Cystic Echinococcosis of the Liver: Correlation Between Intra-Operative Ultrasound and Pre-Operative Imaging

Background: Imaging plays an essential role in the management of hepatic hydatid cysts (HCE). The objective of our study was to determine the correlation between pre-operative ultrasound, computed tomography (CT), and intra-operative ultrasound (IOUS) in studying the characteristics and complications of HCE. Patients and Methods: This was a prospective, descriptive, and analytical study conducted in the General Surgery Department of Habib Bourguiba Hospital in Sfax. The study included patients with HCE who underwent conservative surgery between April 2017 and June 2022. Results: We enrolled 49 patients with 94 cysts. At the end of our study, IOUS allowed for better detection of HCE (98.8%) regardless of the number of cysts per patient. IOUS and CT were accurate in studying the location of cysts (κ = 1), whereas pre-operative abdominal ultrasound was less efficient (κ = 0.870). IOUS was the best examination for detecting exocysts (κ = 0.961), studying daughter cysts (κ = 0.823), and exploring vascular relations, but it was less effective (κ = 0.523) in detecting calcifications. Regarding classifications, ultrasound and CT had similar results. However, IOUS was most reliable in differentiating between CE3b and CE4 types (κ = 0.653). Ultrasound, CT, and IOUS were not sensitive in detecting latent HCE suppurations and cystobiliary fistulas. Conclusions: Performing IOUS is essential to prevent recurrences and reduce post-operative morbidity.

Viability predictive factors of the daughter vesicles in hepatic cystic echinococcosis

INTRODUCTION

Management of cystic echinococcosis (CE) requires knowledge of certain aspects related to the survival of Echinococcus granulosus. The viability of daughter vesicles (DV) is a determining factor in guiding therapeutic indications, particularly for transiently active Cysts type CE3b.

PURPOSE

To determine the predictive factors of DV viability and its impact on the therapeutic management of CE3b type.

MATERIALS AND METHODS

This is a prospective pilot study with an analytical aim on patients with cystic echinococcosis of the liver type CE2 and CE3b, operated in the General Surgery Department of Habib-Bourguiba Academic Hospital, Sfax-Tunisia for 22 months from March 2018 until December 2019. The unit of the study is the DV. A parasitological study of the DV was done in the parasitology laboratory.

RESULTS

During the study period, 27 (40.9%) of 66 operated CE Disease from 21 patients containing 248 DV were explored. The median viability of DV protoscoleces was 16.7%. In bivariate analysis, factors for viability of DV protoscoleces were: fever, acute cholangitis, hyperbilirubinemia, left liver location, rock water and bilious echinococcal fluid (EF), cyst size ≥ 43 mm, Intracystic pressure ≥ 35 mmHg, DV size ≥ 6.5 mm, volume, number of DV/cyst ≥ 5, and opaque wall (p < 0.05). Predictive factors for the Non-viability of DV were: CE3b type, purulent EF, gelatinous EF. In multivariate analysis, only CE2 type, cyst size ≥ 43 mm, number of DV/cyst ≥ 5 and DV size ≥ 6.5 mm were factors significantly associated with the viability of DV protoscoleces.

CONCLUSION

CE3b cysts without the criteria of viability of DV protoscoleces may become candidates for the 'Wait-and-Watch' procedure.

Predicting Waist Circumference From a Single Computed Tomography Image Using a Mobile App (Measure It): Development and Evaluation Study

Background

Despite the existing evidence that waist circumference (WC) provides independent and additive information to BMI when predicting morbidity and mortality, this measurement is not routinely obtained in clinical practice. Using computed tomography (CT) scan images, mobile health (mHealth) has the potential to make this abdominal obesity parameter easily available even in retrospective studies.

Objective

This study aimed to develop a mobile app as a tool for facilitating the measurement of WC based on a cross-sectional CT image.

Methods

The development process included three stages: determination of the principles of WC measurement from CT images, app prototype design, and validation. We performed a preliminary validity study in which we compared WC measurements obtained both by the conventional method using a tape measurement in a standing position and by the mobile app using the last abdominal CT slice not showing the iliac bone. Pearson correlation, student t tests, and Q-Q and Bland-Altman plots were used for statistical analysis. Moreover, to perform a diagnostic test evaluation, we also analyzed the accuracy of the app in detecting abdominal obesity.

Results

We developed a prototype of the app Measure It, which is capable of estimating WC from a single cross-sectional CT image. We used an estimation based on an ellipse formula adjusted to the gender of the patient. The validity study included 20 patients (10 men and 10 women). There was a good correlation between both measurements (Pearson R=0.906). The student t test showed no significant differences between the two measurements (P=.98). Both the Q-Q dispersion plot and Bland-Altman analysis graphs showed good overlap with some dispersion of extreme values. The diagnostic test evaluation showed an accuracy of 83% when using the mobile app to detect abdominal obesity.

Conclusions

This app is a simple and accessible mHealth tool to routinely measure WC as a valuable obesity indicator in clinical and research practice. A usability and validity evaluation among medical teams will be the next step before its use in clinical trials and multicentric studies.

Is moderate-intensity interval training more tolerable than high-intensity interval training in adults with obesity?

