Is there still a role for autopsy in abdominal surgery in 2008?

INTRODUCTION: Although autopsy has been shown to play an important role in certain surgical disciplines as cardiac surgery, few studies have been performed in digestive surgery. The purpose of the study is to determine if autopsy still has a role to play in abdominal surgery in 2008. TYPE OF STUDY: Retrospective study for the period 01.01.1996 to 31.12.2005. METHODS: 8,586 patients underwent abdominal surgery during this period. The average age was 55.2 years and male/female sex ratio was 1.1. Surgery was elective in 82% and emergency in 18% of cases. The surgical approach was laparoscopic in 65% and open surgery in 35% of cases. In-hospital morbidity, reintervention and mortality rates were 9.5%, 0.9% and 2.4% respectively. RESULTS: Among the 210 patients who died, thirty-three with generalized cancer or an extensive mesenteric infarct did not have an indication for autopsy ; 74 of the remaining 177 patients, (42%) had an autopsy. The most frequent causes of death were respiratory complications, sepsis and cardiac complications. In 8% of cases, a surgical complication may have caused death. In 44.5% of cases, the results of autopsy showed either a missed major diagnosis that would have changed the patient's prognosis (Goldman class I: 18.9%), or a missed major diagnosis that would not have changed the patient's prognosis (Goldman class II: 25.6%). CONCLUSION: Despite technological progress, autopsy still has an important role to play in the assessment and improvement of the quality of surgical practice.

Inflammatory cytokines in the pathogenesis of periventricular leukomalacia.

BACKGROUND: Periventricular leukomalacia (PVL) affects the developing white matter of neonatal brain. Inflammatory and infectious conditions are implicated in the cause of PVL. METHODS: The authors investigated the in situ expression of proinflammatory cytokines (interleukin-1beta and -6, tumor necrosis factor alpha [TNFalpha]), adhesion molecules (intercellular adhesion molecule-1, vascular cell adhesion molecule-1) and inflammatory cell markers (CD68, leukocyte common antigen, human leukocyte antigen II) in 19 neonatal brains with PVL. The authors compared the findings with matched non-PVL brains. RESULTS: The inflammatory reaction detected at the early stage of PVL extends until the latest phase of cystic cavitation, though at an attenuated level. There is high expression of TNFalpha and to a lesser extent interleukin-1beta; interleukin-6 remains undetectable. Cytokine immunoreactivity is detected in PVL cases both with and without infection. However, cytokine production was higher with infection. A different pattern of cytokine expression was observed in anoxic brains without PVL: TNFalpha immunoreactivity was significantly lower than the PVL group. CONCLUSIONS: An immune-mediated inflammatory process may play a role in PVL. TNFalpha, a myelinotoxic factor, may be the major mediator.

Interleukin-2 in the pathogenesis of perinatal white matter damage.

Proinflammatory cytokines were reported to be implicated in the pathogenesis of perinatal white matter lesions. The authors document for the first time the in situ detection of interleukin-2 and interleukin-2 receptor (IL-2R) in these human white matter lesions. These results suggest that interleukin-2, reported to be toxic to oligodendrocytes and myelin, could play a role in the molecular cascade leading to white matter damage in periventricular leukomalacia.

Liver transplantation for fulminant and subacute viral hepatic failure in adults.

In our early experience, orthotopic liver transplantation was found to be successful in fulminant and subacute hepatic failure due to viral hepatitis in adults, with 66% 1-year survival rate. In the future, more accurate prognostic criteria would probably improve overall survival rate in acute hepatic failure, by allowing better and earlier selection of patients requiring liver transplantation.

[Stomach ulcers and Helicobacter pylori. Clinical, endoscopic and histological characteristics]. / Ulcères gastriques et Helicobacter pylori. Caractéristiques cliniques, endoscopiques et histologiques.

