[Between body and soul: touch]. / Entre corps et âme, toucher.

A proverb from the Middle Ages says "hand games, naughty games". We would like to reverse it to "hands on games, good games" and show that, from the beginning to the end of life, touch, when practiced with tact, is care. In psychiatry, it takes on the specific meaning of listening, without any preconceived judgment or ideological or normative a priori: taking care, care rather than cure. It is futile to claim to treat mental illness without understanding the singular history of each of those affected. Already in the 18th century, Philippe Pinel and his assistant Jean-Baptiste Pussin had understood this: care is at the source of the "moral treatment of the insane", itself at the origin of institutional psychotherapy. A brief detour through the Middle Ages and the practice of thaumaturgy would confirm that the hand, more than any other sense, is healing.

[Colonic diverticulosis: which patients need surgery?]. / Diverticulose colique: quand opérer?

Diverticular disease has become a very common condition in elder and more recently in younger patients in western countries that emerged at the turn of the 20th century and since then has become epidemic. An increasing incidence and an earlier onset of the disease lead us to update the current therapeutic indications, especially for surgery in elective condition. Whereas elective colectomy was performed for poorly documented suspicions of diverticulitis in the past, a positive diagnosis of diverticulitis on CT scan is needed. Therefore, indications for colectomy are restricted to patients with medical history of related endocarditis, diabetes mellitus, proven structural abnormalities of collagen, immune deficiency, after a second episode of diverticulitis requiring at least an hospitalisation or after a single complicated diverticulitis (abscess, fistula, stricture). A two-months delay between symptoms and surgery is suitable, and permits to perform preoperatively a colonoscopy in a safe condition to rule out concomitant adenoma or colonic cancer. There is no randomised trial of open versus laparoscopic colectomy in this specific indication. As the lesions of resected colon became more severe due to restricted indications, laparoscopic approach will require more surgical skill and conversion rate might increase. In selected cases, open surgery should be preferred.

Macroscopic lymph-node involvement and neck dissection predict lymph-node recurrence in papillary thyroid carcinoma.

OBJECTIVE: Whether lymph-node dissection (LND) influences the lymph-node recurrence (LNR) risk in patients with papillary thyroid cancer remains controversial. The prognostic impact of macroscopic and microscopic lymph-node involvement at diagnosis is also an unresolved issue. A retrospective study was conducted to assess the influence of various LND procedures and to search for LNR risk factors. METHODS: Overall 545 patients without distant metastases prior to surgery and main tumour > or =10 mm were included. A total thyroidectomy was performed in all patients with either no LND (Group 1, n=161), bilateral LND of the central and lateral compartments (Group 2, n=181) or all other dissection modalities (Group 3, n=203). Post-operative radioiodine was given to 496 (91%) patients. The 10-year cumulative probability of LNR was assessed and a prognostic study using multivariate analysis was performed. RESULTS: Macroscopic lymph-node metastases were present in 118 patients, 57 diagnosed before surgery and 61 only at surgery (including 81% in the central compartment). Overall, the 10-year cumulative probability of LNR was 7%. Macroscopic lymph-node metastases (P=0.001), extra-thyroidal invasion (P=0.017) and male gender (P=0.05) were independent risk factors, while bilateral LND of the central and lateral compartments was protective (P=0.028). In patients with macroscopic lymph-node metastases, the 10-year probability was lower in Group 2 than in Group 3 (10% vs 30%, P<0.01). In patients without macroscopic lymph-node metastases (n=427), no significant differences were observed between the three LND groups. CONCLUSIONS: Patients with macroscopic, but not microscopic, lymph-node involvement have a major LNR risk and need an optimal LND at primary surgery.

Usefulness of follow-up after pancreatoduodenectomy for carcinoma of the ampulla of Vater.

BACKGROUND: The prognosis for carcinoma of the ampulla of Vater (CAV) is better than for pancreatic cancer. The 5-year survival median rate after resection of CAV is 45%, but late recurrences remain possible. Several survival factors have been identified (lymph nodes, perineural invasion), but few data are available on the type of recurrences, their impact and their management. PATIENTS AND METHODS: A total of 41 patients treated by pancreatoduodenectomy (PD) for CAV from 1980 to 2003 were studied retrospectively. Patient selection, long-term survival recurrence rate and recurrence treatment were reviewed. Univariate and multivariate proportional hazards analysis were conducted on this series. RESULTS: The mean follow-up was 48 months. Five-year survival was 62.8%. Eleven patients had recurrences (6-67 months). Recurrence was associated with time to all-causes death (hazard ratio [HR] 4.3, p=0.003). Factors predictive of recurrence were perineural invasion (HR 5.3, p=0.02), lymph node invasion (HR 5.3, p=0.02) and differentiation (HR 0.2, p=0.05). Three patients underwent surgical R0 treatment of their recurrences. Two who presented with solitary liver metastasis are alive and disease-free. CONCLUSIONS: Recurrence represents a serious threat in the prognosis of CAV after surgery. Some of these recurrences, in particular liver metastases, are accessible for a curative treatment. This finding supports the usefulness of a close and long-term follow-up after surgery to improve survival of patients with CAV, especially in the group of patients with a good prognosis.

Risk of second primary cancer following differentiated thyroid cancer.