Interval training (IT) has been shown to be a time-effective alternative to traditional training programmes in the management of obesity. Nevertheless, studies comparing the effects of different IT intensities on inflammation, muscle and liver damage, and perceptual responses in people with obesity are relatively scarce. This study aimed to compare the acute effects of two different IT protocols matched by the mean load and duration on biochemical and perceptual responses in sedentary adults with obesity. Twenty-two volunteers (age = 33.40 ± 10.01 years, BMI = 38.29 ± 7.09 kg/m²) were randomized to perform two conditions: moderate-intensity IT (MIIT) 5 × 3 min (70% of peak power output (PPO))/2 min (45%PPO) and high-intensity IT (HIIT) 8 × 1 min (90%PPO)/2 min (45%PPO). Blood samples were drawn before and after exercise for biochemical and haematological measurements. Rating of perceived exertion (RPE) was assessed during and after exercise. Perceptual pain was evaluated before, throughout and after exercise. C-reactive protein, white blood cells and neutrophils increased only after HIIT (p < 0.001, for all). Aspartate aminotransferase, alanine aminotransferase, creatine kinase and lactate dehydrogenase increased in both HIIT and MIIT (p < 0.001, for all), without any difference between sessions. HIIT induced a greater increase of blood lactate compared to MIIT (p < 0.05). Pain and RPE scores were higher during HIIT vs. MIIT (p < 0.001 and p < 0.01, respectively). MIIT induced fewer immune system perturbations and less muscle pain and was perceived as more tolerable compared to HIIT session. Therefore, MIIT could be used as a first step to promote body adaptations before starting a HIIT programme in sedentary people with obesity.

Duplication cyst and diverticulum of the stomach: A case report of an unusual association

Gastric duplication cysts are uncommon findings in adult patients. Accurate diagnosis of these cysts is difficult. Presenting symptoms are often non-specific, and complications are rare. We report an uncommon case of a non-communicating duplication cyst associated to a diverticula of the stomach in 38-year-old women.

Laser utility in the treatment of hemorrhoidal pathology: a review of literature

Hemorrhoidal disease is a common reason for consultation in proctology. It can be treated in several ways (medical, endoscopic, and surgical). Laser treatment has been described since 1960 and has developed in recent years. The purpose of this literature review was to study the results of laser treatment of hemorrhoids and to compare them with those of surgical methods. We performed a systematic search of the literature by querying the Medline, Google Scholar, and Cochrane Library databases. Retrospective studies and case reports were excluded. We selected 11 studies both techniques HeLP (hemorrhoid laser procedure) and LHP (laser hemorrhoidoplasty procedure). The total number of patients was 1179 including 1059 patients treated with laser and 120 treated surgically within the context of comparative studies. The age of the patients varies between 18 and 74 years old. HeLP laser treatment was significantly superior to surgical treatment in terms of postoperative pain (p < 0.001), hemorrhoidal disease downgrading (p < 0.001), and postoperative satisfaction (p < 0.001). Similarly, LHP laser treatment was significantly superior to surgical treatment in terms of operative duration (p < 0.00001), intraoperative bleeding (p < 0.00001), postoperative pain at H12 and H24 (p < 0.00001 and p = 0.0003), and postoperative bleeding rate (p < 0.001). The laser represents a revolution in the field of proctology mainly in the treatment of hemorrhoidal pathology. It is a safe, effective, and less painful mini-invasive technique. More rigorous studies will be needed to better evaluate this technique.

Recommandations of the Tunisian Association of Surgery for the practice of visceral surgery during COVID-19 pandemic

The World Health Organization declared on March 11, 2020 that the COVID-19 epidemic has become a pandemic. In Tunisia, the Ministry of Health has recommended enhanced preventive hygiene measures to contain and limit the spread of the virus. Following the entry of Tunisia into phase 4 of the COVID-19 epidemic, the Tunisian Association of Surgery proposed recommendations related to surgical activity. Surgical emergencies must be treated urgently and without delay. Non-tumor pathologies which require surgery in an elective situation and for which the risk of aggravation or complication is considered low shoud be postponed. For digestive tumor pathology, and apart from complicated forms, neoadjuvant treatment is highly recommended in the context of multidisciplinary concertation staff.

Predictive factors of occult cystobiliary fistula after conservative surgical treatment of the hepatic hydatid cyst A retrospective study of 105 patients

OBJECTIVES

The objective of our study was to determine the predictive factors of their occurrence during conservative surgical treatment of the hepatic hydatid cyst (HHC).

PATIENTS AND METHODS

We carried out a retrospective review of patients who had undergone conservative surgical treatment of the HHC during 6 years. Univariate analyzes were used to determine the predictive factors of an occult cystobiliary fistula (CBF).

RESULTS

This current study included 105 patients. Concerning the predictive factors of an CBF regardless of its pattern of evolution, we noted that the presence of fistula was statistically correlated with the a cyst size (bigger than 8.65 cm ; p = 0.003) and with advanced age (p=0.035). Interestingly enough, the correlation to a degenerated cyst (p=0.069) were of little significance.

CONCLUSION

The size of the cyst greater than 8.65 cm and the advanced age are the risk factors of CBF according to our study.

KEY WORDS

Biliary Fistula, Diagnosis, Echinococcosis, Hepatic, Prevention and control.

