Benefits of a 14-year surgical site infections active surveillance programme in a French teaching hospital.

BACKGROUND: Surgical site infections (SSIs) are the second most common healthcare-associated infection. Active SSI surveillance can help inform preventative measures and assess the impact of these measures. AIM: We aimed to describe the evolution in trends over 14 years of prospective active SSI surveillance and implementations of SSI prevention measures in a French Teaching Hospital. METHODS: We monitored and included in the study all surgical procedures performed from 2003 to 2016 in eight surgical units. The semi-automated surveillance method consisted of weekly collection of SSI declaration forms (pre-filled with patient and procedure administrative data and microbiology laboratory data), filled-in by surgeons and then monitored by the infection control practitioners. FINDINGS: A total of 181,746 procedures were included in our analysis and 3270 SSIs recorded (global SSI rate 1.8%). The SSI rate decreased significantly from 3.0% in 2003 to 1.1% in 2016. This decrease was mainly in superficial SSIs and high infectious risk procedures. Higher SSI rates were observed for procedures associated with the usual risk factors. During this 14-year period, several evolutions in surgical practices occurred that might have contributed to this decrease. CONCLUSIONS: With an overall decrease in SSI rate throughout the surveillance, our results revealed the benefits of an active and comprehensive hospital SSI surveillance programme for understanding the SSI rate trends, analysing local risk factors and assessing the effectiveness of prevention strategies. These findings also highlighted the importance of the collaboration between surgeons and infection control practitioners.

[Adrenal metastasis: survival following surgical resection]. / Métastase surranélienne: survie après chirurgie d'exérèse.

GOAL: This study aims to determine the post-surgical survival after resection of adrenal metastasis from extra-adrenal primary cancers. PATIENTS AND METHODS: A retrospective study of sixteen patients undergoing surgery for adrenal metastasis between 1995 and 2005 analyzed age, type of primary cancer, interval to detection of adrenal metastasis, type of surgery performed, and survival (Kaplan-Meier curve). RESULTS: The study included 10 men and 6 women with a mean age of 55.5 years (25-74). Adrenal metastasis causes no clinical signs or symptoms. Diagnosis was made on the basis of CT scan in 12 cases and PET scan in 4 cases. The primary cancer site was lung (6), kidney (3), melanoma (2), colorectum (2), esophagus (1), pancreas (1), and B-cell lymphoma (1). Metastasis was confined to the adrenal in 7 cases and associated with other-site metastasis in 9. The interval from diagnosis of the primary cancer to detection of the adrenal metastasis ranged from 9 months to 11 years. Surgery consisted of radical resection in 5 cases, metastasectomy in 10 cases, and biopsy in one case. The overall survival was 12 months (range 2-120 months); when the diagnosis of the metastasis was synchronous with that of the primary, survival was just 8 months. CONCLUSION: The survival after surgery for adrenal metastasis is poor; it is even more dismal when the metastasis is diagnosed synchronously with the primary tumor. Surgical management depends on the primary neoplasm and the extent of metastases.

[Acute intestinal strangulation after Scarpa's triangle cow horn injury]. / Occlusion intestinale aiguë suite à un encornage du triangle de Scarpa.

A 52 year-old man, treated by neuroleptic drugs, presented with a cow horn injury in the right Scarpa's triangle. The surgical management found no injury of femoral vessels. Surgical hemostasis of superficial vessels was performed. An ileal strangulation appeared three days later. At laparotomy, we found an internal parietal wound. Here we explain the mechanism of this strangulation.

[Hepatic haemangioendothelioma: case report and review of literature]. / Hémangioendothéliome épithélioïde du foie: à propos d'un cas clinique et revue de la littérature.

A 37 year old-woman complained about persistant pain of right abdominal quadrant. We discovered many hepatic lesions. Histology revealed benign processus. Evolution was marked by peritoneal carcinomatosis. After reexamination of histology we discovered hepatic haemangioendothelioma. The patient died 18 month after diagnosis although chemotherapy.

[Cecal volvulus]. / Les volvulus du caecum.

