Acute mesenteric ischemia of arterial origin: importance of early revascularization

GOAL: The goal of our study was to show that survival was better when early revascularization was performed rather than gastrointestinal resection in the management of acute mesenteric ischemia of arterial origin. METHODS: The reports of patients managed in our center between January 2005 and May 2012 for acute mesenteric ischemia of arterial origin were analyzed retrospectively. Data on clinical, laboratory and radiologic findings, the interval before treatment, the operative findings and the surgical procedures were collected. Follow-up information included the postoperative course, and mortality at 48 h, 30 days and 1 year, the latter being compared between patients undergoing revascularization versus gastrointestinal resection. RESULTS: Of 43 patients treated during this period, 20 had gastrointestinal lesions deemed to be beyond all therapeutic resources, 13 were treated with gastrointestinal resection without revascularization, while 10 underwent early revascularization. There were no statistically significant differences found in the extent of involvement between the two groups (P=0.22). Mortality at 48 h, 30 days and 1 year was 8% (n=1), 30% (n=4) and 68% (n=8) in patients who underwent enterectomy vs. 0% (n=0), 0% (n=0) and 10% (n=1) in patients who underwent revascularization procedures. The difference at 1 year was statistically significant (P=0.02). At 1 year, two patients in the revascularized group had a short bowel syndrome vs. one in the non-revascularized group. CONCLUSION: Acute mesenteric ischemia of arterial origin is associated with high morbidity and mortality. Optimal management should include early revascularization

Rectal metastasis of prostate cancer: about a case

Prostate adenocarcinomas present a high risk of metastasis. We report a case of an atypical prostate cancer metastasis. A male patient presented a prostatic adenocarcinoma treated by surgery. A biological recurrence was discovered during the follow-up by an increased rate of Prostate Specific Antigen (PSA) and was treated by hormonotherapy. Several months later, there was a re-increase of the PSA rate. The CT scan showed a radiation proctitis aspect. An intermittent hormonotherapy was decided. Six months later, he presented abdominal pain. Examinations were performed and showed a rectal carcinosarcoma with prostate origins. A surgical management was realised. The outcomes were an early recurrence. A symptomatic treatment was decided. There are not any rectal localisations reported in the literature. Only loco-regional invasions of the rectum are described and no histological modification of metastasis compared to the primitive tumor has been reported. So, we report a metastasis of a prostate adenocarcinoma which transformed into a carcinosarcoma. KEYWORDS: Adenocarcinoma; Carcinosarcoma; Metastasis; Prostate; Rectal neoplasm

Duplication of the Gallbladder. A Case Report

Gallbladder duplication is a rare anatomic malformation, which can now be detected by preoperative imaging study. We report a case of a symptomatic duplicated gallbladder, successfully treated by laparoscopic cholecystectomy. This anomaly is important to know for surgeons because of associated anatomical variations of main bile duct and hepatic artery and increased risk of common bile duct injury

Should pancreaticoduodenectomy be performed in the elderly?

BACKGROUND/AIMS: Pancreaticoduodenectomy (PD) is indicated in benign or malignant pancreatic head diseases. It is a difficult operation with high morbidity especially in elderly patients. The aim of our study was to determine whether pancreaticoduodenectomy is associated with higher morbidity and mortality in patients ≥ 70 years old. METHODOLOGY: During 17 years, 173 patients were operated by Whipple intervention, whatever the disease. From a prospective database, patients were divided in 2 groups (Group A ≥ 70 years old, Group B <70). RESULTS: Postoperative mortality was not significantly higher in elderly (12% vs. 4.1%; p=0.06). However, re-intervention and morbidity were more important in univariate analysis (p=0.03 and p=0.002 respectively). In multivariate analysis, age ≥ 70 years old was not an independent prognostic factor of mortality (p=0.27) and re-intervention (p=0.07). Whereas age (p=0.04) and preoperative morbidity (p=0.02) were independent prognostic factors of morbidity. CONCLUSIONS: PD requires careful patient selection. However, age should not be a limiting factor

Central pancreatectomy: comparison of results according to the type of anastomosis

INTRODUCTION: The mild pancreatic tumors are more and more treated by central pancreatectomy (CP) in alternative with the widened pancreatectomies. Indeed, their morbidity is lesser but they are however burdened by a rate of important postoperative fistulas. The purpose of our study is to compare pancreatico-jejunal anastomosis and pancreatico-gastric anastomosis. METHODS: This work was realized in a bicentric retrospective way. Twenty-five CP were included and classified according to two groups according to the pancreatic anastomosis (group 1 for pancreatico-jejunal anastomosis and group 2 for the pancreatico-gastric anastomosis). CP was realized according to a protocol standardized in both centers and the complications were classified according to the classification of Clavien and Dindo and the fistulas according to the classification of Bassi. RESULTS: Both groups were comparable. The duration operating and the blood losses were equivalent in both groups. There was a significant difference (P=0,014) as regards the rate of fistula. The pancreatico-gastric anastomosis complicated more often of a low-grade fistula. However, in both groups, the treatment was mainly medical. Our results were comparable with those found in the literature and confirmed the advantages of the CP with regard to the cephalic duodeno-pancreatectomy (DPC) or to the distal pancreatectomy (DP). However, in the literature, a meta-analysis did not report difference between both types of anastomosis but this one concerned only the DPC. CONCLUSIONS: This work showed a less important incidence of low-grade fistula after pancreatico-jejunal anastomosis in the fall of a PM. This result should be confirmed by a later study on a more important sample of PM

