[Poorly differentiated large cell endocrine carcinoma of the extrahepatic bile ducts]. / Carcinome endocrine peu différencié à grandes cellules des voies biliaires extrahépatiques.

We report a case of a poorly differentiated endocrine large cell carcinoma of the extrahepatic bile ducts in a 73-year-old man, revealed by abdominal pain, jaundice and weight loss. Computed tomography and endoscopic retrograde cholangiography found tumoral stenosis of the main bile duct. Brush cytology detected tumor cells. Pathological examination of the resected bile duct disclosed a high-grade large cell carcinoma with morphological endocrine features and positivity for chromogranin A. This tumor was associated with a minor component of adenocarcinomatous cells. Despite polychemotherapy, the patient had widely metastatic disease a few months later. We discuss here the histogenesis of this tumor as well as its nosological position among the endocrine and mixed tumors of bile ducts.

Carcinoembryonic gene member 2 mRNA expression as a marker to detect circulating enterocytes in the blood of colorectal cancer patients.

BACKGROUND: The aim of this study was to report our experience with a new molecular tool to detect circulating enterocytes in the blood of patients with colorectal cancer. METHODS: The study included 193 individuals: 78 patients with colorectal cancer and 115 controls composed of patients with benign colorectal diseases (n = 16), patients with noncolorectal cancer (n = 31), healthy individuals (n = 62), and healthy bone marrow transplantation donors (n = 6). A nested reverse transcriptase-polymerase chain reaction with specific primers for the carcinoembryonic gene member 2 (CGM2) was used to detect circulating enterocytes in the peripheral blood of 78 patients with colorectal cancer. The blood (n = 109) or the bone marrow (n = 6) of the 115 controls was studied to test the absence of CGM2 illegitimate transcription in nucleated blood cells and nucleated blood cell progenitors. The assay sensitivity was effective in detecting 1 CGM2-positive cell per 10(6) nucleated blood cells. RESULTS: Fifty-nine percent (46/78) of patients with colorectal cancer were found positive whereas all negative controls remained negative. Positivity rates were 38% (3/8) in Dukes' A classification, 43% (9/21) in Dukes' B, 77% (23/30) in Dukes' C, and 58% (11/19) in Dukes' D. CONCLUSIONS: The clinical significance of enterocyte detection in the blood of colorectal cancer patients by means of this CGM2 messenger RNA assay needs further evaluation.

[Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery]. / Le traitement laparoscopique de l'ulcère duodénal perforé. Résultats d'une étude rétrospective multicentrique. Société française de chirurgie laparoscopique (SFCL).

STUDY AIM: The aim of this multicentric retrospective study was to report procedures, mortality and morbidity rate in a series of patients operated on for perforated duodenal ulcer with a laparoscopic approach. PATIENTS AND METHODS: Four-hundred and nineteen patients from 18 centers were included. The duration of the study was ten years (1990 to 1999). There were 299 men and 120 women aged from 19 to 98 years (mean: 48 years). The ASA scores were as follows: I (48.7%), II (31.3%), III (17.5%), IV (2.5%). The mean duration between the onset of perforation and the time of operation was 13.4 hours (range: 1-70). The surgical procedures were suture (76.7%), epiploplasty (9.9%), only irrigation of the abdominal cavity (2.7%). RESULTS: Conversion into laparotomy was performed in 10.6% of the patients. Mean operative time was 85 minutes. The morbidity and mortality rates were 13.4 and 1.4% respectively. Seventeen patients were reoperated because of fistula (n = 5), intra-abdominal abscess (n = 5), small bowel obstruction (n = 4), bleeding ulcer (n = 1), iatrogenic perforation of the gallbladder (n = 1) and small bowel (n = 1). Mean hospital stay was 8.5 days. All patients were discharged with a medical treatment of the peptic ulcer disease and in most of the cases, with antibiotics for Helicobacter pylori eradication. Six patients out of 96 with a medical history of chronic peptic ulcer underwent a vagotomy. CONCLUSION: Laparoscopic repair of perforated duodenal ulcer is a safe option providing low rates of morbidity, reoperation and mortality, and can be considered the treatment of choice.

