Court-circuit gastrique (« by pass » gastrique) avec anse en Y de Roux sous laparoscopie : variantes techniques

Technical variants of gastric bypass for morbid obesity are briefly described in this article including the three main steps: Roux-en-Y intestinal loop, gastric pouch and gastrojejunal anstomosis.

[Princeps procedure of gastric bypass for morbid obesity]

Princeps procedure of gastric bypass for morbid obesity is briefly described in this article including the three main steps: Roux-en-Y intestinal loop, gastric pouch and gastrojejunal anastomosis.

[Segmental absence of colonic muscularis propria. Report of a case in an adult]

We report a case of segmental defect of colonic muscularis propria revealed by perendoscopic perforation in a 64-year-old woman. Segmental absence of intestinal musculature is well documented in new-borns and infants and is more frequent in small bowel. It is characterized by localised absence of muscularis propria without fibrous scar. The remaining layers of the bowel wall are intact. The pathogenesis of this lesion is discussed.

[Hepatic hamartoma in adults. Apropos of a case documented by MRI]

A mixed hamartoma of the liver in a 39 year old man is reported. Abdominal ultrasound revealed a 4 cm inhomogeneous echogenic mass with acoustic shadowing. MRI T1 weighted images showed a inhomogeneous low intensity mass with lower gadolinium enhancement than normal liver, a moderate low signal intensity on proton density weighted images, and heterogeneous isosignal intensity on T2 weighted images. Peripheric calcifications were found on pathologic examination.

Laparoscopic cholecystectomy: an original three-trocar technique

At present, laparoscopic cholecystectomy is the treatment of choice for gallbladder stones. The operating technique reported by most authors includes the use of four trocars. We report a group of 710 consecutive patients treated by an original three-trocar technique. The use of the fourth trocar was necessary in only 55 cases (8%). However, among 56 cases of acute cholecystitis the use of the fourth trocar was necessary in 14 cases (25%) (p < 0.01). Twenty-six laparoscopies were converted to open procedures (3.6%). Four common bile duct injuries were observed (0.5%): two of them among the 655 operations with three trocars (0.3%) and two after application of the fourth trocar at the beginning of the procedure because of dissection difficulties. Our results are similar to those using the "classic" four-trocar technique. Moreover, this technique is less expensive and allows one less scar.

Human breast and colon cancers exhibit alterations of DNA methylation patterns at several DNA segments on chromosomes 11p and 17p

In breast and colon adenocarcinomas methylation patterns at CCGG sites of several loci located on the short arm of chromosome 11 were determined by Southern blot analysis. Results obtained indicate that all tumor samples (20/20) exhibit DNA methylation changes when compared to their normal counterparts. In colon tumors, gamma-globin gene is usually hypomethylated (9/10), whereas Ha-ras gene, which is located in the same region, retains an unmodified DNA methylation pattern. Hypomethylation of parathyroid hormone (5/10) and catalase genes (4/10) are also frequently detected in colon tumor specimens. For the catalase gene the region around exon 2 is the only one which is affected by these changes. In breast adenocarcinoma, modifications of the methylation patterns are less frequently observed. However, hypomethylation of the gamma-globin gene is a very common event in these tumors (8/10), and it is also detected (2/2) in lobular carcinoma in situ which is an early step in breast tumorigenesis. In addition, hypermethylation of a CpG island is also observed at the locus 17p13.3 in both colon (5/5) and breast (4/9) adenocarcinomas. In the tumoral tissues analyzed these hypermethylations are not associated with the hypermethylation of the 5' flanking sequences which contain a limited amount of CpG. Some of these alterations seem, therefore, to be tumor and sequence specific.

Adenocarcinoma of the duodenum: factors influencing survival. French Association for Surgical Research

The records of 66 patients with histologically proven adenocarcinoma of the duodenum were reviewed retrospectively to determine factors influencing survival. The parameters studied were age, sex, weight loss, jaundice, anaemia, duodenal stenosis, type of surgical procedure, tumour size and location, depth of parietal invasion, presence and location of lymph node metastases, and pancreatic invasion. These factors were assessed in a group of 46 patients who underwent curative resection of the tumour; 20 patients who received palliative procedures were excluded from statistical analysis. Survival curves were established by the Kaplan-Meier method and compared by the Mantel-Haentszel test. The actuarial 3- and 5-year survival rates of patients undergoing curative resection were 59 and 45 per cent respectively. None of the prognostic factors studied influenced survival. These results indicate that resection of adenocarcinoma of the duodenum should be performed whenever possible, even in the presence of lymph node metastasis and pancreatic spread.

