[Poorly differentiated endocrine carcinoma of the colon]

Small-cell endocrine carcinoma is a particularly aggressive form of endocrine carcinoma characterized by its rapid and early metastatic dissemination. We report a 59-year-old man who presented with abdominal pain as the initial manifestation of a colonic small-cell endocrine carcinoma with early liver metastases and poor prognosis. Poorly differentiated endocrine carcinomas are rare tumours that generally occur in the lung, but are exceptionally localized in other sites. Generally, these tumours have an aggressive behaviour with early metastatic spread, and curative surgical resection is often impossible. Despite aggressive chemotherapy, these extended tumours have an unfavourable outcome.

[Appendiceal mucoceles, pseudomyxoma peritonei and appendiceal mucinous neoplasms: update on the contribution of imaging to choice of surgical approach]

INTRODUCTION

The treatment of pseudomyxoma peritonei (PMPs) and appendiceal mucocele (AM) has changed radically. To assess the contribution of preoperative imaging to the treatment strategy and choice of approach, a surgeon and a radiologist different from the initial radiologist examined the files of all patients treated for PMP or AM in four facilities in one district from January 1, 1996, through December 31, 2008.

PATIENTS AND METHODS

The study included 27 patients (20 men and seven women, mean age: 63+/-13 years). Eleven patients had an intact AM, seven synchronous PMP (malignant appendiceal lesion in two of seven), six metachronous PMP (five with peritoneal mucinous carcinomatosis and one with diffuse peritoneal adenomucinosis) and three a ruptured AM but not PMP. The incidence of mucin-secreting tumors observed (27 cases in 12 years in a region of 500 000 inhabitants) corresponds to a prevalence of approximately five cases per year per million inhabitants. Acute clinical pictures (7/27) were significantly more frequent for the malignant forms (5/7) (p<0,02).

RESULTS AND DISCUSSION

The overall sensitivity of computed tomography (CT) for all the criteria studied was 93%. The predictive value for AM rupture of visualization of thick calcifications was 100%. On the other hand, rupture never occurred when the CT showed an AM under pressure, with thin walls and septa. The predictive value for PMP of "scalloping" was 100%. The diagnostic accuracy of the initial reading was 25/27 for the imaging overall and 25/25 for the CT. Preoperative visualization of the exact size of the intact AM or of diagnostic information about ruptured AM and PMP helped to select an appropriate approach in 25 of 27 cases.

Influence of contact angle on slow evaporation in two-dimensional porous media

We study numerically the influence of contact angle on slow evaporation in two-dimensional model porous media. For sufficiently low contact angles, the drying pattern is fractal and can be predicted by a simple model combining the invasion percolation model with the computation of the diffusive transport in the gas phase. The overall drying time is minimum in this regime and is independent of contact angle over a large range of contact angles up to the beginning of a transition zone. As the contact angle increases in the transition region, the cooperative smoothing mechanisms of the interface become important and the width of the liquid gas interface fingers that form during the evaporation process increases. The mean overall drying time increases in the transition region up to an upper bound which is reached at a critical contact angle thetac. The increase in the drying time in the transition region is explained in relation with the diffusional screening phenomenon associated with the Laplace equation governing the vapor transport in the gas phase. Above thetac the drying pattern is characterized by a flat traveling front and the mean overall drying time becomes independent of the contact angle. Drying time fluctuations are studied and are found to be important below thetac, i.e., when the pattern is fractal. The fluctuations are of the same order of magnitude regardless of the value of contact angle in this range. The fluctuations are found to die out abruptly at thetac as the liquid gas interface becomes a flat front.

Influence of wettability conditions on slow evaporation in two-dimensional porous media

We study numerically the influence of the wettability condition on slow evaporation in two-dimensional pore square networks of aspect ratio 1. We show how evaporation in a hydrophobic network can be simulated numerically by combining imbibition rules and the computation of diffusion transport in the gas phase. Then we conduct a statistical study of drying in hydrophilic or hydrophobic networks based on pore network simulations. We concentrate on the situation where the external transfer resistance and liquid film effect are negligible and the invasion is dominated by capillary effects. It is found that drying in a hydrophilic network is significantly faster than in a hydrophobic one. The dimensionless overall drying time is found to be network size dependent, approaching exponentially a limit for large size hydrophilic networks. The dimensionless average overall drying time is 0.93 and 0.75 in hydrophobic and hydrophilic large networks, respectively. Other properties, such as the overall saturation and the evaporation flux (through the concept of equivalent flat front position) are also studied. In a last part the impact of liquid film flow on the overall drying time fluctuation is briefly investigated for the case of hydrophilic networks. It is found that the films dampen the drying time fluctuations.

[Thoracic sympathectomy: treatment for hyperhidrosis]

Hyperhidrosis is a benign functional anomaly which is highly stressful for the patient. Active management is required. Several medical options are available but are often ineffective. The thoracic sympathic system plays a fundamental role in propagating stimulation of sudoral gland secretion. Endoscopic thoracic sympatecomy thus provides a radical treatment for severe palmar and axillary hyperhidrosis. We describe the technique used in our unit and present results and possible complications. This method has been used by many teams for several Years and despite some differences, most confirm major patient benefit. Phenomena of transferred sudation are frequent by are usually not invalidating. Patients should however be informed of this possibility because the effect is often irreversible.

