Adding corticosteroids to the pudendal nerve block for pudendal neuralgia: a randomised, double-blind, controlled trial.

OBJECTIVE: To compare the effect of corticosteroids combined with local anaesthetic versus local anaesthetic alone during infiltrations of the pudendal nerve for pudendal nerve entrapment. DESIGN: Randomised, double-blind, controlled trial. SETTING: Multicentre study. POPULATION: 201 patients were included in the study, with a subgroup of 122 women. METHODS: CT-guided pudendal nerve infiltrations were performed in the sacrospinous ligament and Alcock's canal. There were three study arms: patients in Arm A (n = 68) had local anaesthetic alone, those in Arm B (n = 66) had local anaesthetic plus corticosteroid and those in Arm C (n = 67) local anaesthetic plus corticosteroid with a large volume of normal saline. MAIN OUTCOME MEASURES: The primary end-point was the pain intensity score at 3 months. Patients were regarded as responders (at least a 30-point improvement on a 100-point visual analogue scale of mean maximum pain over a 2-week period) or nonresponders. RESULTS: Three months' postinfiltration, 11.8% of patients in the local anaesthetic only arm (Arm A) were responders versus 14.3% in the local anaesthetic plus corticosteroid arms (Arms B and C). This difference was not statistically significant (P = 0.62). No statistically significant difference was observed in the female subgroup between Arm A and Arms B and C (P = 0.09). No significant difference was detected for the various pain assessment procedures, functional criteria or quality-of-life criteria. CONCLUSIONS: Corticosteroids provide no additional therapeutic benefits compared with local anaesthetic and should therefore no longer be used. TWEETABLE ABSTRACT: Steroid infiltrations do not improve the results of local anaesthetic infiltrations in pudendal neuralgia.

Omentoplasty decreases deep organ space surgical site infection compared with external tube drainage after conservative surgery for hepatic cystic echinococcosis: Meta-analysis with a meta-regression.

INTRODUCTION: The rate of deep organ space/surgical site infection after conservative surgery for hepatic cystic echinococcosis (HCE) ranges from 12% to 26% with a post-operative mortality rate between 0% and 7.5%. This systematic review with meta-analysis aimed to investigate whether omentoplasty (OP) following conservative surgery for HCE leads to decreased rates of morbidity and mortality compared to external tube drainage ETD. PATIENTS AND METHODS: We identified 4540 articles through database searching. After verifying the inclusion and exclusion criteria, we retained eight studies for final analysis: two randomized controlled trials (RCT), one prospective comparative study and five retrospective comparative studies. The main outcome measure was organ space/surgical site (OS/SS) morbidity that was limited to "deep organ space/surgical site infection (Deep OS/SSI) with or without re-operation". RESULTS: The eight studies reported results for deep OS/SSI (6/374 (OP) and 60/403 (ETD), respectively). There were statistically significantly less deep OS/SSI with OP (vs. ETD) OR=0.17 95%CI [0.05, 0.62] (P=0.007). A random-effect meta-regression, including the eight studies, showed an interaction in favor of OP. There were also statistically significant less biliary leakage±fistula and overall morbidity in OP compared to ETD. On the other hand, no statistically significant difference was found concerning deep bleeding, mortality and recurrence between these two groups. CONCLUSION: This meta-analysis with a meta-regression showed that there were statistically significant less deep OS/SSI, biliary leakage±fistula and overall morbidity in OP compared to ETD.

[Pudendal nerve surgery in the management of chronic pelvic and perineal pain]. / La chirurgie du nerf pudendal dans la prise en charge thérapeutique des douleurs pelvipérinéales chroniques.

OBJECTIVE: To define the place of pudendal nerve surgery in pudendal nerve entrapment syndromes. MATERIALS AND METHODS: Description of the various surgical techniques and published results. RESULTS: The original surgical technique, which remains the reference technique, consists of performing surgical release of the pudendal nerve from the infrapiriformis foramen to Alcock's canal via a transgluteal approach. This surgical procedure is safe and gives encouraging results validated by a prospective, randomized protocol: 66 to 80% of patients are improved. Other transvaginal or transperineal approaches have also been proposed. CONCLUSION: Pudendal nerve surgery is a reasonable treatment option when all other treatments have failed. However, the various techniques proposed and their respective criticisms must be carefully evaluated.

