The sulcus of the caudate process (Rouviere's sulcus): anatomy and clinical applications-a review of current literature.

The sulcus of the caudate process is a horizontal groove on the inferior face of the liver. Its prevalence has not previously been determined. Because of its location, it represents a helpful extra-biliary landmark that could be used in biliary surgery to decrease bile duct injury. The goal of this study is to determine the prevalence of Rouviere's sulcus and describe its anatomy and relevant surgical applications. We conducted a literature review on the various characteristics of the sulcus, selecting anatomical clinical studies and dissections. We performed 10 cadaveric dissections in the Laboratory of Anatomy at Purpan University to determine the contents. We selected 12 anatomical studies, conducted between 1924 and January 1st, 2020, which included 2394 patients. The prevalence of the sulcus is 78.24% ± 9.1. Classification of Singh was used to describe anatomical characteristics. Type I ("deep sulcus") was identified in 50.4% ± 9.8 of cases, mostly consisting of Type Ia (open). Type II ("slit-like") was estimated to account for 13.3% ± 13.2, whereas Type III ("scar") described 12.3% ± 8.0. Average dimensions were estimated for length (26 mm ± 5.7), width (6.5 mm ± 1.5), and depth (7.9 mm ± 1.75). The content of the sulcus consists of the right portal vein and its division, the right hepatic artery, along with the right hepatic bile duct. The sulcus determines the orientation of the common bile duct. The sulcus of the caudate process is a reliable extra-biliary landmark, which presents a useful tool for reducing bile duct injuries during hepatobiliary surgery.

Tolerance and efficacy of dose escalation using IMRT combined with chemotherapy for unresectable esophageal carcinoma: Long-term results of 51 patients.

PURPOSE: The optimal dose in esophageal cancer patients treated with definitive chemoradiation (CRT) remains debated. We herein report on the dosimetric results, treatment-related toxicities and long-term outcomes of escalated dose up to 60Gy delivered with intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: All consecutive patients that received a definitive CRT>50Gy for an unresectable esophageal carcinoma between 2010 and 2015 were retrospectively evaluated for this study. Methodology included data base search, delayed toxicity grading, statistical testing including frequency analysis and survival analysis. RESULTS: A total of 51 patients were irradiated for a squamous cell carcinoma (86.3%) or an adenocarcinoma (13.7%). The median age at diagnosis was 62 years. Seven patients were simultaneously irradiated for another synchronous primary tumor. Forty-six patients (90.2%) received concurrent platin-based chemotherapy. The median prescribed doses were 60Gy (54-66) and 48Gy (44.8-56) delivered in 30 (27-35) fractions to the high and the low risks PTV respectively. The mean dose delivered to the lungs was 11.4Gy (IC 95%: 4.8-19.8), the median volumes receiving up to 20Gy (V20) and 30Gy (V30) were 13.5% (3.0-46.0) and 4.6% (0.7-19.8) respectively. The mean dose delivered to the heart was 13.9Gy (IC 95%:0.3-31.3) with a median V40 of 3.3% (0.0-25.0). One treatment-related death occurred within days after RT completion (neutropenic aplasia). After a median follow-up of 2.7 years (95% CI: 1.9-4.3), the 2-year overall survival, disease free survival and loco-regional control rates were 53.6%, 42.0% and 72.8% respectively. Delayed treatment related-toxicities ≤grade 3 occurred among 25 patients (62.5%) mostly esophageal stricture (79.2%). CONCLUSION: We demonstrated in this study that dose escalation using IMRT in combination with platin-based chemotherapy as a definitive treatment for esophageal carcinoma is safe and results in higher loco-regional and control survival when compared to previously reported data.

[Definitive or neo-adjuvant chemoradiation in esophageal carcinoma?] / Cancer de l'œsophage : radio-chimiothérapie exclusive ou préopératoire ?

