Crystal electric field in the R2Ti2O7 pyrochlore compounds.

Using a simple scaling law, a unique set of crystal-field parameters for the rare-earth ions R in the R(2)Ti(2)O(7) pyrochlore series is shown to provide a proper description of the crystal-field excitations previously observed by neutron scattering. The two spectroscopic g factors are given for the compounds with doublet ground states, as well as the ground-state wavefunctions for all the compounds.

[Pierre Marion, 1914-2000. Past president of the National Academy of Surgery. An illustrious figure in the city of Lyons]. / Pierre Marion, 1914-2000. Ancien président de l'Académie nationale de chirurgie. Figure illustre de la chirurgie lyonnaise.

The surgical work of Pierre Marion extends over a period of 40 years. It takes part in the history of portal hypertension surgery. Pierre Marion has been in France one of the major craftsmen of heart surgery with Paul Santy. In 1952, he performed the first pulmonary-embolectomy with success and later devoted his time to the development of valves and of an artificial heart. The second part of his life was dedicated to the direction of the Bullukian Foundation, founded in 1983, with the goal of helping medical research, supporting the armenian community in our country and promoting literary, artistic and theatrical creation in Lyons and its surroundings. Pierre Marion has written two remarquable books "Afin que batte le coeur", a history of the cardiac surgery epic and "Le génial bonhomme Ampère", consecrated to the life of this great scholar.

Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group.

Because of the rarity of adrenocortical carcinoma, survival rates and the prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors over an 18-year period. A trend study was associated to assess changes in the clinical and biochemical presentations as well as the surgical evolution. A total of 253 patients (158 women, 95 men) with a mean age of 47 years were included. Cushing syndrome was the main clinical presentation (30%), and hormonal studies revealed secreting tumors in 66% of the cases. Altogether, 72% (n = 182) of patients underwent resection for cure, and 41.5% (n = 105) of them had an extensive resection because of metastatic cancer. A lymphadenectomy was performed in 32.5% (n = 89) of the cases. The operative mortality was 5.5% (n = 14). Patients were given mitotane as adjuvant therapy in 53.8% of the cases (n = 135). The results of staging were stage I in 16 patients (6.3%), stage II (local disease) in 126 patients (49.8%), stage III (locoregional disease) in 57 patients (22.5%), and stage IV (metastases) in 54 patients (21.3%). Neither tumor staging nor the rate of curative surgery changed during the study period. More subcostal incisions were performed, and the use of mitotane increased significantly. The 5-year actuarial survival rates were 38% overall, 50% in the curative group, 66% for stage I, 58% for stage II, 24% for stage III, and 0% for stage IV. Multivariate analysis showed that mitotane benefited only the group of patients not operated on for cure. A better prognosis was found in patients operated on after 1988 (p = 0.04), in those with precursor-secreting tumors (p = 0.005), and in those at local stages of the disease (p = 0.0003). Thus mitotane benefited only patients not operated on for cure. Curative resection, precursor secretion, recent diagnosis, and local stage were favorably associated with survival.

Molecular markers and long-term recurrences in a large cohort of patients with sporadic adrenocortical tumors.

Genetic alterations, such as loss of heterozygosity (LOH) at the 17p13 and 11p15 loci and overexpression of the insulin-like growth factor (IGF)-II gene, are associated with the malignant phenotype in sporadic adrenocortical tumors. A high risk of recurrence after surgery for adrenocortical tumors is predicted in cases with regional invasion or distant metastases. However, patients with localized tumors also have a high risk of recurrence. Reliable prognostic markers are required to identify subjects at high risk of recurrence. The aim of this study was to assess the prognostic value of three molecular markers (17p13 LOH, 11p15 LOH, and overexpression of the IGF-II gene) by assessing disease-free survival in a large series of adult patients with sporadic adrenocortical tumors. Adult patients (114) were prospectively followed up from diagnosis of the disease to June 1999 or to death. Malignancy was initially diagnosed in 18 patients (McFarlane stage III: n = 1 and stage IV: n = 17). The remaining 96 patients with localized adrenal disease at diagnosis (stage I: n = 60 and stage II: n = 36) were at risk of recurrence. Histological grade was assessed according to Weiss criteria, and tumors were classified into two groups (Weiss score or=4). Tumor samples were analyzed for LOH at the 17p13 and 11p15 loci and for IGF-II gene mRNA content. 17p13 LOH was a strong predictor of shorter disease-free survival in univariate analysis (P = 0.001; relative risk, 27), as were histological grade (Weiss score >or=4; P = 0.00001; relative risk, 15), 11p15 LOH (P = 0.004; relative risk, 9), tumor size (size >5 cm; P = 0.006; relative risk, 18), and overexpression of the IGF-II gene (P = 0.01; relative risk, 5). In a Cox proportional hazards regression model, histological grade (P = 0.04; relative risk, 4.2) and 17p13 LOH (P = 0.009; relative risk, 21.5) were independently associated with recurrence. Molecular markers, particularly 17p13 LOH, are predictive of long-term outcome in patients with sporadic adrenocortical tumors. In patients who have undergone curative surgery, routine assessment of these tumor markers is a useful complement to histological scoring for predicting recurrence and guiding decisions for subsequent follow-up and management.