Laparoscopic-assisted perineal rectosigmoidectomy with pullthrough

We report for the first time the treatment of an early rectal cancer by laparoscopically assisted rectosigmoidectomy with pullthrough. The low colorectal anastomosis was constructed using a double-stapling technique. We believe that this procedure might offer a promising new option for the treatment of midrectal cancer with sphincter saving. Further investigation is recommended.

A technique of laparoscopic gastrectomy and Billroth II gastrojejunostomy

This report describes a technique of total intraabdominal laparoscopic gastrectomy using laparoscopic stapling and suturing. The reestablishment of continuity of the upper gastrointestinal tract was performed by gastrojejunostomy (Billroth II) using the Endo GIA stapler. This procedure merits inclusion in the armamentarium of approaches toward surgical treatment of recurrent gastric ulcer.

Thoracoscopic dissection of the esophagus in human cadavers

A technique for thoracoscopic dissection of the esophagus is described which gives a large and magnified view of the pleural cavity, the mediastinum, and the esophagus. This technique was developed on human cadavers which gives excellent technical resources for learning and practicing endoscopic surgical anatomy of the esophagus. It avoids the need to change the position of the patient to perform a total thoracoabdominal esophagectomy via a triple surgical approach.

[Subtotal colectomy under celioscopy]

Indications for laparoscopic surgery of digestive disease are increasing in scope and now include colorectal affections. A technique for subtotal colectomy with ileorectal anastomosis under laparoscopic control is described.

Characterization of the DiFi rectal carcinoma cell line derived from a familial adenomatous polyposis patient

The DiFi human colorectal cancer cell line was recently established from a familial adenomatous polyposis patient with extracolonic features characteristic of the Gardner syndrome. These cells have now been propagated for 150 passages in standard culture media and vessels without feeder layers or collagen coatings. They retain features of colonic epithelial cells such as surface microvilli, secretory vesicles, and desmosomes. Cytosol of DiFi cells contains a high level (502 U/mg protein) of the mucin CA 19-9. In addition, DiFi cells produce carcinoembryonic antigen, and induce tumors in athymic mice. Cytoskeleton analysis of DiFi cells by fluorescence microscopy showed a pronounced disorganization of actin cable structure. The isozyme genetic signature of DiFi cells is unique (0.01 probability of finding the same genetic signature in a different cell line), differs from that of HeLa cells, and has expressional features seen in other colorectal cell lines. The DiFi cell karyotype is tetraploid, contains many marker chromosomes, and shows numerous episomal particles. Two copies of chromosome 18 were absent, and only a single normal chromosome 17 was found. This parallels detection of allelic losses from DiFi cell DNA at loci on chromosomes 17p and 18 using molecular (cDNA) probes. DiFi cells clearly express transcripts for the c-myc proto-oncogene, the c-myb proto-oncogene, and the p53 tumor suppressor gene. Transforming growth factor beta inhibits DiFi cell growth in soft agar and suppresses c-myc expression in these cells. The value of this cell line in the study of genetic alterations in colorectal cancer is discussed.

Growth effects of tamoxifen on Lovo colon carcinoma cells and cultured cells from normal colonic mucosa

The growth effects of tamoxifen (TAM) were studied using normal and malignant colonic epithelial cells. Addition of TAM (0.8 to 10 microM) to cultured normal human colon epithelial cells and Lovo colon adenocarcinoma cells produced a dose response decrease in growth of 42 to 76%. Histamine (1 to 10 microM) did not affect cell growth and did not negate the TAM effect. Calmodulin (2 micrograms/ml) totally blocked growth inhibitory effects of a calmodulin antagonist, trifluoperazine (10 microM), but did not block the TAM inhibitory effect. These data suggest that antiestrogen binding sites (AEBS) may play an important role in the growth-inhibitory effects of TAM on colon cells. Competition with estrogen and antagonism with histamine or calmodulin do not appear to be significant in this regard.