Management of resectable esophageal carcinoma is based on a multimodal treatment associating neo-adjuvant chemoradiation before surgery. This therapeutic sequence allows a disease-free survival rate at 2 years around 45% but remains associated with a high post-operative morbidity. In case of definitive chemoradiotherapy, the dose delivered to the macroscopic disease is a controversial topic since decades and the prognosis of patients treated in this setting at the dose of 50Gy remains poor. This article proposes a review of the main published data and the ongoing studies related to the management of these patients.

Mid-term outcomes after biologic mesh use: Does their performance meet our expectations?

INTRODUCTION: The indications for use of biological mesh prostheses are very limited because of their high cost, but include parietal repair in a contaminated setting. Their efficacy has been questioned by several recent studies. We therefore studied the results of all of our patients who received a biological prosthesis, including hernia recurrence and infectious complications. PATIENTS AND METHODS: We retrospectively reviewed the outcomes of 68 patients who underwent biological prosthesis placement from 2009 to 2015 in a single center. RESULTS: The site of implantation was on the anterior abdominal wall in 49 (72%) of cases, in the pelvis in 19 (28%). The median follow-up was 19 months. In the early post-operative period, 22 (32.3%) of patients presented with wall abscess; eight (11.7%) underwent surgical revision and seven (10.2%) underwent interventional radiological drainage. In the medium term, 41/56 (73%) had a late complication; 32 (57%) of the patients developed recurrent herniation and 15 (26.7%) of them were re-operated. In addition, nine (16%) of patients developed a late surgical site infection and eight (14.2%) a chronic residual infection. In multivariate analysis, the risk factors for recurrence were parastomal hernia (P=0.007) and a history of recurrent hernia (P=0.002). CONCLUSION: A majority of patients developed recurrent incisional herniation in the medium term. This puts the use of biological prostheses into question. These results need to be compared to those of semi-absorbable prostheses.

Gastric bleeding risk following spleen preserving distal pancreatectomy with excision of the splenic vessels: a long-term follow-up.

BACKGROUND: Spleen-preserving distal pancreatectomy with resection of the splenic vessels (VR-SPDP) is an effective procedure. However, hemodynamic changes in splenogastric circulation may lead to the development of gastric varices (GV) with a risk of gastrointestinal (GI) bleeding. This retrospective study aimed to assess the long-term postoperative clinical follow-up of patients and review the late postoperative abdominal computed tomography (CT) or endoscopic examination. METHODS: From 1988 to 2015, 48 consecutive VR-SPDP for benign or low-grade malignant disease were included. Late postoperative follow-up was undertaken with the use of a prospective database and assessment undertaken by CT and/or endoscopy. RESULTS: The median follow-up was 76 months (range: 12-334 months). Two patients were lost to follow-up. Gastrointestinal hemorrhage occurred in one patient. Endoscopy and abdominal CT showed submucosal GV in five patients. Ten patients had perigastric varices (27%), but none developed clinical complications from their varices. All varices occurred within one year after distal pancreatectomy and remained stable during follow-up. DISCUSSION: Asymptomatic varices frequently occurred in patients who underwent VR-SPDP, but bleeding risk seemed low. Abdominal CT could identify GV and distinguish submucosal varices with a higher risk of gastric bleeding.

Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons.

BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.

Gallbladder volvulus.

Gallbladder volvulus is a rare condition caused by torsion of the cholecystic pedicle and is favored by a long or nonexistent cholecystic mesentery. Gallbladder torsion presents clinically as gangrenous cholecystitis. Emergency cholecystectomy is the standard treatment. Lack of awareness of this condition can result in delayed diagnosis and worsen the prognosis of elderly patients.

[Small bowel adenocarcinoma]. / Adénocarcinome de l'intestin grêle.

Small bowel adenocarcinoma is a rare tumor. These tumors are more often sporadic but there is some predisposing disease (Crohn disease, genetic syndrome and rarely celiac disease). Diagnosis is usually performed at an advanced stage because of non-specific nature of clinical manifestations. New methods of radiological and endoscopic exploration of small intestine should allow earlier diagnosis. Surgical resection remains the only potentially curative treatment for non-metastasic tumors. The main prognosis factor is lymph nodes involvement. The role of adjuvant chemotherapy is unclear. For metastatic tumors, 5-fluorouracil and platinum salt combination appears to be the most effective chemotherapy despite of the absence of randomized studies. A national prospective cohort study is currently evaluating the results of chemotherapy (recommended protocol: FOLFOX) as adjuvant and palliative treatment of small bowel adenocarcinoma.