[Videothoracospy in thoracic trauma and penetrating injuries]

Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.

The role of videothoracoscopy in management of precordial thoracic penetrating injuries

OBJECTIVES

To report on the value of diagnostic videothoracoscopy in patients with possible penetrating cardiac wounds.

METHODS

Thirteen patients admitted over a 4 year period with hemodynamic stability and a penetrating injury in cardiac proximity had exploratory videothoracoscopy. All data related to those patients were retrospectively reviewed.

RESULTS

Eighty-five percent of patients had videothoracoscopy within 8 h of trauma. In most cases (eight of 13), operations were performed on patients in the supine position with the chest slightly rotated. Nine patients had a left hemothorax, five had pulmonary lacerations and five had a bleeding parietal vessel. Pericardial exploration was achieved either by direct vision (nine patients), or by the performance of a pericardial window (four patients). Acute hemopericardium related to a cardiac wound was diagnosed in two patients. Procedures included evacuation of clotted hemothorax (six patients), stapling of pulmonary laceration (four patients), and electrocoagulation of bleeding parietal vessel (four patients). Four patients required conversion to thoracotomy: two for repair of a cardiac wound, one for adequate exposure of the pericardium and one for ligation of a bleeding intercostal artery. The mean operative time was 37+/-23 min. Two patients experienced postoperative complications (coagulopathy, subcutaneous emphysema) and the in-hospital mortality was 0%. The mean hospital stay was 10+/-4 days.

CONCLUSIONS

In the hands of an experienced surgeon, videothoracoscopy may represent a valid alternative to subxiphoid pericardial window in patients with hemodynamic stability and a suspected cardiac wound. Videothoracoscopy can rule out a cardiac injury and allows for the performance of associated procedures such as diaphragm assessment/repair, evacuation of clotted hemothorax, hemostasis of parietal vessels or pulmonary laceration and removal of projectiles.

[Inguinal hernia in Africa and laparoscopy: utopia or realism?]

Inguinal hernia is a common indication for surgery in Africa. Most cases involve men and are treated in advanced stages often with complications. Until now the benchmark technique for surgical management has been the well-defined herniorrhaphy technique. Use of prosthetic implants has been rare because of high cost. Recently there has been a growing interest in video-assisted surgery throughout developing countries. However this enthusiasm should not obscure the fact that the technique is still in the developing stage and thus is more costly for the local economy. Indications for video-assisted surgery should be carefully selected in function of local conditions as well as problems specific to developing countries.

[Acute post-traumatic aortic insufficiency: transesophageal echocardiography in the diagnosis and therapy of the lesions]

A 58-year-old car driver suffered a road accident responsible for severe blunt thoraco-abdominal trauma. Transoephageal echocardiography, performed following the secondary development of a diastolic murmur, confirmed the presence of aortic incompetence due to commissural avulsion and guided the surgical treatment, which consisted of commissural suspension under cardiopulmonary bypass via a mini transverse trans-sternal incision. The rarity of acute aortic valve incompetence following non-penetrating thoracic trauma is illustrated by the data of the literature. This lesion is due to either avulsion of a sigmoid cusp or commissure, or laceration of the valvular tissue. Transthoracic echocardiography confirms the reality of aortic incompetence suggested clinically by appearance of a diastolic murmur, but confirmation of the mechanism of the lesions is based on transoesophageal echocardiography which allows perfectly safe and rapid visualization of the mechanism of the valvular lesion, investigation of associated lesions and guidance of therapeutic management.

Thoracoscopic splanchnicectomy for control of intractable pain in pancreatic cancer

BACKGROUND

Pain is the most distressing feature of pancreatic cancer. Thoracoscopic splanchnicectomy, first performed in 1993, has caused a resurgence of interest in surgical treatment of such excruciating pain.

METHODS

Twenty patients underwent splanchnicectomy for pancreatic cancer pain over a period of 50 months. All were opiate dependent and unable to pursue normal daily life activities. We evaluated the type of splanchnicectomy performed and the long-term results procured.

RESULTS

The number of splanchnicectomies was 24: unilateral videothoracoscopic splanchnicectomy, n = 11; unilateral videothoracoscopic splanchnicectomy with associated vagotomy, n = 5; and bilateral videosplanchnicectomy, n = 4. There was no postoperative complication. Pain was totally relieved and drug addiction stopped in 16 patients: 10 with unilateral videothoracoscopic splanchnicectomy, 2 with unilateral videothoracoscopic splanchnicectomy and associated vagotomy, and 4 with bilateral videosplanchnicectomy. Pain was not relieved after 4 unilateral videothoracoscopic splanchnicectomies, but bilateralization was not attempted in that subgroup.