An uncommon cause of acute bowel obstruction: the left para-duodenal hernia

Internal hernias of the abdomen are uncommun. They represent less than 1% of bowel obstruction cases. The left paraduodenal hernia is the most frequent type of internal hernias. We report a case of 77 year-old woman consulting for bowel obstruction evolving since two days. The abdominal computed tomography revealed a retroperitoneal small bowel contained in a peritoneal sac. The surgical exploration confirmed the diagnosis of a left internal paraduodenal hernia by showing incarcerated jejunal loops in a paraduodenal hernia through a narrow opening to the left of the angle of Treitz. A surgical reduction of the hernia and closure of the hernia neck were performed. The follow-ups were uncomplicated. Through this observation and a literature review, we try to recall the clinical and radiological characteristics of this disease and to clarify the therapeutic modalities. KEY WORDS: Computer tomography Internal hernia, Paraduodenal hernia, Small bowel obstruction.

Correlation of radiological findings with surgical findings in hepatic hydatid disease. A prospective study of 79 cases

OBJECTIVES

The liver is the most frequent anatomic location of hydatid disease. Imaging modality nowadays are numerous and increasingly efficient. The objective of our study is to precise the correlation between Ultrasonography, computed tomography and intraoperative findings on the different characteristics of hepatic hydatid cyst.

PATIENTS AND METHODS

We conducted a prospective study including all hepatic hydatid cyst operated in 2015. We evaluated statistically, by calculating the coefficient K or the intraclass correlation coefficient, the concordance between Ultrasonography, computed tomography (CT) and intraoperative findings on the different characteristics of hepatic hydatid cyst.

RESULTS

In our study, we included 48 patients with 79 hepatic hydatid cysts. It was concluded that Ultrasonography performs better than CT in the study of type of cyst, pericyst, relationships with portal vein and main bile duct. While CT is better than echography in terms of number, localizations of cyst, relationship with the vena cava inferior, other localizations and the remaining liver, both examinations remain limited in the determination of pericyst characteristics and the identification of biliary fistula.

CONCLUSION

Ultrasonography and CT cannot provide accurate data for the study of pericyst and biliary fistula, hence requiring prospective studies of the place of MRI and intraoperative echography in this domain.

KEY WORDS

Diagnostic, Imaging, Echinococcosis, Hepatic, Intraoperative Care.

Should we treat white line hernias by laparoscopy? About a prospective study of 42 cases

We report a prospective study of 42 cases of primary uncomplicated umbilical and epigastric hernia operated by laparoscopy with a 1 year mean follow-up. The purpose of our study is to investigate the contribution of laparoscopy in the treatment of in terms of results in the short and medium term. Early surgical morbidity was 14.3%. There was no mortality. At 6 months of the intervention, 28.5% of patients have kept umbilical pain. At 1 year of intervention, 2 patients have kept umbilical chronic pain. No case of recurrence was noted. In conclusion, the laparoscopic approach should be reserved for cases of large hernias and for recurrent and incisional hernias.

KEY WORDS

Epigastric hernia, Laparoscopy, Mesh, Umbilical hernia.

Primary squamous cell carcinoma of the pancreas: a report of two cases and review of the literature

Primary squamous cell carcinoma (SCC) of the pancreas is extremely rare. We herein report two such cases. Aside from various morphological characteristics, the clinical presentation of pancreatic SCC is the same as that of adenocarcinoma. The treatment is controversial, and the prognosis is poor.

Hydatid cyst of the pancreas. About 12 cases

INTRODUCTION

Pancreatic localization of hydatid disease is atypical and extremely rare; it accounts for less than 1% of cases. Preoperative diagnosis may be difficult regarding the absence of clinical or radiological signs.

MATERIALS AND METHODS

We report a retrospective study of twelve cases of hydatid cyst of the pancreas over a period of 30 years (1980 to 2010). By means of our study we try to clarify clinical manifestation, radiological features and therapeutic modalities.

RESULTS

The twelve patients consisted on eight men and four women with an average age of 25.8 years. Abdominal pain was the most frequent clinical signs. Jaundice was noted in 4 cases and abdominal mass in 2 cases. Hydatid serology, practiced in 7 cases was positive in 6 cases. Abdominal ultrasound, practiced in 11 cases, completed in 7 cases by abdominal computed tomography (CT), showed cystic lesions in 10 cases, in 7 cases the cystic lesion was dependent of the pancreas. All patients were operated by median laparotomy. Partial cystectomy was performed in six cases, cystic punture in one case, pancreaticoduodenectomy one case, distal spleno pancreatectomy in 2 cases, distal pancreatectomy in one case and trans-duodenal puncture of the cyst in 2 cases with pancreatico-duodenal anastomosis in one case.

CONCLUSION

Hydatid cyst of the pancreas is extremely rare even in endemic countries, it should be considered in the differential diagnosis of cystic lesions of the pancreas. Ultrasound and CT coupled with hydatid serology could be helpful for the diagnosis. Surgery remains the treatment of choice in pancreatic hydatid cysts.

[Complications of Meckel's diverticulum. Report of 42 cases]

AIM

Our aim was to report the main complications of the Meckel's diverticulum.

METHODS

Our retrospective study concerns 42 cases of complicated Meckel's diverticulum, collected during one period of 18 active years from January 1988 to December 2005. The yearly impact is 2,33 cases/year. We excluded the asymptomatic Meckel's diverticulum, of fortuitous discovery during intervention.