[Transjugular intrahepatic portosystemic shunt before hepatic surgery in a patient with cirrhosis and portal hypertension: case report]. / Dérivation portocave intrahépatique transjugulaire avant chirurgie hépatique en cas de cirrhose compliquée d'hypertension portale.

Major abdominal surgery may be contraindicated in patients with cirrhosis because of the high risk of intraoperative bleeding and postoperative decompensation. Careful preparation of these patients is essential, aimed especially at reducing portal hypertension. We report the case of a patient with cirrhosis complicated by hepatocellular carcinoma, whose portal hypertension manifested almost exclusively by reanastomosis from the umbilical vein. A transjugular intrahepatic portosystemic shunt (TIPS) was placed before surgery to prepare the patient for hepatic resection. In addition to the singularity of the presentation of portal hypertension, this case prompts us to consider neoadjuvant TIPS as a means of preparing these at-risk patients for major abdominal surgery.

Splitting bone marrow trephines into frozen and fixed fragments allows parallel histological and molecular detection of B cell malignant infiltrates.

Clonality analysis of the immunoglobulin heavy chain (IgH) gene is helpful in identifying malignant B cell infiltrates in the bone marrow and is usually carried out on separate aspirates or on the same formalin-fixed decalcified bone marrow specimen. To determine whether the removal of the decalcification step would improve the molecular analysis, we first studied 12 bone marrow specimens with lymphoma infiltration split into a fixed and a small frozen fragment. Both the detection rate of IgH gene monoclonality and DNA quality were found to be superior in the frozen part than in the fixed part. Conversely, to evaluate whether the split would compromise histological analysis, we selected a series of 134 bone marrow specimens obtained from patients with small B cell lymphoma and showing IgH monoclonality on the frozen part. The histological detection rate of infiltrated or suspicious infiltrates (95%) on the fixed part was not altered by saving a frozen part.

Utility of staging laparoscopy in subsets of biliary cancers : laparoscopy is a powerful diagnostic tool in patients with intrahepatic and gallbladder carcinoma.

BACKGROUND: The aim of this study was to evaluate the utility of staging laparoscopy in patients with biliary cancers in the era of modern diagnostic imaging. METHODS: From September 2002 through August 2004, 39 consecutive patients with potentially resectable cholangiocarcinoma underwent preoperative staging laparoscopy before laparotomy. Preoperative imaging included ultrasonography and triphasic computed tomography for all patients and magnetic resonance cholangiography in 35 patients (90%). Final pathological diagnosis included 20 hilar cholangiocarcinomas (HC), 11 intrahepatic cholangiocarcinomas (IHC), and eight gallbladder carcinomas (GBC). RESULTS: During laparoscopy, unresectable disease was found in 14/39 patients (36%). The main causes of unresectability were peritoneal carcinomatosis (11/14) and liver metastases (5/14). At laparotomy, nine patients (37%) were found to have advanced disease precluding resection. Vascular invasion and nodal metastases were the main causes of unresectability during laparotomy (eight out of nine). In detecting peritoneal metastases and liver metastases, laparoscopy had an accuracy of 92 and 71%, respectively. All patients with vascular or nodal involvement were missed by laparoscopy. For prediction of unresectability disease, the yield and accuracy of laparoscopy were highest for GBC (62% yield and 83% accuracy), followed by IHC (36% yield and 67% accuracy) and HC (25% yield and 45% accuracy) CONCLUSION: Staging laparoscopy ensured that unnecessary laparotomy was not performed in 36% of patients with potentially resectable biliary carcinoma after extensive preoperative imaging. In patients with biliary carcinoma that appears resectable, staging laparoscopy allows detection of peritoneal and liver metastasis in one third of patients. Both vascular and lymph nodes invasions were not diagnosed by this procedure. Due to these limitations, laparoscopy is more useful in ruling out dissemination in GBC and IHC than in HC.

