[Symptomatic lumbar incisional hernia after open nephrectomy: What are the risk factors?]. / Éventrations lombaires symptomatiques après néphrectomies par lombotomie: quels sont les facteurs de risque?

OBJECTIVE: Lumbar incisional hernias after open nephrectomy are rare but can lead to aesthetic disorder, discomfort or intestinal obstruction. The aim of the study is to highlight their risk factors. PATIENTS AND METHODS: The characteristics of patients who suffered from symptomatic and surgically treated lumbar incisionnal hernia after open nephrectomy (study group "GE") were compared to those of patients who underwent open nephrectomy without postoperative incisional hernia (control group "GT") using the Student's t test and Mann-Whitney test (statistical significance P value<0.05). GT patients were randomly selected with a 1/4 ratio (1 lumbar incisionnal hernia vs 4 controls). RESULTS: From 2004 to 2014, 417 open nephrectomies were performed in one university hospital. Forty-five patients were included: 9 in GE and 36 in GT. There was no statistically significant difference between GT and GE for weight, height, body mass index (BMI), emergency, partial nephrectomy, laterality, rib resection, laparoscopic conversion to open surgery, postoperative complications, smoking, diabetes mellitus, cardiovascular history, obesity and sex, but there was a statistically significant difference for age, operative time, chronic obstructive pulmonary disease (COPD) and severe obesity (BMI>35) with, respectively, P=0.05, P=0.02, P=0.04 and P=0.02. CONCLUSION: Risk factors for lumbar incisional hernia after open nephrectomy are age, operative time, severe obesity and COPD. LEVEL OF EVIDENCE: 5.

The effect of immune therapy on surgical site infection following Crohn's Disease resection.

BACKGROUND: Patients with Crohn's disease are increasingly receiving antitumour necrosis factor α (anti-TNF-α) therapy. Whether anti-TNF-α therapy increases the risk of postoperative infectious complications in Crohn's disease is a matter of debate. METHODS: This was a retrospective study of three referral centres. The charts of patients who underwent ileocaecal or ileocolonic resection for Crohn's disease between 2000 and 2011 were reviewed. The impact of baseline characteristics and Crohn's disease-related medications on the risk of postoperative intra-abdominal infectious complications was investigated by univariable and multivariable analysis. RESULTS: A total of 217 patients were included in the study. Median age at the time of surgery was 36·8 (range 15-78) years. A postoperative intra-abdominal infection occurred in 24 (11·1 per cent) of 217 patients. No deaths were reported. On univariable analysis, age less than 25 years (P = 0·023), steroid use (P = 0·017), anti-TNF-α therapy (P = 0·043) and anti-TNF-α treatment in combination with steroids (P = 0·004) were associated with an increased risk of postoperative intra-abdominal infectious complications. On multivariable analysis, only anti-TNF-α therapy in combination with steroids significantly increased this risk (odds ratio 8·03, 95 per cent confidence interval 1·93 to 33·43; P = 0·035). CONCLUSION: Combined use of steroids and anti-TNF-α therapy was associated with an increased risk of postoperative intra-abdominal infectious complications.

[Surgical treatment of hidradenitis suppurativa: a retrospective study of 93 cases]. / Maladie de Verneuil: étude rétrospective chez 93 malades traités chirurgicalement.

