An MRI study of typical anatomical variants of the anterior communicating artery complex.

PURPOSE: This magnetic resonance imaging study examined the most frequent anatomical variants of the anterior communicating artery (ACoA) complex of the cerebral arterial circle, and aimed to determine whether they were associated with ACoA complex aneurysm. METHODS: The study enrolled 669 patients. Using three-dimensional time-of-flight magnetic resonance angiography, 617 patients were classified into the following groups based on the anatomical variation in the ACoA complex: no ACoA complex anomaly; ACoA complex aneurysm; and vascular anomaly distant from the cerebral arterial circle. RESULTS: Of the 617 classified subjects, the classical anatomical description applied to 48.73% in the no ACoA complex anomaly group and 37.5% in the ACoA complex aneurysm group. One variant (left anterior cerebral artery segment A1 hypoplasia) was significantly more frequent in the ACoA complex aneurysm group. There was no sex difference in the prevalence of any variant. CONCLUSIONS: Anatomical variants of the ACoA complex of the cerebral arterial circle were found in almost half of the subjects. One variant seemed to be associated with a higher likelihood of an aneurysm, but causality could not be inferred.

Bile Duct Injury During Cholecystectomy: Necessity to Learn How to Do and Interpret Intraoperative Cholangiography.

Introduction: Biliary duct injury (BDI) is a serious complication during cholecystectomy. Perioperative cholangiography (POC) has recently been generating interest in order to prevent BDI. However, the current literature (including randomized controlled trials) cannot conclude whether POC is protective or not against the risk of BDI. The aim of our study was to investigate whether POC could demonstrate earlier BDI and which criteria are required to make that diagnosis. Methods: We performed a retrospective study between 2005 and 2018 in our French tertiary referral center, which included all patients who had presented following BDI during cholecystectomy. Results: Twenty-two patients were included. Nine patients had POC, whereas 13 did not. When executed, POC was interpreted as normal for three patients and abnormal for six. In this latter group, only two cases had a BDI diagnosed intraoperatively. In other cases, the interpretation was not adequate. Conclusion: BDIs are rare but may reduce patients' quality of life. Our study highlights the surgeon's responsibility to learn how to perform and interpret POC in order to diagnose and manage BDIs and potentially avoid catastrophic consequences.

C-reactive protein is a predictive factor for complications after incisional hernia repair using a biological mesh.

The introduction of biological or absorbable synthetic meshes has provided an alternative to conventional repair for incisional hernia. The ability to predict the development of complications after hernia surgery is important, as it guides surgical planning and patient management. This retrospective study assessed whether the postoperative C-reactive protein (CRP) level can predict complications after incisional hernia repair using biological mesh reinforcement. Patients who underwent incisional hernia repair surgery using biological meshes between February 2009 and February 2015 were screened for study inclusion. Patients included in the study were divided into two groups: those with and without postoperative complications. The two groups were analysed based on sex, surgical operation, length of intensive care unit stay (ICU), complications and mortality. Laboratory values, including white blood cell (WBC) count and CRP levels, were determined preoperatively and up to postoperative day (POD) 10. Postoperative complications requiring further management occurred in 32 of the 60 patients (53.3%). Among 47 patients, the mean CRP and WBC levels were 6.6 mg/L and 9.073 G/L in the group without complications vs. 141.0 mg/L, 16.704 G/L in the group with complications (p < 0.001). Patients with complications also had a longer ICU stay (10.1 vs. 0.6 days, p < 0.0001). A cut-off was 101 mg/L and offered 80.00% sensitivity (IC 61.43% to 92.29) and 95.24% specificity (76.18% to 99.88%) for postoperative complication. The rate of postoperative complications before POD10 was 95% in the group with CRP > 100 mg/L vs. 46% in the group with CRP < 100 mg/L (p = 0.000372). A high postoperative CRP level (> 100 mg/L) up to POD10 may serve as a predictor of postoperative complications in patients undergoing incisional hernia using biological meshes.

Correlations of the rectus abdominis muscle anatomy with anthropometric measurements.