[Hepatic epithelioid hemangioendothelioma: review of 3 cases]. / Hémangioendothéliome épithélioïde hépatique: à propos de 3 cas.

Hepatic epithelioid hemangioendothelioma (EHE) is a rare neoplasm of vascular origin. EHE is an intermediate-grade malignancy, between benign hemangioma and angiosarcoma, with variable aggressiveness. Involvement often is multinodular simulating metastases from a primatry extra-hepatic malignancy leading to delays in diagnosis. We report the imaging features in three cases of histologically proven hepatic EHE. The imaging features suggestive of EHE will be emphasized, especially for multinodular lesions suggesting liver metastases in patients with no known primary.

Genomic stability prevails in North-African hepatocellular carcinomas.

The molecular pathogenesis of hepatocellular carcinoma, a tumour characterized by a vast clinical heterogeneity, remains unexplored outside Europe and Eastern Asia. We analysed by direct sequencing or loss of heterozygosity assay, the common targets of genomic alterations in 42 hepatocellular carcinomas collected in western North-Africa. Overall, genomic instability was uncommon, allelic losses affecting mostly chromosomes 1p, 4q, 8p and 17p (24-28% of cases). CTNNB1 and TP53 were infrequently mutated (9 and 17% of cases, respectively). Surprisingly, TP53 mutation R249S, diagnostic of aflatoxin B1 exposure, usually frequent in Africa, was exceptional (one case), indicating that in western North-Africa, hepatocellular carcinoma genetics differs markedly from that of the remainder of the continent.

Neurosurgical treatment of perineal neuralgias.

Perineal pain is the basis of presentation to different specialities. This pain is still rather unknown and leads the different teams to inappropriate treatments which may fail. For more than twenty years, we have seen these patients in a multidisciplinary consultation. Our anatomical works have provided a detailed knowledge of the nervous supply of the perineum which allowed us to propose the description of an entrapment syndrome of the pudendal nerve. Other disturbances of different origins were highlighted helping colleagues to a better analysis of this enigmatic painful syndrome. Cadaveric studies have been done to guide treatments by blocks and surgery if necessary according to well defined criteria. A randomized prospective study validated the surgery. The retrospective study concluded that two thirds of the patients improved after treatment. New anatomical concepts are leading us to enlarge the field of this type of surgery, with the hope of improving the success rate.

[Congenital cystic dilatation of bile ducts]. / Les dilatations kystiques congénitales des voies biliaires.

Congenital cystic dilatation of bile ducts is a rare condition. We report a retrospective study about 18 patients having congenital bile duct cysts. According to Todani's classification, 11 cases were type I and 7 were type V. Six patients from the first group had a pancreatobiliary maljunction. A total resection of the cyst was conducted in the type I cysts. Anatomopathologic examination showed an adenocarcinoma of a common bile duct cyst. In one case, a cancer of the gall bladder associated to a common bile duct cyst in another case. Three patients with segmental dilatation of intrahepatic bile ducts (type V) underwent liver resection. Four patients had a diffuse form, one of them was treated by percutaneous drainage, and in the other cases a hepatojejunostomy was performed. Postoperative course was complicated with acute cholangitis in these four cases. Percutaneous drainage and antibiotics allowed a positive outcome in most of the cases. In one case, secondary biliary cirrhosis occurred as a long-term complication. Congenital cystic dilatation of bile ducts is considered to be a precancer state. Enterocystic anastomosis is proscribed and the resection has to be as complete as possible.

[Survival and prognostic factors of colorectal adenocarcinoma: analytic multifactor review of 150 cases]. / Survie et facteurs pronostiques des adénocarcinomes colorectaux: étude analytique uni- et multifactorielle de 150 cas.