INTRODUCTION: Hidradenitis suppurativa is a chronic disease, severe forms of which may be highly invalidating. Although wide surgery is usually considered the most effective curative therapy, few medical teams in France have extensive experience of this approach. Our aim was to evaluate the clinical history and the results of surgery in all patients operated with curative intent in an experienced centre. PATIENTS AND METHODS: Medical records were reviewed for all patients operated between January 1985 and January 2007. In addition, the patients were contacted by telephone and/or letter and asked about their clinical history, the repercussions of their disease on their daily lives, postsurgical relapse and their overall satisfaction regarding surgery. Separate analyses were carried out for patients and for individual operated sites. RESULTS: Of 93 patients followed-up for between one and 205 months (mean: 30 months), 209 anatomical sites were operated with curative intent, using either limited excision (i.e. including all visible lesions without margins) or wide excision (i.e. including all lesions with a significant margin). The disease had been present for an average of 7.6 years before surgical treatment, with onset seven years earlier in women. Most patients had previously received multiple and often unsuitable medical treatments. Patients' personal and professional lives were highly affected. Surgery required hospitalization for an average duration of 6.6 days, caused complications in 21% of cases and was often perceived as trying. Relapse in the operated areas occurred in 33% of cases and this was more frequent after limited excision. Nevertheless, 74% of patients were ultimately satisfied with their surgical treatment and most regarded surgery as the only really effective therapy. DISCUSSION: Our study confirms the heavy repercussions of hidradenitis suppurativa on patients' day-life as well as the value of surgical management by experienced surgeons. CONCLUSION: Wide excision remains the mainstay of therapy in extensive forms of hidradenitis suppurativa. However, this chronic, disseminated and recurrent disease continues to be insufficiently understood and innovative medical approaches, including the development of clinical trials, are required.

The European hernia society groin hernia classification: simple and easy to remember.

After reviewing the available classifications for groin hernias, the European Hernia Society (EHS) proposes an easy and simple classification based on the Aachen classification. The EHS will promote the general and systematic use of this classification for intraoperative description of the type of hernia and to increase the comparison of results in the literature.

Open retromuscular large mesh reconstruction of lumbar incisional hernias including the atrophic muscular area.

PURPOSE: Lumbar incisional hernias (LIH) are a rare wall defect, whose surgical management is challenging because no recommendation exists. Moreover, LIH are frequently associated with flank bulging which should be taken into account during LIH surgical repair. We aimed to describe a cohort of patients operated on for LIH using a homogeneous surgical technique and to report surgical outcomes. METHODS: The records of all consecutive patients operated on in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh into the retroperitoneal space posteriorly, placed with the largest overlap inferiorly and posteriorly, and fixed through the controlateral abdominal wall muscles under strong tension to correct the flank bulging. RESULTS: The cohort included 31 patients, of median age 62, who presented two or more comorbidities in 68% of cases. LIH was recurrent in 45% of patients, and was related to nephrectomy in 61% of patients. The mesh was totally extraperitoneal in 65% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 32.3%, and the rate of overall postoperative morbidity (Clavien-Dindo classification) was 38.7%. After a median follow-up of 27.5 months, the recurrence rate was 6.5% and 9.7% reported chronic pain. CONCLUSION: The open approach for LIH repair was safe and enabled treating flank bulging simultaneously in all patients. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of LIH surgical management.

[Endometriomas of the abdominal wall: Imaging findings]. / Endométriomes de la paroi abdominale: apport de l'imagerie.

Endometrioma of the abdominal wall is a not well-recognized disease and usually develops after pelvic surgery. The most common presentation is a mass of the abdominal wall associated with pain during menstruation. We report six cases of parietal endometriomas studied with ultrasonography, CT, and in one case with MRI. Our results are compared with recent findings in the literature. The purpose of this study was to describe the clinical and imaging findings in abdominal wall endometriomas that can help reach a presurgical diagnosis.

The use of Dacron in the repair of hernias of the groin.

Two French surgical teams particularly interested in hernia problems detail the use of Dacron (Mersilene) mesh in the treatment of groin hernias for the reinforcement or the replacement of the fascia transversalis , as by an artificial endoabdominal fascia. The article reports the experiences and techniques of the two teams, which have used Dacron for 20 years, either by the inguinal or the preperitoneal abdominal approach. The good results reported allow the statement that, without ruling out classic techniques for simpler cases, surgical repair using prostheses offers an excellent opportunity for use and for preventing the recurrence of hernias.

[Retromuscular prosthetic repair: experience from France]. / Retromuskuläre Netzplastik: Erfahrungen aus Frankreich.