The effects of steroid hormones on a human colon cancer cell line in vitro

Estrogen analogues, moxestrol (10(-8)-10(-5) M) and ethinyl estradiol (10(-8)-10(-6) M), produced a 30% and 15% inhibition of LoVo cell growth, respectively, in serum-free Ham's F-10 medium. Under the same conditions, no growth effects were observed on these cells following the addition of progesterone or testosterone (10(-8)-10(-6) M); however, metribolone (10(-8)-10(-6) M), a synthetic androgen with glucocorticoid receptor-binding properties, moderately stimulated cell growth (18%). The synthetic antiandrogen, RU 23908 (10(-6) M), did not reduce metribolone effects, and hydrocortisone (10(-9)-10(-7) M) stimulated LoVo cell growth by 31% in serum-free medium. In medium containing 10% charcoal-treated fetal bovine serum, the inhibitory effects of estrogens were not observed, and the lower concentrations (10(-11) M) of moxestrol and ethinyl estradiol facilitated cell growth (10 to 15%). The other steroid hormones produced the same results as observed with serum-free medium. These data suggest that estrogen and glucocorticoid hormones may play an important role in the growth of colon carcinoma cells. Androgen and progesterone hormones appear to be less significant in this regard. Serum factors alter the effects of estrogen, but not of glucocorticoids.

Status of sex steroid hormone receptors in large bowel cancer

To determine the potential role of sex steroid hormones in the development of colorectal tumors in humans, specific androgen (AR), estrogen (ER), and progesterone (PGR) receptors were investigated in normal mucosa (NM) and in tumor (T) paired biopsy specimens from 94 patients. Androgen receptors were detected in 98% and 96% of NM and T samples, ER in 91% and 83% of NM and T biopsy samples, whereas PGR were detected only in 14% and 10% of NM and T specimens, respectively. These incidences are independent of the sex and age of the patients. They are not related to tumor localization, histologic grade, or stages of Dukes' classification. Scatchard analysis of labeled ligand binding indicated the existence of one single class of high affinity binding sites; the calculated dissociation constant (Kd) was 1.7 +/- 0.6 10(-9) molar concentration (M) for 5 alpha-dihydrotestosterone (DHT) and 0.6 +/- 0.3 10(-9) M for estradiol (E2). These values were identical in NM and T tissue for both AR and ER. The binding capacity for DHT was 148 +/- 67 and 93 +/- 43 fmol/mg of cytosol protein in NM and T tissues, respectively (P less than 0.05). The ER content was lower and similar in NM and T biopsy specimens: 19 +/- 9 and 18 +/- 10 fmol/mg protein, respectively. The PGR content was 10 +/- 4 in NM versus 17.5 +/- 6 fmol/mg protein in T specimens. It is observed that the elevated AR in normal mucosa is not related to any known function for androgens in the digestive tract. The receptor pattern observed in tumors does not support the hypothesis previously raised in the case of chemically induced colonic tumors in rodents.

1,25-Dihydroxyvitamin D3 receptors and human colon adenocarcinoma

Epidemiological evidence suggests that dietary calcium and 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) might have a protective effect against colorectal cancers. Since the presence of receptors is required for steroid action, specific 1,25-(OH)2D3 receptors (RD3) were investigated in biopsies taken at different levels of the colon. The study involved 90 biopsies from patients operated on for colorectal adenocarcinoma. They were paired biopsies from adenocarcinoma tissue and adjacent normal mucosa. In addition, 26 normal intestinal mucosa biopsies from patients without cancer were examined. RD3 receptors were assayed in tissue extract by the dextran-coated charcoal technique and also characterized by sucrose density gradient sedimentation. Scatchard analysis showed a single class of specific high affinity-low capacity sites binding for 1,25-(OH)2D3. The incidence of RD3 was 86 per cent in normal mucosa (n = 77) and lower in carcinoma (n = 34), for which the incidence decreased significantly (P less than 0.001) from right colon (58 per cent) to left colon (37 per cent) and rectum (19 per cent). These data suggest that the normal colon is a potential target organ for 1,25-(OH)2D3 which might modulate calcium transport in the colon. Loss of receptivity to 1,25-(OH)2D3 is associated with malignant transformation.

