[Amebic liver abscess and late recurrence with no travel in an endemic area]. / Abcès amibien hépatique avec récidive tardive en l'absence de séjour récent en zone d'endémie.

Amebic liver abscess is the main complication of amebic dysentery. Recurrences after treatment and apparent healing are very uncommon. The purpose of this report is to describe the case of a patient with a very late relapse of an amebic liver abscess, 10 years after the first episode. This recurrence seems due to an incomplete initial treatment. This case illustrates the reason for and importance of complying with the current therapeutic strategy: nitroimidazole followed by a luminal agent to eradicate intestinal amebic colonization.

Intraperitoneal treatment of incisional and umbilical hernias using an innovative composite mesh: four-year results of a prospective multicenter clinical trial.

Intraperitoneal positioning of conventional parietal mesh provides efficient reconstruction but causes visceral adhesion formation in 80-100% of the cases. The purpose of this clinical trial was to assess the performance and tolerance of a new generation of polyester mesh protected by a hydrophilic resorbable film. Eighty patients were included in a prospective multicenter clinical trial. Patients were treated for ventral hernia via an open approach (64%) or laparoscopically (36%). All meshes were implanted in a midline intraperitoneal location. The main objective was to evaluate the anti-adhesive capability of the mesh in relation to the viscera. In order to assess the absence of visceral adhesion objectively, an ultrasound (US) specific examination was initially validated (pre-operative prediction vs. per-operative findings) and then used during the follow-up. The usual clinical parameters were also collected to follow the patients on a period up to 4 years. Pre-operative US prediction vs. per-operative macroscopic findings: sensitivity 79%, overall accuracy 76%, negative predictive value 85%. After 12 months, 86% of the patients were ultrasonically adhesion free. Early post-operative complications were: seroma/hematoma (16%), subcutaneous infection (4%), cutaneous necrosis (1%) and occlusions (outside the mesh) (2.5%). No mortality was reported. Clinically, after 12-month follow-up, no complication related to post-operative adhesions to the mesh was noted: (occlusion 0%, fistula 0%). Late complications were: mesh sepsis (1%), new defects (4%) and recurrence (2.5%). Finally, 56 patients (75.7%) were clinically evaluated with a mean follow-up of 48+/-6 months. One direct recurrence was noted while six patients experienced new defect outside the mesh. No long-term severe complication such as occlusion or enterocutaneous fistula was observed. Based on a mean clinical follow-up of 4 years, the results of this prospective multicenter clinical trial demonstrate the safety and the efficiency of this composite mesh in the intraperitoneal treatment of incisional and umbilical hernia. In particular there was no early or long-term main complication due to the intraperitoneal location of the mesh.

[Natural history of the pancreatic stump after duodenopancreatectomy of the pancreatic head]. / Histoire naturelle du moignon pancréatique après duodénopancréatectomie céphalique (DPC).

UNLABELLED: Major complications following pancreaticoduodenectomy are thought to be chiefly associated with exocrine secretion of the pancreatic remnant which is not well known. This work aims to assess the exocrine secretion of the pancreatic remnant within the early post-operative period. PATIENTS AND METHODS: Seventy-five patients undergoing pancreaticoduodenectomy for presumed tumour were included in a prospective multicentre study. A tube was inserted in the pancreatic duct at the time of construction of the pancreatic anastomosis. Peripancreatic drainage was routinely used. Pancreatic juice and peripancreatic drainage fluid were collected and measured and pancreatic enzyme monitored. For 7 days patients received total parenteral nutrition and continuous infusion of randomly Somatostatin 14 (S-14) at a dose of 6 mg/24 h (days 1-6) and 3 mg/24 h (day 7) or matching placebo. Pancreatic fistula was defined as a daily drainage of more than 100 cc of amylase-rich fluid after day 3, persisting after day 12 or associated with symptoms or needing specific treatment. RESULTS: Daily output of pancreatic juice was low during the first postoperative day and then increased gradually until day 5. A high enzyme concentration was observed in pancreatic juice on the first post-operative day. S-14 infusion resulted in a significant decrease of both pancreatic fistula rate and enzyme concentration in peripancreatic fluid. CONCLUSIONS: During the first postoperative days, the outflow of the exocrine secretion of the pancreatic remnant is low but contains a high enzyme concentration with significant leaks within the peripancreatic area. S-14 infusion results in a decrease of pancreatic juice leaks from the pancreatic remnant.