Concerns remain over the risk of cancer following differentiated thyroid carcinoma and its causes. Iodine-131 ((131)I) and external irradiation are known to have potential carcinogenic effects. Thyroid carcinoma is a polygenic disease which may be associated with other malignancies. We investigated the incidence of second cancer and its aetiology in a cohort of 875 patients (146 men, 729 women) with differentiated thyroid carcinoma originating from Basse-Normandie, France. Cancer incidence was compared with that of the general population of the Département du Calvados matched for age, gender and period. The cumulative proportion of second cancer was estimated using the life-table method. Factors that correlated with the risk of second cancer were studied using the Cox model. After a median follow-up of 8 years, 58 second cancers had been observed. Compared with general population incidence rates, there was an overall increased risk of second cancer in women [standardised incidence ratio (SIR)=1.52; P<0.01], but not in men (SIR=1.27; P>0.20). Increased risk related to cancers of the genitourinary tract (SIR=3.31; P<0.001), and particularly to cancer of the kidney (SIR=7.02; P<0.01). Multivariate analysis showed that age above 40 years (P<0.01) and a history of previous primary cancer (P<0.001) correlated with risk. In contrast, neither cervical irradiation nor cumulative activity of (131)I was related to the risk. These data confirm that women with differentiated thyroid carcinoma are at risk of developing a second cancer of the genitourinary tract and kidney. Only age and medical history of primary cancer before thyroid carcinoma are risk factors for second cancer. Common environmental or genetic factors as well as long-term carcinogenic effects of primary cancer therapy should be considered.

[Laparoscopic resection of benign submucosal stomach tumors. A report of 65 cases]. / Exérèse laparoscopique des tumeurs sous-muqueuses bénignes de l'estomac. A propos de 65 cas.

AIM OF THE STUDY: The aim of this retrospective multicenter study was to evaluate the feasibility and the results of laparoscopic resection of benign submucosal gastric tumors. PATIENTS AND METHODS: We reviewed the cases of 65 patients (20 centers) who have been operated on laparoscopically for benign submucosal gastric tumors. The tumor was symptomatic in 56 cases, located on the posterior wall in 23 cases. The mean size of the tumor was 3.8 cm (1.5-10). RESULTS: A laparoscopic wedge resection was performed in 53 cases. In 1 case a laparoscopic-assisted gastrectomy was done. A conversion to laparotomy was mandatory in 11 cases because of difficulties in localization of the tumor (n=5), in excision (n=5) or for safety reasons (n=1). There was no mortality. Two patients required reoperation because of bleeding. During follow-up, one patient developed recurrence requiring a second laparoscopic excision. CONCLUSION: Most submucosal benign gastric tumors can be removed by laparoscopy. The location of the tumor (posterior wall or closed to the lesser curvature) or the size of the tumor (large or very small) can make the laparoscopic approach difficult.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura.

We conducted a retrospective multicenter study by questionnaire to evaluate the results of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP). Between 1991 and 1998, 209 patients with a mean age of 41.2 years (range, 10-83) had a laparoscopic splenectomy for idiopathic thrombocytopenic purpura. Preoperatively, 178 patients (85%) underwent medical treatment aimed at achieving a satisfactory platelet count. Twenty-nine patients were obese, with a body mass index greater than 30%, and 14% were HIV-seropositive. The so-called hanging spleen technique in the right lateral decubitus position was used most often. The average duration of surgery was 144 minutes (45-360). This was significantly longer in cases of conversion (170 minutes; P < 0.01). The factors influencing the duration of laparoscopy were operator experience and patient obesity (P < 0.01). A conversion was necessary in 36 cases (17.2%) because of hemorrhage. The conversion rate varied from 5.3% to 46.7%, depending on the surgical team. A multivariate analysis of factors disposing to conversion identified two causes: obesity and operator experience. One or more accessory spleens were found in 34 patients (16.2%). The average weight of the spleens was 194.2 g. There were no deaths. There were no complications in 187 patients (89.5%), with a mean hospital stay of 6.1 days. Patients who did not require a conversion had a significantly earlier return of intestinal transit, used less analgesic, and had a shorter length of hospitalization. Overall morbidity was 10.5% (22 cases), due to subphrenic collections (7 cases), abdominal wall complications (6 cases), re-intervention for actual or suspected hemorrhage or pancreatitis (3 cases), pneumopathology (2 cases) and others (4 cases). A multivariate analysis about morbidity shows a statistically significant difference in conversions (P < 0.05) but not in obesity or in surgeon's experience. Normal activity was achieved on average by the twentieth postoperative day--earlier if conversion was not required (18.4 versus 33.9 days). The average preoperative platelet count was 92.7 x 10(9)/L (range, 3 to 444). Twenty patients had a count of less than 30 x 10(9)/L and in this group the conversion rate was 30% (6 cases). Ninety-six patients were seen in the outpatient clinic, with an average follow-up time of 16.2 months (3 to 72 months), and the average platelet count was 242 x 10(9)/L (6 to 780). Eight patients (8.3%) were failures with a platelet count of <30 x 10(9)/L. In the 20 patients with a preoperative platelet count <30 x 10(9)/L, there were 3 early failures and 5 late relapses. There were 2 late deaths: chest infection at 3 months in an HIV seropositive patient and one case of pulmonary embolus at 6 months. Laparoscopic splenectomy constitutes a real alternative to conventional splenectomy for the treatment of idiopathic thrombocytopenic purpura. It is associated with fewer postoperative complications, a shorter duration of hospitalization and an earlier return to normal activity. The limiting factors are the experience of the operator and patient obesity. The long-term results are identical to those of conventional splenectomy, with a better than average success rate in patients that have failed preoperative medical treatment.