Sex steroid and 1,25-dihydroxyvitamin D3 receptors in human colorectal adenocarcinoma and normal mucosa

In order to determine the potential role of sex steroid and 1,25-dihydroxyvitamin D3 in the spreading of colorectal cancer, previously hypothesized from epidemiological and experimental data, specific androgen (AR, n = 94), estrogen (ER, n = 60), progesterone (PGR, n = 50), and 1,25-dihydroxyvitamin D3 receptors (VDR, (n = 111) were investigated in human colorectal adenocarcinoma (AC) and compared with the normal adjacent mucosa (NM). Scatchard analysis and competition studies of binding data did not reveal any difference between the biochemical behavior (affinity, specificity, and sedimentation coefficient) of the normal and tumoral tissue receptors. For ARs and ERs, high incidences were found (92 of 94 and 90 of 94 in NM versus 46 of 60 and 40 of 60 in AC, respectively) in both classes of tissues, while they were low for progesterone (7 of 50 and 5 of 50 in NM versus AC). While for sex steroid receptors the incidences did not vary with sex and age of the patients or the location and histopathological grade of the tumor, the VDR incidence was lower in AC (35 of 111) than in NM (99 of 111) and decreased significantly from the right colon to the rectum in adenocarcinoma. Binding capacities were similar in NM and AC for ERs and VDRs, whereas AR levels in NM were significantly higher than in AC. The expression of VDRs in some colorectal tumors suggests a possible clinical significance. No known function for sex steroid receptors is related to their presence in human colorectal tissues and their pattern in carcinoma does not support any hypothesis previously raised in the case of chemically induced colonic tumors in rodents.

Evidence of 1,25-dihydroxyvitamin D3-receptors in human digestive mucosa and carcinoma tissue biopsies taken at different levels of the digestive tract, in 152 patients

Epidemiological and experimental data suggest that dietary calcium and 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) are protective against colorectal cancers, while their activity on colon mucosa still remains unknown. Since the presence of receptors is required for steroid action, specific 1,25-(OH)2D3 receptors were investigated in biopsies taken at different levels of the digestive tract from the oesophagus to the rectum and in pancreas. The total study involved biopsies from 152 patients. In 82% of the cases they were paired biopsies in adenocarcinoma tissue and in adjacent normal mucosa (NM). There were 120 operated on for colorectal adenocarcinoma (HCRA). 1,25-(OH)2D3 receptor was assayed in tissue extract by the dextran-coated charcoal (DCC) technique and also characterised by sucrose density gradient centrifugation. Scatchard analyses showed a single class of specific high affinity-low capacity sites binding for 1,25-(OH)2D3 with a Kd = 1.48 +/- 0.8 x 10(-10) M (n = 119). The sedimentation coefficient of the steroid receptor complex was approximately 3.2 S. The incidence of 1,25-(OH)2D3 receptors was significantly higher in NM (82.5%) than in HCRA (34.5%). In HCRA this incidence decreased from right colon (64.7%) to left colon (27.7%) and rectum (15%). All positive HCRA in left colon and rectum (16/76) were histologically well differentiated. The receptor content in NM and HCRA was in the same range: (median) 10-314 (58) and 13-175 (64) fmol/mg protein. These data suggest that 1,25-(OH)2D3 may modulate calcium transport in colon, as in the intestine. Also, loss of receptivity to 1,25-(OH)2D3 is observed as associated with malignant transformation of the human colorectal mucosa.

[Hepatic alveolar echinococcosis: diagnosis and treatment]

Alveolar echinococcosis is a parasitic disease which is relatively rare in humans. It almost exclusively affects patients of rural origin living in enzootic regions (Eastern France, Auvergne) and most lesions are in the liver. Several anatomico-clinical forms have been described; the most frequent is the multilocular form, but the disease may consist of one single cyst or abscess. The liver structure is always deeply altered, with compression, inflammation or superinfection. Jaundice, liver enlargement, abdominal pain or signs of secondary localizations are manifestations that lead to the discovery of hepatic alveolar echinococcosis. The anatomical features of the lesions are demonstrated by ultrasounds and computerized tomography. The main differential diagnosis is tumoral pathology of the liver. In most cases the diagnosis of echinococcosis is confirmed by serological tests, although needle or even surgical biopsy might be necessary. Diagnosed at an early stage, alveolar echinococcosis can be amenable to surgical treatment (hepatectomy), and liver transplantation may even be performed. Medical treatment with benzimidazoles seems to be promising.

