Endoscopic approach for orbital apex lesions: case series and review of the literature.

OBJECTIVE: The transnasal endoscopic approach may provide better visualisation and a safer approach to the orbital apex. This study presents a case series of orbital apex lesions managed by this approach. METHOD: This study was an eight-year retrospective analysis of seven patients who were operated on for orbital apex lesions in two tertiary medical centres. RESULTS: Complete tumour removal was performed in three patients and partial removal was performed in four patients. Visual acuity improved in three patients, remained stable in one patient and decreased in the other two patients. The visual field improved in four patients and did not change in two patients. Complications included worse vision and visual fields in 28.6 per cent of patients and late enophthalmos (of -1.25 ± 4.6 mm) in 2 patients. CONCLUSION: The transnasal approach to orbital apex lesions in selected cases may provide a rational alternative to transorbital surgery. Complete tumour removal should be weighed against the risk of damage to the optic nerve.

Endoscopic sinus surgery for dental implant displacement into the maxillary sinus-a retrospective clinical study.

The aims of this retrospective clinical study were to present our management protocol for the retrieval of impacted dental implants that have become displaced into the maxillary sinus cavity and to define the role of endoscopic sinus surgery in this setting. All 24 patients (25 implants) who underwent surgical retrieval of dental implants displaced into the maxillary sinus between 2012 and 2019 were included. Data on surgical interventions and complications were collected retrospectively. Eleven patients (46%) had chronic sinusitis associated with the migrated implant. All implants were successfully retrieved via transnasal endoscopic approach alone: 80% via a middle meatal antrostomy and 20% via a combined middle and inferior meatal antrostomy. Five patients required a concomitant transoral approach for oro-antral fistula repair. None required a transoral approach for displaced implant retrieval. All patients healed uneventfully without complications. Transnasal endoscopic sinus surgery via a middle meatal antrostomy or a combined middle and inferior antrostomy is recommended as the primary choice for dental implant retrieval from the maxillary sinus. A transoral approach should be performed simultaneously only for oro-antral fistula repair. This surgical protocol proved to be safe and efficient, and it obviated the need for osteotomies of the anterolateral maxillary wall.

[Tolerance of hypofractionated stereotactic radiotherapy for hepatic tumours]. / Tolérance de l'irradiation stéréotaxique hypofractionnée des tumeurs hépatiques.

PURPOSE: The purpose of the study was to evaluate the outcomes of stereotactic radiation therapy for primary and secondary liver tumours in Jean-Perrin cancer centre (Clermont-Ferrand, France) in terms of efficacy and safety. MATERIALS AND METHODS: Between December 2013 and June 2016, 25 patients were included. Treatment was performed on a linear accelerator Novalis TX®. The prescription dose was 42 to 60Gy in three to five fractions. Local control at 1 year was evaluated with modified Response Evaluation Criteria in Solid Tumours (mRECIST) and RECIST criteria. Acute and late toxicity were evaluated with Common Terminology Criteria for Adverse Events (CTCAE) v4.0 criteria. RESULTS: Median follow-up was 10.5 months. Treatment tolerance was good with few side effects grade 3 or above, no acute toxicity and only one late toxicity. We have highlighted that hepatic artery haemorrhage was associated with the presence of a biliary prosthesis in contact with the artery (P=0.006) and in the irradiation field. There was no correlation with the dose delivered to the artery and hepatic artery haemorrhage. CONCLUSION: Stereotactic radiation therapy for liver tumours allows a good local control with few secondary effects. Caution should be exercised when treating patients with biliary prostheses in the vicinity of the target volume because there is a risk of haemorrhage of the hepatic artery in contact with the prosthesis.

[Extragenital endometriosis: Parietal, thoracic, diaphragmatic and nervous lesions. CNGOF-HAS Endometriosis Guidelines]. / Endométriose extra-génitale : atteinte pariétales, thoraciques, diaphragmatiques et nerveuses. RPC Endométriose CNGOF-HAS.

According to some studies, extragenital endometriosis represents 5% of the localisations. Its prevalence seems to be underestimated. The extra pelvic localisation can make the diagnosis more difficult. Nevertheless, the recurrent and catamenial symptomatology can evoke this pathology. Surgery seems to be the unique efficient treatment for parietal lesions. Pain linked to nervous lesions (peripheric and sacral roots) seems to be underestimated and difficult to diagnose because of various localisations. Neurolysis seems to have encouraging results. Diaphragmatic lesions are often discovered either incidentally during laparoscopy, or by pulmonary symptomatology as recurrent catamenial pneumothorax or cyclic thoracic pain. Surgical treatment seems as well to be efficient.

