Transinguinal preperitoneal groin hernia repair using a preperitoneal mesh preformed with a permanent memory ring: a good alternative to Lichtenstein's technique.

PURPOSE: The transinguinal preperitoneal (TIPP) technique uses a preperitoneal mesh preformed with a permanent memory ring, which greatly facilitates application of Rives' technique. The purpose of this retrospective study was to evaluate our primary results by systematic clinical and ultrasound evaluations more than 1 year after surgery. METHODS: This unicentric study included all consecutive adult patients treated with surgery for a groin hernia by the same surgeon using the same technique between December 2006 and December 2008. Any patient who participated in this study had both a systematic clinical and ultrasound control between 6 months and 3 years after surgery. RESULTS: In this study, we performed 145 hernia repairs. There was no infection of the mesh and no clinical recurrence; additionally there was an ultrasound recurrence (n = 3) in 2% of asymptomatic patients and chronic pain in 4.8% of patients who did not require the consumption of systematic painkillers and are not limited in their activities. CONCLUSIONS: It is feasible to correct a groin hernia using a preperitoneal preformed mesh with a permanent memory ring. Our study confirms the positive results of Pélissier and colleagues (Pélissier and Ngo, Ann Chir 131:590-594, 2006; Pélissier et al. J Chir 144(4):5S35-5S40, 2007; Pélissier et al. Hernia 11:229-234, 2007; Pélissier et al. Hernia 12:51-56, 2007) and Berrevoet et al. (Hernia 13:243-249, 2009; Langenbeck's Arch Surg 395:557-562, 2010) and is the first study to use a systematic clinical and ultrasound control more than 1 year after surgery. This technique has a low rate of complications, including ultrasound recurrence in 2% of patients without any clinical recurrence and chronic pain in 4.8% of patients who did not require the consumption of systematic painkillers and are not limited in their activities. This technique consisted of the placement of a patch in the preperitoneal space, which combines the benefits of the anterior approach (i.e., easy technique, short learning curve, low cost) and the preperitoneal placement of the mesh (less recurrence, less pain). This procedure is a good alternative to Lichtenstein's technique.

Total perineal reconstruction after abdominoperineal excision for rectal cancer: long-term results of dynamic graciloplasty with Malone appendicostomy.

AIM: This study aimed to assess long-term function after total perineal reconstruction (TPR) with dynamic graciloplasty (DG) and systematic Malone appendicostomy (MA) adjunction after abdominoperineal excision (APR) for rectal cancer. METHOD: From 1999 to 2004, TPR using DG and MA was performed in 10 patients [seven women; median age 40 (range 28-55) years] after APR for rectal cancer (cT2 in one patient, cT3 in six patients and cT4 in three patients). We prospectively recorded early and late morbidity, mortality, oncological outcome, functional results (using the modified Working Party on Anal Sphincter Replacement 'WPASR' scoring system) and quality of life (QoL; using the European Organisation for Research and Treatment of Cancer 'EORTC' QLQ-C30 and QLQ-CR38 questionnaires). RESULTS: There was no procedure-related mortality. One patient required intra-abdominal re-operation. Nine patients required local and multiple revisions [there was one coloperineal anastomosis (CPA) stenosis, five CPA mucosal prolapse, three stenosis related to graciloplasty, two MA stenosis and one MA reflux]. After a median follow up of 78 months, there was no local recurrence and six patients were alive and disease-free. Regarding the functional results, the median modified WPASR score, of 8, after a follow up of 78 months, was good. The overall QoL scores remained stable over time. CONCLUSION: In carefully selected patients who want to avoid definitive abdominal colostomy after APR for rectal cancer, reconstruction involving MA and DG after APR for low rectal cancer is followed by good long-term function and QoL.

[Traumatic perforation of the sigmoid colon: role of computed tomography]. / Perforation sigmoïdienne traumatique: intérêt du bilan tomodensitométrique.

The authors report a case of a delayed traumatic perforation of the sigmoid colon, presenting three days after a motor vehicle accident. A review of the literature is presented.

Adult liver transplantation and steroid-azathioprine withdrawal in cyclosporine (Sandimmun)-based immunosuppression - 5 year results of a prospective study.