Laparoscopic repair of incisional hernia: a retrospective study of 159 patients.

BACKGROUND: In this long-term retrospective study, a laparoscopic technique was used for incisional hernia repair. METHODS: Over a 6-year period, we performed laparoscopic repairs with prosthetic mesh in 159 patients suffering from incisional hernia. Morbidity factors were noted and operative data were collected. In addition, early and long-term complications and recurrences were analyzed. RESULTS: There were no deaths as a result of the procedure. In 21 patients (13.8%), the operation was converted to an open procedure. Small bowel perforation occurred in three patients (1.9%). Mean hospital stay was 3.5 days. Early complications occurred in 61 patients (44%). The mean follow-up time was 49 months. There were no infections of the prosthetic mesh. Residual abdominal pain was reported in 31 patients (26%). Bowel obstructions requiring resection were found in two patients (1%), and hernia recurrence was observed in 19 patients (15.7%). CONCLUSIONS: Laparoscopic herniorraphy is a promising technique with all the advantages of minimal-invasive surgery. Nevertheless, close attention needs to be paid to the choice of the hernia and mesh size and to the fixing of the mesh.

[Port-site metastasis after laparoscopic resction of a duodenal stromal tumor]. / Métastase sur orifice de trocart après exérèse laparoscopique d'une tumeur stromale du duodénum.

Gastro-intestinal stromal tumors are rare and their evolution is dubious. This observation of port site metastasis after laparoscopic resection of a small duodenal stromal tumor would be, to our knowledge, the first case reported in the literature. Several direct and indirect mechanisms were supposed to be involved in the appearance of metastases after laparoscopic surgery, but the risk of dissemination remains badly evaluated on its frequency as well as on its mechanisms.

[Bile duct papillomatosis: unrecognized preoperative diagnosis]. / La papillomatose des voies biliaires: un diagnostic préopératoire méconnu.

The diffuse biliary or pancreatic papillomatosis is a rare pathology. Reported cases in the literature underscore the difficulties of preoperative diagnosis of these lesions, their extensive nature, their tendency to relapse, and their malignant potential. The case that we report differs by the isolated involvement of the biliary tract and by the increasing role of imaging (MRCP) for diagnosis and follow-up.

[Acute abdominal pain of vascular origin]. / Douleurs abdominales aiguës d'origine vasculaire.

Pain of vascular origin generally reflects severe intestinal involvement and lesions that are rapidly irreversible. Diagnosis is difficult and treatment is often delayed. Such involvement should be considered systematically when confronted with any atypical abdominal pain, especially if it is intense and appears abruptly, in any patient with vascular disease or having cardiac rhythm disorder. At an early stage, the contrast between the severity of pain and the lack of general and physical signs should suggest emergency CT scan followed by GI arteriography for diagnosis and deciding treatment. If such measures are impossible, laparotomy should be performed. At the stage of infarct, the presence of an unstable haemodynamic condition and peritoneal signs require emergency laparotomy without paraclinical examinations. The severity of prognosis depends on the causes, the extent of lesions, patient background and the rapidity with which treatment is initiated.

Intraperitoneal chemohyperthermia for peritoneal carcinomatosis: original modeling, clinical tolerance and results study about 30 patients.