Biliary stenting is not a prerequisite to endoscopic placement of duodenal covered self-expandable metal stents.

BACKGROUND: Duodenal covered self-expandable metal stent (cSEMS) can be used in malignant or benign gastroduodenal obstruction. The need for biliary stenting in patients with no concomitant biliary stricture, before duodenal cSEMS placement, remains unknown. The aim of this study was to determine whether cSEMS placement is responsible for biliary obstruction. METHODS: This is a single-center, retrospective, case-controlled study, including 106 patients with symptomatic gastric outlet obstruction or duodenal fistula who received a covered nitinol duodenal stent by using through-the-scope/over-the-wire placement procedure. The main outcome measurement was the occurrence comparison of jaundice and bilirubin level, between patients with previous or concomitant biliary stenting (cSEMS + BS group), and patients with no biliary stent (cSEMS group) during an observational period of 90 days. RESULTS: Hundred and six patients underwent cSEMS placement between June 2005 and March 2014: 53 in the cSEMS group (58% male, mean age 66.4 ± 13.3 years) and 53 in cSEMS + BS group (60% male, mean age 70.4 ± 11.6 years). The obstruction was due to cancer in 45% in cSEMS group and 87% in cSEMS + BS group. No case of jaundice was reported in the cSEMS group or in the cSEMS + BS group. In cSEMS group, the mean bilirubin level (µmol/L ± SD) was 8.0 ± 4 at baseline and 8.5 ± 4.6 at day 10, while in the cSEMS + BS group it was 91.4 ± 108 at baseline and 35.3 ± 39 at day 10 (p < 0.01). Patients from the two groups were matched on age, gender and bilirubin level at baseline. Evolution of bilirubinemia was +0.98 ± 2.76 µmol/L in experimental group and +0.39 ± 522 µmol/L in the control group (p = 0.34). No significant difference was observed between the two groups in term of technical success, clinical effectiveness, migration and other complications. CONCLUSIONS: Previous biliary stenting is not required before endoscopic covered duodenal stent placement in patients with no associated biliary obstruction. Prospective studies are needed.

Landscape and climatic characteristics associated with human alveolar echinococcosis in France, 1982 to 2007.

Human alveolar echinococcosis (AE) is a severe hepatic disease caused by Echinococcus multilocularis. In France, the definitive and intermediate hosts of E. multilocularis (foxes and rodents, respectively) have a broader geographical distribution than that of human AE. In this two-part study, we describe the link between AE incidence in France between 1982 and 2007 and climatic and landscape characteristics. National-level analysis demonstrated a dramatic increase in AE risk in areas with very cold winters and high annual rainfall levels. Notably, 52% (207/401) of cases resided in French communes (smallest French administrative level) with a mountain climate. The mountain climate communes displayed a 133-fold (95% CI: 95-191) increase in AE risk compared with communes in which the majority of the population resides. A case-control study performed in the most affected areas confirmed the link between AE risk and climatic factors. This arm of the study also revealed that populations residing in forest or pasture areas were at high risk of developing AE. We therefore hypothesised that snow-covered ground may facilitate predators to track their prey, thus increasing E. multilocularis biomass in foxes. Such climatic and landscape conditions could lead to an increased risk of developing AE among humans residing in nearby areas.

[Transvaginal hydrolaparoscopy for infertility investigation: a retrospective study, about 262 patients]. / Intérêt de la fertiloscopie dans la prise en charge de l'infertilité: étude rétrospective, à propos de 262 cas.

