Foramen of Winslow hernia: a case report of a rare life-threatening situation.

Internal hernias through the foramen of Winslow are considered as rare events. A 66-year-old female patient presented to our emergency department with epigastric and right upper quadrant pain associated with abdominal distention, nausea and vomiting and signs of shock. A computed tomography scan showed bowel strangulation with distended loops identified within the lesser sac. The diagnosis was confirmed by a midline laparotomy procedure. The ileum, the caecum and the ascending colon were found to herniate into the foramen of Winslow. A right hemicolectomy with a resection of the necrotic segment was performed. The patient recovered well postoperatively and was discharged on 10th day after surgery. The diagnosis and management of this rare disease remains challenging. Cross-sectional imaging with reconstruction is considered as the diagnostic modality of choice. Moreover, right hemicolectomy is a preferred procedure in order to decrease the rate of recurrence.

Correction to: Pneumatosis cystoides intestinalis induced by the alpha-glucosidase inhibitor complicated from sigmoid volvulus in a diabetic patient.

The name and the email information of one of the author on the original published version of this article were presented incorrectly. The author name "Hamdi Brham" with email information Hamdi.brham@ch-simoneveil.fr should have been presented as "Hamdi Braham" with the correct email information, Hamdi.braham@ch-simoneveil.fr.

Pneumatosis cystoides intestinalis induced by the alpha-glucosidase inhibitor complicated from sigmoid volvulus in a diabetic patient.

INTRODUCTION: We present the case of a diabetic patient on treatment with acarbose who had presented a sigmoid volvulus with localized cystic pneumatosis of the sigmoid colon. CASE REPORT: A 72-year-old patient with a medical history of atrial fibrillation, DNID in treatment since 10 years by acarbose. The patient was admitted to the emergency for abdominal pain and occlusive syndrome since 48 h without fever or nausea or vomiting. A CT scan was performed that showed a dolichocolon with a sigmoid volvulus. The colonic wall was thickening as well as submucosal and subserosal gas, without extra digestive air or collections. A rectosigmoidoscopy was achieving that showed a sigmoid volvulus with multiple small projections like a submucosa gas bubbles. A laparoscopic non-oncologic sigmoidectomy with primary termino terminal colorectal anastomosis was performed. During the surgical procedure, an aspect of PCI of the sigmoid colon was found. The sigmoid colon was long like a dolichocolon, dilated, and partially twisted. DISCUSSION: PCI is a rare condition characterized by the presence of multiple pneumokystes at different layers of the colonic wall. In emergency setting, the presence of colonic pneumatosis precludes the differential diagnosis between the PCI and mesenteric ischemia or ischemic colitis. It can be the cause of unnecessary explorative laparotomy. CONCLUSION: PCI is rare disease, in emergency setting, we had to consider in differential diagnosis with colonic vascular disorders.

The efficacy of surgical shunts to treat severe portal hypertension after a Kasai procedure for biliary atresia.

BACKGROUND: To assess the outcome of patients with biliary atresia (BA) who underwent a surgical shunt (SS) for severe portal hypertension (PH) following a Kasai procedure. METHODS: We collected and analyzed the data and outcomes of patients with BA who underwent SS for severe PH following a Kasai procedure between 1974 and 2014, focusing on complications related to the procedure, overall survival (OS), and transplant-free survival (TFS). RESULTS: SS was performed at a median age of 5.5 years [2-13.5] in 38 patients. Conjugated bilirubin level (cBL) was ≤20 µmol/l in 24 patients at time of SS. Median follow-up was 15 years [1-32]. OS at 5 and 10 years was 91% and 87% respectively. TFS at 5 and 10 years was 84% and 70% respectively. Long-term complications included hepatic encephalopathy in 9 patients, and hepatopulmonary syndrome in 3. At last follow-up, 10/14 patients without LT and 18/ 24 who had a delayed LT at a median delay of 11 years [1.5-22] were alive. CONCLUSION: Surgical shunt for severe portal hypertension in biliary atresia may delay the need for liver transplantation. However complications are indications for transplantation. LEVEL OF EVIDENCE: Type of study: Therapeutic. Level of evidence III.

Complicated colorectal cancer in nonagenarian patients: is it better not to perform anastomosis in emergency?