The cecum is the second most common site of colonic volvulus after the sigmoid. The mechanism is torsion or hyperflexion of the enlarged, poorly-fixed, and hypermobile cecum. It presents clinically as an acute bowel obstruction with strangulation. Diagnosis can be made by plain abdominal X-ray in more than half the cases on the basis of cecal distention (with a classical "teardrop" or "comma" appearance), proximal small bowel distention with air-fluid levels, and a gasless distal colon. Barium enema shows lack of filling of the cecum, often with a "beaked" termination of the column of contrast. CT images are pathognomonic when they reveal a cecal "vortex". After surgical reduction of the torsion, ileo-cecal resection is usually the best therapeutic alternative. Cecopexy may be aDDrouriate in older and debilitated Datients if there is no concomitant cecal necrosis.

[Inferior mesenteric arteriovenous fistulas. Report of a case]. / Les fistules artérioportales mésentériques inférieures. A propos d'un cas.

We report a case of postoperative inferior mesenteric arteriovenous fistula. Arteriovenous fistula represents a rare disease. Symptoms are due to portal hypertension and distal ischemy. Treatment of these fistulas is embolization. Surgery is possible by ligature or excision of the fistula because vascularisation is obtained by Riolan arcade and hypogastric artery.

[Giant diverticulum of the sigmoid colon with jejunal fistula]. / Diverticule géant du côlon sigmoïde fistulisé dans le jejunum.

An 80-year-old woman with sigmoïd diverticula was treated by corticosteroid for Horton disease. She presented abdominal pain, and abdominal mass in left iliac fossa. Radiological examinations revealed a colo-jejunal fistula. At laparotomy it was a giant diverticulum of colon sigmoid with fistula in the jejunum. The pathogeny of giant diverticulum and the role of corticosteroid are discussed.

[Aberrant pancreas: report of five cases]. / Les pancréas aberrants: à propos de cinq cas.

We herein report five cases of heterotopic pancreas localized on common bile duct, gastric antrum, duodenum (two cases including one with cystic dystrophy), and jejunum. The choledocal localization was revealed by jaundice. The duodenal localization with cystic, diagnosed by endoscopic ultrasound, was revealed by onsets of acute pancreatitis. All localizations were treated by resection: antrectomy, bowel resection, and pancreaticoduodenectomy. Postoperative course was uneventful. Review of the literature shows that, even in uncomplicated cases, resection is usually performed.

[Apropos of a case of bilateral axillary supernumerary breasts]. / A propos d'un cas de seins surnuméraires axillaires bilatéraux.

We herein report a case of axillary localization of supernumerary breast. It is a matter of axillary bilateral masses mistaken as lipoma at clinical examination and ultrasonography. We here explain this confusion between lipoma and supernumerary breast. The aim of this work is to specify clinical characters of an axillary mass that must lead to suspect a supernumerary breast.

[A case of right liver atrophy]. / A propos d'un cas de sagittalisation des voies biliaires droites.

The authors report a case of right liver atrophy. This rare anomaly was suspected during post-operative period on abnormalities of cholangiogram. This biliary tract anomaly was diagnosed by CT scan. This congenital abnormality may be associated with biliary tract abnormalities, portal hypertension and other congenital abnormalities.

Right hepatectomies without vascular clamping: report of 87 cases.

BACKGROUND/PURPOSE: Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping. METHODS: From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 +/- 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava). RESULTS: There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 +/- 2.7 units. The mean operative length was 280 +/- 60 min and the mean hospital stay was 12.8 +/- 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week. CONCLUSIONS: In our experience with major liver resections, vascular clamping is not necessary.

Laparoscopic liver resection of benign liver tumors.

OBJECTIVE: The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting. BACKGROUND: Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors. METHODS: A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. RESULTS: From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD. CONCLUSIONS: Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.

Development of colonic stenosis following severe acute pancreatitis.

BACKGROUND: Colonic necrosis after acute pancreatitis is rare. When it does occur, it is commonly due to ischaemia or inflammation and may necessitate early colonic resection. CASE OUTLINE: A 72-year-old man developed colonic necrosis 6 weeks after severe acute pancreatitis. CT scan revealed a bulky mass near the left colon. Barium enema and colonoscopy revealed stenosis of the left colonic flexure, and this segment of bowel was successfully resected. DISCUSSION: Severe acute pancreatitis must be recognised as a cause of colonic ischaemia and necrosis. The possible pathogenic mechanisms include severe local inflammation and an ischaemic process. This complication is associated with a very poor prognosis despite surgical intervention, but a timely resection may prevent further problems.

[Intrathyroid metastases from kidney cancers: two case reports]. / Métastases intrathyroïdiennes des cancers du rein: à propos de deux cas.