INTRODUCTION: Prognostic factors have a pivotal role in clinical oncology. They are helpful in the selection of treatment; provide insights into the disease process and the therapic response. The number of possibility useful prognosis factors in the colorectal cancer is large. This study attempts to observe the survival of colorectal adenocarcinoma and to find prognostic factors and other variables potentially associated with outcome of colorectal adenocarcinoma. MATERIAL AND METHODS: It's a retrospective study based on 150 patients with colorectal adenocarcinoma from 1990 to 2002. There were 150 patients aged of 58 years (median 61 years) with 1.4 sex-ratio. 84 patients had colon adenocarcinoma and 66 patients had rectal adenocarcinoma. In histological exam the adenocarcinoma was well differenced in 69 cases (46%), and undifferentiated in 17 cases (18, 3%). RESULTS: Locoregional extension was found in 18 cases and metastatic extension in 45 cases with hepatic metastasis in 37 cases and pulmonary metastasis in 8 cases. There were 6 cases of peritoneal localized carcinosis and 6 cases of ovary metastasis. There were 6 patients (4%) Dukes stage I TNM, 61 stage II (40, 7%), 51 stage III TNM (34%) and 32 patients stage IV TNM (34%). All patients had surgical curative resection associated with adjuvant chemotherapy in 60 cases of colon adenocarcinoma and preoperative radiotherapy in 33 cases of rectal adenocarcinoma. After a follow up of 46 months, 52 patients was died (10 operative mortality), 35 patients were lost of view and 63 patients were still alive at the point date. Median survival was 20 months with 95% confidence interval: (4, 2-7, 8). Overall one year and 5 years survival were respectively 92,8% and 26,3%. Various prognostic factors had been identified through univariate (Kaplan-Meier) then multivariate (Cox) analyze. In addition to the clinical factors, we found of significant prognostic value undifferentiated adenocarcinoma and an elevated value of serum carcinoembryonic antigen>5 ng/ml.

[Results of laparoscopic treatement of common bile duct lithiasis. Report of 30 cases]. / Resultats du traitement laparoscopique de la lithiase de la voie biliaire principale. Etude de 30 cas.

AIM: The aim of this retrospective study was to report the results of the laparoscopic management of common bile duct stones in an unicentric series of 30 patients. METHODS: From January 2001 to April 2004. 30 patients: 23 women, 7 men (mean age: 54 years). underwent a common bile duct exploration for lithiasis through a laparoscopic approach. The patients were hospitalized for angiocholitis (n = 12), cholecystitis (n= 4), jaundice (n = 4), pancreatitis (n = 3), abnormality of hepatic tests (n = 7). All the patients underwent an intra operative cholangiography. Removal of the stones was tried in 30 cases through a choledochotomy. never through the cystic duct, using Dormia and Fogarty catheters. External biliary drainage with T tube (kehr) and postoperative cholangiography was done systematically. RESULTS: In 21 patients (70 %), removal of the stones was laparoscopically successful. The average diameter of the common bile duct was 10.5 mm (range 6-20 mm). The median number of stones was 5 (E: 1-12). The median operation time was 180mn (range 150-300mn). In 9 patients, a conversion into laparotomy was necessary for several reasons. In 2 patients with residual common bile duct, the stones were treated successfully by endoscopic sphincterotomy. There was no mortality and the morbidity rate was 10 %. The mean postoperative hospital stay was 14.7 days (range 7-18days) and 13.3 days in case of successful laparoscopic management. CONCLUSION: In 70 % of the patients, the treatment of the common bile-duct lithiasis could be achieved laparoscopically, but conventional approach and endoscopic sphincterotomy are still useful in case of failure of the laparoscopic management.

[Duodenal metastatic leiomyosarcoma of the uterus. A case report]. / Métastase duodénale d'un leiomyosarcome utérin. A propos d'une observation.