The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult

AIM OF THE STUDY: The Alvarado score is a validated test in clinical adult surgery practice which can be helpful in the diagnosis of acute appendicitis. This study aimed to assess the reliability and the reproducibility of this score for patients presenting in the emergency room with acute right lower quadrant abdominal pain. MATERIAL AND METHODS: A prospective monocenter study included all adults who presented in the emergency room with right lower quadrant abdominal pain. The score was calculated by assessing six symptoms and two laboratory values weighted by coefficients. The diagnosis of acute appendicitis was confirmed by the histological examination of the resected appendix. Three groups of patients with high, low, and intermediate scores were defined as described in the literature. RESULTS: Of the 233 patients studied, 174 underwent surgery: three had a normal appendix on histological exam. The statistical analysis of the results showed that a score lower than 4 was significantly associated with the absence of acute appendicitis while a score higher than 6 was significantly associated with acute appendicitis which required surgical care. But a score between 4 and 6 was not discriminant. CONCLUSION: The Alvarado score is a reliable, cheap and reproducible tool for the diagnosis of acute appendicitis in the emergency room; if the score is higher than 6 or lower than 4, there is no need for complementary exams. Patients with a score between 4 and 6, require serial reassessment of physical findings and score over 24 hours and/or complementary diagnostic exam such as ultrasound or CT scan

Respiratory motion correction in dynamic MRI using robust data decomposition registration - Application to DCE-MRI.

Motion correction in Dynamic Contrast Enhanced (DCE-) MRI is challenging because rapid intensity changes can compromise common (intensity based) registration algorithms. In this study we introduce a novel registration technique based on robust principal component analysis (RPCA) to decompose a given time-series into a low rank and a sparse component. This allows robust separation of motion components that can be registered, from intensity variations that are left unchanged. This Robust Data Decomposition Registration (RDDR) is demonstrated on both simulated and a wide range of clinical data. Robustness to different types of motion and breathing choices during acquisition is demonstrated for a variety of imaged organs including liver, small bowel and prostate. The analysis of clinically relevant regions of interest showed both a decrease of error (15-62% reduction following registration) in tissue time-intensity curves and improved areas under the curve (AUC60) at early enhancement

Intraperitoneal mesh repair of small ventral abdominal wall hernias with a Ventralex hernia patch

BACKGROUND: Various surgical procedures have been described in the treatment of small ventral abdominal wall hernias. Mesh repair is becoming popular because of a low recurrence rate. AIM: The aim of this prospective study was to evaluate an open intraperitoneal technique using the Bard Ventralex hernia patch in the treatment of small midline ventral hernias. METHODS: 101 patients were operated on (59 male, 42 female) with a mean age of 54.5 years (range 17-85). Mean operative time was 33 min (range 16-65). The median hospital stay was 2 days (range 1-15). RESULTS: Two patients had a hematoma without wound infection. There were 2 recurrences (2%). Mean postoperative follow-up time was 28.5 months (range 6-55). CONCLUSIONS: Our preliminary results suggest that Ventralex hernia patch repair for ventral hernias can be performed with minimal postoperative morbidity and a low recurrence rate

Évolution des cancers de l’œsophage : impact de la stratégie thérapeutique

PURPOSE: To assess the outcome of esophageal cancer according to therapeutic strategy. PATIENTS AND METHODS: One-hundred and twenty patients with esophageal cancer treated by an association of radiotherapy and chemotherapy and possibly surgery, between 2004 and 2010, were retrospectively studied. The first site of relapse was classified as follows: local (tumour), locoregional (tumour and/or nodal: celiac, mediastinal, sus-clavicular) or metastatic. RESULTS: With a 15.7-months (1.4-62) median follow-up, there were 89 deaths and 79 recurrences. Three types of treatments were performed: 50Gy exclusive chemoradiotherapy (47 patients) or 50 to 65Gy exclusive chemoradiotherapy (44 patients) or chemoradiotherapy followed by surgery (27 patients). The local first relapse was as much frequent as distant relapse (50 patients). With a-5cm margin up and down to the tumour, there was only one nodal relapse. Two-year survival was 39.5% (95% confidence interval [IC]: 30.5-40.8) and relapse-free survival was 26.5% (CI: 18.6-35). Multivariate analysis revealed that treatment type and disease stage had a significant impact on survival, relapse-free survival and locoregional control. Compared to exclusive chemoradiotherapy, surgery improved locoregional control (40.2 versus 8.7 months, P=0.0004) but in a younger population. Despite postoperative mortality, the gain was maintained for distance relapse-free survival (40.2 versus 10 months, P=0.0147) and overall survival (29.3 versus 14.2 months, P=0.0088). Compared to 50Gy chemoradiotherapy, local control was improved if high dose chemoradiotherapy was performed (13.8 versus 7.5 months, P=0.05) but not overall survival (14.0 versus 15.4 months, P=0.24). CONCLUSION: More than one-third relapse is local. Locoregional control is better with high dose chemoradiotherapy. In this study, surgery performed in selected patients only, improved locoregional control, relapse-free disease and overall survival