Large incisional hernias cannot be cured without prosthetic material. A large pore size prosthetic tissue seems to be the best alternative, since connective invasion of the mesh provides a very strong fixation of the prosthesis. In our view, the mesh should be placed in the rectus sheath, in a position we have described as "retromuscular prefascial". With this technique, a good result can be achieved in 98% of very large incisional hernias.

[Is there still a place for surgery in the treatment of communicating pseudocyst in chronic pancreatitis?]. / Reste-t-il une place pour la chirurgie dans le traitement des pseudo-kystes communicants de la pancréatite chronique?

The purpose of this study was to evaluate the results of long term percutaneous catheter drainage in the treatment of chronic pancreatic pseudocysts communicating with pancreatic ducts. Since 1986, 13 consecutive patients with symptomatic pseudocysts were treated prospectively. All pseudocysts were associated with chronic pancreatitis. The location was head (n = 8), body (n = 3) or tail (n = 2). The procedure included fine needle aspiration under ultrasonic control, percutaneous drainage along a guide wire and closed suction aspiration. A radiological control was performed weekly and the catheter was left in place until total resolution of pseudocyst. Immediate relief of pain and resolution of pseudocyst were obtained in all 13 patients. The average length of hospital stay was 12.2 +/- 8 days (1 to 23). The average duration of drainage was 36 days. There was no mortality of morbidity related to the drainage. There were two asymptomatic recurrences, but long-term follow-up (mean 3 years) showed that all 13 patients were symptom-free. The clinical results of such a long-term catheter drainage seem better in our study than in other previous series. It is a simple and innocuous procedure, and could be carried out in an outpatient unit. Such drainage represents an efficient alternative to endoscopic or surgical treatment of chronic pancreatic pseudocyst with ductal communication. In our experience surgery is no longer indicated.

[Evolution of indications for Hartmann's operation. Reflexions on a series of 160 cases]. / Evolution des indications de l'opération de Hartmann. Réflexions à propos d'une série de 160 observations.

The authors report the results and indications of 160 Hartmann's procedures performed over a period of 15 years. Between 1978 and 1992, 160 patients (90 males, 70 females), with a mean age of 72, underwent Hartmann's procedure for rectosigmoid carcinoma in 55% of cases, for complications of sigmoid diverticulitis in 36% and for other lesions in 14%. Hartmann's procedure was performed either electively (42%) or as an emergency (58%) with a mortality of 6% and 32% respectively. The majority of complications included wound infections or intraperitoneal abscess, and the overall morbidity was 30%. Re-establishment of bowel continuity was performed in 30.7% of patients, most of whom had been initially operated as an emergency for a benign lesion. These 160 cases of Hartmann's procedure represent 27% of the 590 operations performed during the same period as an emergency or electively for rectosigmoid lesion. Hartmann's procedure remains a most effective technique for emergency surgery for benign or malignant lesions with colonic septic complications, and is also indicated electively for palliative treatment of rectosigmoid carcinoma.

[Exteriorized suture of injuries of the colon]. / La suture extériorisée des plaies du côlon.

When the use of an intraperitoneal suture of a colon wound does not appear reasonable due to a delay in treatment or the marked peritoneal contamination, temporary exteriorization of the sutured colon can constitute a valuable alternative to pure and simple exteriorization of the colon wound. Cicatrization of the colon suture can be obtained outside the abdominal cavity in more than half the cases. The colon can then be integrated simply at about the 15th day, avoiding in this way the disagreeable need for prolonged colostomy and the potential risks of a construction of a secondary circuit. This process was used in 6 injured patients and healing was obtained in 3.

[Modern peroperative radiology in biliary surgery. Results obtained in a continuous series of 341 cases (author's transl)]. / La radiologie moderne per-opératoire en chirurgie biliaire. Résultats obtenus dans une série continue de 341 observations.

