Cure of inguinal hernias with large preperitoneal prosthesis: Experience of 2,312 cases

It is clear that the recurrence rates after nonprosthetic methods for the repair of inguinal hernias, like McVay, Bassini or Shouldice techniques, are high (6–10%). Since 20 years, we are convinced, in the GREPA-EHS group, about the advantages of the use of a prosthetic mesh in majority of patients for repairs of primary or recurrent inguinal hernias and incisional hernias. We describe our typical technique for the cure of all inguinal hernias. We place a large supple mesh, by open inguinal route, posterior to the transversalis fascia and anterior to the peritoneum. We have made a double modification in the initial technique of Rives - the use of a very large unsplit prosthesis (15 × 17 cm) and the parietalization of the spermatic cord helped by a wide opening of the Fruchaud's orifice by diversion of the epigastric vessels. The positioning of the mesh is about the same as in the TEP technique but with the advantages of reduction in the vital laparoscopic risks and reinforcement of the wall by a short tension-free McVay technique.

For this prospective study, we repaired 2,312 consecutive hernias in 1,828 patients, 284 of which were recurrent. We present our results in terms of quality of repairs, recurrence rates (0.4%), morbidity rate (8%), and mortality rate (0.8%).

This technique involves the placement by an open incisional route of a large preperitoneal sheet of mesh for initial treatment of all inguinal hernias - including scrotal, giant or femoral - to ensure a definitive solid muscular wall, even for recurrent hernias.

[Carcinoid tumor from the small bowel]

Carcinoid tumors are non-pancreatic digestive neuroendocrine tumors well differentiated. Most of time they are developed from enterochromaffin cells of the digestive tract. Most of them are localized in ileum, rectum, stomach and appendix. Only bronchi are a frequent extra-digestive localization (20 to 25%). Most of these tumors are asymptomatic and discovered incidentally during a laparotomy or secondary to the exploration of a carcinoid syndrome. From a case report and a recent review of literature, diagnosis, histology and treatment of small bowel carcinoid tumors are summarized.

[Androgenic alopecia revealing an androgen secreting ovarian tumor]

INTRODUCTION

Androgen-producing tumors of the ovary are rare in postmenopausal women and are revealed by severe virilization. Leydig hilus cell tumors are the most frequent postmenopausal virilizing tumors. In this report, an unusual and rare cause of alopecia due to Leydig cell hyperplasia within the wall of a simple cyst and in the ovarian hilus is described.

OBSERVATION

An 80 year-old woman complained of a 10-year history of severe androgenic alopecia associated with very mild facial hirsutism, without others signs of virilization. Hormonal blood levels showed markedly elevated testosterone. Computed tomographic scan of the adrenals and the ovaries revealed an enormous left ovarian cystic mass. Bilateral hystero-ophorectomy was performed. Histological examination demonstrated bilateral Leydig cell hyperplasia within the wall of the cyst and in the right ovarian hilus. Two months postoperative hormonal evaluation demonstrated dramatically decreased plasma levels of testosterone.

COMMENTARY

The clinical, X ray and histologic aspects of this case, although rare, show that the presence of virilization should lead to a search for an androgen-secreting ovarian or adrenal tumor.

[Suspected acute appendicitis. Role of enhanced helical computed tomography. Prospective study of 100 patients]

AIM OF STUDY

To assess the diagnosis accuracy of helical computed tomography (CT) in patients with suspected appendicitis.

PATIENTS AND METHODS

This prospective study included 100 consecutive patients hospitalized for suspected appendicitis. There were 57 men and 43 women with a median age of 30 years (range: 17-91). An enhanced helical CT was performed at admission, without digestive opacification. Four criteria were interpreted as positive signs for appendicitis: appendix enlarged > or = 7 mm, right lower quadrant inflammation, stercorolith, and peri-appendicular collection. The patient was managed by the surgeon without knowing the result of CT. The final diagnosis was made pathologically.