[Esophageal diverticula]. / Diverticules de l'oesophage.

Esophageal diverticula are classified by location-phrenoesophageal (Zenker's diverticulum-70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration. Barium swallow and upper endoscopy will help to establish the diagnosis while esophageal manometry may reveal underlying dysmotility. Diverticula should not be treated unless they are symptomatic. The treatment of Zenker's diverticulum is surgical and consists of either diverticulectomy or diverticular suspension with a myotomy of the cricopharyngeus muscle via cervical approach. Transoral endoscopic stapled diverticulostomy is a new and simple approach which may become the treatment of choice, particularly in elderly and high-risk patients. Treatment of diverticula of the mid and low esophagus must take into account any motor anomalies or associated lesions. Diverticulectomy with esophageal myotomy and an anti-reflux procedure through a left thoracotomy is the standard approach, but endoscopic approaches seem feasible, particularly for epiphrenic diverticula, and may become the norm in years to come.

Induction of CYP2C genes in human hepatocytes in primary culture.

The expression and inducibility of four CYP2C genes, including CYP2C8, -2C9, -2C18, and -2C19, was investigated in primary cultures of human hepatocytes. By the use of RNase protection assay and specific antibodies, each CYP2C mRNA and protein were quantified unequivocally. The four CYP2C mRNAs were expressed in human livers and cultured primary hepatocytes, but only the CYP2C18 protein was not detected. Compounds known to activate the pregnane X receptor (PXR) such as rifampicin, or the constitutively activated receptor (CAR) such as phenobarbital, induced CYP2C8, CYP2C9, and to a lesser extent CYP2C19 mRNAs and proteins. CYP2C18 mRNA was expressed but not inducible. The concentration dependence of CYP2C8 and CYP2C9 mRNAs in response to rifampicin and phenobarbital paralleled that of CYP3A4 and CYP2B6, the maximum accumulation being reached with 10 microM rifampicin and 100 microM phenobarbital. In contrast, dexamethasone produced maximum induction of CYP2C8 and CYP2C9 mRNAs at 0.1 microM while in these conditions neither CYP3A4 nor CYP2B6 was significantly induced. Moreover, the concentration dependence of CYP2C8 and CYP2C9 mRNAs in response to dexamethasone paralleled that of tyrosine aminotransferase. Furthermore, dexamethasone, which has been recently shown to up-regulate PXR and CAR expression through the glucocorticoid receptor, potentiated CYP2C8 and CYP2C9 mRNA induction in response to rifampicin and phenobarbital. Collectively, these results suggest the possible implication of at least three receptors in the regulation of CYP2C8 and CYP2C9 expression, i.e., glucocorticoid receptor, PXR, and/or CAR.

[Stomach cancer: have changes in surgical strategy influenced the results? 20-year retrospective study]. / Cancer de l'estomac: les changements dans la stratégie chirurgicale ont-ils une influence sur les résultats? Etude rétrospective sur 20 ans.

STUDY AIM: The aim of this retrospective study was to compare a group of patients who underwent resection for gastric adenocarcinoma (cancer of cardia excluded) and to assess the influence of radical lymphadenectomy on postoperative mortality and morbidity and 5-year survival rate. PATIENTS AND METHOD: One hundred and six patients were operated on from 1975 to 1985 and 99 from 1986 to 1995 for gastric adenocarcinoma located in the distal portion of the stomach in 56% and 61% respectively and, undifferenciated in 56%. Gastric resection was a subtotal gastrectomy for cancers of the lower third and total gastrectomy for cancers of the middle and superior thirds. In the first group (1975-1985), a D1 lymphadenectomy was performed in all patients. In the second group (1986-1995) a D1.5 lymphadenectomy without systematic splenectomy and pancreatectomy was applied to 49 patients. RESULTS: In the second group, the proportion of curative resection was higher (85% versus 75%) along with a higher rate of total gastrectomy (42% versus 17%). The postoperative mortality rate was 2% in the first group and 1% in the second group. The morbidity rate was 33% in the first group and 15% in the second group with a rate of anastomotic leak of 11% and 2% respectively. Among the second group, the morbidity rate was 20% after D1,5 lymphadenectomy versus 10% after D1 lymphadenectomy. The overall 5-year survival rate was 29% in the first group versus 38% in the second group. In this latter group, the overall 5-year survival was 32% after D1 lymphadenectomy and 46% after D1,5 (p = 0.038). CONCLUSION: Radical lymphadenectomy without associated splenic or pancreatic resection in good general status patients may provide a better staging of resected gastric cancer without increase of the postoperative mortality. However, the influence of radical lymphadenectomy on long-term survival remains to be proven.