RESULTS

The middle age of our patients is 25 years, with extremes going from 2 to 74 years. The sex-ratio is 3,2. The diagnosis before intervention of the complicated Meckel's diverticulum was not evoked in any time. The clinical features were an acute intestinal closure in 22 cases, an appendicitis in 13 cases, an appendicular peritonitis in 6 cases, and an acute intestinal intussusceptions in one case. In any case, it is the surgical exploration that permitted to confirm the diagnosis of a complicated Meckel's diverticulum. The approach way was median in 27 cases, MacBurney in 13 cases, and laparoscopic in 2 cases. The surgical exploration showed peritonitis in 16 cases, one diverticulitis in 23 cases, an acute intestinal intussusception in one case, a tumour in one case, and haemorrhagic diverticulum's ulcer in one case. The treatment consisted in a segmental resection of ileum with end to end anastomosis (37 cases) and a cuneiform resection (5 cases). The histological exam showed heterotopy of gastric tissue in 12 cases, of pancreatic tissue in two cases, and a Burkitt's lymphoma on a diverticulum in one case. We noted a precocious death following a septic shock.

CONCLUSION

The Meckel's diverticulum constitutes a most common benign malformation of the digestive tube. The prognosis is related extensively to the gravity of its complications that can benefit, not only of the contribution of the laparoscopic diagnosis, but also therapeutic.

[Hydatid cysts of the spigelian lobe (segment I) of the liver: clinical and therapeutic particularities]

OBJECTIVE

Hydatid cysts of the spigelian lobe, that is, segment I of the liver, are rare. We analyzed their clinical and therapeutic particularities.

METHODS

We conducted a retrospective search for the hydatid cysts of the liver treated surgically in our department from January 1, 1994, through December 31, 2005. Cases were identified and confirmed with the following investigatory techniques: routine abdominal ultrasonography, abdominal computed tomography recommended by the ultrasound operator when a cyst was discovered in segment I, routine intraoperative cholangiography, and three separate serological techniques: electrosyneresis, hemaglutination and ELISA (enzyme-linked-immunosorbent assay)(the latter two being quantitative). The cystic cavity was treated with hypertonic serum. Several surgeons performed different combinations of the following techniques: deroofing, sometimes with omentoplasty, simple drainage, and subtotal pericystectomy.

RESULTS

We treated 44 hydatid cysts of segment I surgically in 10 men and 34 women, with a mean age of 40.6 years. Ten patients (22.7%) had a history of hydatid cysts. Symptoms or complications were noted at admission in 45% of cases. Only five cases (11.4%) required emergency surgery. Surgical examination confirmed vascular compression in 17 cases (38.6%) and a biliary fistula in 17 cases (38.6%). Surgical treatment consisted of deroofing in 37 cases (84,1%), with omentoplasty in 23 (54%), subtotal pericystectomy in 3 and simple drainage in 4. Large biliary fistulas (> 5 mm) were treated with bipolar drainage in 2 cases and internal transfistulary drainage in 3. Some hemorrhaging occurred during surgery in 5 cases, and one cyst ruptured in the peritoneal cavity. Albendazole was prescribed postoperatively for nine patients. There was one intraoperative death, secondary to hemorrhage resulting from erosion of the inferior vena cava. Morbidity was 25%. After a mean follow-up of 32 months, five patients had recurrences in the liver but outside segment I.

CONCLUSION

Segment I of the liver is a rare site for hydatid disease, and a site where vascular and biliary complications are frequent. Its management requires a good knowledge of the vascular anatomy of the liver and wide experience of hydatid cyst surgery and especially of simple surgical procedures.

[Peritoneal gelatinous ascites]

Pseudomyxoma peritonei or gelatinous ascites is a rare clinical entity, and its pathogenesis remains obscure. It most often follows a mucinous tumor of the appendix. An ovarian origin in woman has been suggested but remains controversial. Its onset is often insidious: an increase in the abdominal perimeter may be the first sign noted. Preoperative diagnosis is facilitated by modern imaging techniques. Ultrasonography and computed tomography provide complementary signs: septa and scalloping of the liver margins, respectively. Effusion in the lesser peritoneal cavity suggests this diagnosis. Magnetic resonance imaging, by showing the gelatinous ascites, their septa and the scalloping of liver and spleen, can strengthen the probability of the diagnosis. Only laparotomy can confirm it, however. Appendectomy is required in all cases. Recurrence is more frequent in the forms associated with malignant or bipolar tumors. Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy is the only therapy shown to be effective in cases of recurrence or malignant forms.

[Acute hyperlipemic pancreatitis (2 cases)]

THE AIM of this work was to study the clinical and therapeutic features of this affection.

CASE REPORT

Our retrospective study concerned two cases of hyperlipemic pancreatitis treated during 6 years from 1998 to 2003. The incidence of this affection was 1.42%. Our patients were respectively a man aged 32 years without any significant history and a pregnant woman aged 24 years with a positive history of dyslipidemia. Clinical, biologic and radiological data didn't differ from those of other causes of acute pancreatitis. The hyperlipemic origin was confirmed by a lactescent serum and a rate of triglycerides greater than 10 g/l. The course was characterized by the recurrence of pancreatitis related to the increased triglycerid serum level over 10 g/l. Plasmapheresis and administration of heparin and/or insulin seem to be efficient in reducing the serum level of triglyceride and in improving the course. Hygieno-dietary measures and hypolipemiant treatment were necessary for the level of triglyceirdes in serum below 10 g/l. We in the absence of comolicatons, surgery seemed umnecessry in the two cases.

