Laparoscopic Repair of Larrey Hernia: A Case Report and Literature Review.

Morgagni-Larrey hernia is a rare pathology resulting from an anterior diaphragmatic defect. Diagnosis is often made in adulthood due to the lack of symptoms associated with this condition. Various surgical techniques have been reported for its treatment, but no standard approach has been established due to its rarity. Here, we present the case of a 42-year-old patient with a symptomatic Larrey hernia successfully treated with a laparoscopic approach. The rationale for documenting this case lies in contributing to the understanding and management of this rare condition.

Results of surgical treatment of uncontrollable upper gastrointestinal hemorrhage using endoscopy.

BACKGROUND/AIMS: Acute hemorrhage of the upper gastrointestinal tract occurs at a rate of 50 to 100 per 100,000 annually in the Western adult population. With the increased use of therapeutic endoscopy, the role of surgery is decreasing; surgical intervention is now only used in cases of failure of endoscopic hemostasis. The goal of this study is to determine whether there are predictive factors associated with high-risk post-operative mortality. METHODOLOGY: This retrospective study included 30 patients treated from March 1996 to September 2008 at Brugmann Hospital. These patients presented with upper gastrointestinal non-variceal hemorrhage that was treated first endoscopically then surgically for recurrent hemorrhage. Multiple risk factors (variable and fixed) and parameters were evaluated to determine their influence on mortality. RESULTS: Of 30 patients, 10 (33%) developed recurrent hemorrhage following surgical treatment. A total of 8 (26.6%) deaths occurred of which 4 were related to hemorrhage. Three deaths occurred after the first intervention and 5 occurred after a second intervention. Logistic regression analysis revealed that the total number of blood units transfused and the presence of at least one surgical reintervention both significantly increased mortality rate (p = 0.0426 and p = 0.0068). Other parameters were not significant. However, there is a lack of power due to the small sample size. CONCLUSION: For recurrent massive upper gastrointestinal hemorrhage following endoscopic treatment and necessitating more than 19 blood transfusions, early surgical intervention is recommended and surgical reintervention should be avoided. If reintervention is necessary, radical surgery is recommended. However, the small number of patients treated over a 12-year period limits the results of this study, and these results may represent simple coincidences.

Neuroendocrine tumors of pancreas: how can we apply the 2006 TNM proposal?

BACKGROUND/AIMS: In 2006, a TNM system for foregut neuroendocrine tumors has been proposed. Our study aimed to present the management of neuroendocrine tumors of pancreas according to this classification and to highlight some of its limitations. METHODOLOGY: Clinical, biochemical, radiological, surgical and pathological data were retrospectively collected on 22 consecutives patients, who underwent surgery for neuroendocrine tumors of pancreas between November, 1991 and September, 2005. These data were used to set the TNM. RESULTS: After excluding 5 patients, the remaining 17 patients were analyzed. In 9 patients, with a mean age of 39 years, tumors were benign with a mean size of 1.8 cm, classed at stage I-IIa, whereas for 8 patients with a mean age of 57 years, tumors were malignant with a mean size of 6cm and were classed at stage IIb-IV. There were 3 deaths in stage IIb-IV, and none in stage I-IIa. CONCLUSION: TNM may be considered as a useful tool for prognostic stratification, but true benign tumors need to be excluded in order to improve the classification. Size and age appeared as variables affecting malignant behavior and the prognosis.

Randomized controlled trial comparing somatostatin with octreotide in the prevention of complications after pancreatectomy.

BACKGROUND/AIMS: The postoperative morbidity following pancreaticoduodenectomy (PD) remains very high. Somatostatin or octreotide are indicated in the prevention of pancreatic stump-related complications. The aim of this study is to compare the efficacy of somatostatin and octreotide after PD. METHODOLOGY: Between November 2000 and December 2003 we collected prospectively clinical and biological data from patients with a benign or malignant pancreatic tumor requiring a PD. Fifty patients were randomized into two groups, 25 treated with somatostatin (group S) and 25 with octreotide (group O). RESULTS: There was no postoperative death. Complications occurred in 20 patients (40%), 11 in group S, 9 in group O (NS). General complications occurred in 7 patients in group S, and 5 patients in group O. Local complications related to the pancreatic stump were found in 4 patients in both groups. At the end of the period of administration of the two study drugs, 2 patients (8%) had a pancreatic fistula in group S and 3 in group O (12%) (p=0.52). A trend of more rapid decreased level of amylase and lipase concentrations in surgical drainage was observed in group S but it is not statistically significant (p=0.29). CONCLUSIONS: In patients requiring PD for pancreatic tumor, somatostatin and octreotide seem to behave similarly in the postoperative period.

Cold ischemia is a major determinant of acute rejection and renal graft survival in the modern era of immunosuppression.

BACKGROUND: The aim of our study was to examine, in a recent cohort of kidney transplant recipients who have received modern immunosuppressive therapy, the respective role of cold ischemia time (CIT) and delayed graft function (DGF) on acute rejection (AR) rates and long-term graft survival. METHODS: We retrospectively reviewed the charts of 611 renal transplantations between 1996 and 2005. Most patients received a calcineurin inhibitor as maintenance therapy, either cyclosporine (43%) or tacrolimus (52%) and 76% of the patients received an antilymphocyte induction therapy. Study endpoints were DGF, first-year AR, and long-term graft survival. Uni- and multivariate analyses were performed to determine factors that may have influenced the study outcomes. RESULTS: DGF was observed in 16.2% of patients. Both older donor age and longer CIT were significant risk factors for DGF. DGF rates were similar whether patients received a calcineurin inhibitor before transplantation or not. AR occurred in 16.5% of grafts during the first year. Independent predictors of AR by multivariate analysis were duration of dialysis, CIT, current panel-reactive lymphocytotoxic antibody more than 5%, and the number of human leukocyte antigen-A, B, and DR mismatches. Each hour of cold ischemia increases the risk of rejection by 4%. With respect to death-censored graft survival, three pretransplant parameters emerged as independent predictors of graft loss: younger recipient age, peak panel-reactive lymphocytotoxic antibody more than 5% and longer CIT. The detrimental effect of CIT on graft survival was entirely because of its propensity to trigger AR. When AR was added to the multivariate Cox model, CIT was no longer significant whereas first-year AR became the most important predictor of graft loss (Hazards ratio, 4.6). CONCLUSION: Shortening CIT will help to decrease not only DGF rates but also AR incidence and hence graft loss. Patients with prolonged CIT should receive adequate immunosuppression, possibly with antilymphocyte preparations, to prevent AR occurrence.