OBJECTIVES: To evaluate fertiloscopy's results and to redefine its place in the management of female infertility. PATIENTS AND METHODS: Retrospective study including 262 cases of fertiloscopy and 260 patients with primary or secondary idiopathic infertility. Analysis of infertility assessment's findings (hysterosalpingography), perioperative data (operating technique, laparoscopic conversion, failures and complications). Comparison of hysterosalpingography's findings and peroperative data; comparison of fertiloscopy and laparoscopy's findings. RESULTS: Access to peritoneal cavity was possible for 248 fertiloscopies (95%), and pelvic exploration was considered as complete for 226 cases (86%). Laparoscopic conversion was necessary in 54 cases (21%) and indicated by surgical pathology in more of one third of the cases (n=20). Our failure rate was only 5,3% (n=14), partially thanks to posterior colpotomie (70% of failures avoided). We deplored 8 complications (3.05%) which were not severe (no bowel injury), among which half were linked with the hysteroscopy (uterus perforation). In the cases of laparoscopic conversion, laparoscopic findings confirmed per-fertiloscopic data, considering adhesions and tubal patency. Hysterosalpingography had poor sensibility and positive predictive value. DISCUSSION AND CONCLUSION: Fertiloscopy is a safe, reproducible and not much invasive procedure. It can be substituted to laparoscopy in infertility assessment when there is no obvious surgical indication. Moreover, it could be considered as a first line way of investigation in female infertility management, instead of hysterosalpingography which has poor sensibility and positive predictive value.

A feature selection based framework for histology image classification using global and local heterogeneity quantification.

Biopsy remains the gold standard for the diagnosis of chronic liver diseases. However, the concordance between readers is subject to variability causing an increasing need of objective tissue description methods. A complete framework has been implemented to analyze histological images from any kind of tissue. Based on the feature selection approach, it computes the most relevant subset of descriptors in terms of classification from a wide initial list of local and global descriptors. In comparison with equivalent methods, this implementation is able to find lists of descriptors which are significantly shorter for an equivalent accuracy and furthermore it enables the classification of slides using combinations of global and local measurements. The results have pointed that it could reach an accuracy of 82.8% in a human liver fibrosis grading approach by selecting 6 descriptors from an initial set of 258 global and local descriptors.

[Fibrolamellar hepatocellular carcinoma in a patient with chronic viral B hepatitis]. / Carcinome hépatocellulaire fibrolamellaire chez un patient suivi pour hépatite chronique virale B.

In most cases, fibrolamellar hepatocellular carcinoma has specific and distinctive histopathological features that distinguish it from hepatocellular carcinoma. Magnetic resonance imaging can provide characteristic features to obtain a diagnosis of this entity. We report a case of fibrolamellar hepatocellular carcinoma with a radiological-pathological correlation in a 37 year-old man with chronic viral hepatitis B without cirrhosis who underwent right hepatectomy.

Multicentre randomised phase III trial comparing Tamoxifen alone or with Transarterial Lipiodol Chemoembolisation for unresectable hepatocellular carcinoma in cirrhotic patients (Fédération Francophone de Cancérologie Digestive 9402).

The FFCD 9402 multicentre phase III trial was designed to compare the effects of the combination of Transarterial Lipiodol Chemoembolisation (TACE) and tamoxifen with tamoxifen alone on overall survival and quality of life in the palliative treatment of hepatocellular carcinoma with cirrhosis. From 1995 to 2002, 138 patients were randomised between the two groups. One hundred and twenty three patients were eligible including 61 in the Tamoxifen group and 62 in the TACE group. Baseline characteristics were similar: Child-Pugh class A: 70%, alcoholic cirrhosis: 76%, Okuda stage I: 71%, multinodular tumour: 70% and segmental portal vein thrombosis: 10%. At 2years, the overall survival was 22% and 25% in the Tamoxifen and TACE groups (P=.68), respectively. Multivariate analysis identified four independent prognostic factors for survival: alpha-fetoprotein (AFP)>400ng/mL (P=.008), abdominal pain (P=.011), hepatomegaly (P=.023) and Child-Pugh score (P=.032). The Spitzer Index level assessing the quality of life during follow-up did not differ between the two groups (P=.70). Amongst patients with stage Okuda I, the 2-year overall survival was 28% in the Tamoxifen group and 32% in the TACE group (P=.58). In this subgroup, two prognostic factors were statistically significant for survival: AFP>400ng/mL (P=.004) and Spitzer Index (P=.013) as shown by multivariable analysis. In conclusion, this study suggests that TACE improves neither the survival nor the quality of life in patients with HCC and cirrhosis.

Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients.