RESULTS

Eighty-one patients were operated on laparoscopically for suspected appendicitis. Intraoperative diagnosis was corrected in three cases and 78 appendectomies were performed (73 histological appendicitis, six normal appendix). Final diagnosis was a medical disease in 19 patients. The findings of 67 CT were interpreted as positive (63 true positive and four false positive) and the findings of 33 CT were interpreted as negative (24 true negative, nine false negative). Sensitivity was 87%, specificity was 86%, positive predictive value was 94%, and negative predictive value was 73%. If the nine false negative cases with minimal lesions at pathological examination were considered as true negative, the rates would be 100%, 89%, 94%, 100%, respectively.

CONCLUSION

Enhanced helical CT is a good imaging diagnostic tool for suspected appendicitis. It may reduce the number of patients admitted for observation and decrease the rate of negative appendectomy.

[Laparoscopic treatment of perforated duodenal ulcer]

OBJECTIVE

The aim of this study was to determine if laparoscopic simple closure for perforated duodenal ulcer is possible, efficient and safe.

METHODS

Thirty-five consecutive patients with perforated duodenal ulcer and peritonitis were treated by simple closure, peritoneal lavage and omentoplasty. This treatment was performed laparoscopically.

RESULTS

Diagnosis was confirmed in all cases. Conversion to laparotomy was necessary in two patients due to a technical problem and poor tolerance to pneumoperitoneum, respectively. Mean operative time was 120 min. Morbidity and mortality rates were 2.8%. Mean hospital stay was 7.8 days. No recurrence was found after eradication of Helicobacter pylori with a long-term follow-up of 38 months.

CONCLUSION

Laparoscopic suture of perforated duodenal ulcer is possible and safe. It can avoid laparotomy with septic complications in peritonitis. In emergency there is no place for radical treatment of ulcer disease because of efficiency of medical treatment.

[Non-secreting pheochromocytoma of the broad ligament revealed by appendicular peritonitis]

BACKGROUND

Non-secreting pheochromocytoma is an endocrine tumor located in the adrenal medulla in 85% of the cases. Extra-adrenal localizations account for the other 15%. A broad ligament localization related to an accessory adrenal gland is exceptional.

CASE REPORT

A tumoral formation was observed during computed tomographic exploration of appendicular peritonitis in a 25-year-old patient. The tumor had developed from an ectopic adrenal gland included in the large ligament of the uterus. Pathology reported non-secreting pheochromocytoma confirmed by immunolabeling.

DISCUSSION

The broad ligament localization is exceptional for pheochromocytomas and may mislead diagnosis. Resection is the only treatment. Recurrence and metastases have been reported to develop in some cases many years later, particularly after incomplete resection. Pathogenically, this tumor is remnant embryonic chromaffin tissue issuing from the parasympathetic nodes and developing in an ectopic adrenal gland.

[Laparoscopic appendectomy in the adult]

AIM OF THE STUDY

The benefits of laparoscopic appendectomy remain controversial. The aim of the study was to evaluate the advantages and disadvantages of this technique.

MATERIAL AND METHODS

Four hundred and forty-eight patients operated on for suspected appendicitis during a 5-year period were analysed in a retrospective study. The preoperative diagnosis was corrected in 21.4% of the cases (8.1% for males and 28.7% for females) and the conversion rate was 9.7%. There were 17 patients with generalized peritonitis and 28 with localized peritonitis. During the past year, this surgical method was introduced in another hospital and a prospective study included 92 consecutive patients operated on for appendicitis. The operating time was 53 minutes and the conversion rate was 7.6%. There were five patients with generalized peritonitis and eight with localized peritonitis.

RESULTS

There were no postoperative deaths. In the first period, the morbidity rate was 2.3% in the laparoscopic group without conversion. After pathological examination, there was a 14.2% rate of normal appendix. The mean hospital stay was 4.3 days. In the second period, there were only three minor complications and the mean hospital stay was 4.19 days.