[Adrenocortical tumors with oncocytic cells: benign or malignant?]. / Tumeurs surrénaliennes à cellules oncocytaires: bénignité ou malignité?

Adrenocortical tumor with oncocytic cells are exceptional. They are composed exclusively or almost exclusively of oncocytic cells, which are large cells with eosinophilic granulations, corresponding to numerous mitochondria in electronic microscopic examination. This tumor is usually non-functional and benign, and has to be differentiated from the adrenocortical carcinoma.

[Jean Vaysse (1917-1975)]. / Jean Vaysse (1917-1975).

Jean Vaysse (1917-1975) participated during the 1950s et '60s in the great discoveries of modern surgery: renal grafts, cardiopulmonary bypasses, and surgery for arterial hypertension. He died prematurely. To right this injustice, to reveal the man out of the spotlight of hospital and university success stories though all the while participating decisively in some of surgery's greats movements, to find, above the pioneer, the questioning of the meaning of life, the nature of being and the knowledge of its private side: these are our intentions as we consider the life and work of Jean Vaysse.

[Open versus video-endoscopic approach in the treatment of hypercortisolism by bilateral adrenalectomy]. / Comparaison de la voie ouverte et de la vidéo-endoscopie dans le traitement des hypercortisolismes par surrénalectomie bilatérale.

Progress in the technique of the hypophysectomy and in the imaging procedures reduced drastically the indications of bilateral adrenalectomy (BA) in the treatment of hypercortisolism (HC). Indeed BA is indicated in 10 to 30% after failure of pituitary surgery, when HC is related to ACTH ectopic secretion, and in HC related to autonomous adrenal secretion. The purpose of this work is to demonstrate the validity of the bilateral video endoscopic adrenalectomy (BVA) in regard to open surgery. During the last 20 years, 88 patients were operated on by open adrenalectomy (Group 1), either by transperitoneal approach, or bilateral posterior lombetomy. From 1994, 62 patients (Group 2), were operated by video endoscopy. Two death occurred in group 1. The frequency of the preoperative complications were identical in each group, but postoperative morbidity were lower in the group 2. The fall in the postoperative pain, the simplicity of the follow up, the rapid hospital discharge, the low rate of parietal complications were observed in BVA. We conclude that the postoperative follow up is better after BVA a specialized training and time of adaptation are imposed to the surgeon.

[Which adrenal incidentalomas are to be operated?]. / Quels incidentalomes surrénaliens faut-il opérer?

AIM OF THE STUDY: The goal of this retrospective study was to recognize the incidence of adrenal tumors called incidentalomas, that are in fact symptomatic or hormone secreting tumors, to assess if the diagnostic criteria proposed in the literature are reliable for adrenal tumors found incidentally. PATIENTS AND METHOD: The records concerned 147 patients operated between April 1981 and December 2000 for an adrenal mass measuring 3 cm in diameter and larger on CT scan. Clinical and laboratory findings as well as hormone levels and imaging examinations (CT Scan, IRM, scintigraphy) were correlated with operative findings and results of histologic examinations. One hundred and three patients were operated by a traditional approach and forty four by videoendoscopic techniques. RESULTS: In 41 patients (28%), the tumors had to be classified as false incidentalomas (group 1) postoperatively. In 106 patients (72%), the nature of tumor was non definite. In this group 2, there were ten malignant tumors, two pheochromocytomas and 94 benign lesions. Age of patient, size of tumor, increase in size over time and radiological appearance represent criteria that are not reliable to separate malignant from benign tumors. CONCLUSIONS: Tumors of indeterminated and non specific nature only should be classified as incidentalomas. Imaging techniques as well as other criteria of malignancy cannot be relied upon to separate benign from malignant tumors. The risk even small of cancer or pheochromocytoma leads us to recommend excision of tumors > or = 3 cm in radiological diameter. The videoendoscopic approach is a good alternative to open operation in centers with this special expertise.