[Role of somatostatins in the preventin of pancreatic fistulae and the treatment of digestive fistulae]. / Place des somatostatines dans la prévention des fistules pancréatiques et le traitement des fistules digestives.

Somatostatin and analogues exert an extraordinary range of inhibitory effects which eventually may have a variety of therapeutic applications. Treatment of intestinal and pancreatic fistula are the main targets in general and digestive surgery. The perioperative and prophylactic application of somatostatin or octreotide in patients who undergo major pancreatic surgery reduces the postoperative complication rate. This prevention seems indicated following Whipple procedure in patients with soft pancreatic tissue. The efficacy of somatostatin or analogues in the treatment of intestinal or pancreatic fistulae is still in debate. Fistula output frequently decreases but closure rate, healing time and complications rate are not reduced. The treatment and care of patients with high output fistulae may be simplified by somatostatin or analogues if a positive effect on output is obvious in the first days of treatment.

[Results of laparoscopic treatment of perforated ulcers]. / Résultats du traitement coelioscopique des ulcères perforés.

STUDY AIM: The aim of this retrospective survey was to evaluate the results of laparoscopic treatment in perforated peptic ulcer. PATIENTS AND METHODS: From 1989 to 1998, 84 patients were operated on for perforated ulcer. Sixty nine patients, operated on with videolaparoscopy, were included in this study: 53 men and 12 women with a mean age of 45 +/- 16 years (19-85). Nine had a history of peptic ulcer disease and 12 received anti-inflammatory drugs. Perforation occurred in the duodenum (60 patients) and in the stomach (five patients). Laparoscopic treatment included peritoneal lavage and either a simple duodenal closure (51 patients), a closure with a highly selective vagotomy (one patient), an epiplooplasty (eight patients), or an excision-closure for the gastric ulcers (five patients). Drainage was associated in 38 patients (58%). RESULTS: A conversion into laparotomy was necessary in six patients. Among the 59 patients treated with laparoscopy, 56 were only managed laparoscopically, three had exploration and peritoneal lavage through laparoscopy, and underwent suture of the perforation through minilaparotomy. Mean operative time was 105 +/- 40 minutes (30-240). Mean postoperative hospital stay was 8.2 +/- 4 days. Reoperation was performed in three patients for leakage (n = 2) and gall bladder perforation (n = 1). Complications were medically treated in three patients. There was no in-hospital mortality. CONCLUSION: Laparoscopic management in perforated peptic ulcer is successful in 90% of the patients. Results are good. There was no postoperative death in this series.

[Evaluation and interest in new molecular markers in colon cancer]. / Evaluation et intérêt de nouveaux marqueurs moléculaires en cancérologie colique.

The presence of colonic tumor cells in the circulation may predict colorectal carcinoma recurrence and metastases. We have developed a highly sensitive nested RT-PCR assay, with primers derived from the cytokeratin 20 (CK20) and the carcinoembryonic gene CGM2, to detect occult microdisseminated enterocytes in blood of colorectal cancer patients. Among 82 healthy controls analyzed, 40.2% (33/82) have a positive expression of CK20 mRNA which is not statistically different from the 45.5% (15/33) of positive results found in colon cancer patients. This sensitive method may detect non-tissue specific constitutive low level (illegitimate) expression of CK20 mRNA in peripheral nucleated blood cells (PNBC) of a significant number of healthy control as well as in a number of normal bone marrow. The low specificity of this assay therefore hampers its value to detect blood colon cancer dissemination. In 47 patients with colorectal carcinoma, CGM2 primers detected circulating enterocytes in 25 of them (53%). In disseminated Dukes' stage C disease patients, 17 out of 29 (59%) were found positive whereas in localized adenocarcinoma (Dukes's stage A and B), CGM2 primers detected enterocytes in 44% suggesting that an hematogenous spillage of colonic cells may be a relatively early event in colon cancer. None of the patients suffering from benign colonic pathologies or from diverticulitis were found positive for this assay. The analysis of 56 healthy individuals without known colorectal cancer, of 20 non-colorectal cancer patients and of 6 normal bone marrows provide evidence that this assay is highly specific and may predict an hematogenous spread of colonic cells in patients with organ-confined disease. Nevertheless, the clinical significance of enterocyte detection and the potential applications of this molecular tool merit longer term follow-up.