The thyroid metastasis are under estimated in clinical practice because they are in the vast majority of cases "silent". Over than 50% of clinically apparent metastatic lesions are due to kidney carcinomas. We report two cases of thyroid metastasis from clear-cell renal carcinoma occurred 3 years and 8 years after nephrectomies. The previous history of any type of carcinoma should suggest a possibility of metastasis for every thyroid nodules. Fine-needle aspiration cytology is recommended by some authors. Finally, clear-cell carcinoma metastases seem to have a propensity to occur in abnormal thyroid tissue and further study could be interesting.

[Mesenteric-portal confluence aneurysm]. / Anévrysme du confluent mésentérico-portal.

The authors take interest in the portal aneurysm about the observation of a 52 year-old woman with an echographic lesion in the head of the pancreas. Radiological examination was done with abdominal CT and MRI. Because of no accurate diagnosis, an explorative laparotomy was done and showed an aneurysm at the junction of the portal and superior mesenteric veins. These lesions are rare: they can be acquired particularly with underlying hepatocellular diseases and portal hypertension; they can be congenital due to an incomplete obliteration of the right vitelline vein. If asymptomatic, only a close surveillance must be proposed.

[Duodenal duplication: pathologic anatomy and embryogenesis. Case report in an adult]. / Duplication duodénale: anatomie pathologique et embryogenèse. A propos d'un cas chez l'adulte.

Duodenal duplication is a rare congenital entity and less than 100 cases have thus far been reported in the literature. This was first described by Sanger in 1880. By definition, they are located in or adjacent to the wall part of the gastrointestinal tract, have smooth muscle in 2 layers and are lined by alimentary tract mucosa. With the case report of a 18 year-old patient with pancreatitis, we expose modern imaging procedure and surgical management. Although the exact etiology of enteric duplications is not known, the two main hypothesis are dysembryogenesis and dysorganogenesis.

[Composite, non-resorbable parietal prosthesis with polyethylene terephtalate-polyurethane (HI-TEX PARP NT): prevention of intraperitoneal adhesions. Experimental study in rabbits]. / Prothèse pariétale composite et non résorbable en polyéthylène téréphtalate-polyuréthane (HI-TEX PARP NT): prévention des adhérences intrapéritonéales. Etude expérimentale chez le lapin.

The authors report an experimental study in the rabbit with a new composite non absorbable mesh in Polyethylene Terephtalate-Polyurethane used for incisional hernia repair in intraperitoneal positioning. This new mesh has one permeable side in polyethylene terephtalate for rapid tissue fixation and another side in polyruethane, hydrophob in order to avoid cell penetration. Eighteen rabbits were operated. A wound was created in aponeurose, muscle and peritoneal abdominal wall. The mesh was placed in intraperitoneal positioning and was taken off at 4, 9 and 13 months for histologic examination and electronic microscopical examination. Tolerance, adhesion, tissular reaction and neoperitoneum formation have been studied. All the meshes were well integrated and without sepsis. In 18% of cases small and monocclusive intraperitoneal adhesions were found. This new composite mesh in intraperitoneal positioning gave good results at medium-term in the rabbit. It's an attractive alternative for incision hernias repair with intraperitoneal mesh.

[Role of the lymphatics of the diaphragm in the absorption of intraperitoneal liquids]. / Rôle des lymphatiques du diaphragme dans l'absorption des liquides intra péritonéaux.

The diaphragm is the major site of the lymphatic absorption of the intra peritoneal liquids. Known since the middle of the last century, this lymphatic network is at present studied under transmission electron microscopy. The stomata which are intercellular sluices between adjacent mesothelial cells, are the entry of the diaphragmatic network. These stomata open into the lacunae which are dilatations the diaphragmatic subserous lymphatic network. The architecture of these structures explains their one-way character from the abdomen to the thorax and the role of the respiratory movements. This network collects the fluids into the trans diaphragmatic lymphatics. Pleural effusion appears when the quantity of liquids in the diaphragmatic lymphatic network exceeds the capacities of drainage of the lymphatic efferents, thus explaining the reactional pleural effusion caused by underdiaphragmatic inflammatory processes.

[Portal hypertension in a patient with hepatitic C revealing an iatrogenic arterioportal fistula]. / Hypertension portale chez un malade porteur d'une hépatite C, révélatrice d'une fistule artérioportale iatrogène.

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.