Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study.

BACKGROUND: Minimally invasive pancreatoduodenectomy (MIPD) is increasingly being performed because of perceived patient benefits. Whether conversion of MIPD to open pancreatoduodenectomy worsens outcome, and which risk factors are associated with conversion, is unclear. METHODS: This was a post hoc analysis of a European multicentre retrospective cohort study of patients undergoing MIPD (2012-2017) in ten medium-volume (10-19 MIPDs annually) and four high-volume (at least 20 MIPDs annually) centres. Propensity score matching (1 : 1) was used to compare outcomes of converted and non-converted MIPD procedures. Multivariable logistic regression analysis was performed to identify risk factors for conversion, with results presented as odds ratios (ORs) with 95 per cent confidence intervals (c.i). RESULTS: Overall, 65 of 709 MIPDs were converted (9.2 per cent) and the overall 30-day mortality rate was 3.8 per cent. Risk factors for conversion were tumour size larger than 40 mm (OR 2.7, 95 per cent c.i.1.0 to 6.8; P = 0.041), pancreatobiliary tumours (OR 2.2, 1.0 to 4.8; P = 0.039), age at least 75 years (OR 2.0, 1.0 to 4.1; P = 0.043), and laparoscopic pancreatoduodenectomy (OR 5.2, 2.5 to 10.7; P < 0.001). Medium-volume centres had a higher risk of conversion than high-volume centres (15.2 versus 4.1 per cent, P < 0.001; OR 4.1, 2.3 to 7.4, P < 0.001). After propensity score matching (56 converted MIPDs and 56 completed MIPDs) including risk factors, rates of complications with a Clavien-Dindo grade of III or higher (32 versus 34 per cent; P = 0.841) and 30-day mortality (12 versus 6 per cent; P = 0.274) did not differ between converted and non-converted MIPDs. CONCLUSION: Risk factors for conversion during MIPD include age, large tumour size, tumour location, laparoscopic approach, and surgery in medium-volume centres. Although conversion during MIPD itself was not associated with worse outcomes, the outcome in these patients was poor in general which should be taken into account during patient selection for MIPD.

Solitary fibrous tumour of the liver with IGF-II-related hypoglycaemia. A case report.

INTRODUCTION: We report a rare case of solitary fibrous tumour (SFT) of the liver associated with non-islet cell tumour hypoglycaemia (NICTH), which caused a hypoglycaemic coma due to over-production of big-insulin-like growth factor-II. DISCUSSION: Although generally benign, SFTs are better characterised, lately due to Western blot, but less than 40 cases have been reported where the liver is the target organ. In only two benign cases has hypoglycaemia been a feature. CONCLUSION: We report for the first time a demonstrable relationship between benign liver SFT and NICTH.

Outpatient hemithyroidectomy: A retrospective feasibility analysis.

BACKGROUND: Outpatient surgery is a major public health policy issue. It is controversial for total thyroidectomy, which raises the question of hemithyroidectomy. The present study assessed our experience in outpatient hemithyroidectomy. OBJECTIVES: To evaluate the rates of postoperative hematoma and unscheduled hospital admission. MATERIAL AND METHODS: A multicenter retrospective analysis was conducted in two hospital centers between January 2009 and December 2013. Exclusion criteria for outpatient hemithyroidectomy comprised: ASA score >2, anticoagulant therapy, risk of completion procedure, and associated procedure requiring >12 hours' surveillance. Data were collated for age, gender, weight, postoperative complications, and unscheduled hospital admission. RESULTS: During the study period, 294 hemithyroidectomies were performed, 130 of which on an outpatient basis (44%). There were no medical contraindications to outpatient surgery in 64% of patients operated on under conventional admission. In the outpatient group, mean age was 44 years. Eight completion thyroidectomies were performed in the outpatient group, and only two patients required admission for surveillance, with no revision surgeries. All patients were satisfied or very satisfied with outpatient management. CONCLUSION: In our experience, outpatient hemithyroidectomy was safe and reliable.

Surgical management of internal fistulas in Crohn's disease.