PURPOSE: The anterior abdominal muscle wall has a strong aesthetic connotation, primarily because of the classical anatomical description of the rectus abdominis muscle in the collective consciousness. However, the morphological reality of the general population considerably deviates from this description. Therefore, we investigated the anthropometric characteristics correlated with the anatomy of the rectus abdominis muscle. METHODS: We performed a computed tomography scan anatomical study of recti abdominis muscles in 86 patients with no history of abdominal surgery. We noted the transverse and anteroposterior measurements of the rectus abdominis muscle, the transverse measurement of the linea alba, and the cutaneous and muscular abdominal perimeters. We compared these morphological elements with anthropometric data (sex, age, weight, height, and body mass index [BMI]). RESULTS: BMI was positively correlated with cutaneous abdominal perimeter (r = 0.89, p < 0.001) and muscular abdominal perimeter (r = 0.7, p < 0.001). The correlation of BMI with cutaneous abdominal perimeter was not influenced by sex (r = 0.90 and r = 0.89 in men and women, respectively). The correlation of BMI with muscular abdominal perimeter was greater in men than in women (r = 0.80 vs. r = 0.75). The muscular abdominal perimeter was more strongly correlated with the transverse measurement of the rectus abdominis muscle in men than in women (r = 0.75 vs. r = 0.59). The muscular abdominal perimeter was more strongly correlated with the linea alba in women than in men (r = 0.51 vs. r = 0.31). CONCLUSION: The anatomy of the anterior abdominal wall correlated with anthropometric data, including BMI. Rectus abdominis muscles and linea alba structures differed between men and women.

Implantation of biologic mesh in ventral hernia repair-does it make sense?

BACKGROUND: Biological acellular porcine dermis mesh, such as Permacol™, has been used since 2009 to treat abdominal incisional hernias in a septic context. This study investigated the risk factors for incisional hernia recurrence after biological mesh augmentation. RESULTS: Over a period of 6 years from February 2009 to February 2015, 68 patients underwent surgery. The mesh was placed intraperitoneally with closure of the anterior fascia in 27 cases (39.7%). The biological mesh was placed in the retromuscular pre-fascial plane in 1 case (1.5%) and pre-aponeurotic plane in 1 case (1.5%). Closure of the anterior fascia was not achieved in 39 cases, including 20 cases in which the mesh was placed intraperitoneally (intraperitoneal bridging group, 29.4%) and 19 cases in which the mesh was placed between the edges of the fascia (inlay bridging group, 27.9%). There were 37 cases of postoperative surgical site infections (54.4%), and Clavien-Dindo morbidity staging indicated stage I-II and III-IV complications in 19.1% and 44.1% of the cases, respectively. The recurrence rate was 61.8%, and the mortality rate was 0%. The rate of recurrence was significantly lower in the «fascia approximated¼ group (37%), p = 0.001). Univariate analyses of risk factors for procedural failure indicated an increased risk of recurrence in cases of postoperative surgical site infections, complications of Clavien-Dindo grade III or higher, an absent fascial closure in front of the mesh (OR = 8.69), an operating time longer than 180 min, and a VHWG score higher than 2. After logistic regression, the risk factors for recurrence were postoperative infections (OR = 6.2), placement of bridged biological mesh (OR = 22.3), and postoperative morbidity grade III or higher (OR = 16.7). CONCLUSIONS: Patients with postoperative surgical site infections are at an increased risk for recurrence, and bridged mesh placements lack efficacy. Overall, this study challenges the purported advantage of biologics in treating incisional hernia repairs.

Identification of risk factors for morbidity and mortality after Hartmann's reversal surgery - a retrospective study from two French centers.