OBJECTIVES: The aim of the study was to determine in a large group of patients with a gastric ulcer the differences between patients, ulcers and gastric mucosa as related to the presence or absence of Helicobacter pylori (H. pylori). METHODS: This prospective study evaluated 150 patients with a benign gastric ulcer. A patient was considered as H. pylori positive on the basis of a positive culture or the presence of gastritis and another positive diagnostic test for H. pylori (urease test, cytology, histology, serology). RESULTS: One hundred and five patients were positive for H. pylori (70%) whereas 45 patients were not infected (30%). There were significant differences regarding the clinical characteristics of patients, the ulcer and the mucosa. H. pylori positive patients differed in terms of past history of ulcer (63 vs 12%), age (57 vs 50 years), sex (48% males vs 24%) and consumption of non steroidal antiinflammatory drugs (39 vs 75%). H. pylori positive ulcers were more often single (79 vs 53%) and located on the small curvature (76 vs 33%). Chronic gastritis was always present in positive patients, with associated intestinal metaplasia (35 vs 2%) and atrophy (45 vs 9%). Negative patients often had a normal gastric mucosa (53%) or reactive gastritis (27%). CONCLUSION: Seventy percent of gastric ulcer are associated with H. pylori infection, corresponding to the classical ulcer. The majority of H. pylori negative ulcers appears to be associated to non steroidal antiinflammatory drugs.

Gallbladder volvulus: a case report.

Gallbladder volvulus, a rare disease generally affecting older aged women, is generally due to an abnormal anatomical fixation of the gallbladder. As clinical and radiological signs are poor the diagnosis is generally made at laparotomy. The prognosis is excellent when early surgical treatment is performed.

[A case report of desmoid tumor of the finger]. / A propos d'un cas de fibromatose desmoïde digitale.

We report the case of a 20-year-old woman with a desmoid fibroma of the finger, which is an extremely rare location. Desmoid fibromas are benign but very infiltrative tumors, known for their frequent recurrences. Because of the many vascular and nervous structures concentrated in the finger, complete surgical excision is difficult.

The reliability of urease tests, histology and culture in the diagnosis of Campylobacter pylori infection.

The accuracy of various staining techniques for immersion microscopy, of five media for culture and five urease test modalities for the detection of Campylobacter pylori infection is reported. It was found that 2% urea unbuffered gel preparation is the most accurate urease test (sensitivity: 89%, specificity: 98%) but a minimal amount of 10,000 CFU/ml is necessary to observe positivity and the sensitivity of urease tests drops to 52% in patients under antimicrobial treatment. For histological diagnosis, modified Giemsa staining was shown to be slightly superior to H&E. The most valuable diagnosis technique is culture when the biopsy specimen is transported and processed under appropriate conditions. A 94% sensitivity rate was observed with 'BCC agar', a new medium containing brain heart infusion, activated charcoal and horse serum.

Subacute mitochondrial liver disease in a patient with AIDS: possible relationship to prolonged fluconazole administration.

Azole-derived antifungal medications are particularly involved in drug-induced hepatic injury encountered in patients with AIDS. Fluconazole may induce multiple hepatic abnormalities usually characterized by asymptomatic and reversible mild hepatic necrosis. We here describe severe subacute liver damage occurring in a patient with AIDS who was receiving fluconazole maintenance therapy for a cryptococcosis. Hepatotoxicity was essentially characterized by mixed cytolytic and cholestatic liver tests abnormalities which improved after fluconazole discontinuation and worsened on fluconazole rechallenge. Optical microscopy demonstrated nonspecific abnormalities including granular aspect of the cytoplasm of the hepatocytes. In contrast, analysis of electron microscopy revealed unusual unreported features characterized by giant mitochondria with paracrystalline inclusions and enlarged smooth endoplasmic reticulum. All microscopic abnormalities were reversed after discontinuation of fluconazole. We suggest that persistent increased hepatic enzymes in HIV-infected patient taking fluconazole should prompt suspension of the treatment. Prospective studies are needed to determine whether careful monitoring of hepatic tests should be recommended in AIDS patients on prolonged fluconazole maintenance therapy.

[Sarcomatoid carcinoma of the larynx]. / Carcinome sarcomatoide du larynx.

In this paper the clinical and pathological aspects of a case of sarcomatoid carcinoma (spindle cell squamous carcinoma) of the larynx are reported. The diagnosis is confirmed by immunohistochemical analysis.