[Single-layer digestive sutures. Tribute to Pierre Jourdan, its promotor]. / Suture des tuniques digestives en un plan Hommage à Pierre Jourdan, son promoteur.

Since Antiquity, people have tried to suture intestinal injuries and many procedures have been imagined. In 1953, Pierre Jourdan published his book on single-layer intestinal anastamosis, which convinced all surgeons.

Comparison of the hemodynamic parameters of open and laparoscopic adrenalectomy for pheochromocytoma.

Laparoscopic adrenalectomy has gained widespread popularity for treating a variety of adrenal disorders including pheochromocytoma, but the effects of pneumoperitoneum on the hemodynamics of patients with catecholamine-secreting tumors are poorly understood. The goal of this study was to compare the effects of carbon dioxide pneumoperitoneum and tumor manipulation on the hemodynamic parameters in two groups of patients with sporadic pheochromocytomas less than 7 cm in size. Group 1 patients (n = 11) underwent lateral transabdominal laparoscopic adrenalectomy, and group 2 (n = 11) underwent adrenalectomy by the open anterior approach. The mean follow-up was 37 months in group 1 (range 26-51 months) and 52 months in group 2 (range 27-72 months). All patients undergoing laparoscopic adrenalectomy experienced intraoperative hypertension (blood pressure > or = 200/90 mmHg), as did 73% with the open approach, but the difference was not significantly different. Intraoperative hypotension (systolic blood pressure < 80 mmHg) occurred in four group 1 patients compared to six patients in group 2. Mean arterial pressure, central venous pressure, and pulmonary capillary wedge pressure were significantly higher in group 1 patients prior to tumor excision, but there was no difference in pulse, cardiac index, or left ventricle work index at any point during the procedure. There were no conversions or complications in the laparoscopic group; one patient in group 2 developed an incisional hernia. Although laparoscopic adrenalectomy for pheochromocytoma is associated with a greater increase in mean arterial pressure, central venous pressure, and pulmonary capillary wedge pressure, the creation of pneumoperitoneum does not significantly change the cardiac index or left ventricle work index. Carbon dioxide pneumoperitoneum is well tolerated in patients with pheochromocytoma.

Unilateral neck exploration under local anesthesia: the approach of choice for asymptomatic primary hyperparathyroidism.

BACKGROUND: Conventional parathyroidectomy involves a bilateral neck exploration with the patient under general anesthesia with a thorough search for all parathyroid tissue. The purpose of this study was to assess the efficacy and safety of unilateral neck exploration under local anesthesia in patients with asymptomatic primary hyperparathyroidism (first-degree hyperparathyroidism). METHODS: Of 679 patients who underwent parathyroidectomy for first-degree hyperparathyroidism from July 1989 to June 1997, 230 asymptomatic patients underwent unilateral neck exploration under local anesthesia. Selection criteria for this approach included the successful identification of a solitary parathyroid adenoma on preoperative imaging, no thyroid disease, and no family history of multiple endocrine neoplasia. Intact parathyroid hormone levels were monitored during the operation. RESULTS: Total serum calcium levels were normal in 220 patients (96%) 3 to 6 months after surgery. Ten patients (4%) experienced persistent hypercalcemia, 8 of whom had multiple gland disease and 2 of whom had false-positive imaging. Two of these patients underwent bilateral neck exploration under general anesthesia and were cured, although 8 patients remained asymptomatic and were followed up non-operatively. The mean operating time was 30 minutes (range, 12-65 minutes). There were two complications (0.87%) including one wound hematoma and one transient recurrent laryngeal nerve palsy. CONCLUSIONS: Unilateral neck exploration under local anesthesia is an efficacious and safe approach to the treatment of first-degree hyperparathyroidism and should be considered in all patients with asymptomatic disease.