CONCLUSION

the clinical pattern of acute hyperlipemic pancreatitis doesn't include any specific elements, but its treatment and prevention must take into account the associated hyperlipidemia.

[Linitis plastica]

Linitis plastica accounts for 3-19% of gastric cancers. Its diagnosis requires morphology findings of an infiltrating stomach tumor and pathology findings including signet-ring cells and fibrous stroma. Its etiology is not known, and it has no particular features. Diagnostic sensitivity of endoscopy is poor because of the difficulty of biopsies: "Forceps slide on the infiltrated walls." Its characteristic radiologic appearance is due to the infiltration and stiffness that causes it to be known as "leather-bottle stomach". Endosonography is currently the reference examination and has made it possible to identify localized linitis. Unlike other stomach cancers, it frequently extends into the peritoneum and lymphatic system. Curative treatment remains radical surgical resection. Modern chemotherapy protocols based on oral derivatives of 5-FU (TS-1) and of paclitaxel appear promising. The severity of its prognosis is explained by the frequency of peritoneal dissemination, lymphatic invasion and extension toward neighboring organs.

[Gastric sarcoma]

Sarcoma of the stomach is a rare histological entity. These differentiated mesenchymal tumors do not differ clinically from other gastric cancers. Endoscopic ultrasonography is the preferred means of exploration because it determines the existence of a submucosal lesion and provides guidance in determining its type. Certainty of diagnosis requires pathologic and immunohistochemical examinations of the surgical specimen. Malignant gastric stromal tumors are the first differential diagnosis of sarcoma of the stomach. They can be better characterized by testing their expression of the c-kit protein. Histological confirmation of malignancy sometimes remains difficult. Locoregional invasion and distant metastases confirm malignancy. Treatment is essentially surgical. Prognosis depends on tumor size, extension, rupture and histological grade.

Cannabis and Psychosis: What is the Link?

Growing evidence supports the hypothesis that cannabis consumption is a risk factor for the development of psychotic symptoms. Nonetheless, controversy remains about the causal nature of the association. This review takes the debate further through a critical appraisal of the evidence. An electronic search was performed, allowing to identify 622 studies published until June 1st 2005. Longitudinal studies and literature reviews were selected if they addressed specifically the issues of the cannabis/psychosis relationship or possible mechanisms involved. Ten epidemiological studies were relevant: three supported a causal relationship between cannabis use and diagnosed psychosis; five suggested that chronic cannabis intake increases the frequency of psychotic symptoms, but not of diagnosed psychosis; and two showed no causal relationship. Potential neurobiological mechanisms were also identified, involving dopamine, endocannabinoids, and brain growth factors. Although there is evidence that cannabis use increases the risk of developing psychotic symptoms, the causal nature of this association remains unclear. Contributing factors include heavy consumption, length and early age of exposure, and psychotic vulnerability. This conclusion should be mitigated by uncertainty arising from cannabis use assessment, psychosis measurement, reverse causality and control of residual confounding.

Liver cystic echinococcosis: which cysts are correlated with false negative indirect passive hemagglutination (IHA)?

BACKGROUND

It's generally agreed that calcified liver cystic Echinococcosis (CE) is associated with negative serology; the influence of other cystic features on serologic result remains unclear. The aim of this study is to determine predictive factors of negative indirect passive hemagglutination (IHA) in liver CE.

METHODS

119 patients operated on for liver CE, had preoperative IHA. Correlation was studied between serological result and sex, age of patient and number (single vs multiple), size, ultrasonic type (unilocular, multivesicular, degenerative) and intrabiliary rupture of cyst.

RESULTS

IHA sensitivity was 74.8%. Univaried analysis showed that false negative serology was correlated with age <10 or >20 years (p < 0.01), single cyst (p < 0.006), cystic size <9 cm (p < 0.03) and unilocular or degenerative cyst in comparison with multivesicular type (p < 0.01 and p < 0.03 respectively).

IN CONCLUSION

in liver CE, cystic predictive factors of false negative IHA are single cyst, unilocular or degenerative type and size inferior to 9 cm.

[Breast cancer in men]

Breast cancer in men is rare and most often occurs at or after the age of 60 years. Prognosis is poor when it is discovered at a late stage, as it often is in men, although it should be easier to detect because men have so little breast tissue. The causal mechanism appears to depend on hormone metabolism abnormalities related to elevated estrogen or prolactin levels. A family history of breast cancer is found in 5-10% of cases. Infiltrating ductal carcinoma accounts for most cases (70-90%) of male breast cancers. In situ but not invasive carcinoma is exclusively ductal and accounts for 7% of cases. Spread to lymph nodes is observed in 50-75% of cases. Immunohistochemical analysis shows that tumors are positive for progesterone and estrogen receptors more frequently in men than women. Diagnosis is based on clinical examination, ultrasonography, and mammography. Aspiration cytology often makes it possible to confirm the malignancy. Excisional biopsy with an immediate intraoperative pathology examination confirms malignancy and makes wider excision possible during the same procedure. A modified radical mastectomy with removal of some lymph nodes (Patey's mastectomy) is the standard basic treatment. Locoregional radiotherapy is very often indicated. Hormone therapy is also a first-line treatment. Chemotherapy is reserved for young men with substantial lymph node invasion and negative for hormonal receptors. The prognosis of breast cancer in men remains uncertain because of the frequently late diagnosis, unpredictable course, and high potential for metastasis.