The authors study the results obtained in biliary surgery using modern radiological and electronic equipment, combining rapid-sequence image intensified fluorography modular cabinet, television screens and videorecorder. The performance of this apparatus has enabled them to obtain precise measurements of pressure as required, a continuous film reproducing the televised image, films taken in series at the time of and during the desired programming with a very short time required for setting up and with multiple views. Under such conditions, it is possible to avoid troublesome superimpositions, to reduce to the order of 0% the figure for missed calculi and to adequately explore the choledoco-duodenal junction with the possibility of precisely determining the indications for sphincterotomy (Oddi). Finally, the apparatus offers the possibility of combining an abdominal vascular assessment with the biliary investigation, in those cases where such a study may appear useful. Finally, the price of the apparatus is acceptable since it may be used by several departments at the same time within the context of a common operating suite.

[Variations in the parathyroid glands. Number, situation and arterial vascularization. Anatomical study and surgical application]. / Les variations des parathyroïdes. Nombre, situation et vascularisation artérielle. Etude anatomique et applications chirurgicales.

The authors have made a study of the variations in the parathyroid glands, basing their report on 100 block dissections of the neck injected with latex. The results allow a better understanding of certain types of parathyroid insufficiency following surgery to the thyroid gland. In almost half the cases the vascular arrangement was sufficient to explain how hypoparathyroidism might come about following surgery to the thyroid gland.

[Anatomic pitfalls of recurrent laryngeal nerve dissection]. / Les pièges anatomiques de la dissection du nerf récurrent.

Based on findings during 600 thyroid operations and pathological examination of 100 specimens, the principal difficulties encountered during dissection of the recurrent laryngeal nerve related to its anomalies and normal variations are discussed. Studied successively are variations in relations of the nerve with the inferior thyroid artery and its branches, the extralaryngeal bifurcations of the nerve, and the non-recurrence of the inferior laryngeal nerve.

[Is vesicular cholesterolosis a particular anatomo-clinical form of cholesterol lithiasis? Apropos of a case of cholesterol polyp manifested by an acute complication]. / La cholestérolose vésiculaire est-elle une forme anatomo-clinique particulière de la lithiase cholestérolique? A propos d'une observation de polype cholestérolique révélé par une complication aiguë.

A case of cholesterolic polyp, revealed by the formation of an infundibulo-cystic enclave, is reported, the polyp having the appearance of a cholesterolic calculus, but a pediculated one, and one acting as a calculus. The extreme rarity of this complication is emphasized. Despite the frequency of associated lithiasis, the cholesterolosis are included in a different framework from lithiasis, that of the cholecystoses that on histology show typical pure parietal lesions without inflammation. Findings in this atypical case suggest possible common pathogenic factors for the two affections, and raise a proposal for inclusion of cholesterolosis within the nosologic framework of lithiasis.

[Combination of colorectal tumor and Streptococcus bovis endocarditis. Apropos of 3 cases]. / Association d'une tumeur colo-rectale et d'une endocardite à Streptococcus bovis. A propos de trois observations.

The authors report about 3 cases of bovis endocarditis revealing a colic carcinoma. This morbidity confirms the need for routine digestive investigations in endocarditis due to group D streptococci and eventually a liver disease.

[Role of vascular erosion in massive colonic hemorrhage of diverticular origin. Apropos of a case]. / Rôle de l'érosion vasculaire dans les hémorragies coliques massives d'origine diverticulaire. A propos d'une observation.

A case of massive hemorrhage from colon of diverticular origin is reported. A complete study of operative specimen allowed precise localization of diverticulum responsible and guidance of histopathologists in their search for the arterial erosion. Histology showed loss of arterial substance with total communication with diverticular lumen. A literature review emphasized vascular relations of diverticuli and the role of stercoliths in the mechanical agression responsible for the massive hemorrhage. It also illustrated the predominance of arteriography in the modern diagnostic and therapeutic approach to these lesions.