Hartmann's reversal procedures are often fraught with complications or failure to recover. This being a fact, it is often difficult to select patients with the optimal indications for a reversal. The post-recovery morbidity and mortality rates in the literature are heterogeneous between 0.8 and 44%. The identification of predictive risk factors of failure of such interventions would therefore be very useful to help the practitioner in his approach. Given these elements, it was important to us to analyze the practice of two French university hospitals in order to highlight such risk factors and to allow surgeons to select the best therapeutic strategy. We performed a bicentric observational retrospective study between 2010 and 2015 that studied the characteristics of patients who had undergone Hartmann surgery and were subsequently reestablished. The aim of the study was to identify factors influencing morbidity and postoperative mortality of Hartmann's reversal. Primary outcome was complications within the first 90 postoperative days. 240 patients were studied of which 60.4% were men. The mean age was 69.48 years. The median time to reversal was 8 months. 79.17% of patients were operated as emergency cases where the indication was a diverticular complication (39.17%). Seventy patients (29.2%) underwent a reversal and approximately 43% of these had complications within the first 90 postoperative days. The mean age of these seventy patients was 61.3 years old and 65.7% were males. None of them benefited from a reversal in the first three months. We identified some risk factors for morbidity such as pre-operative low albuminemia (p = 0.005) and moderate renal impairment (p = 0.019). However, chronic corticosteroid use (p = 0.004), moderate renal insufficiency (p = 0.014) and coronary artery disease (p = 0.014) seem to favour the development of anastomotic fistula, which is itself, a risk factor for mortality (p = 0.007). Our study highlights an important rate of complications including significant anastomotic fistula after Hartmann's reversal. Precarious nutritional status and cardiovascular comorbidities should clearly lead us to reconsider the surgical indication for continuity restoration.

Long-term survival after surgery of pancreatic primary squamous cell carcinoma: A case report and literature review.

Pancreatic primary squamous cell carcinoma is rarer and no optimal treatment has been validated according to the tumor stage. The surgical resection was the only curative option. The radiotherapy or chemotherapy was performed for the other cases.

What is the cost of endoscopic submucosal dissection (ESD)? A medico-economic study.

Introduction: Endoscopic submucosal dissection (ESD) is the gold-standard treatment for superficial lesions of the digestive tract. No medico-economic study has been conducted in Europe. Material and methods: A monocentric study was conducted including all patients undergoing ESD between January 2015 and December 2017. The global cost of hospital stays was measured by microcosting, and revenue was based on the diagnosis-related group (DRG) system. The primary objective was to assess the cost/revenue balance. A medico-economic comparison with surgery was performed as a secondary outcome. Results: A total of 193 patients were prospectively included. The cost per procedure was €3463.79, subtracted from a €2726.84 revenue, with a deficit of -€736.96 per stay. Presence of comorbidities/complications increasing DRG value was the only predictive factor for a positive budgetary balance in a multivariate analysis (odds ratio 49.21, 95% confidence interval 11.3-214.25, p < 0.0001). In comparison with surgery, ESD was associated with shorter length of stay (11 vs 2 days; p < 0.0001) and lower morbidity (28% vs 14%; p = 0.061), lower cost (€8960 vs €1770; p < 0.0001). Conclusion: The ESD cost/revenue balance is negative in 80% of cases. Given the benefits of ESD in terms of patient morbidity and financial savings compared with surgery, the implementation of a specific ESD reimbursement is warranted.

Stepwise management of hepatocellular carcinoma associated with Abernethy syndrome.

Patients with congenital agenesis of the portal vein may develop hepatocellular tumors due to enhanced arterial blood flow. These tumors may be benign (FNH, adenomas) or malignant (hepatoblastoma, HCC). Liver resection can be proposed, and preoperative arterial embolization may decrease blood loss during surgery. Liver transplantation with PV reconstruction is also an option.

Chemotherapy outcome predictive effectiveness by the Oncogramme: pilot trial on stage-IV colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) remains a major public concern. While conventional chemotherapeutic regimens have proved useful against advanced/metastatic diseases, progresses are to be made to effectively cure the large portion of patients not benefiting from these treatments. One direction to improve response rates is to develop chemosensitivity and resistance assays (CSRAs) efficiently assisting clinicians in treatment selection process, an already long preoccupation of oncologists and researchers. Several methods have been described to this day, none achieving yet sufficient reliability for recommended use in the clinical routine. METHODS: We led a pilot study on 19 metastatic CRC patients evaluating capacity of the Oncogramme, a standardized process using tumor ex vivo models, to provide chemosensitivity profiles and predict clinical outcome of patients receiving standard CRC chemotherapeutics. Oncogramme responses were categorized according to the method of percentiles to assess sensitivity, specificity and concordance. RESULTS: We report from a primary analysis a success rate of 97.4 %, a very good sensitivity (84.6 %), a below-average specificity (33.3 %), along with a global agreement of 63.6 % and a concordance between Oncogramme results and patients' responses (Kappa coefficient) of 0.193. A supplementary analysis, focusing on CRC patients with no treatment switch over a longer time course, demonstrated improvement in specificity and concordance. CONCLUSIONS: Results establish feasibility and usefulness of the Oncogramme, prelude to a larger-scale trial. Advantages and drawbacks of the procedure are discussed, as well as the place of CSRAs within the future arsenal of methods available to clinicians to individualize treatments and improve patient prognosis. TRIAL REGISTRATION: ClinicalTrials.gov database, registration number: NCT02305368.