Chromosomal aberrations in hepatocellular carcinomas: relationship with pathological features.

Fluorescence in situ hybridization performed on tissue sections can reveal chromosomal abnormalities related to histopathological features. This technique was performed on serial frozen sections from seven normal livers and 29 hepatocellular carcinomas (HCCs) using pericentromeric repeat-specific probes for chromosomes 1, 4, 6, 7, 8, 16, and 17. For each HCC and each probe, the percentage of cells showing one, two, or more than two signals was counted and compared with the distribution in the normal liver. According to these results, HCCs were categorized as monosomic, disomic, or polysomic (more than two signals) for the chromosome tested. These data were compared with the main histopathological characteristics of HCC. Chromosome gains were very common, preferentially affecting chromosome 1 (23 of 27 cases, 85%), chromosome 16 (16 of 27 cases, 59%), chromosome 7 (16 of 29 cases, 55%), chromosome 6 (15 of 29 cases, 52%) and chromosome 8 (14 of 29 cases, 48%). Monosomy was seen more rarely, affecting preferentially chromosome 16 (19%), chromosome 17 (14%), and chromosome 4 (10%). A significant correlation was observed between aneusomy of chromosome 4 and tumor size (P < .05) or the presence of vascular embolism (P < .05). In conclusion, chromosomal gains are frequent genetic events in human HCC. A significant association between a gain in chromosome 4 and large tumor size or vascular embolism suggests that this genetic abnormality is a late event in liver carcinogenesis.

[Role of celioscopy in acute obstructions of the small intestine]. / Place de la coelioscopie dans les occlusions aiguës du grêle.

OBJECTIVES: The aim of this study was to evaluate the possibilities of laparoscopy in the diagnosis and treatment of acute small bowel obstruction. METHODS: Thirty five patients, with less than three abdominal incisions, who had undergone initial laparoscopy for acute small bowel obstruction, were reviewed. The small bowel was mobilized to determine the cause and site of obstruction. RESULTS: In 31 cases, small bowel obstruction was caused by a single or numerous obstructing bands. Among 31 cases of adhesions, laparoscopic treatment of intestinal obstruction was possible in 16 cases (51.6%). In 15 cases, laparoscopy had to be completed by laparotomy: numerous adhesions could not be divided in 12 cases; intestinal ischemia which required resection was present in 3 cases. There was no hospital mortality and postoperative complications occurred in 19% of cases. Multivariate analysis demonstrated a relation between need to complete laparoscopy by laparotomy and two factors : presence of signs of peritoneal irritation (P < 0.05) and intestinal obstruction caused by numerous adhesions or bands (P < 0.05). Mean hospital stay and postoperative ileus were significantly shorter in the "laparoscopy" group than in the "laparoscopy + laparotomy" group. CONCLUSIONS: Laparoscopic treatment of acute small bowel obstruction is difficult and was possible in only half of the cases. The first port should be inserted by open technique to avoid the risk of perforation of distented small bowel. When laparoscopy shows numerous adhesions, laparoscopic treatment should not be pursued, and laparotomy should be recommended to avoid the risk of visceral perforation.

[Portal hypertension with hepatic-portal fistula on a cirrhotic liver]. / Hypertension portale avec fistule hépatico-portale sur foie cirrhotique.

We report a case of hepatico-portal fistula following liver needle biopsy in a cirrhotic patient with repeated gastrointestinal bleeding related to esophageal varices. Angiographic embolization of the fistula was carried out because of its possible role in portal hypertension, and the potential risks of primary porta-caval shunt. Because of the failure of the embolization, we performed porta-caval shunt with no complications, apart from the hepaticoportal fistula.

