtalate-Polyurethane used for incisional hernia repair in intraperitoneal positioning. This new mesh has one permeable side in polyethylene terephtalate for rapid tissue fixation and another side in polyruethane, hydrophob in order to avoid cell penetration. Eighteen rabbits were operated. A wound was created in aponeurose, muscle and peritoneal abdominal wall. The mesh was placed in intraperitoneal positioning and was taken off at 4, 9 and 13 months for histologic examination and electronic microscopical examination. Tolerance, adhesion, tissular reaction and neoperitoneum formation have been studied. All the meshes were well integrated and without sepsis. In 18% of cases small and monocclusive intraperitoneal adhesions were found. This new composite mesh in intraperitoneal positioning gave good results at medium-term in the rabbit. It's an attractive alternative for incision hernias repair with intraperitoneal mesh.

[Portal hypertension in a patient with hepatitic C revealing an iatrogenic arterioportal fistula]

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.

[Video-guided retrosternoscopy: a new approach in retrosternal esophagoplasty]

In this study, the authors described a new videoscopically guided approach for tunneling in esophagoplasty and insertion of an esophageal prosthesis.

[Role of the lymphatics of the diaphragm in the absorption of intraperitoneal liquids]

The diaphragm is the major site of the lymphatic absorption of the intra peritoneal liquids. Known since the middle of the last century, this lymphatic network is at present studied under transmission electron microscopy. The stomata which are intercellular sluices between adjacent mesothelial cells, are the entry of the diaphragmatic network. These stomata open into the lacunae which are dilatations the diaphragmatic subserous lymphatic network. The architecture of these structures explains their one-way character from the abdomen to the thorax and the role of the respiratory movements. This network collects the fluids into the trans diaphragmatic lymphatics. Pleural effusion appears when the quantity of liquids in the diaphragmatic lymphatic network exceeds the capacities of drainage of the lymphatic efferents, thus explaining the reactional pleural effusion caused by underdiaphragmatic inflammatory processes.

[Laparoscopic treatment of solid and cystic tumors of the liver. Study of 33 cases]

AIM OF THE STUDY

Laparoscopic liver surgery is still in its early stages. The aim of this study was to report our experience in the laparoscopic management of solid and cystic liver tumours.

PATIENTS AND METHODS

From April 1991 to December 1999, 32 patients with various lesions of the liver underwent laparoscopic liver surgery. One group of patients presented with cysts (n = 15) (11 giant solitary cysts and 4 polycystic liver diseases) and one group of patients presented with solid tumours (n = 18): focal nodular hyperplasia (n = 8), haemangioma (n = 6), adenoma (n = 2), isolated metastasis from a colonic cancer (n = 1) and hepatocellular carcinoma (n = 1). Fifteen cyst fenestrations and eighteen liver resections were performed via a laparoscopic approach including 1 right lobectomy, 5 left lateral segmentectomies, 2 subsegmentectomies IVb, 1 segmentectomy III and 9 non-anatomical resections.

RESULTS

Conversion to laparotomy was performed in one case (3%) at the end of the operation (patient who had successfully undergone left lateral segmentectomy for hepatocellular carcinoma) to check the resection margins and surgical transection had been performed in healthy parenchyma. Mean diameter of solid tumours was 6.5 cm and 15.7 cm for solitary cysts. The mean operating time for hepatic resections was 232 minutes. There was no postoperative mortality. Complications occurred in one case for each group and consisted in intestinal stricture through a port site requiring intestinal resection. Mean postoperative hospital stay was 5.6 days for solid tumours and 7.5 days for cystic lesions. In the group of cystic lesions, the recurrence rate was 50% with a 5.5-months follow-up.

CONCLUSION

Laparoscopic liver surgery can be safely performed, but requires a good experience in open hepatic surgery and laparoscopic surgery. The laparoscopic approach is indicated in patients with symptomatic or atypical benign solid tumour, giant solitary cyst and polycystic liver disease, located anteriorly on the liver. Indications for malignant lesions have not been clearly defined and require further information.

[Bilobar Thyroid Agenesis]

A case of a 27-year-old female patient presenting with bilateral agenesis of the thyroid gland and a benign euthyroid adenoma of the isthmus and the pyramidal lobe is reported. The patient had for several years been followed for a cystic nodule that was presumed to have developed from the left thyroid lobe, having recently increased in size. Scintigraphic and echographic studies evoked the absence of right lobe. Direct examination at cervicotomy found hypoplasia of the two lobes. This report highlights the similarity of this rare anomaly to widely known hemiagenesis.