The digestive metastases of uterine leiomyosarcoma are rare. We report a case of a duodenal tumor detected in a 50 year-old woman, 3 years after she underwent a total hysterectomy for uterine leiomyosarcoma. The stenosing duodenal mass was thought to be a mesenchymal tumor. A pancreaticoduodenectomy was performed. The resected lesion was morphologically similar to the uterine leiomyosarcoma. In fact, the histopathological study confirmed a submucosal tumor with typical features of the uterine leiomyosarcoma. Immunohistochemistry was performed and it showed negative CD117 and CD 34. Markers displayed positivity for actin smooth muscle and desmin. Considering the patient history and the immunohistochemical observations, we diagnosed a duodenal metastasis of uterine leiomysarcoma. Through this exceptional observation we want to emphasize the epidemiological and the pathological features of the metastatic uterine leiomyosarcoma. We will also point out the progress of tumoral cells and the histopathological distinctive criteria with a primitive digestive mesenchymal tumor.

[Dialysis-associated spondyloarthropathy. Case report and literature review]. / La spondylarthropathie érosive du dialysé rénal. A propos d'un cas, revue de la littérature.

Hemodialysis has considerably prolonged the life of patients suffering from terminal renal failure. However, long-term hemodialysis leads to new bone complications and spinal disorders such as destructive spondyloarthropathy (DSA). At the present time DSA is reported in 8% to 18% of the dialysed patients. Diagnosis is based on severe narrowing of the intervertebral disk, erosions and geodes of the adjacent vertebral plates simulating infectious spondylitis. Lesions progressively involve posterior joints and may lead to severe destruction of the spine. The pathogenesis of this syndrome is still unknown. Several factors have been implicated, including microcrystal deposition, amyloidosis, inflammatory and foreign body reactions and suggest that the pathogenesis of erosive spondyloarthropathies of hemodialysed patients is multifactorial. Spinal instability inducing myelopathy and radiculopathy were observed in 8% of the cases. Treatment must be accorded to the natural disease course and to the quality of the bone. We report the case of a chronic dialysed patient with destructive spondyloarthropathy involving the cervical and thoracic spine. Pathogenesis, radiological datas and therapeutic approach are discussed.

Acute celiac trunk thrombosis revealed by biliary peritonitis.

Acute thrombosis of the celiac trunk is a very uncommon condition, which is a life-threatening emergency. The clinical presentation is highly variable depending on the extent of the ischemic territory. We report a case of biliary peritonitis related to an acute thrombosis of the celiac trunk. This case highlights the role of abdominal computed tomography in the diagnosis of acute upper abdominal pain.

Intrahepatic Osler's disease: report of two cases and review of the literature.

Osler-Weber-Rendu disease is a hereditary vascular disease with multiple manifestations. The liver is involved rarely. Vascular abnormalities include telangiectasis and arteriovenous fistulas, sometimes associated with fibrosis and cirrhosis. Hepatic arteriovenous shunting may include secondary portal hypertension, reduced liver function and high cardiac output. Two cases of Osler-Weber-Rendu disease with extensive hepatic arteriovenous fistulation were described in detail and we report on their clinical features. In the first patient, treatment was symptomatic since liver transplantation is not indicated because the patient was asymptomatic. Embolization treatment of hepatic arteries was indicated in the second patient because he had biliary disease and recurrent cholangitis secondary to vasculo-biliary shunts. Therapy with arterial embolization, banding, or ligature of hepatic arteries is still limited and provides unsatisfactory long-term results. Liver transplantation offers now another therapeutic option for patients with intrahepatic high shunting and secondary pulmonary hypertension.

Cystic mesenchymal hamartoma of the liver report of a case and review of the literature.