[Cystic lymphangioma of the abdominal cavity. Report of 11 cases]

OBJECTIVE

Our aim was to assess the epidemiological particularities, the circumstances of the diagnosis and the therapeutic indications of the cystic lymphangioma of the abdominal spaces.

METHODS

Our retrospective and analytic survey concerns 11 cases of cystic lymphangioma of the abdominal spaces: mesentere 6 cases, epiploon 1 case, retroperitoneum 3 cases and under peritoneum 1 case. The incidence was of 1/2476 hospitalizations (0.04%).

RESULTS

The median age was 28 years. The sex-ratio was of 1.2. The main circumstance of discovery of the cystic lymphangioma was an abdominal mass in 7 cases. The other circumstances were: a pseudoappendicular syndrome, an ascitis, a disembowelment and a direct traumatism of the abdomen. Total resection of the cystic lymphangioma was performed in 7 cases. In 4 cases a simple enucleation and in 3 cases a resection of a segment of the organ that supports the lymphangioma. Only a partial resection of the lymphangioma has been achieved for the remnant patient. A cystic lymphangioma relapsed 13 years after a total resection in one case. Mortality rate was nul.

CONCLUSION

The circumstances of diagnosis of the cystic lymphangioma were in relation with the volume of the tumor or a mechanical, infectious or hemorrhagic complications. The recidivism after a total resection let evoke the possibility of multiple and diffuse cystic lymphangioma.

[The results of laparoscopic treatment of the gallbladder lithiasis. About 500 cases]

BACKGROUND

Laparoscopic cholecystectomy is at present the gold standard treatment of gallbladder lithiasis.

AIM

Assesment of Laparoscopic cholecystectomy

METHODS

Through a retrospective series of 500 laparoscopic cholecystectomies during a period going from January 1996 to March 2000, we tried to evaluate our experience by comparing our results to the literature data.

RESULTS

There were 420 women and 80 men with a sex ratio of 0.19. Average age was 50 years. 16.2% of our patients were obese. 13 patients had a history of respiratory disease and 122 history of a cardiovascular pathology essentially arterial hypertension. All our patients benefited from at least one hepato-biliary ultrasound examination before the intervention. Antibioprophylaxy was administrated in 93.8% of cases. In 23 cases (4.6%), a conversion was necessary for different causes. We noted 11 surgical complications (2.2%) among which 2 required a surgical resumption, and 11 medical complications dominated by broncho-pulmonary infections. We had no death.

[Fibrocystic mastopathy and cancer of the breast. About 111 cases]

OBJECTIVE

Our aim was to identify the predictive factors of degeneration of the fibrocystic mastopathy.

METHODS

This work is a retrospective survey of 111 observations of isolated fibrocystic mastopathies or associated to a breast cancer among 542 women admitted for tumor of the breast during one period of 13 active years from 1991 to 2003. The diagnosis has been gotten by anatomo-pathologic exam in 95.5% (106 cas) on the operative piece and 4.5% (5 cas) on a material of biopsy.

RESULTS

The fibrocystic mastopathy represented 30% of the set of the benign tumors of the breast. They were associated to a breast cancer in 45 cases (40.5%). The isolated benign fibrocystic mastopathy was observed in 66 cases with a middle age of 37 years, whereas the shapes associated to a breast carcinoma were noted in 45 cases. The middle age was 53 years. The non proliferative fibrocystic mastopathy is the most frequent histological type and represent 54.6% of the cases. The proliferative form with atypies was observed at 21 women (46.8%). The carcinoma the more frequently associated to the fibrocystic mastopathy was the infiltrating canalled carcinoma in 91% of cases, with a predominance of the II rank (SBR).

CONCLUSION

The discovery of a mastopathy must search a luteal failure and risk factors of breast cancer notably a proliferative shape of mastopathy with atypies.

[Retro-peritoneal liposarcoma. About 5 cases and revue of literature]

Liposarcomas are malignant mesenchymatous tumors developed from elements constituting the greasy tissue in various stages of differentiation. It is one of the most frequent mesenchymatous sarcomas. Retro-peritoneum is a privileged site of development in 12 to 15% of cases. During 9 years, from 1994 till 2002, we have colligated and operated 5 cases of retro-peritoneal liposarcomas. Average age was 50 years (extremes 34 to 79 years) with a sex-ratio of 1.5. Diagnosis was late beyond 6 months. Abdominal pain and the appearance of an enormous mass (20 cm) were the revealing signs. No imagery method allowed to evoke the diagnosis. The cyto-puncture realized once, was not able to determine with precision the histological type. Immunohistochimy occupies nowadays an important place to classify a sarcoma. Large surgical resection realized in 5 cases did not allowed the complete ablation of the tumour in 3 cases considering the advanced loco-regional extension, which was at the origin of 3 recurrences. Well differentiated histological type was noted in 3 cases, myxoid type in a case and not differentiated type in a case.

[Pyogenic liver abscesses: a study of 25 cases]

OBJECTIVE

Our aim was to study the anatomo-clinic particularities and the therapeutic modes of the infectious abscesses of the liver.