BACKGROUND/AIMS: The authors' objective is to report their experience of the intraperitoneal chemohyperthermia after a thermal modeling study which has allowed the optimization the intraperitoneal chemohyperthermia circuit and its running parameters and to evaluate the intraperitoneal chemohyperthermia tolerance. Intraperitoneal chemohyperthermia is considered more and more as an interesting therapeutic option in cases of some abdominal carcinomatosis, particularly of digestive origin. However, the main technical problem of this treatment is the homogenization of the temperature distribution in the abdominal cavity. METHODOLOGY: A thermal modeling has allowed us to finalize a reliable and well-tolerated intraperitoneal chemohyperthermia technique. The achievement of a physical model of the abdomen has allowed us to make an experimental study of the temperature distribution in a given liquid volume. Two steps were carried out. The first step was the characterization of the model with a thermal study carried out on the physical model and which has led to dynamic data about the heat balance leading to a knowledge model. The second step was the identification of a theoretical model of the thermal behavior which would correlate best with the experimental data. Between January 1995 and January 1998, 30 patients with peritoneal carcinomatosis were studied. Twenty-six patients underwent maximal cytoreductive surgery with abdominal evisceration, intraperitoneal chemohyperthermia. Intraperitoneal chemohyperthermia was carried out for 1 hour, at 42 degrees C, with a flow rate of 0.9 L/min in the 30 patients. The thermal modeling has shown the main purpose of a high flow rate of 0.9 L/min in the homogenization of temperature distribution. RESULTS: The 2 steps are shown to converge. This coherency between the 2 models proves that the thermal aspects of the process have been properly identified. Our initial results have shown that intraperitoneal chemohyperthermia was properly tolerated. Major intraoperative complications occurred for 1 patient. CONCLUSIONS: The experimental study with thermal modeling results should help to optimize the intraperitoneal chemohyperthermia circuit and its running parameters for human treatment, with an acceptable morbidity in 30 patients.

[Peritoneal carcinomatosis treated by cytoreductive surgery and intraperitoneal chemohyperthermia]. / Carcinoses péritonéales traitées par chirurgie de réduction tumorale et chimiohyperthermie intrapéritonéale.

STUDY AIM: The aim of this prospective non-randomized trial was to report a series of intraperitoneal carcinomatosis due to miscellaneous causes, treated by intraperitoneal hyperthermic perfusion (IPHP) and cytoreductive surgery. PATIENTS AND METHOD: From January 1995 to May 1999, 35 patients were treated by IPHP and 26 of them underwent maximal cytoreductive surgery. IPHP was performed for 60 minutes at an intraperitoneal temperature of 42 degrees C with Mitomycin C (10 mg/L) or cisplatinum (12 mg/L) at a flow rate of 0.9 L/min. RESULTS: There was one (2.8%) postoperative death due to respiratory complications on day 16. Three patients (8.5%) were admitted to the intensive care unit. A high morbidity rate (54%) was observed with intra-abdominal complications in 28.5% of patients, requiring reoperation in three patients. In patients with stages 1 and 2 peritoneal carcinomatosis (granulations less than 5 mm), the 12- and 24-month survival rates were 63.1% and 31.5%, respectively. In patients with advanced stage 3 (diffuse malignant nodules less than 2 cm) and stage 4 carcinomatosis (malignant nodules larger than 2 cm), the 12- and 24-month survival rates were 31.2% and 12%, respectively. Six patients survived for more than 30 months. CONCLUSION: IPHP appears to be an effective treatment for peritoneal carcinomatosis. IPHP combined with cytoreductive surgery is aggressive with a high morbidity rate. Rigorous patient selection is necessary. IPHP is still under evaluation. Prospective randomized trials with identical IPHP protocols are required.

[Laparoscopic excision of a duodenal neuroendocrine tumor]. / Exérèse laparoscopique d'une tumeur neuroendocrine duodénale.