[Experiences with adrenalectomy in 1997. Apropos of 247 cases. A multicenter prospective study of the French-speaking Association of Endocrine Surgery]. / Expérience de la surrénalectomie en 1997. A propos de 247 cas. Etude prospective multicentrique de l'Association francophone de chirurgie endocrinienne.

STUDY AIM: The aim of this prospective study conducted by the AFCE was to analyze the indications, approach and results of all adrenalectomies performed during the year 1997 in 17 centers, active or specialized in endocrine surgery. PATIENTS AND METHODS: During 1997, adrenalectomy was performed in 247 patients, 149 men and 98 women (mean age: 51 years). The lesion was located in the right side in 166 patients, in the left side in 99, in both sides in 28 patients and ectopic in four patients. Pheochromocytomas (n = 61), Conn adenomas (n = 50) and Cushing syndrome lesions (n = 48) were the most frequent in this series. Laparoscopic adrenalectomy was performed in 172 patients (70%) through a transperitoneal approach in all cases except one, and by 'open' surgery in 75 patients (30%). RESULTS: In patients operated on by the laparoscopic approach, the mean duration of surgery was 132 min, and there were peroperative complications in 15 patients (8.7%), mainly hemorrhages. Conversion rate into laparotomy was 7%. In the postoperative course, there were three reoperations and two deaths, an early one in a patient reoperated for bleeding and a very late one in relation with necrotising acute pancreatitis. Mean duration of hospitalization was 5.8 d. Mean tumoral size was 49 mm. In patients operated on by 'open' surgery, the mean duration of surgery was 148 min. There was a postoperative complication in eight patients (10.6%), mostly hemorrhages, and two intraoperative deaths in relation with uncontrollable bleeding. Mean duration of hospitalization was 11 d. Mean tumoral size was 72 mm. CONCLUSION: Laparoscopic adrenalectomy is now indicated for the majority of adrenal tumors. Several complications observed in this series were related to the learning curve in several centers. Laparoscopic adrenalectomy is the 'gold standard' in uni- or bilateral benign tumors no larger than 6 or 7 cm. 'Open' surgery is indicated in malignant tumors, especially in adreno-cortical carcinomas, and in all large tumors.

[Bilateral video-endoscopic adrenalectomy in Cushing's disease. Experience in 24 patients]. / Surrénalectomie bilatérale vidéo-endoscopique dans la maladie de Cushing. Expérience chez 24 patients.

The purpose of this study was to compare the results of bilateral laparoscopic adrenalectomy (BLA) to bilateral open adrenalectomy (BOA) in the treatment of Cushing's disease. Twenty-four patients (23 Cushing's disease, 1 congenital adrenal hyperplasia) were divided into 3 groups. Group 1 patients (n = 15) underwent BCA using the lateral transabdominal approach, Group while 2 patients (n = 9) underwent laparoscopic adrenalectomy on one side and conventional open adrenalectomy on the contralateral side. Groups 1 and 2 were compared retrospectively to 15 patients (Group 3) who underwent BOA as part of larger series of 61 patients. There was no difference in the degree of hypercortisolism in the 3 groups. At the beginning of the experience, the duration of surgery was longer in Groups 1 and 2 compared to the open surgery group, but this difference subsequently decreased during the study. There was no difference in intraoperative blood loss or transfusion rate. Group 1 patients experienced fewer wound and intraabdominal complications and less postoperative pain, shorter hospitalization, and quicker recovery than groups 2 and 3 patients. Technically obesity and tissue fragility are easily overcome by the laparoscopic approach. BCA also achieves success rate of hypercortisolism correction. In conclusion, BLA is the surgical procedure of choice for the treatment of Cushing's disease when surgical therapy is indicated.

[Pancreatic echo-endoscopy and preoperative localization of insulinomas]. / Echo-endoscopie pancréatique et localisation pré-opératoire des insulinomes.