[Celioscopic treatment of cholelithiasis in benign acute biliary pancreatitis]. / Traitement coelioscopique de la lithiase biliaire au décours des pancréatites aiguës biliaires bénignes.

OBJECTIVES AND METHODS: To evaluate the laparoscopic treatment of cholelithiasis in mild acute gallstone pancreatitis, 35 patients with gallstone pancreatitis and less than 4 Ranson's prognostic signs at 48 h were retrospectively included. RESULTS: Eight patients underwent preoperative endoscopic retrograde cholangiopancreatography. Surgery was performed a median of 15 (range: 4-60) days after the onset of pancreatitis, and included laparoscopic cholecystectomy with intraoperative cholangiography that was successful in 30 out of 32 cases (93%). A common bile duct stone was present in 4 patients (11%). Conversion to open surgery was necessary in 3 patients (8%). Choledocholithiasis was successfully removed by laparoscopy in two cases, and by laparotomy and postoperative endoscopic sphincterotomy in one case each. CONCLUSION: Laparoscopic treatment can be recommended as the primary treatment within a few days after the onset of mild gallstone pancreatitis.

Intraperitoneal fluid collection after laparoscopic appendectomy. Sonographic analysis in asymptomatic patients.

The aim of this prospective study was to evaluate the frequency of postoperative fluid collection after laparoscopic appendectomy in patients with normal postoperative development. Twenty-eight patients were included. The surgical technique, histological data, and postoperative development during the first postoperative month were recorded. A sonographic analysis was performed on the 5th postoperative day by a radiologist who was not aware of the histological and surgical data. Ten cases of fluid collection were found (37%). The frequency was higher in cases of suppurated appendicitis and significantly higher with associated periappendicitis. Peritoneal irrigation or retrocecal dissection did not influence the occurrence of fluid collection. Postoperative serous fluid collection occurs with a high frequency after laparoscopic appendectomies, and one must be careful in interpreting sonographic analyses in looking for deep abscesses in patients with difficult postoperative development.

Laparoscopic pericystectomy of a liver hydatid cyst.

The case of a patient with a liver hydatid cyst in the sixth hepatic segment is reported. Its favorable localization and its calcified state incited us to treat it by laparoscopy. The employed technique is discussed.

[Benign thyroid oncocytomas. Outcome after more than 4 years]. / Tumeurs thyroïdiennes oncocytaires bénignes. Devenir à plus de 4 ans.

OBJECTIVES: Occasional malignant transformation after partial thyroidectomy for Hürthle cell tumours has led certain authors to propose total thyroidectomy in all cases. The aim of this retrospective study was to evaluate outcome 4 years after partial thyroidectomy in patients with Hürthle cell tumours. METHODS: Ten patients (9 females, 1 male; mean age 45 years; age range 21-65 years) underwent thyroid surgery for Hürthle cell tumours from 1980 to 1989. Lobectomy was performed in 7, subtotal thyroidectomy in 2 and tumourectomy in 1. The extemporaneous pathology examination reported 4 apparently benign vesicular lesions, 2 apparently benign oncocyte lesions, 2 fetal adenomas, 1 thyroiditis, 1 trabecular adenocarcinoma. Pathology examination of the surgical specimen reported isolated benign oncocyte tumours in 4 cases and benign oncocyte tumours with associated vesicular adenomas in 5. In 1 case it was not possible to confirm whether the oncocyte lesion was benign or malignant. All 10 patients were seen again 6 months later for consultation and thyroid hormone assays and thyroid echography in doubtful cases. RESULTS: All patients were seen for follow-up (mean 88 months; range 47-148 months). New thyroid nodules were observed in 2 but did not require surgery. No cervical lymph node enlargement was found. CONCLUSION: The diagnosis of Hürthle cell tumour was confirmed intraoperatively in 8 of the 10 cases. No malignant transformation was observed. These findings demonstrate that total thyroidectomy cannot be indicated intraoperatively and would not appear to be indicated after partial thyroidectomy.