Specific receptors for 1,25-dihydroxyvitamin D3 (1,25-DR) and human colorectal carcinogenesis

Because it is a common prerequisite for steroid responsiveness in target tissue, we investigated the presence of specific 1,25-DR in spontaneous human colorectal adenocarcinomas (ADC) and adjacent normal-appearing mucosa (NAM) from 23 operative specimens (12 male and 11 female patients). 1,25-DR was determined in cytosol by a DCC assay technique. 1,25-DR was present in 21 of 23 NAM and in only 4 of 23 HCRA. All positive ADC were well differentiated. Receptor content expressed in femtomoles/mg of protein (mean +/- SEM) was respectively 63.9 +/- 7.6 for right colon NAM and 51.3 +/- 12.9 for left colon or rectum NAM. When we compared all NAM specimens, receptor content was 56.7 +/- 8.0 femtomoles/mg of protein. No difference in 1,25-DR NAM level was observed between right colon and left colon or rectum. In adenocarcinoma the mean content was 66.5 +/- 14 fmoles/mg of protein. Scatchard analysis showed a single class of specific high-affinity saturable 1,25-DR with a dissociation constant (Kd) of 0.97 +/- 0.57 and 1.03 +/- 0.39 chi 10(-10) M in NAM and ADC respectively. These preliminary data represent the first demonstration of 1,25-DR throughout the entire human colon and indicate that the receptivity for this hormone is often lost during malignant transformation of the human colorectal mucosa. In addition, 1,25-DR could be a marker of differentiation in ADC. These preliminary results provide evidence supporting the addition of Vitamin D to the roster of developmental cancer chemopreventative agents.

[Sarcomatous recurrence of leiomyoma of the inferior vena cava]

In a 63-year old woman, a surgically removed leiomyoma of the inferior vena cava recurred, 4 years later, as a leiomyosarcoma. These two smooth muscle tumours, one benign the other malignant, seldom involve the inferior vena cava. Both produce few clinical symptoms and therefore are belatedly diagnosed, except for suprarenal or retrohepatic lesions which rapidly exhibit signs of compression. Computerized tomography, angioscans and cavography are necessary to make a provisional diagnosis and determine the operative strategy. The differential diagnosis between leiomyoma and leiomyosarcoma rests on cellular or nuclear atypias, mitotic index and sometimes cytological and staining details showing the myofibril. These tumours develop slowly in the renal segment. Treatment is primarily surgical. The case reported here raises the problem of the leiomyoma-leiomyosarcoma sequence: are we confronted with degeneration, or is there such a thing as a smooth muscle fibre disease?

The role of vitamin D3 in the proliferation of a human colon cancer cell line in vitro

LoVo, a cultured colon cancer cell line, is shown to possess a receptor for 1,25-dihydroxy vitamin D3 (1 alpha,25(OH)2D3) with a low capacity (28 fmol/mg protein) and high affinity (Kd: 1.9 x 10(-21)0M). When these cells were grown in monolayer culture in a chemically defined serum-free medium, a significant inhibition of proliferation was seen in the presence of 10 nM to 1 microM of 1 alpha,25(OH)2D3 (p less than 0.005. Furthermore, 1 alpha,25(OH)2D3 delayed early attachment of cells. After 8 days of treatment, aggregated cuboidal cells showed a marked change to an apparently spindle like morphology. The 1 alpha,25(OH)2D3 growth-inhibitory effect was modulated by verapamil (1 microM), a calcium channel blocker, hydrocortisone (1 microM), and moxestrol (1 mM), an estrogen analogue, and 2% charcoal-treated fetal bovine serum. This study represents the first demonstration of 1 alpha,25(OH)2D3 modulation of growth of human colon cells.