BACKGROUND: Colorectal cancer (CRC) is predominantly a disease of elderly people. Cancer in nonagenarian patients presents an ethical dilemma for surgeons and oncologists, and management of this group of patients in emergency for complicated CRC is debated. Presently described is retrospective study reporting experience of 6 departments of emergency surgery with management of nonagenarian patients sent to emergency surgery for CRC complications. METHODS: Data concerning patients aged over 90 years hospitalized from January 2011 to June 2015 in 6 departments of emergency surgery for complicated CRC were retrospectively analyzed. Data were collected in a dedicated database. Statistical analysis was conducted using IBM software SPSS 22 (IBM Corp., Armonk, NY, USA); statistical significance was set at p=0.05. RESULTS: In the period of study, 19 patients aged over 90 underwent surgery in emergency department for complicated CRC. Of the total, 52.63% were female, with sex ratio F:M of 1.11:1. Mean age was 92.52 years (range: 90-97 years; SD 1.49). Preoperative assessment of surgical risk was made using American Society of Anesthesiologists (ASA) score. There was no statistically significant difference in terms of in-hospital mortality between patients with ASA score ≤ 3 and patients with an ASA score >3. Primary anastomosis was performed in 6 of 19 patients (31.57%), all of whom had right-side colon cancer. Diverting stoma was created for 12 of 19 patients (63.15%). There was a statistically significant difference in incidence of postoperative complications between patients with right-side colon cancer and patients with left-side colon cancer (p=0.0498). Mean length of hospital stay was 12.78 days (range: 2-31 days; SD 6.31). In-hospital mortality rate was 21.05% (n=4). At follow up, overall survival was 47.36% (n=9). CONCLUSION: Elective surgery is the best way to manage CRC in all patients affected. Emergency surgery for CRC complications in patients over 90 is feasible with careful preoperative selection and evaluation of the patient. One-stage surgery is the best choice, in selected patients. Two- and three-stage surgery is indicated in case of peritonitis, for frail patients, for hemodynamically unstable patients. If there is high risk of anastomotic leakage, decompressive stoma is suggested as bridge to elective surgery, and in advanced neoplastic disease, as palliative procedure. In emergency setting, diverting stoma is a good surgical option in nonagenarian patients to decrease surgical risk, morbidity, and mortality; however, clinical randomized controlled trials are necessary to confirm this.

Total vascular exclusion of the liver enhances the efficacy of retroviral-mediated associated thymidine kinase and interleukin-2 genes transfer against multiple hepatic tumors in rats.

BACKGROUND: Recent advances in gene transfer technology render gene therapy an attractive treatment of disseminated liver metastases for which other treatments remain disappointing. In this setting, total vascular exclusion of the liver could improve gene transfer to cancer cells and prevent extrahepatic vector spreading during portal infusion of therapeutic genes. We evaluate the efficiency of combined herpes simplex virus type-1 thymidine kinase (HSV1-TK) and interleukin-2 retrovirus-mediated gene transfer through the portal vein, under total vascular exclusion of the liver, in a model of macroscopic multiple liver metastases in rats. METHODS: Multifocal liver metastases were established in BDIX rats with intraportal injection of DHDK12 colon cancer cells. On randomization, rats received either vector-producing cells or saline solution under total vascular exclusion of the liver. Vector-producing cells released retroviral vectors encoding Lac-Z in marking studies or HSV1-TK or interleukin-2 in therapeutic studies. Rats were either killed for pathologic studies, or followed for survival. RESULTS: Total vascular exclusion of the liver markedly improved gene transfer efficacy in marking studies. In therapeutic studies we observed a significant reduction in tumor volume of treated rats compared with untreated controls (2170 +/- 310 mm(3)). Although singular HSV1-TK or interleukin-2 gene transfer showed significant efficacy, the greatest tumor volume regression was observed in rats treated with combined HSV1-TK + interleukin-2 gene therapy (145 +/- 60 mm(3); P =.0001 vs control). This translated into an increased median survival rate compared with either control rats (P =.006) or rats treated with single gene therapy. CONCLUSION: In a rat model, a significant antitumoral effect against macroscopic multifocal liver metastases can be observed after retrovirus-mediated HSV1-TK and interleukin-2 gene transfer through the portal vein under total vascular exclusion of the liver, followed by ganciclovir administration. We believe that this well-tolerated and efficient therapeutic approach deserves clinical evaluation in patients with disseminated colorectal liver metastases.