CONCLUSIONS

Unilateral videothoracoscopic splanchnicectomy is the treatment of choice of intractable pancreatic pain, affording drug cessation and recovery of daily activity in most patients. Failure may be treated secondarily by bilateralization with excellent results. Bilateral videosplanchnicectomy need not be performed by first intention.

Are endoscopic procedures able to predict the benignity of ampullary tumors?

BACKGROUND

Malignant ampullary tumors (AT) require pancreatico-duodenectomy (PD) for curative treatment whereas benign AT can be appropriately treated by local resection. This study evaluated the accuracy of endoscopic exploration combining side-viewing duodenoscopy (SVD) with forceps biopsies, endoscopic sphincterotomy (ES), and endoscopic ultrasonography (EUS) to distinguish benign AT from malignant one.

PATIENTS AND METHODS

Twenty-six patients with AT had preoperative SVD with forceps biopsies, including 9 with ES, and EUS. Nodal status was evaluated by EUS in all patients, but could not evaluate parietal spread in 6 in whom ES was previously done. Results of endoscopic examination were compared with pathologic examination after resection (2 local excisions for 2 benign AT, and 24 PD for 20 malignant and 4 benign AT).

RESULTS

Accuracy of histologic examination of the 26 biopsies of the papilla was 69%. After ES, accuracy of intra-ampullary biopsies was 77%. The EUS had a 75% accuracy for the parietal spread (tumor limited to ampulla or not) and a 69% accuracy for the nodal status. In 11 patients, all explorations were consistent with a benign lesion, but 6 of these patients had a histologically proven malignancy, including one with nodal metastases and two with duodenal involvement.

CONCLUSIONS

Side-viewing duodenoscopy with biopsies, even after ES, combined with EUS is not accurate enough to preoperatively ensure that an AT is benign. Indication for a local resection based on these explorations alone is not safe.

[Abdominal gunshot wounds. Ballistic data and practical management]

The mortality from abdominal gunshot wounds remains high, either in civilian or military cases. The severity factors of these wounds include bullet calibre and energy transfer of the missile. This paper studies some of the ballistics features of abdominal gunshot wounds. Practical guidelines are inferred concerning diagnosis and treatment of these wounds.

[Malignant triton tumor of the posterior mediastinum treated by thoracoscopic approach. Apropos of a case]

A tumour of the posterior mediastinum was removed via thoracoscopy. The histology report was a triton tumour. This is a rare (less than 80 cases reported in the literature) malignant tumour of the nervous system: malignant schwannoma with rhabdomyoblastic differentiation. The characteristics of this rare tumour and the consequences of videoassisted surgery in this specific case are discussed: a second access is required to widen the thoracotomy and complementary radiotherapy is needed.

[Osteoblastomas of the coccyx. Apropos of a case. Review of the literature]

A 24-year-old man presented with a painful and invalidating coccyx. Exploration revealed a bony lesion involving parts of 2nd and all of the 3rd coccygeal vertebrae. The pathology examination of the surgical specimen revealed the diagnosis of benign osteoblastoma of the coccyx. This exceptional localization required complete surgical resection going into healthy tissues to allow a full histological study and to ensure the absence of relapse. Post-operative follow-up was uneventful and the functional result was excellent.

[Gunshot wounds of the ureter]

Lesions of the ureter caused by penetrating wounds of the abdomen rare a are complication of abdominal gunshot wounds, of which the reported incidence is 2 to 17%. The preoperative diagnosis is difficult and unrecognized initially in every third case. There are no early clinical signs of ureteral lesions. There is often no hematuria. Only IVP can make the preoperative diagnosis possible. As a matter of fact, the diagnosis will often be established by the surgical exploration made during the laparotomy required by the extent of the associated lesions. The ureteral blast contusion is an important cause of secondary necrosis with fistula. The treatment is mainly based on ureteroureterostomy after debridement. The transanasmotic drainage of urine is controversial. Mortality results from associated abdominal lesions and morbidity consists in a risk of secondary nephrectomy.

[Cancer of the urachus. A rare form of tumors of the bladder]

Cancers of the middle umbilical fold are very infrequent, making up 0.1% to 0.7% of all bladder tumors. This type of tumor affects male subjects in 60% to 75% of cases, in the 5th or 6th decade of life. In more than 90% of all cases, the lesion is a mucosecretory adenocarcinoma developing from embryonic remains within the wall of the bladder and respecting the superficial urothelium of the bladder, which is affected only secondarily, contrary to what occurs in the other adenocarcinomas of the bladder. The pathogenesis remains controversial, especially the role of middle umbilical fold patency and of bladder carcinogens. The diagnosis is most often established late, because of a long clinical latency. It is mainly based on ultrasonography and computed tomography. Explorations of the bladder are useful only at an advanced stage. The prognosis is very poor, survival at 5 years ranging from 6.5% to 25% according to the authors. The treatment is mainly surgical. Only extensive exeresis with partial cystectomy extending to the peri- and supravesical environment, including the peritoneum and the umbilicus, and associated with pelvic lymphadenectomy may give some hope. Chemotherapy and radiation therapy, either alone or complementary, are disappointing. The prognosis may be improved only by an early diagnosis.