BACKGROUND: Internal fistulas in Crohn's disease join a diseased intestinal segment to a "victim organ" (VO) that is affected by proximity. While the diseased segment is resected, the other can be sutured in selected cases. STUDY DESIGN: Seventy-four patients with 100 internal fistulas were retrospectively reviewed to assess the results of this conservative operative approach. RESULTS: Closure of the fistulous defect of the VO was achieved by resection (n = 41) or suture (n = 59). The VO was histologically unaffected by Crohn's disease in 86 cases. One patient died postoperatively. Three patients had postoperative fistulas after suture of the VO. There was no long-term recurrence of an internal fistula. CONCLUSIONS: Surgical treatment of internal fistulas can be achieved safely by resection of the source of the fistula and suture repair of the VO when the latter is not affected by active Crohn's disease and when local conditions make it feasible.

Minimally invasive management of insulinomas. A case report.

BACKGROUND: Recently, preoperative endoscopic ultrasonography (EUS) was shown to be less time consuming, posing less risk of adverse events than other more invasive diagnostic procedures used for locating insulinomas. Furthermore, laparoscopy can be part of a less aggressive approach in the management of such tumors, avoiding open surgery, which is used all out of proportion for benign small-size lesions, as insulinomas frequently are. CASE REPORT: The reported case of pancreatic insulinoma involved a 45-year-old woman suffering from a neuroglycopenic syndrome. Tumor location was possible with endoscopic ultrasonography, which detected a hypoechoic 10 x 10-mm mass in the pancreatic tail. Tumor enucleation was accomplished laparoscopically. CONCLUSIONS: Insulinomas may be managed with videolaparoscopy, but this approach, which is not applicable for multiple or malignant tumors, must be contraindicated also in single insulinomas located on the posterior wall or deeply in the head of the pancreas. The disadvantages of the laparoscopic approach, as compared with conventional surgery, are the absence of palpation and difficulty exploring the whole pancreas, which is partly overcome, but not completely eliminated, by EUS. The advantages are the absence of a parietal incision and good postoperative comfort. The reported low-invasive EUS laparoscopy sequence may be successful in selected cases of pancreatic insulinomas. However, it seems this treatment could be proposed for many patients affected by this benign disease.

[Entero-enteral fistulas in Crohn disease: radical or conservative surgical treatment of the "victim" segment?]. / Les fistules entéro-entérales de la maladie de Crohn: traitement chirurgical radical ou conservateur du segment "victime"?

OBJECTIVES AND METHODS: Entero-enteral fistulas join a segment affected by Crohn's disease to another which becomes a drainage route and a "victim" of the process. Surgical treatment can be radical (extensive resection of both segments) or conservative (resection of involved bowel and conservation of the "victim"). Fifty-nine patients operated on for Crohn's disease and having 80 entero-enteral fistulas were retrospectively studied. RESULTS: Main surgical indications were symptomatic intestinal stenosis (56%) or abdominal mass (20%) unresponsive to medical treatment. Fistula was discovered during operation in 33 patients (56%). Conservative treatment was performed in 39 fistulas (49%). In 41 fistulas (51%), proximity of fistulous ends, or Crohn's disease's extension, led to radical treatment. In 66 fistulas (82.5%), histologic examination revealed that Crohn's disease affected only one bowel segment, the other demonstrating only non specific features; in the 14 remaining fistulas (17.5%), Crohn's disease affected both segments. CONCLUSIONS: The clinical presentation of entero-enteral fistulas (non-specific symptoms, frequent peroperative diagnosis), their pathological features (victim segment often free of Crohn's disease) plead for a conservative surgical approach, i.e. adapted to real bowel involvement by Crohn's disease.

Heterotopic gastric mucosa presenting as gallbladder polyps.

The authors report the case of a 16-year-old man with recurrent abdominal pain. Ultrasonography showed two gallbladder polyps, one of them larger than 10 mm. Laparoscopic cholecystectomy was performed. Histologic examination revealed gastric heterotopia. The authors discuss the clinical, pathophysiologic and histologic features of the present case and those reported in the literature.

[Duodenal somatostatinomas associated with von Recklinghausen's neurofibromatosis. Apropos of 2 cases]. / Somatostatinomes duodénaux et neurofibromatose de von Recklinghausen.

Somatostatinomas are rare neuroendocrine tumors; they are essentially located in the pancreas and in the duodenum. The association with a neurofibromatosis type I is especially observed when the tumor is located in the ampulla of Vater. These tumors are not associated with a "somatostatin syndrome", but often present with gastrointestinal bleeding, abdominal pain and obstructive jaundice. The diagnosis is confirmed by immunohistochemical studies. The aim of this study is to report 2 cases of metastazing duodenal periampullary somatostatinomas associated with von Recklinghausen's disease and to discuss the prognosis of these tumors. Future genetic research are necessary as point out the familial feature of this association in one of our cases.