CONCLUSION

The choice of laparoscopic approach is associated with some advantages: corrections of the diagnosis (mainly in young women) and simplification of the postoperative course, provided that the surgeon has sufficient experience.

Idiopathic thrombocytopenic purpura associated with Crohn's disease

Besides cytopenia related to treatment, several hematological disorders such as anemia, abnormal platelet activity, thrombosis, presence of anticardiolipin or anti-neutrophil antibodies, cyclic neutropenia, and myelodysplasia, have been reported in patients with Crohn's disease (CD). The case we report here is the first one documenting the association of idiopathic thrombocytopenic purpura (ITP) with CD.

Idiopathic thrombocytopenic purpura as the presenting feature of a primary bilateral adrenal non Hodgkin's lymphoma

Primary lymphomas arising in the adrenal gland are extremely rare. The presenting symptoms are nonspecific and may be related to lymphoma or to associated adrenal insufficiency. In this report we describe the case of a 61 year old woman with idiopathic thrombocytopenic purpura and primary bilateral non Hodgkin's lymphoma of the adrenals.

Pancreatic transplantation in experimental non-insulin-dependent diabetic rats

The effect of pancreatic transplantation on noninsulin -dependent diabetes mellitus (NIDDM) had not been evaluated in animal models. We assessed its impact by the insulin-glucose clamp study in experimental diabetic rats. NIDDM was induced in Lewis female rats by streptozocin at the age of 5 days (n5-STZ). To determine its effect on insulin sensitivity, we measured the glucose turnover rate and performed euglycemic hyperinsulinemic clamp studies, evaluating hepatic glucose production (HGP) and glucose uptake. This assessment was conducted on 5 groups of 6 female Lewis rats: 2 groups n5-STZ tested at the age of 10 and 14 weeks, respectively; 2 normal age-matched groups; and a fifth group (n5-STZ) transplanted at 10 weeks of age and tested at 14 weeks. Heterotopic pancreaticoduodenal transplantation was performed, using an end-to-side anastomosis between the donor celiac artery and portal vein to the recipient infrarenal aorta and vena cava, respectively. Pancreatic drainage was achieved by an end-to-side duodenojejunostomy. At 10 weeks of age, diabetic n5-STZ rats showed decreased body weight, hyperglycemia, moderate insulinopenia, a significantly higher basal HGP as compared with normal controls (28.5 +/- 10 vs. 10.7 +/- 4 mg/kg/minute, P<0.05), and ineffective suppression of the HGP by the insulin infusion. Glycemia, body weight, and basal HGP were normalized in the transplanted group and were statistically similar to age-matched normal controls. HGP was totally suppressed by the insulin infusion. However, the blood insulin level remained significantly higher than in the normal groups (P<0.05). We conclude that n5-STZ is a reliable model of NIDDM and that pancreatic transplantation, without immunosuppressive drugs in this isogenic line, corrects all tested parameters of glucose homeostasis and improves insulin sensitivity.

[Is there a role for pancreas transplantation in the treatment of type II diabetes mellitus? Experimental study]

There is no experimental basis for transplantation of the pancreas in patients with non-insulin-dependent diabetes mellitus. We compared results in normal and grafted non-insulino-dependent Lewis rats. A heterotopic pancreatico-duodenal graft was implanted with end-to-side anastomosis of the coeliac artery and the portal vein of the donner on the infrarenal aorta and inferior vena cava of the recipient. The diabetic rats showed weight loss, high blood glucose levels (3.30 +/- 1.25 milligrams), moderate insulinopenia and significantly elevated liver production of glucose. Glycaemia, weight and liver production of glucose were the same as those in the group of normal animals. We concluded that transplantation of the pancreas in an isogenic model without immunosuppression can correct glucose levels and insulino-resistance. It could be suggested in man.