PATIENTS AND METHODS

Our retrospective study concerns 25 cases of the infectious abscesses of the liver collected on one period of 12 years from January 1992 to December 2003. They are 11 primitive abscesses and 14 secondary abscesses.

RESULTS

We noted 14 women and 11 men, median age was 51.5 years. The Fontan triad was present in 7 cases. A liver mass with an abdominal sensitivity was found in 14 cases. Anomalies in the biologic exam of the liver were present in the 1/3 of the cases. We noted a double right and left localization in 3 cases and a multiple localization in 1 case. The hemoculture and the pyoculture permitted a bacteriological diagnosis in 52%. The percutaneous treatment achieved in 7 cases, permitted the recovery in 2 cases. One dead was noted following a severe cardiopathy. A surgical drainage has been achieved at 22 patients. 4 cases after the failure of the percutaneous treatment. Mortality rate was 20% (5 cases) related to the delay of diagnosis, the gravity of the septic shock. the advanced age and the flaws associated.

CONCLUSION

The infectious abscess of the liver was a serious affection that affects the vital prognosis. The percutaneous treatment associated to the antibiotherapy. is the method of choice in the treatment of the abscesses of the liver. The surgical treatment must be reserved to the failure of the percutaneous treatment.

Cannabinoids in medicine: A review of their therapeutic potential

In order to assess the current knowledge on the therapeutic potential of cannabinoids, a meta-analysis was performed through Medline and PubMed up to July 1, 2005. The key words used were cannabis, marijuana, marihuana, hashish, hashich, haschich, cannabinoids, tetrahydrocannabinol, THC, dronabinol, nabilone, levonantradol, randomised, randomized, double-blind, simple blind, placebo-controlled, and human. The research also included the reports and reviews published in English, French and Spanish. For the final selection, only properly controlled clinical trials were retained, thus open-label studies were excluded. Seventy-two controlled studies evaluating the therapeutic effects of cannabinoids were identified. For each clinical trial, the country where the project was held, the number of patients assessed, the type of study and comparisons done, the products and the dosages used, their efficacy and their adverse effects are described. Cannabinoids present an interesting therapeutic potential as antiemetics, appetite stimulants in debilitating diseases (cancer and AIDS), analgesics, and in the treatment of multiple sclerosis, spinal cord injuries, Tourette's syndrome, epilepsy and glaucoma.

[Tumors of the vaterian region indications, findings and prognosis : about 49 cases]

This retrospective study is about 49 cases of tumors of the vaterian region collected between 1976 and 2001. Tumors of the vaterian region represented 7% of the bilio-pancreatic tumors. The study was about 18 women and 31 men, with sex-ratio of 1.7. The mean age was 61 years. Treatment was surgical : cephalic duodeno-pancreatectomy (28 patients) or ampullectomy (5 patients). Rate of tumor resectability was 69.4%. Bilio-digestive derivation was practiced on 13 patients and therapeutic abstention was decided for 3 patients. Age over 65 years, rate of bilirubine superior to 120 mmol/l and surgery done in emergency were elements of bad prognosis that increased post-operative mortality of following cephalic duodeno-pancreatectomy. Global mortality and morbidity were respectively 16% and 24%. Factors of poor prognosis were essentially: Tumor of large size, infiltration of the surrounding structures and tumor with metastases. The survival after bilio-digestive derivation didn't pass the 8 months. Five year survivals cephalic duodeno-pancréatectomy represented 20%. It depended on the degree of the local invasion. This 5 years survival rate to was 85% for stage I (classification of Martin) and 10% for stage IV.

[Late post-operative adhesive small bowel occlusions. About 258 cases]

This retrospective study reports a series of 258 patients operated on for late developing post-operative adhesive occlusions. The impact of anterior interventions on these occlusions. The impact of anterior interventions on the occllusions as well as he clinical and paraclinical patterns are discussed before any approach to the different therapeutic aspects of this complication. Previous surgery had an impact not by number of the operations performed (80% of patient had undergone only one intervention on the pelvis or abdomen) but essentially by the nature of the opertions since most of the adhesions occured following surgery on the appendix. The diagnosis should be made urgently ont basis of findings yielded by physical examination and plain abdominal x-rays (ct-scan of the abdomen is hardly indicated for the absence of hydroaeric levels on the plain abdominal film does not defintely exclude the strangulation). Laparoscopic adhesiolys is an adegnate treatment in case of a single adhesion. This laparoscopic is an adegnate treatment in case of a single adhesion. This laparoscopic procedure practised on 11 patients had to be transformed in 3 cases in to an open laparoctomy. Resection rate was 11.6%. Mortality and morbidity rates were 2% and 17% respectively.

[Anastomotic ulcer after vagotomy for duodenal ulcer]

Between January 1981 and December 2000, 2609 patient underwent surgery for duodenal ulcer. 2274 underwent isolated vagotomy; 1590 had vagotomy associated with GI anastomosis. Only relapses of anostomic ulcers after vagotomy associated with gastrojejunal anastomosis were included in this study. 22 patients (20 males, 2 females) aged between 26 and 79 years had anastomic ulcer relapses (1.38%) after vagotomy and GI anastomosis. Incomplete vagotomy was diagnosed in 14 cases (93%) associated with a defect in setting in 2 cases. Despite the ongoing controversy about the role of Helicobacter in the pathogenesis of anastomotic ulcers, medical treatment remains the primary therapy, and a partial gastrectomy alone or with vagotomy is necessary only in unresponsive cases.