Anatomical study of the clavicle: endomedullary morphology.

BACKGROUND: The treatment of clavicle fractures remains controversial. The objective of this study was to investigate the possibility of clavicular intramedullary fixation by nailing through an anatomic study combined with CT scan studies. METHODS: For the anatomic study, 20 clavicles of donated bodies to science (10 men, 10 women, 10 right, 10 left) were used. We measured the length of the clavicle, lateral epiphysis diameter, mean diaphysis diameter, medial epiphysis diameter, lateral width, lateral radius of curvature, medial width and medial radius of curvature. Intramedullary cavity diameter (anteroposterior and superoinferior) and calibration were measured by CT scan study on 20 clavicles. RESULTS: Average length was 152 mm for men and 140 mm for women. The anteroposterior curvature was most pronounced. The medullary canal had a gradually decreasing size from the distal portion to the middle segment, but never disappeared. CONCLUSION: Evaluation of morphological data can clarify the specifications of an intramedullary nail: flexibility of the nail to match clavicle curvature and a locking system to ensure primary stability. Intramedullary fixation by nailing in displaced fractures of the middle portion of the clavicle is a minimally invasive surgical technique, with excellent functional and cosmetic results.

The anterior intermeniscal ligament of the knee: an anatomic and MR study.

BACKGROUND: The purposes of this study were to identify the presence of the anterior intermeniscal ligament of the knee (AIL), to study its attachment patterns and relationships to other anatomic structures within the knee and to evaluate the potential association of its rupture with other pathology of the knee. METHODS: Ten human cadaver knees were dissected excluding knees with surgical scars. Fifty-one MR examinations were performed in symptomatic patients. Arthroscopic observations were carried out on ten patients. RESULTS: AIL was found in nine dissected knees with type I insertion in six cases, type II insertion in three cases. The average length was 31.2 mm (25-45 mm). The average distance between AIL and insertion of the anterior cruciate ligament was 12 mm (11-15 mm). Concerning MR study, AIL was found in 34 cases (82.9%). Four (9.75%) ruptures of the AIL were encountered. Where AIL was intact, 14 patients presented meniscal lesions (46.6%). Where AIL was ruptured, three patients presented meniscal lesions (75%). CONCLUSION: The present study demonstrates through anatomical and MR studies that AIL is present in more than 80% of the cases with predominant type I insertion. The association of meniscal and AIL lesions was highlighted demonstrating that AIL is not only an anatomical point of interest but also a clinical and surgical reality.

Long-term results of mesocaval shunts with polytetrafluoroethylene grafts.

