Pseudo-tumoral hepatic tuberculosis: a report of two cases.

Tuberculosis involving the liver in the absence of active pulmonary or miliary tuberculosis is very rare. The inflammatory pseudo-tumoral form is an entity difficult to diagnose. We report two patients, who underwent laparoscopic segmentectomy for suspected malignant tumour. Pathology showed tuberculoid granuloma with central caseous necrosis in both patients. The diagnosis in the first patient was made retrospectively on the resection specimen, whereas an active pre-operative work-up for tuberculosis diagnosis (biopsy and Polymerase Chain Reaction) remained futile in the second patient. The management of pseudo-tumoral hepatic tuberculosis needs a multidisciplinary concertation and a surgical approach is often the best way to ensure the diagnosis.

Laparoscopic treatment in acute complicated diverticulitis: a review of 11 cases.

AIMS: We wanted to test the role of laparoscopy in complicated diverticulitis. METHODS: All acute complicated sigmoid diverticulitis cases were reviewed during the last 6 years (December 1999 to 2006). Patients whose medical treatment had failed and patients admitted with peritonitis underwent emergency surgery. However, only laparoscopic procedures were included in the study. Patients were programmed 2 to 4 months later for laparoscopic elective colon resection if they underwent first lavage and drainage of the peritoneal cavity. RESULTS: Eleven patients were treated by laparoscopic procedures out of a total of 37 who underwent emergency surgical therapy for acute perforated diverticulitis. Laparoscopic resection with primary anastomosis was performed in 2 patients (Hinchey I and IIA). Laparoscopic lavage and drainage was performed in the remaining 9 patients (one stage IIA, three stage IIB and five stage III). Three conversions into open Hartmann were needed (stage III). One patient (stage IIB) was lost during follow-up and reappeared 16 months later in general peritonitis. Two patients needed earlier resection because of persistent symptoms. Three remaining patients had a 2nd stage resection at the allocated time. No postoperative death was encountered. Long-term follow-up (mean 6 months) showed one incisional hernia in a converted patient. DISCUSSION: In perforated diverticular disease, even though laparoscopic lavage and drainage avoids a colostomy and facilitates a 2nd stage resection, few patients have complete resolution of the inflammatory process. Resection remains mandatory after 8 to 12 weeks. In Hinchey stage III, the success rate still remains to be investigated and weighed against the Hartmann procedure or primary resection. Faecal peritonitis and instable patients should not be considered for laparoscopy.

Patient's opinion about written information before laparoscopy: a consecutive series of 100 cases.

PURPOSE: The aim of this study was to assess the opinion of the surgical patient concerning written information before laparoscopic operations. MATERIAL AND METHODS: A prospective and consecutive series of 100 patients was studied. Information sheets concerning the planned laparoscopic operation were distributed at preoperative consultation. A short and clear questionnaire regarding this information was answered upon hospitalization. RESULTS: The majority of the 87 patients, who had read the information, were very pleased to be informed about the techniques (91%) and the risks (97%), although a significant group was worried by the explanations of the risks (41%). None of the patients cancelled the planned operation. None of the patients had become less confident in the surgeon. Most of the patients (95%) found this system of informed consent necessary. CONCLUSIONS: Surgeons should no longer be reluctant to distribute standardized information sheets, as a majority of patients find this system of information necessary.

Laparoscopic approach for acute appendicular peritonitis: efficacy and safety: a report of 96 consecutive cases.

SUMMARY: Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

Safety of laparoscopic approach for acute cholecystitis: retrospective study of 609 cases.

Laparoscopic cholecystectomy (LC) is now widely accepted as the modality of choice for the treatment of symptomatic uncomplicated cholelithiasis. The application of the laparoscopic technique in the setting of acute cholecystitis (AC) is more controversial. The precise role as well as the potential benefits of LC in the treatment of the acutely inflamed gallbladder have not been clearly established through large clinical series. The aim of our study was to assess the feasibility, safety, benefits, and specific complications of the laparoscopic approach in patients with AC. A retrospective chart analysis involving the patients admitted to two busy emergency digestive surgical units between October 1990 and December 1997 was carried out. Six hundred and nine patients meeting our criteria for AC were identified and evaluated. Overall complication rate was 15% with 12 postoperative bile leakages (1.97%) and 4 biliary tract injuries (BTI) (0.66%). The overall mortality rate was 0.66%. Local and overall complication rates were significantly correlated with the delay between the onset of acute symptoms and the operation but not the rate of general complications nor deaths. Our results demonstrate the safety and feasibility of LC in the setting of AC. Early cholecystectomy within 4 days is strongly recommended to minimize complications and increase the chances of a successful laparoscopic approach.

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones. Lessons and limits from an initial experience of 92 patients.

BACKGROUND: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. METHODS: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. RESULTS: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. CONCLUSIONS: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage.

[Is laparoscopic cholecystectomy effective and reliable in acute cholecystitis? Results of a prospective study of 221 pathologically documented cases]. / La cholécystectomie coelioscopique est-elle performante et fiable en cas de cholécystite aiguë? Resultats d'une étude prospective portant sur 221 cas vérifiés histologiquement.