PURPOSE: To assess the endovascular treatment of splenic artery aneurysms and false aneurysms. METHODS: Twelve patients (mean age 59 years, range 47-75 years) with splenic artery aneurysm (n = 10) or false aneurysm (n = 2) were treated. The lesion was asymptomatic in 11 patients; hemobilia was observed in one patient. The lesion was juxta-ostial in one case, located on the intermediate segment of the splenic artery in four, near the splenic hilus in six, and affected the whole length of the artery in one patient. In 10 cases, the maximum lesion diameter was greater than 2 cm; in one case 30% growth of an aneurysm 18 mm in diameter had occurred in 6 months; in the last case, two distal aneurysms were associated (17 and 18 mm in diameter). In one case, stent-grafting was attempted; one detachable balloon occlusion was performed; the 10 other patients were treated with coils. RESULTS: Endovascular treatment was possible in 11 patients (92%) (one failure: stenting attempt). In four cases among 11, the initial treatment was not successful (residual perfusion of aneurysm); surgical treatment was carried out in one case, and a second embolization in two. Thus in nine cases (75%) endovascular treatment was successful: complete and persistent exclusion of the aneurysm but with spleen perfusion persisting at the end of follow-up on CT scans (mean 13 months). An early and transient elevation of pancreatic enzymes was observed in four cases. CONCLUSION: Ultrasound and CT have made the diagnosis of splenic artery aneurysm or false aneurysm more frequent. Endovascular treatment, the morbidity of which is low, is effective and spares the spleen.

[Complicated polycystic liver disease with intracystic hemorrhage and obstructive jaundice]. / Polykystose hépatique compliquée d'une hémorragie intra-kystique et d'un ictère compressif.

Polycystic liver disease, which is generally part of the autosomal dominant polycystic kidney disease, is often asymptomatic. We report a case of obstructive jaundice caused by compression of the biliary tract by a large haemorrhagic liver cyst. The patient was a man with sporadic polycystic liver disease without polycystic kidney disease and with normal renal function for his age. Ultrasound combined with cholangio-MRI provided non-invasive confirmation of intracystic bleeding and intrahepatic biliary dilatation. Obstructive jaundice was confirmed by cyst puncture-aspiration which resolved symptoms and normalized biology. The initial treatment of haemorrhagic liver cyst complicating polycystic liver disease must be medical with cyst aspiration-drainage and sclerotherapy to avoid surgery in these fragile patients.

Hemoperitoneum in patients receiving hemodialysis.

Acute abdominal pain in chronic hemodialysis patients has well-known causes, including acute pancreatitis, mesenteric arterial insufficiency, or complicated duodenal ulcer. Others, such as hemoperitoneum, are far less common. Although hemoperitoneum occurs in patients receiving peritoneal dialysis, dialysis is seldom if ever the direct cause of the bleeding. Hemoperitoneum is often related to menses or ovulation, particularly to ovarian cyst rupture; therefore, it is more common in young women. In most cases, no specific treatment is required. Hemoperitoneum is rarely considered as the cause of acute abdominal pain in chronic hemodialysis patients. In this report of hemoperitoneum confirmed by emergency laparotomy in 3 women, bleeding was not related to gynecologic origin. All of the women were younger than age 50 and undergoing long-term hemodialysis. All patients had a history of acute abdominal pain associated with shock. The cause of bleeding was always an organ lesion: hepatic amyloidosis with suspected portal hypertension or sclerosing peritonitis and acute hemorrhagic pancreatitis. Coagulation abnormalities and the use of anticoagulants during hemodialysis sessions may have been aggravating factors in all three patients. Hemoperitoneum is difficult to diagnose, particularly in the minor forms, and consequently its incidence may be underestimated. Therefore, it should be considered whenever a chronic hemodialysis patient presents with persistent acute abdominal pain.

[Sarcoidosis gastropathy: diagnosis and contribution of echo-endoscopy]. / Gastropathie sarcoïdosique: diagnostic et apport de l'écho-endoscopie.

We report a case of gastric sarcoidosis in a 36-year old woman. The clinical and endoscopic ultrasonography findings initially suggested linitis plastica. Subsequently the discovery of unexpected gastric and then, bronchial granulomas after bronchoscopy and bilateral ocular fixation on gallium scanning, led to the diagnosis of sarcoidosis. Endoscopic ultrasonography showed abnormal hypertrophy of the third hyperechoic layer. These findings usually suggest among the etiologies of giant gastric folds, malignant diseases and particularly linitis plastica.

[Hepatocellular carcinoma in cirrhosis: semeiology and performance of magnetic resonance imaging and lipiodol computed tomography]. / Carcinome hépatocellulaire sur cirrhose: sémiologie et performances de l'imagerie par résonance magnétique et de la tomodensitométrie après artériographie lipiodolée.