New immunosuppressants are said to be superior to cyclosporine due to their higher incidence of steroid sparing and to the reduced incidence of side-effects. From May 1992 to February 1995, 79 adults underwent primary liver transplantation using cyclosporine A (Sandimmun)-based triple drug immunosuppression. Nine patients who died early after liver transplantation due to reasons unrelated to immunological problems were excluded from this analysis. The long-term outcome of the remaining 70 patients was prospectively studied in relation to steroid and azathioprine withdrawal. They were re-evaluated 6-monthly in relation to liver and kidney function; cholesterolemia, infection, de novo diabetes mellitus and arterial hypertension, malignancy, ophthalmological and osteomuscular diseases. In case of rejection occurring during or after steroid tapering, patients were switched, by protocol, to tacrolimus therapy. Median follow-up was 81 months (range 60-96). Forty-four patients (62.8 %) were biopsied 5 years after transplant; 20 patients (28.6 %) were biopsied at a median follow-up of 32 months (range 7.8-47). Six patients (8.6 %) who refused biopsies more than 1 year after liver transplantation had normal liver values throughout the whole follow-up period. Five-year actual patient and graft survivals were 75 % and 65.8 %, respectively, for the whole group (n = 79) and 85.7 % and 74.3 % for the studied group (n = 70). Steroids could be withdrawn in all but two patients (97.1 %) at a median time of 7 months (range 3-42). Steroids were restarted in six patients (8.6 %) for extrahepatic reasons. Freedom from steroids was thus observed in 62 patients (88.6 %). Seven patients (10 %) had rejection after steroid tapering; six were switched to tacrolimus. Two patients (2.9 %) needed retransplantation because of acute and chronic rejection whilst still being on full immunosuppression. In total, three patients (4.3 %) had histological signs of chronic rejection during follow-up. At 5 years post-transplant, 66.6 % and 13.3 % of the 60 patients at risk were on cyclosporine and tacrolimus monotherapy, respectively; 93.3 % were steroid-free. Mean creatinine and cholesterol levels were 1.56 +/- 1.3 mg/dl and 193.5 +/- 56.6 mg/dl; incidences of de novo arterial hypertension, insulin dependent diabetes mellitus were 26.6 % and 13.3 %. Two patients (2.8 %) developed post-transplant lymphoproliferative disease, two (2.8 %) had skin cancer. Cyclosporine-based immunosuppression allows safe steroid withdrawal in most patients and cyclosporine monotherapy can be achieved in two-thirds without compromising graft and patient survival. Results of new immunosuppressive strategies should be approached with caution, especially when considering steroid sparing and the incidence of side-effects.

Adult hepatic retransplantation. UCL experience.

INTRODUCTION: Retransplantation is a rescue operation in orthotopic liver transplantation. Its appropriateness has been questioned on medical, economical and also on ethical grounds. MATERIAL AND METHODS: During the period february 1984-december 1997, 54 (14.5%) of 372 adult patients were retransplanted; three (0.8%) of them had two retransplantations. Indications were graft dysfunction [(primary non function (8x) and early dysfunction (14x in 13 patients)], immunological failure [acute (9x in 8 patients) and chronic (9x) rejection], technical failure [(hepatic artery thrombosis (5x in four patients), allograft decapsulation (1x), ischaemic biliary tract lesions (6x)] and recurrent viral allograft disease [HBV (4x) and HCV (1x)]. RESULTS: Five year actuarial patient survival after retransplantation was 70.8%, which was identical to this of non retransplanted patients (72%). Early (< 3 mo) mortality was significantly lower in elective procedures (9.1%--2/22 pat. vs 34.4%--11/32 pat. in urgent procedures--p < 0.05). Mortality was highest in the graft dysfunction (23.8%, 5/21 pat.) and immunological failure (41%, 7/17 pat.) groups. Five of six patients retransplanted for rejection, whilst being on renal support, and two of three patients retransplanted urgently twice died of infectious complications. All patients retransplanted because of recurrent allograft disease were long-term (> 3 mo) survivors. Both HBV-infected patients died of allograft reinfection 7 months later; the two HBV-Delta infected patients were, free of infection, 44 and 6 months after retransplantation under HBV-immunoprophylaxis. Length of hospitalisation after primary transplantation and retransplantation were identical (median of 16 days--range 11 to 40 vs 14 days (range 7 to 110). Economical study during the period 1990-1995 showed that costs of the first hospitalization of primary transplantation and of retransplantation could be equalized during the period 1994-1995 as a consequence of the more frequent use of elective retransplantation (median 1.3 million BF, range 720,988 to 8,887,145 vs 1.1 million BF, range 943,685 to 1,940,409). CONCLUSIONS: Hepatic retransplantation is a successful safety net for many liver transplant patients. Every effort should be made to do this intervention electively under minimal immunosuppression. In case of immunological graft failure and hepatic artery thrombosis retransplantation must be done early in order to avoid infectious complications; the same holds for ischaemic biliary tract lesions which cannot be cured by interventional radiology. Retransplantation for recurrent benign disease should be restricted to those diseases which can be effectively treated by (neo- and) adjuvant antiviral therapy.

Surgical treatment of thyroid papillary carcinoma: current controversies.

Papillary cancer is the most frequent thyroid cancer occurring in all age groups with a good prognosis. Surgery is commonly recognized as the primary treatment of PC, but controversy concerning the type of resection continues. We are still waiting for the best predictors of tumor aggressiveness which would help us to select patients for the type of surgery according to the tumor prognosis. We currently recommend total thyroidectomy in all cases leading to eradicate all tumoral tissue specially in multicentric disease, to optimize the effect of postoperative Iodine-131 therapy and to allow thyroglobulin levels to be reliably used as a marker of recurrence. We advocate lymphnode dissection only if chain nodes are palpable. Total thyroidectomy should be made by experienced surgeon in order to minimize post-operative morbidity.