From December 1989 to May 1995, a prospective study of laparoscopic cholecystectomy was carried out in our department, in order to assess the reliability and safety of this method in the case of acute cholecystitis. During this period, 1453 patients underwent laparoscopic cholecystectomy. Acute cholecystitis was diagnosed in 280 patients, based on clinical history and macroscopic lesions. Only 221 cases (15%) were included in the study after positive histology was obtained (M: 86; F: 135). The mean age was 62 years (20-90). Sixty-two patients (28%) were classified as ASA III and IV. The mean interval between the first symptoms and the operation was 9.9 days (1-53). The mean operating time was 130 minutes (45-420). Conversion to an open procedure was necessary in 22 cases (10%). The operative mortality was 0.9% (2 ASA IV patients) and the overall morbidity was 13.5%. A bile duct injury occurred in 0.4% of cases (1/221). In conclusion, laparoscopic cholecystectomy for acute cholecystitis is a safe procedure, when performed by operators experienced in laparoscopic surgery.

Application of the IFSSH(3)-classification for congenital anomalies of the hand; results and problems.

The extended classification proposed by the IFSSH was used to classify 1013 hand anomalies in 925 hands of 650 patients. We found associated anomalies in 26.7%. The classification was straightforward in 86%, difficult in 6.6% and not possible in 7.8%. In group I the radial and ulnar deficiencies, limited to the hand and without forearm deficiencies should be included. Group II was the most important group including 513 anomalies. We propose to include in this group the Madelung deformity, the Kirner deformity and congenital trigger fingers and trigger thumbs. Triphalangeal thumbs are a problem, we suggest to list this anomaly in group III and to consider it as a duplication in length. It is not always possible to evaluate the (transverse) absence of the fingers or hand. Longitudinal deficiencies (group IIB), symbrachydactyly group (V) and amniotic bands (group VI) occasionally develop a phenotype similar to the genuine transverse deficiency (group IA).

Laparoscopy for management of nontraumatic acute abdomen.

The diagnostic and therapeutic influence of laparoscopy has been studied in 255 patients presenting with nontraumatic acute abdominal pain. Laparoscopy provided a correct diagnosis in 93% (236 of 255) of the cases, the others requiring a laparotomy. An erroneous preoperative diagnosis was corrected by laparoscopy in 50 patients (20%), which called for a change of treatment in 25 patients (10%). Seventy-three percent (186 of 255) of acute abdominal conditions were treated exclusively by laparoscopy, 23% (58 of 255) by conventional surgery, and 4% (11 of 255) by laparoscopically assisted surgery. Mortality was 2% (5 of 247) and morbidity 11% (28 of 247). We conclude that laparoscopy is a valuable tool for the general surgeon facing a patient with an acute abdomen.

[Laparoscopic cholecystectomy in the elderly patient]. / Cholécystectomie coelioscopique chez le sujet âgé.

Biliary surgery in the elderly is associated with a high morbidity and mortality rate. The aim of this prospective study is to determine the complications or benefits of laparoscopic cholecystectomy in patients over 75. From December 1989 to July 1992, 60 women and 15 men, all aged over 75, underwent laparoscopic cholecystectomy. 32 (43%) were at high surgical risk. In one half of cases, complications were present (30 cases of acute cholecystitis and 13 cases of choledocolithiasis). 10 underwent endoscopic sphincterotomy preoperatively and 4 patients with common bile duct stones were treated by laparoscopy during the same operating time. Eight conversions were necessary because of inflammatory process. The global morbidity rate was 10.6%. Local complications were: 1 wound abscess, 1 wound dehiscence, 2 biliary leaks and 2 cases of bleeding at puncture sites. The general complications concerned the respiratory tract except for one case of urinary tract infection. The mortality rate was zero. Laparoscopic cholecystectomy seems to be better tolerated than laparotomy. It allows curative treatment of gallstones, complicated or not, with a low morbidity rate.

[Value of celioscopy in non-traumatic acute abdomen]. / Intérêt de la coelioscopie dans les abdomens aigus non traumatiques.

The diagnostic and therapeutic value of laparoscopy in emergency was studied in 314 patients presenting with non-traumatic acute abdomen. Laparoscopy gave a correct and complete diagnosis of the underlying disease in 92% (290/314) of cases. An erroneous preoperative diagnosis was corrected by laparoscopy in 18% (58/314) of cases. This implied a change of the therapeutic strategy in 9% (27/314). Seventy five per cent (234/314) of patients were exclusively treated by laparoscopy, 22% (68/314) by laparotomy and 3% (11/314) by laparoscopically assisted surgery. Mortality was 2.5% (8/314) and morbidity 9% (29/314). In conclusion, laparoscopy is a valuable diagnostic tool for the surgeon in the context of acute abdomen and is an interesting therapeutic alternative in selected cases. However, it requires extensive experience in laparoscopic techniques.

[Effect of curarization on sensitivity of chicken latissimus dorsi to electric current]. / Effet de la curarisation sur la sensibilité au courant électrique du latissimus dorsi du poulet

(1.) To test the sensitivity to electric current of the latissimus dorsi and, therefore, its ability to yield action potential, we have studied the effect of curarisation on the amplitude of the isometric tetanus during "massive" stimulations by alternative current. (2.) Curarisation causes a considerable but reversible reduction of the tetanic tension of the latissimus dorsi anterior (L.D.A.) but has no effect on the tetanus of the latissimus dorsi posterior (L.D.P.). It is concluded that a part of the L.D.A. is not sensitive to electric current and is thus unable to yield action potentials, unlike the opinion of some authors. (3.) Rising the temperature has an inverse effect on the speed of the tetanus ascending phase, depending on whether the L.D.A. has been curarised or not. This show the existence of two types of excitation processes of very different nature in this muscle. (4.) Direct current is much less efficient than alternative current on the curarised L.D.A.