OBJECTIVES: a) Describe hepatocellular semiology in magnetic resonance imaging and lipiodol computerized tomography in patients with cirrhosis, who are candidates for surgery; b) Clarify the respective roles of magnetic resonance imaging and lipiodol computerized tomography in hepatocellular detection. METHODS: Twenty four patients with suspected hepatocellular carcinoma underwent successive magnetic resonance imaging and lipiodol computerized tomography. Thirty-four of the 67 lesions seen by lipiodol computerized tomography and 28 of 52 lesions seen by magnetic resonance imaging were confirmed histologically. RESULTS: In lipiodol computerized tomography, 44% of hepatocellular carcinomas had a dense and homogeneous pattern; 24% had a homogeneous but slightly dense pattern. Sixteen distinct deposits were described: 4 were confirmed as hepatocellular carcinoma and 12 were not controlled histologically. In magnetic resonance imaging 57% of hepatocellular carcinomas have a high intensity on T1 and T2 weighted spin echo images, 38% were hyperintense on T2 and hypo or isointense on T1 weighted images. Eighty-six percent of hyperintense T1 and T2 weighted images were hepatocellular carcinoma. When the gold standard was histology, lipiodol computerized tomography sensitivity (81%) was higher than magnetic resonance imaging (68%). When the gold standard was lipiodol computerized tomography, the sensitivity of magnetic resonance imaging was 47 +/- 12%. CONCLUSIONS: a) The sensitivity of lipiodol computerized tomography was better than resonance magnetic imaging; b) the homogeneous and slightly dense pattern corresponded to a hepatocellular carcinoma in 50% of cases; c) on magnetic resonance imaging any lesions with high intensity on T1 and T2 spin echo images strongly suggests hepatocellular carcinoma; d) if surgical resection after ultrasonography is being considered, the second step should be an magnetic resonance imaging.

[Regression of a focal nodular hyperplasia after stopping oral contraceptives]. / Régression d'une hyperplasie nodulaire focale après arrêt d'une contraception orale.

The complete regression of a focal nodular hyperplasia of the liver with typical MRI patterns 5 years after withdrawal of oral contraceptives was observed. Effects of oral contraceptives on this tumor's evolution and appropriate imaging by MRI are discussed.

Tenoxicam, a non-steroid anti-inflammatory drug, is unable to increase the response rate in patients with chronic hepatitis C treated by alpha interferon.

The purpose of this study is to compare a combination of interferon (IFN)-alpha2a (Roferon) + Tenoxicam with IFN-alpha2a alone in the treatment of chronic hepatitis C. This prospective, randomized double-blind study included 149 patients, all of whom were diagnosed with active chronic hepatitis C but non-cirrhotic (ALT > or = 1.5 upper limit of normal, anti-hepatitis C virus (HCV) positive by enzyme-linked immunosorbant assay2 and RIBA3). The patients were randomized in two groups, as follows: G1 (n = 76): IFNalpha2a 3 million units times per week during 6 months + placebo; and G2 (n = 73): IFNalpha2a 3 million units three times per week + Tenoxicam (20 mg/day) during 6 months. Alanine aminotransferase (ALT) and HCV RNA were determined before and at months 6 and 12 of treatment. 2'5' oligoadenylate synthetase activity (2'5' AS) was dosed in mononuclear cells before and at 3-month treatment intervals in 28 patients. Liver biopsy was performed before and 6 months after the end of therapy. Parameters were similar before therapy for both groups. Biochemical and virological responses were similar for both groups at month 6 (49.3% vs. 42.9% and 43.3% vs. 38.3%, respectively) and month 12 (28.3% vs. 23.8% and 17.2% vs. 17.5%, respectively). HCV RNA level significantly decreased in both groups at month 6, with no difference whatever the therapy; however, the HCV RNA level returned to initial values at month 12 and was the only significant prognostic factor of a sustained response. No peak of 2'5' AS activity was observed during treatment in patients with dual therapy. A histological improvement was also noted in both groups without difference, regardless of therapy. The percentage of adverse events was identical for both groups. Paracetamol intake, assessed in 80 patients, was 49.1 g per 6 months in the G1 group and 22.5 g per 6 months in the G2 group (not significant). In conclusion, the non-steroid anti-inflammatory drug, Tenoxicam, does not increase IFNalpha efficacy in the treatment of chronic hepatitis C. This combination is well tolerated and partially lowers Paracetamol intake, but not preexisting alpha-IFN adverse events.