Reactive oxygen intermediates and eicosanoid production by kupffer cells and infiltrated macrophages in acute and chronic liver injury induced in rats by CCl4.

OBJECTIVE AND DESIGN: The aim of the present study was to characterize during acute and chronic liver injury induced by CCl4, macrophage phenotypes and whether a change in reactive oxygen intermediates (ROI) and eicosanoids production by Kupffer cells (KC) was observed. MATERIAL AND METHODS: Liver steato-necrosis and cirrhosis were induced in rats after 3 weeks and 9 weeks of CCl4 intoxication, respectively. Monocytes and tissue macrophages were identified by immunohistochemical study using monoclonal antibodies ED-1 and tissue macrophages using the antibody ED-2. The release of ROI and eicosanoids in response to the phorbol ester TPA (protein kinase activator) and to the calcium ionophore A23187 was assessed in cultivated cells. RESULTS: As compared to healthy controls, livers of rats with steato-necrosis or cirrhosis exhibited a significant increase of ED-1 and ED-2 positive cells. Only KC from rats with liver steato-necrosis were found to have higher A23187, TPA + A23187 or opsonized zymosan induced ROI production than healthy controls (p < 0.01). After TPA + A23187 or opsonized zymosan stimulation, KC from both rats with steato-necrosis or cirrhosis produced more TxB2 and leukotrienes and less PGE2 as compared to healthy controls (p <0.05). CONCLUSIONS: These results suggest an influx of monocytes into the liver during acute and chronic injury induced by CCl4. Functional changes of this inflammatory infiltrate have been demonstrated with an increase of ROI production only in the early stage of liver injury whereas a rise in KC leukotriene production and an imbalance between cytoprotective and cytotoxic prostanoids were observed at all stages of liver disease.

[Percutaneous drainage of infected pancreatic necrosis: an alternative to surgery]. / Drainage percutané des nécroses pancréatiques infectées: alternative à la chirurgie.

AIM OF THE STUDY: To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series. PATIENTS AND METHODS: Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration. RESULTS: Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enterococcus, staphylococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical procedure including two necrosectomies was necessary in six patients. CONCLUSION: This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.

[Recent progress in the curative surgical treatment of stomach cancer]. / Acquisitions récentes dans le traitement chirurgical curatif du cancer de l'estomac.

Surgical resection is currently the only potentially curative treatment for gastric cancer. Nodal extension, present in 3/4 of the patients, is related to topography and penetration of the tumor and is progressive, beginning by the perigastric proximal lymph nodes N1 to the perivascular distal nodes N2. A subtotal gastrectomy is possible for distal cancers and total gastrectomy is necessary for cancers of the middle and upper portions. D1 lymphadenectomy is the resection of the N1 perigastric nodes (> 15) and D2 lymphadenectomy is the resection fo the N2 perivascular nodes (> 25). In Japan, 5 year survival after D2 resection is very high, around 60%, but all the series are retrospective with a high proportion of superficial cancers. In several recent European controlled studies, D2 resection is responsible for a high mortality rate (> 10%) and the reported 45% survival is not statistically different from the D1 resection. In Western patients an "in-between" lymphadenectomy without spleno-pancreatectomy can be recommended with analysis of at least 15 nodes, and with a mortality lower than 5%. Pathological analysis of the operative specimen allows to use the new TNM classification where the number of positive lymph nodes is the main independent prognostic factor.