Early experience with laparoscopic approach for solid liver tumors: initial 16 cases

OBJECTIVE

To evaluate the feasibility and outcome of laparoscopic hepatectomy in patients with solid liver tumors.

SUMMARY BACKGROUND DATA

Although the laparoscopic approach has become popular in the surgical field, the value of laparoscopy in liver surgery is unknown.

METHODS

Fifteen patients with solid liver tumors underwent 16 consecutive laparoscopic resections at the authors' institution between 1994 and 1999. Indications were symptomatic hemangioma, focal nodular hyperplasia, liver cell adenoma, isolated metastasis from a colon cancer, and hepatocellular carcinoma. The laparoscopic procedure was performed using four to seven ports (four 10-mm, two 5-mm, and one 12-mm).

RESULTS

One patient underwent a major hepatic resection (right lobectomy); the others underwent minor hepatic resections (left lateral segmentectomies, IVb subsegmentectomies, segmentectomy, and nonanatomical excisions). The laparoscopic procedure was uneventful in 15 patients; one patient required conversion to open laparotomy because of inadequate free surgical margins.

CONCLUSION

Laparoscopic surgery of the liver is feasible. The use of this new technical approach offers many advantages but requires extensive experience in hepatobiliary surgery and laparoscopic skills. The authors' experience suggests that laparoscopic procedures should be reserved for benign tumors in selected cases. Its application must be verified by further studies.

The value of fibrin sealant in thyroid surgery without drainage

Fibrin sealant is widely used to achieve complete hemostasis in many fields of surgery. A retrospective review of the surgical management of 81 patients with thyroid diseases between 1992 and 1998 was undertaken to determine if drainage after thyroid surgery could be safely avoided and substituted by fibrin sealing before closure of the wound. Complications were few and resulted in one patient with hoarseness, four minor oedemas and one case of unexplained fever during 48 h. The subjective discomfort from the collar incision was unusual and aesthetic healing was obtained in most of the cases (93.8%). These results suggest that the application of fibrin sealant can be advocated in thyroid surgery as an adjunct to a good surgical procedure and perhaps that prophylactic drainage is unnecessary.

[Pancreatic neuroendocrine tumors and von Hippel-Lindau disease]

Pancreatic neuroendocrine tumors are rare in von Hippel-Lindau disease, most often asymptomatic, nonfunctioning, non secreting, and benign. We report a case of low grade malignant pancreatic, secreting and asymptomatic neuroendocrine tumors, occurring in a 27 year old woman in the setting von Hippel-Lindau disease with recurrent pheochromocytoma, retinal and medullary hemangioblastomas, paraganglioma of the carotid body and ovarian cystadenoma. Neuroendocrine pancreatic tumors of von Hippel-Lindau disease are often constituted by clear cells, in the contrary of other neuroendocrine tumors of the pancreas. Occurrence of a pancreatic neuroendocrine tumor, especially in association with pheochromocytoma, may be misdiagnosed with a type 2 multiple endocrine neoplasia syndrom instead of von Hippel-Lindau disease.

[Ruptured hepatocarcinoma. Report of 22 cases]

STUDY AIM

Spontaneous rupture of hepatocellular carcinoma (HCC) causing massive hemoperitoneum is a critical and life threatening complication. The study aim was to report a retrospective series of 22 cases observed in the same centre.

PATIENTS AND METHODS

From 1978 to 1998, 22 patients (18 males and four females, mean age: 63 years, range: 18-83) were treated for ruptured H.C.C involving a cirrhotic liver in 17 cases and a normal liver in five cases. In 14 cases, the diagnosis of acute hemoperitoneum indicated an immediate laparotomy. The site of rupture was predominant in the left lobe (eight cases). The surgical treatment was: left lobectomy (n = 7), right hepatectomy (n = 2), excision (n = 4), hepatic artery ligation (n = 5), direct hemostasis (n = 4).

RESULTS

Postoperative mortality was 45.4%. Among the 12 survivors, nine died within a delay of 6 to 29 months. Three patients were still alive at the time of this study at 32, 40 and 66 months.

CONCLUSION

Acute rupture of HCC requires emergency procedures with a high risk of mortality. Curative operation with hepatic resection is the most effective procedure but is not often feasible because of the spreading of the tumor or/and the cirrhosis. The ligation of hepatic artery seems to be an alternative procedure to obtain an immediate hemostasis. Fissuration allows performance of complementary explorations and possibly preoperative arterial embolization with better immediate results.