Despite the introduction of new procedures such as pharmacologic reduction of portal pressure and endoscopic sclerotherapy, the role of surgery in portal hypertension must be reconsidered. The aim of this retrospective study was to evaluate the long-term results of mesocaval interposition shunting in the treatment of recurrent variceal bleeding after sclerotherapy failure or in patients with intractable ascites in whom optimal medical treatments failed. Over a 20-year period, 85 patients (66 men and 19 women; mean age, 53.96 +/- 11.57 years) underwent a mesocaval interposition shunt procedure. Sixty-six patients had recurrent variceal bleeding, and 19 patients had refractory ascites. The underlying etiology of portal hypertension was alcoholic cirrhosis (n = 69), posthepatitis cirrhosis (n = 10), cryptogenic cirrhosis (n = 3), primary biliary cirrhosis (n = 2), and Budd-Chiari syndrome (n = 1). Thirty-one patients were in Child-Pugh grade A, 34 were in grade B, and 20 were in grade C. The mean diameter of the graft was 11.85 +/- 1.53 mm (range, 10-14 mm). Overall, in-hospital mortality was 10.5% (9 of 85 patients). There were 3 postoperative recurrences of variceal hemorrhage and 5 recurrent bleeds during the follow-up. The overall incidence of shunt thrombosis of this series was 10.5%. The total incidence of encephalopathy was 10.5%. Intraoperative gradient pressure measurements before and after shunt showed satisfactory pressure reduction (16.90 +/- 5.32 to 5.12 +/- 2.50/ mmHg; P < 0.0001). The mean follow-up period was 26.09 +/- 25.3 (range, 1-90) months. Nine patients (10.5%) later received liver transplants, with time intervals ranging from 2 months to 5 years. The actuarial survival rate was 92% at 1 year and 75% at 5 years. In our series, the interposition mesocaval shunt seems to be an effective procedure for the control of complications of portal hypertension in cirrhotic patients with good long-term results. Moreover, the procedure can be considered as a solution of choice in patients who are current liver transplant candidates, leaving the hepatic hilus intact.

[Ewing sarcoma of the mesocolon]. / A propos d'un sarcome d'Ewing du mésocôlon.

This case-report studies the clinical, radiological, anatomopatholo-gical and therapeutic aspects of peripheral primitive neuroectodermal tumours (PNET). PNET are neoplasms with a similar histology to tumours in the Ewing family. Diagnosis requires histopathology, immunohistochemistry and cytogenetic studies. To our knowledge, this rare tumour has never been reported in the mesocolon (our case). The treatment, which is usually similar to that for Ewing's sarcoma is complex and has not yet been codified, which is another difficult aspect of this disease with a poor prognosis.

[The Alzheimer's disease or the fall of the neocortical empire at the age of nonsense]. / La maladie d'Alzheimer ou la chute de l'empire néocortical à l'âge de déraison.

If we observe the evolution of the Alzheimer's disease of a premature entorhinal stage at an evolved stage of the neocortex, the succession of the confusions of the simple mnesic complaint in the aphasia, praxia, gnosia, visual, psychological and comportemental difficulties testify of the extension of the lesions in the neocortical structures. This neocortical regression seems to take the inverse road of the phylo- and ontogenetic evolution, where this hegemonic neocerebral cortex - which had grown again on the borders of the archeocortical and paleocortical barbarian empire - sees itself dispossessed of its conquests and gives free rein to these ancestral structures. We could compare the Alzheimer's disease with the fall of the neocortical empire at the age of nonsense.

Platelet-activating factor in cirrhotic liver and hepatocellular carcinoma.

AIM: Platelet-activating factor (PAF) is a pro-inflammatory and angiogenic lipid mediator. Here we aimed to investigate levels of PAF, lyso-PAF (the PAF precursor), phospholipase A(2) (PLA(2), the enzymatic activity generating lyso-PAF), acetylhydrolase activity (AHA, the PAF degrading enzyme) and PAF receptor (PAF-R) transcripts in cirrhotic liver and hepatocellular carcinoma (HCC). METHODS: Twenty-nine patients with HCC were enrolled in this study. Cirrhosis was present in fourteen patients and seven had no liver disease. Tissue PAF levels were investigated by a platelet-aggregation assay. Lyso-PAF was assessed after its chemical acetylation into PAF. AHA was determined by degradation of [(3)H]-PAF. PLA(2) levels were assessed by EIA. PAF-R transcripts were investigated using RT-PCR. RESULTS: Elevated amounts of PAF and PAF-R transcripts 1 (leukocyte-type) were found in cirrhotic tissues as compared with non-cirrhotic ones. Higher amounts of PAF and PAF-R transcripts 1 and 2 (tissue-type) were found in HCC tissues as compared with non-tumor tissues. PLA(2), lyso-PAF and AHA levels were not changed in cirrhotic tissues and HCC. CONCLUSION: While the role of PAF is currently unknown in liver physiology, this study suggests its potential involvement in the inflammatory network found in the cirrhotic liver and in the angiogenic response during HCC.