A 75-year-old woman with melena was found to have a carcinoid tumor in the posterior wall of the duodenal bulb. The biology was normal. The tumor measured 10 mm in size, and endoscopic ultrasonography showed only submucosal involvement. There was no liver metastasis and no regional lymph nodes. Tumoral resection was performed laparoscopically with success. Postoperative course was uneventful. Laparoscopic resection could be an appropriate minimally invasive treatment for selected small size duodenal tumors.

Pleomorphic giant cell carcinoma of the esophagus with coexpression of cytokeratin and vimentin and neuroendocrine differentiation.

A pleomorphic (giant cell) carcinoma of the esophagus is reported in a 52-year-old man who had dysphagia and weakness. The 8-cm-high vegetating tumor consisted of solid sheets of poorly cohesive epithelioid cells broken into clusters by strands of stroma. Numerous giant cells showing phagocytic phenomenon were present. Immunochemical analyses demonstrated the epithelial origin of the neoplasm, although most of the tumor cells strongly expressed vimentin. Numerous tumor cells expressed synaptophysin. Neurosecretory granules were detected in some tumor cells on electron microscopic examination. The patient died 4 months after he became symptomatic. As far as we can ascertain, this is the first case report describing a pleomorphic carcinoma arising in the esophagus. This poorly differentiated carcinoma might be of neuroendocrine differentiation. In the esophagus, pleomorphic carcinoma must be distinguished from polypoid tumors such as carcinosarcoma and malignant melanoma.

[Results of laparoscopic hernioplasty. A study of 401 cases in 318 patients]. / Résultats des hernioplasties coelioscopiques. Etude de 401 cas chez 318 patients.

STUDY AIM: The aim of this retrospective study was to report a series of laparoscopic hernioplasty performed in two surgical centers, and to evaluate the results with a mean follow-up of 31 months. PATIENTS AND METHODS: From January 1992 to January 1997, 318 patients with 401 inguinal hernias were operated on through laparoscopy by six senior surgeons and six junior surgeons. There were 302 men and 16 women (mean age: 53 years). The operation was performed through an extra-peritoneal approach (TEP) in 298 hernias, a trans-abdomino-preperitoneal approach (TAPP) in 62 hernias, and an intra-abdominal approach (IPOM) in 41 hernias. RESULTS: Conversion into open surgery was necessary in 7% of the patients. There was no postoperative death. The postoperative morbidity rate was 10%. The average hospital stay was three days. With a 1 to 5 year follow-up, 4% of the 94% of the patients who answered the questionnaire showed a recurrence (3% in the extra-peritoneal group; 4% in the trans abdomino-preperitoneal group; 10% in the intra-abdominal group). CONCLUSION: Laparoscopic hernioplasty seems as efficient as traditional hernoplasty with the advantages of mini-invasive surgery. The extra-peritoneal approach was preferred and performed in most cases of this series. The intra-peritoneal approach was abandoned.

[Management of acute intestinal arterial ischemia]. / Conduite à tenir devant une ischémie artérielle intestinale aiguë.

Acute mesenteric ischemia is an infrequent abdominal emergency. The 90% mortality of this affection is related to a delayed diagnosis. The mesenteric ischemia and the mesenteric infarction are two different pathologic stages characterized by two different treatment and prognosis. Superior mesenteric artery embolism is the most frequent cause of mesenteric ischemia. According a difficult clinical diagnosis and the necessity of an early diagnosis we suggest an aggressive attitude. All the patients presenting risk factors and an abdominal pain must have a mesenteric angiography. The purpose of the angiography is diagnostic and therapeutic. The aim of surgery in case of mesenteric ischemia is to restore a normal vascularisation. In spite of this attitude the prognosis of this affection remain poor.

[Para-esophageal hiatal hernia with acute gastric volvulus]. / Hernie hiatale para-oesophagienne avec volvulus gastrique aigu.

We report 3 observations of acute gastric volvulus on paraesophageal hiatus hernia requiring emergency laparotomy. The main characteristics of this complication of hiatus hernia are described and the importance of early diagnosis, because of unfavorable prognosis, is stressed.