Laparoscopic treatment of a gastric outlet obstruction caused by a gallstone (Bouveret's syndrome).

Duodenal impaction of a gallstone after its migration through a cholecystoduodenal fistula is an uncommon cause of gallstone ileus described as Bouveret's syndrome. Surgical treatment is recommended, but the morbidity and mortality rates are nearly 60% and 30%, respectively. To reduce these rates using improved endoluminal surgery, a laparoscopically assisted intraluminal gastric surgery could be considered. A 74 year-old woman was admitted with typical Bouveret's syndrome. An intraluminal gastric laparoscopy was performed. The large stone impacted in the first duodenum was removed through the pylorus and pulled into the stomach. After its mechanical fragmentation, the stone was extracted with a sterile retriever bag through the main trocar. In the case of Bouveret's syndrome, treatment of the duodenal obstruction is mandatory. Surgical treatment of the cholecystoduodenal fistula still is controversial. We never perform a one-stage procedure, and we reserve a biliary operation for the patient who remains symptomatic. In this way, laparoscopically assisted intraluminal gastric surgery with transpyloric extraction of the stone can be a safe and interesting approach for this type of pathology.

[Emphysematous pyelonephritis in a diabetic patient. Literature review apropos of a case]. / Pyelonéphrite emphysémateuse (P.N.E.) chez une patiente diabétique. Revue de la littérature à propos d'un cas.

We report the history of a 65-year-old woman, diabetic for 25 years who presented progressive alteration of consciousness with hyperthermia, right upper quadrant pain and vomiting. Bacteriological and radiographic investigations, especially computerized tomography scan of the abdomen, led to the diagnosis of emphysematous pyelonephritis caused by Escherichia coli. Despite a large spectrum antibiotic therapy and surgical drainage of the gas collection, the patient remained septic. An emergency nephrectomy was eventually performed. We review the characteristics of emphysematous pyelonephritis. Early diagnosis is essential because without early nephrectomy mortality rates reach 75%.

[Cholestatic jaundice complicating lipomatous pseudo-hypertrophy of the pancreas]. / Ictère choléstatique compliquant une pseudo-hypertrophie lipomateuse du pancréas.

The authors describe a major pancreatic lipomatous infiltration, causing a "pseudo-hypertrophy" of the pancreas, in a 70-year-old man. This lesion was responsible of a hyperechogenic area at ultrasonography and of an empty pancreatic bed ("vanishing pancreas") at computed tomography, suggesting lipomatosis. This entity is a special modality of senescence of pancreatic tissue whose origin remains obscure. The progressive atrophy of the acinar lobules and the islets of Langerhans was finally responsible of a mild degree of malabsorption and of diabetes type II. The compression of the main bile duct by the enlarged lipomatous pancreas, demonstrated by percutaneous cholangiography, caused a cholestatic jaundice with abdominal pain, which was treated by a surgical derivation (hepatico-duodenostomy). This is the first description of a lipomatous pseudohypertrophy of the pancreas causing an obstruction of the common bile duct.

[Acute pancreatitis caused by a voluminous umbilical hernia. Case report]. / Une pancréatite aiguë causée par une volumineuse hernie ombilicale. Observation d'un cas.

A 65 year old woman, who had a giant umbilical hernia since more than 30 years, was admitted for a transitory cerebrovascular ischemia. During her stay, she presented an episode of acute pancreatitis localized in the head of the pancreas. All current causes of acute pancreatitis were ruled out, especially alcoholism and gallstones. Endoscopic retrograde cholangio-pancreatography performed in the patient lying on the left side demonstrated localization of the antrum and the duodenum with the head of the pancreas into the umbilical hernia. It seems clear that the giant umbilical hernia caused a progressive and intermittent passage of the head of the pancreas through chronic traction on the ligament of Treitz and acute pancreatitis by incarceration. At our knowledge, this mechanical cause of acute pancreatitis was not yet described in the literature.

[Is jaundice a cause of error in the interpretation of CA 19-9 blood levels?]. / L'ictère est-il une cause d'erreur dans l'interprétation du CA 19-9 sérique?

Serum CA 19-9 has been proposed as a tumour marker for pancreatic cancer (PC). However, false positive results are seen in sera of patients with benign jaundice. The CA 19-9 assay was performed by a solid state radioimmunoassay in 86 icteric patients (total bilirubin greater than 2 mg/dl). 24/86 had PC (12 men, 12 women, mean age 74 years) and 62/86 had benign jaundice (29 men, 33 women, mean age 56 years; cirrhosis: n = 20, angiocholitis: n = 21, hepatitis: n = 21). At a cut-off level of 60 U./ml, for detecting icteric PC, sensitivity was 83%, and specificity was 79%. At 120 U./ml, sensitivity was 79%, but specificity was increased to 92%. We conclude that 21% of patients with benign jaundice had a CA 19-9 level greater than 60 U./ml, and using a CA 19-9 level of 120 U./ml, the specificity of the test to detect icteric PC was increased, with little decrease in the sensitivity.