UNLABELLED: Preoperative localization of insulinomas often fails because of the small size of these tumors. The aim of this study was to analyse the value of endoscopic ultrasonography of the pancreas in comparison with them to those of conventional localization procedures. PATIENTS AND METHODS: From 1983 to 1997, 32 patients, operated with a preoperative diagnosis of insulinoma, underwent one or more localization procedures: ultrasonography (US) (n = 31), computed tomography (CT) (n = 31), magnetic resonance imaging (MRI) (n = 10), angiography (ANG) (n = 6), transhepatic portal venous samplings (THPVS) (n = 3), and/or endoscopic ultrasonography (EUS) (n = 25). More recently, 4 patients had scintigraphy with labelled octreotide. During surgery, intraoperative palpation and ultrasonography of the pancreas, performed in all but one cases (laparoscopy), allowed the localization of 29 solitary tumors and 2 multiple tumors (one of which in a case of a MEN II). A malignant tumor was found in 6 patients. RESULTS: The sensitivity of the localization procedures was as follows: US = 19%, CT = 39%, IRM = 30%, ANG = 33%, THPVS = 0%, EUS = 96%. Labelled octreotide scintigraphy was positive in 3/4 cases. Surgical procedures included: 15 enucleations or partial resections, 14 left pancreatectomies (5 of which with splenectomy), 3 duodenopancreatectomies. In one case the tumor was resected laparoscopically (distal pancreatectomy). CONCLUSION: EUS was the best preoperative localization procedure in this study. It may avoid the need for other imaging procedures. Combined with intraoperative ultrasonography, EUS could allow laparoscopic resections in selected cases.

[Possibilities and limits of surgical treatment of malignant adrenal cortex carcinomas. Apropos of a series of 74 cases]. / Possibilités et limites du traitement chirurgical des cortico-surrénalomes malins. A propos d'une série de 74 cas.

The aim of this study was to report our experience of 74 patients operated on for adrenocortical carcinomas in the last 15 years with particular reference to survival rate and prognostic factors. The tumors were secreting in 78% of the cases and non secreting in 22% of the cases, encompassing stade I: 7%, stade II: 43%, stade III: 21%, stade IV: 29%, according to the MacFarlane classification. All patients were operated on whatever the stade. Adrenalectomy with regional lymphadectomy was performed in 50% of the cases. Other procedures included extended adrenalectomy with nephrectomy (n = 27), hepatectomy (n = 7), and desobstruction or resection of inferior vena cava (n = 13). The resection was curative for 66% of the patients and palliative in 34% of the patients. Local recurrences were operated on in 13 patients. Operative mortality was 4%. Stade I and II had significantly the best actuarial survival rates (78 and 62% at 5 years, respectively), when compared to stade III (27%). Extension to the vena cava was not considered as a contra indication even in cases of massive extension. The survival rate of patients with local recurrences was the same as patients wich stade III: 32% at 5 years. Stade IV tumors had the poorer prognosis with a survival rate of 5% at 3 years. In this group, some patients may have benefited from mitotane. Further studies are mandatory to appreciate the benefit of adjuvant therapy with mitotane and palliative chemotherapy.

Effectiveness and limits of preoperative imaging studies for the localisation of pheochromocytomas and paragangliomas: a review of 282 cases. French Association of Surgery (AFC), and The French Association of Endocrine Surgeons (AFCE).

OBJECTIVE: To find out the optimal strategy for the preoperative location of pheochromocytomas and paragangliomas. DESIGN: Retrospective study. PATIENTS: 282 patients operated on for histologically confirmed pheochromocytoma in France between 1980 and 1991, the past decade. MAIN OUTCOME MEASURES: The results of imaging procedures, i.e. computed tomography (CT), (131)I meta-iodobenzylguanidine scintigraphy (MIBG) and magnetic resonance imaging (MRI) were reviewed. RESULTS: Pheochromocytomas were sporadic in 206 (73%). They were unilateral in 189 (67%), bilateral in 54 (19%) and extra-adrenal in 39 (14%). Overall sensitivity of the studies was 89% for CT, 98% for MRI, and 81% for (131)I-MIBG. In unilateral adrenal lesions sensitivity were 100% for CT and MRI, and 88% for (131)I-MIBG; in bilateral lesions 66% for CT, 100% for MRI, and 62% for (131)I-MIBG; in extra-adrenal lesions 64% for CT, 88% for MRI, and 64% for (131)I-MIBG. CONCLUSION: The accuracy with which pheochromocytomas and paragangliomas can be visualized questions nowadays the routine use of abdominal approach. In selected cases of sporadic unilateral chromaffin tumours, a posterior, lateral, or even laparoscopic approach should be considered.