[Infectious pulmonary and neurologic complications of Kaposi's sarcoma. Anatomo-clinical correlation with an ultrastructural study]. / Complications infectieuses pulmonaires et neurologiques d'un sarcome de Kaposi. Corrélation anatomo-clinique avec étude ultrastructurale.

The authors report a case of generalised Kaposi sarcoma complicated by pulmonary cryptococcosis and cerebral toxoplasmosis. Clinical features were dominated by the cerebral condition. The infectious pathogenesis could be related to disturbances in immune defences. Ultrastructural study revealed the presence of several types of tumour cells. Endothelial cells formed vascular lumens and contained Weibel-Palade granules and reticulo-tubular inclusions.

Computerized morphonuclear cell image analyses of malignant disease in bladder tissues.

We analyzed the relationship between several morphonuclear parameters related to nuclear size, densitometry (deoxyribonucleic acid content and ploidy) and the chromatin pattern versus the histopathological grading of 46 bladder cancer samples graded according to the World Health Organization classification. We used a SAMBA 200 cell image processor with software allowing for the discrimination of 15 different parameters on Feulgen-stained imprint smears. In addition, we set up preliminary data banks that enable objective and reproducible grading of unknown cases. This approach must be validated in a large series of cases to create an expert system for bladder malignancy diagnosis.

Campylobacter pylori-associated gastritis: attempts to eradicate the bacteria by various antibiotics and anti-ulcer regimens.

The efficacy of various antimicrobial and anti-ulcer agents on the eradication of Campylobacter pylori in patients with antral gastritis or duodenal ulcers was investigated by several open studies or double-blind, placebo-controlled protocols. Among the anti-ulcer agents, ranitidine, cimetidine or sucraflate had no effect on C. pylori. Colloidal bismuth subcitrate achieved clearance of C. pylori in 40% of treated patients at the end of therapy but a high relapse rate (14/16 patients) was observed after a 6-month follow-up period. The antibacterial agents doxycycline, minocycline, ofloxacin, clindamycin, paromomycin and nifuroxazide failed to eradicate C. pylori in most patients. By contrast, short term elimination of C. pylori could be achieved in more than 90% of patients treated with amoxycillin. However, relapse occurred as a rule in all amoxycillin-treated patients within one month after therapy. Overall, we observed no correlation between the in-vitro activity of the different antibacterial agents and their in vivo efficacy. Development of resistance during therapy does not seem to account for this discrepancy since it occurred only with ofloxacin. On the basis of these results, we conclude that long term eradication of C. pylori from the gastric antrum cannot be achieved after monotherapy either with antibiotics or with bismuth salts.

Per rectal thallium scintigraphy for the assessment of portosystemic shunt: an experimental study in the bile duct ligated rats.

Bile duct ligated rats (n = 7) have been investigated for 6 months. Two patterns of evolution have been observed: (i) progressive development of cirrhosis and portosystemic shunt (detected by 201Tl per rectal scintigraphy) in three animals, (ii) repermeabilization of the biliary tract in four animals. Despite the small number of animals investigated, the 201Tl per rectal scintigraphy seems to be a good indicator of portosystemic shunt secondary to biliary cirrhosis.

Epithelioid hemangioendothelioma of the liver following contact with vinyl chloride. Recurrence after orthotopic liver transplantation.

Malignant epithelioid hemangioendothelioma of the liver is a recently recognized and uncommon neoplasm of vascular origin. Few cases have been reported and the treatment remains therefore difficult to define. A relationship to oral contraceptive use has been suggested but no other toxic agents have been incriminated. We report here the first case occurring after a close contact with vinyl chloride. Because of wide hepatic destruction and serious portal hypertension with bleeding varices, the patient underwent orthotopic liver transplantation. After a disease-free interval of 20 months, he died from variceal hemorrhage and encephalopathy due to local tumor recurrence with portal thrombosis. Nevertheless, orthotopic liver transplantation remains the only hope of salvage when extensive liver destruction and life-threatening complications are present.