A cost-benefit comparison of intensive diabetes management with implantable pumps versus multiple subcutaneous injections in patients with type I diabetes

OBJECTIVE

To investigate if intraperitoneal (IP) insulin infusion via programmable implantable pumps is a potential alternative to subcutaneous (SC) insulin via multiple injections.

RESEARCH DESIGN AND METHODS

We compared the cost-benefits of the two methods using a randomized, prospective, 6-month, crossover design in 10 adult type I diabetic patients.

RESULTS

When judged on the last month of IP versus SC periods in the nine patients who completed the study, metabolic data showed better glycemic control (HbA1c: 7.2 +/- 0.2 IP vs. 8.5 +/- 0.7% SC, mean +/- SE, P = 0.02), reduced glycemic fluctuations (SD of capillary glucose values: 3.4 +/- 0.2 IP vs. 4.6 +/- 0.2 mM SC, P < 0.01), and fewer mild hypoglycemic events (5.7 +/- 2.0 IP vs. 10.0 +/- 3.1 events/month SC, P = 0.02). Quality of life, judged by Diabetes Control and Complications Trial questionnaires, was unaffected by pump therapy. Direct costs, including pump acquisition, implantation, and follow-up, were 2.6-fold higher with IP than with SC delivery.

CONCLUSIONS

The implantable pump is more effective in the short term, equally accepted, but more costly than multiple injections and should be limited to patients with unsatisfactory glycemic control despite intensive diabetes management with SC insulin. In addition, longer-term, larger-scale, and comparative evaluation is required.

[Cost benefits of intensive insulin therapy using injections, external pumps and implantable pumps]

Since feasibility is now proven, cost-efficacy of external sub-cutaneous (EXT) and implantable programmable (IMP) insulin pumps needs to be compared to those of intensified conventional insulin therapy (CONV). Only metabolic efficacy and short-term direct costs are easily evaluable. We (WHO-CSII Study) and others have shown that glycemic control and severe hypoglycemia risk are slightly improved, while ketoacidosis risk and costs are aggravated with EXT vs CONV. We (CEDIT Study) and others have shown that glycemic control, mild and severe hypoglycemic risks are improved, with no increase in ketoacidosis rates although a doubling in costs with IMP vs CONV. Rigid interpretation of the above data would limit indications of insulin pumps to patients experiencing frequent hypoglycemias while on intensified conventional insulin therapy.

Computed tomography of retained abdominal sponges and towels

The diagnosis of retained sponges and towels a year or more after surgery is often very difficult. We describe the computed tomographic (CT) findings in 4 patients with this complication; 2 cases of retained sponges and 2 cases of retained towels. While the CT appearance of the retained sponges was not specific, the particular appearance of the retained towels had not been previously described. This appearance is characteristic enough to suggest the correct diagnosis before reoperation.

[Rectocolic endometriosis]

The authors distinguish two major varieties of rectocolonic endometriosis: the isolated benign sigmoid endometrioma which is difficult to distinguish from malignant lesions of the mucosa; the tendency to progressive stenosis is an indication for surgical excision of this lesion. Genital endometriosis which has spread to the intestinal tract. The genital and peritoneal lesions facilitate the diagnosis of the recto-sigmoid lesion. On the other hand, the intestinal involvement complicates the therapeutic. Low rectal involvement usually consists of endometriosis grafted to a perineal scar.

[Turner's syndrome phenotype and spontaneous menstruation. Apropos of a case of 45 X syndrome]

The authors report a new case where a women of 28 years of age started periods spontaneously in spite of having the phenotype of Turner's syndrome and a 45 X karyotype in her lymphocytes and fibroblasts. When she had been stimulated with Clomiphene it was even possible to prove that she had ovulated and produced a functional corpus luteum. No Barr bodies were to be found in the cells from her ovaries and the karotype did not suggest a mosaic which would normally explain this sort of state. All the same, it is difficult to see how any part of the basic follicles can persist in cases of monosomy 45 X if there is no mosaicism.