[Cardiopexy using the umbilical ligament of the liver in the treatment of gastro-esophageal reflux. Results of experience with 100 cases]. / La cardiopexie par le ligament ombilical du foie dans le traitement du reflux gastro-oesophagien. Résultat d'une expérience de 100 interventions.

The authors report their experience of the surgical treatment of gastroesophageal reflux using a circular cardiopexy with the ligamentum teres (Rampal-Marchal's procedure) associated with a 180 degrees posterior fundoplication. 100 patients with severe reflux (76% oesophagitis) were operated on with this procedure over a 6 year period. Symptoms of reflux disappeared immediately in 99% cases, which corresponded to the healing of oesophagitis with 45 out of the 46 patients controlled with endoscopy, and to a significant increase of inferior sphincteric pressure (from 12 cm H20 to 24 cm H20). Objective controls by post prandial pHmetry evidenced persistent reflux with 4 patients, but 3 of them are totally free of symptoms. Operative mortality was 2%. Transient dysphagia was observed in 25% cases. 96 patients were reviewed with a mean follow up of 23 months. 3 clinical recurrence of reflux were observed (4%) but no oesophagitis was found on endoscopic controls with these 3 patients and none had to be reoperated on. Actuarial chance to remain free of recurrence was estimated at 96.6% up to 48 months according to the Kaplan-Maier's method. Cardiopexy with the ligamentum teres ensures the lengthening of the abdominal portion of the esophagus and anchors the antireflux assembly within the positive pressure environment of the abdomen in a strong and flexible way. It seems to be an advisable procedure for the treatment of GE reflux.

[Digestive cancers and choroid metastasis. Diagnostic circumstances and prognostic value apropos of 2 cases]. / Cancers digestifs et métastases choroïdiennes. Circonstances du diagnostic et intérêt pronostique à propos de 2 observations.

We report two observations of malignant gastric and pancreatic tumors with choroid metastasis. Clinical course was rapidly and spontaneously unfavorable.

[Comments on emergency treatment of biliary lithiasis in patients over 75 years of age. Apropos of 157 cases]. / Réflexions sur le traitement des urgences de la maladie biliaire lithiasique chez les sujets de plus de 75 ans. A propos de 157 observations.

Surgery remains the ideal emergency treatment for biliary lithiasis in elderly subjects despite perioperative morbidity and mortality. Minimally invasive techniques appear promising but require assessment. The aim of this work was to determine the usefulness of these techniques and evaluate outcome in a series of 157 patients over 75 years of age who were hospitalized in an emergency setting of complicated biliary lithiasis from January 1990 to December 1996. There were 103 women and 54 men, mean age 82 years. The patients' general status was evaluated according to the ASA classification; 66% of the patients were ASA III, IV or V. Diagnoses at admission were acute cholecystitis (n = 71, 45%), angiocholitis (n = 50, 31%) subintrant hepatic colic (n = 17, 10.8%), pancreatitis (n = 10, 6%), isolated jaundice (n = 2), peritonitis (n = 2) and occlusion (n = 5). Within 24 hours of admission, 7 patients underwent emergency surgery, and the 150 others were given medical treatment. Among these 150 patients, cure was considered to have been achieved with medical treatment alone in 41 (subsequent surgery being required in only one 6 months later), semi-emergency was performed in 17, and a minimally invasive procedure was performed in the 92 others (echo-guided percutaneous cholecystostomy in 42, endoscopic sphincterotomy in 50) followed by a subsequent operation in 29. In the 103 patients (65.5%) in this series who did not undergo surgery, mortality was 3.8% and in the 54 patients (34.5%) who did, mortality was 15%, but this rate was only 6.9% when the open procedure followed a minimally invasive technique. Surgical treatment of complicated biliary disease remains the ideal therapy but indications should be carefully weighed in these elderly fragilized subjects. Under surgical observation, abstention from surgery or use of minimally invasive techniques can play an important role in the therapeutic strategy aimed at lowering perioperative mortality.