Mesenchymal Hamartoma (MH) of the liver constitutes the third or the fourth most common tumour of the liver in childhood and occurs most commonly in the first two years of life. It is often misdiagnosed clinically as a malignant tumour because of its rapid increase in size within a short period of time, or as a hepatic collections or abscess because of its cystic appearance. Although a benign lesion, MH may cause heart failure due to arteriovenous shunts, or death as a result of respiratory complications. A typical case of MH was recently encountered in a 6-years-old-boy. The patient presented with progres sive abdominal distension; surgery revealed a large mass arising from the right lobe of the liver. The mass was predominantly formed by fluid collections. Loose mesenchymal tissue and branched, tortuous bile ducts were the key diagnostic features. When predominantly cystic, MH may mimic lymphangioma both grossly and microscopically. Prudent examination of the cystic structures can establish a correct diagnosis.

[Unilocular macrocystic serous cystadenoma of the pancreas: a morphologic variant to be considered]. / Le cystadénome séreux macrokystique uniloculaire du pancréas: une variante morphologique à connaître.

Serous cystadenoma of the pancreas is a benign cystic tumor, which radiological diagnosis is easy in its typical microcystic variant. The macrocystic variant is uncommon and raises diagnostic problems with other macrocystic lesions of the pancreas such as pseudocysts and mucinous cystadenomas. We report the case of a young woman with a unilocular macrocystic serous cystadenoma of the pancreas which was identified on pathologic examination of the surgical specimen, after unconclusive abdominal ultrasound and CT-scan. This case describes an unusual clinical presentation of this cystic tumor and emphasizes that the diagnosis of such an entity is still based on pathological examination after cyst removal.

[Primary spinal osteosarcomas]. / Ostéosarcomes primitifs vertébraux.

The rarity of primary osteosarcoma of the spine led us to index the 66 reported cases published in literature. From this analysis a difference was found between spinal osteosarcoma and osteosarcoma of the extremities. Tumors of the spine appear to be two times more frequent in the male population in their thirties. The average period between the beginning of the symptoms and the first consultation is seven months. Back pain is permanent and localized to the affected vertebra. In 80 percent of the cases, neurological symptoms already exist at the stage of the diagnosis. Magnetic resonance imaging (MRI), computed tomography and standard X-ray remain complementary in the morphological analysis of this tumor. All the aspects from the lytic to sclerotic forms are noted, although the lytic form is common. Among spinal osteosarcoma, the lumbar vertebrae are the most frequently affected. Diagnosis can only be established by pathology, even though this may also lead to some errors. In all the reported cases surgery is used, but carcinological methodology is not possible and a complete removal of affected tissue is difficult, with this being achieved in only a quarter of the cases. Radiation therapy, when used, requires doses of 70 Gy to 80 Gy without any certitude of controlling the tumour and with high risks of post-radiation complications. Chemotherapy on its own, despite the use of high-dose methotrexate, only has a temporary effect due to partial action on the primary center. Twenty years ago, only twenty percent of all patients suffering from osteosarcoma lived beyond two years, with worse prognosis for spinal osteogenic sarcoma. Today, the therapeutic approach for spinal tumors uses techniques developed in the treatment of osteosarcoma of the extremities, which can now expect more than seventy percent of all patients to live beyond five years. Present day methods recommend a rapid confirmation of the diagnosis, and then a neoadjuvant chemotherapy followed by surgery to remove all the affected area. This strategy allows an evaluation of the tumor chemosensitivity and to adapt the treatment in consequence. The latest results of this treatment on spinal osteosarcoma appear to be encouraging.

[Primary spinal osteosarcoma. Apropos of a case]. / Ostéosarcome primitif vertébral. A propos d'une observation.

We report a case of primary osteogenic sarcoma of the third lumbar vertebra, detailing the neuroradiologic and therapeutic aspects. The clinical presentation was limited to low back pain which radiated to the left thigh for 5 months. Lumbosacral spine roentgenograms revealed a sclerotic lesion of the left part of the body of the third lumbar vertebra. Treatment consisted of total vertebrectomy, chemotherapy completed with radiotherapy. Fourteen months after a complex combined treatment no recurrence was observed. A review of the literature highlighted the rarity of this tumor. Usually, patients with vertebral osteogenic sarcoma do poorly. Today, the therapeutic approach for these spinal tumors should use techniques developed in the treatment of osteosarcoma of the extremities because of their encouraging results.