[Value of selective clamping in major hepatectomies]. / Intérêt du clampage sélectif dans les hépatectomies majeures.

Charts of 100 consecutive patients who had undergone liver resection, performed by a single surgeon, during the 10 year period from 1983 to 1993 were reviewed. Liver trauma was excluded. The age of the patients ranged from 14 to 78 years, with a mean age of 52 +/- 12.3. Indications for liver resection were malignant tumors in 73 patients and benign disease in another 27 patients. The remnant liver was pathologic in 24 cases (21 cirrhosis, 3 chronic hepatitis). The extent of liver resection was major (> 3 segments) in 51 cases, and minor in 45 cases. Postoperative complications, including death, occurred in 24% of cases. Five complications required reoperation. Hospital mortality was 4%. Multivariate analysis demonstrated two major risk factors of morbidity: intraoperative blood transfusion, and cirrhosis. Age of patients was the only risk factor of mortality. In major resection, four categories of patients were established according to the type of hepatic inflow occlusion. Each group was comparable. Selective vascular clamping (selective control of the hilar vessels to the liver and selective hepatic vein occlusion) decreased the morbidity and post operative liver failure rate (p < 0.05). On the other hand, no correlation was observed between the type of hepatic inflow occlusion and the hospital mortality.

[Value of celioscopy in the diagnosis of abdominal wounds]. / Intérêt de la coelioscopie pour le diagnostic des plaies abdominales.

Gunshot or stab wounds with equivocal evidence of intraabdominal injury lead to negative laparotomy in 20% to 30% of cases. The aim of this prospective study was to evaluate, in hemodynamically stable patients, the role of laparoscopy in order to reduce the rate of unnecessary laparotomies for such wounds. This study was carried out in 21 patients. Laparoscopy revealed 15 penetrating wounds (71.4%) with two isolated diaphragmatic injuries. Eight laparotomies (38%) for visceral injuries were performed on the 15 penetrating wounds. The laparoscopic exploration was complete in 7 cases without laparotomy. Thirteen unnecessary laparotomies were avoided (62%). Laparoscopy was found to have a 100% specificity and sensitivity for the diagnosis of peritoneal effraction and diaphragmatic injury. Laparoscopy is very effective for evaluation of equivocal penetrating wounds.

[Acute pancreatitis associated with biliary lithiasis]. / Pancréatite aiguë associée à la lithiase biliaire.

The physical characteristics of gallstones and anatomical predisposing factors strongly suggest that acute pancreatitis associated with gallstones is due to a transient blockage of the ampulla of Vater by migrating stones. The diagnosis of acute pancreatitis is based on clinical probabilities and is supported by a threefold elevation in serum amylase. In cases of acute biliary pancreatitis the initial serum amylase value is higher and its decline more rapid than in pancreatitis due to other causes. The diagnostic sensitivity and specificity of serum amylase are higher in cases of acute biliary pancreatitis. The early detection of gallstones in acute pancreatitis by standard imaging techniques may be misleading; ultrasonography fails to identify the gallbladder in almost one-third of patients. The reported accuracy of systems for the clinico-biochemical detection of gallstones in acute pancreatitis is 75 percent. Their lack of specificity prohibits their use as the sole means of detecting gallstones, but they may allow the selection of patients who require further investigations. Ranson's multiple laboratory criteria are generally recognized as providing the best early assessment of severity in acute pancreatitis; a modified scoring system is required for patients known to have pancreatitis due to gallstones. The timing of surgery in gallstone pancreatitis is no longer controversial. In patients with benign pancreatitis the time of surgery appears to have little effect on the outcome, whereas in patients with severe pancreatitis early surgery results in a significant increase in morbidity and mortality rates. Surgery should be performed in the first days following hospital admission, soon after the pancreatitis has subsided. Further investigations are warranted before advocating a widespread use of early endoscopic sphincterotomy in the treatment of severe gallstone acute pancreatitis.