[Duodeno-pancreatic trauma. About 14 cases]

Through a series of 14 cases brought over a period of 12 years, we realized a retrospective, analytical and descriptive study of these traumatisms. We aimed to release recommendations to improve their management. It was 2 women and 12 men, whom mean age was 24.4 years (extremes: 50 and 60 years), divided into 10 pancreatic injuries, 2 duodenal injuries and 2 duodeno-pancreatic injuries. Etiology was dominated by traffic accidents 7 cases (50%). Trauma was closed in 13 cases (92%). Associated lesions were present among 13 patients (92%). The traumatism appeared by an urgent surgical abdomen among 9 patients, secondarily in 3 cases, tardily in 2 cases: a case of deep suppuration 3 months after a traumatism treated into ambulatory and a case of persistent ascites after a past unperceived traumatism. Abdominal ultrasonography was made among 4 patients. It allowed diagnosing only a case. Scanner was made among 4 patients. It allowed diagnosing all the cases. Only a patient was treated medically, it was a post-traumatic acute pancreatitis. Surgical treatment was made in 13 cases: conservative in 7 cases and radical in 6 cases. Follow-up was complicated in 11 cases (78%) and non-complicated in 3 cases. Mortality rate was 7.1%.

[Acute rupture of hydatid cysts in the peritoneum: 17 cases]

OBJECTIVE

Specify the clinical and progressive characteristics of acute rupture of hydatid cysts in the peritoneum.

METHOD

We retrospectively studied patients who had undergone surgery for a hydatid cyst (HC) of the abdomen between January 1990 and December 2000 and in whom the exploration had confirmed the diagnosis of acute rupture of a hydatid cyst in the peritoneum.

RESULTS

Over this period of 11 Years, 970 patients had undergone surgery for hydatid cysts of the liver and the spleen, 17 of whom had presented an acute rupture of the hydatid cyst in the peritoneum, that is to say 1.75% of the cases. The mean age was 30 Years and sex ratio was 0.41. Rupture was secondary to a trauma in 6 cases and to an intense physical effort in one case. The clinical table was acute peritonitis in 14 cases, acute intestinal occlusion in one case, suggested anaphylactic shock in one case, and a non-complicated hydatid cyst in one case. Ultra-sonographic diagnosis was made in all the cases, but that of rupture in 12 cases only. No scans were performed. Intervention was decided on within a delay of less than 72 hours in 16 cases. Surgical treatment consisted in the treatment of the peritonitis, the ruptured hydatid cyst, the associated hydatid cysts in the liver and the spleen, and the hydatid cyst of the right lung in two cases. Post-operative follow-up was complicated in 4 cases with two deaths through septic shock. Distant follow-up was marked by a secondary peritoneal hydatidosis in a patient whom has not benefited from medical treatment. The latter, based on albendazole, was prescribed in 6 patients with satisfying results and a mean follow-up of 32 months.

CONCLUSION

The therapeutic progress has improved the prognosis of ruptured hydatid cysts in the peritoneum. Secondary peritoneal hydatidosis is fundamentally enhanced by the delay in diagnosis and treatment and the absence of medical treatment. The optimal strategy is to treat the patients at the non-complicated stage of the hydatid cyst and, above all, prevent the hydatid infestation.

[Gaucher's disease uncovered late]

Gaucher's disease is an uncommon inborn recessive autosomal disease, due to a deficient activity of the lysosomal enzyme beta glucocerebrosidase. This disease is usually diagnosed in the first or second decade of life with the arising of bone pains, splenomegaly and hemorragic manifestations due to thrombocytopenia. When the enlarged spleen is not evident, or after splenectomy, patients may be mis-identified as having Gaucher's disease. We present here two cases of elderly patients aged 70 and 46 years respectively, in whom the disease was a surprising finding of bone marrow examination, during check up for pancytopenia.

Fracture spacing in layered materials

We perform an elastostatic analysis of a periodic array of cracks under constant loading. We give an analytical solution and show that there is a limitation to the fracture spacing, due to a transition from an opening to a compressive loading. For this configuration, the threshold of the fracture spacing depends on neither the applied strain nor the elastic parameters of the material. This result shows that, in the general case of layered materials, the physical mechanism that is responsible for the limitation in the density of fractures is related mainly to the geometry of the problem. This is in agreement with observations and with recent numerical results.

Dynamics of singularities in a constrained elastic plate

Large deformations of thin elastic plates usually lead to the formation of singular structures which are either linear (ridges) or pointlike (developable cones). These structures are thought to be generic for crumpled plates, although they have been investigated quantitatively only in simplified geometries. Previous studies have also shown that a large number of singularities are generated by successive instabilities. Here we study, experimentally and numerically, a generic situation in which a plate is initially bent in one direction into a cylindrical arch, then deformed in the other direction by a load applied at its centre. This induces the generation of pairs of singularities; we study their position, their dynamics and the corresponding resistance of the plate to deformation. We solve numerically the equations describing large deformations of plates; developable cones are predicted, in quantitative agreement with the experiments. We use geometrical arguments to predict the observed patterns, assuming that the energy of the plate is given by the energy of the singularities.