One-stage laparoscopic procedure versus two-stage procedure in the management of common bile duct stones in patients aged 75 and more.

INTRODUCTION: The management strategy for common bile duct stones (CBD) in patients over 75years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients. MATERIAL AND METHODS: This study included eighty-two patients over 75years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n=40) or by sequential endoscopy and surgery (ES group, n=42). RESULTS: Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P=0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (>3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively. CONCLUSION: The "surgery alone" attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledocholithiasis.

Medical and surgical triage.

In terrorist attacks and industrial catastrophes, management of a massive afflux of wounded must adhere to logistic imperatives while at the same time taking into account basic traumatology principles. This implies a firm, unequivocal, and precise doctrine for all stages of care. Medical and surgical triage allows a logical classification of victims according to severity of injury, the necessity of treatment and the degree of urgency. Triage should be early, dynamic, and lead to a categorization that optimally utilizes resources while ensuring efficient management.

[Cavernous hemangioma: rare incidentaloma of the adrenal gland]. / L'hémangiome caverneux : un incidentalome rare de la surrénale.

The hemangioma of the adrenal gland is an adrenal gland lesion rare, benign and usually asymptomatic. Discovered incidentally during an abdominal imaging study, it is part of incidentalomas. Imagery is the best to characterise these silent adrenal masses (computed tomography [CT], Magnetic Resonance Imaging [MRI]± Positron Emission Tomography [PET scan] with 18F-FDG). The main risks of the hemangioma are ignorance of malignancy, bleeding and abdominal mass syndrome. The analysis of the literature shows the importance of laparoscopy. A multidisciplinary discussion on this type of lesion appears indispensable both diagnostic and therapeutic.

[Caloric value of food and coverage of the recommended nutritional intake of vitamins in the adult human. Principle foods containing vitamins]. / Valeur calorique del l'alimentation et couverture des apports nutritionnels conseillés en vitamines del l'homme adulte. Principaux vecteurs alimentaires de vitamines.

Two daily food consumption models were defined. One of them (I) is representative of the French eating habits, the other (E) of a diet with a theoretically balanced content of macronutrients for a caloric intake of 2,500 kcal. For each of these two models, four menus were calculated to obtain four caloric levels (1,500, 2,000, 2,500 and 3,000 kcal). The vitamin content of these menus was established on the basis of the literature (food composition tables). Nutritional losses resulting from usual cooking methods were taken into account. The results show that the dietary intake of some vitamins, such as folic acid, pantothenic acid, vitamin A, beta-carotene, vitamin C and B1, was likely to be inadequate and are in agreement with those of epidemiologic surveys carried out in developed countries. The threshold of 80% of the recommended allowances is not reached with a caloric level of 2,500 kcal (balanced diet) or 2,700 kcal (unbalanced diet). For an allowance of 1,500 kcal, most of the vitamins do not reach or just reach 50% of the recommended level. This result shows that the former eating habits of the French population, whose caloric intake was high (more than 3,000 kcal), were correct as they covered the recommended intakes of micronutrients. This work corroborates the great importance of some food groups in covering the recommended vitamin intakes and underlines the necessity of diversifying food.