[Microscopic thyroid papillary cancers presenting as cervical lymph node metastases]. / Métastases ganglionnaires cervicales révélatrices des micro-cancers papillaires de la thyroïde.

Microscopic papillary thyroid cancer (< 1 cm in diameter) is reputed to have an excellent prognosis. In 10 to 20% of cases, it presents in the form of lymph ode metastases. Immediately metastatic forms can be associated with unfavourable prognostic factors, such as multifocal tumours, extension to adjacent tissues, capsular effraction and development of distant metastases. We report 4 cases of microscopic papillary thyroid cancer presenting in the form of lymph node metastases. No primary thyroid lesion was palpable in any of these patients, but the subsequent course was complicated by ling metastases in one case. All patients underwent total thyroidectomy with lymph node dissection followed by adjuvant therapy with radioactive iodine and thyroxin inhibitory treatment. Lung metastases were observed in one case. The authors propose a therapeutic approach based on analysis of severity factors, which determine the recurrence rate.

[Enterovesical fistulas in Crohn disease: diagnosis and treatment]. / Les fistules entéro-vésicales de la maladie de Crohn: diagnostic et traitement.

Internal fistula is a complication of Crohn's disease. Among 589 patients operated upon at Hôpital Saint-Antoine between 1970 and 1992, 17 (2.9%) had entero-vesical fistula. Ileovesical fistulas were twice as frequent as sigmoidovesical fistulas. Typical symptoms were pneumaturia, fecaluria, and recurrent urinary tract infection. Cystoscopy was performed in 8 patients and determined the site of the fistula in each case. The indication for operation was the fistula itself (35%) or another complication of Crohn's disease (65%). Associated lesions were as follows: 6 entero-enteral, 2 ileogenital, 5 enterocutaneous fistulas and 6 intraabdominal abscesses. Resection of the bowel segment responsible for the fistula was performed in every case, with primary anastomosis in 9 cases and enterostomy in 8 cases. The vesical opening was excised and sutured in 10 cases and left open in 7 cases. An urethral catheter was left in place for at least 7 days. There was no postoperative death; one postoperative external vesical fistula healed without reoperation. Seven enterostomies have been closed, one is definitive. There were no late recurrences of vesical fistula.

[Resection of the prostate after 75 years]. / La résection de prostate après soixante-quinze ans.

The authors report a series of 100 endoscopic resections performed in patients over the age of 75 years. In patients with no risk factors, there was no mortality and the morbidity was 5%. In patients with one risk factor, mortality was 5% and morbidity was 10%.

[Splenic abscess. A rare pathology requiring a multidisciplinary approach]. / Abcès splénique. Une pathologie rare qui nécessite une approche multidisciplinaire.

The clinical presentation of the splenic abscess is poorly specific. Its natural evolution is often fatal. The three case reports illustrate the difficulty of the diagnosis and management of this disease. Ultra sound and C.T. scan are the procedures of choice for the diagnosis and follow-up. The choice of the treatment depends on the number of abscesses, their volume, and also the presence of extrasplenic involvement. Antibiotherapy and interventional radiology have modified its therapeutical approach. Although the conservative treatment (antibiotherapy, transparietal drainage) is often successful, splenectomy is still indicated as a first line treatment, or as a salvage procedure.

[110 consecutive laparotomies for hepatic metastasis]. / 110 laparotomies consécutives pour métastases hépatiques.

From 1978 to 1988, we performed 110 laparotomies for hepatic metastases. With 41 resections for colorectal metastases, the survival was 34% at 3 years. The operative mortality was 7%. With 25 resections for non colorectal liver metastases, the survival was 42% at 1 year, 12% at 3 years. The results, compared with those of literature justify, in the absence of any other potential curative treatment, to remove colorectal liver metastases. For metastases from other tumours, results of resection for endocrine tumours and few sarcomas invite us to an aggressive approach.

[Pancreatic trauma: diagnostic and therapeutic emergency. Apropos of 35 cases]. / Traumatismes du pancréas: urgence diagnostique et thérapeutique. A propos de 35 cas.

35 consecutive pancreatic trauma were operated (21 blunt trauma and 14 penetrating injuries). 30 patients were operated in emergency and diagnosis was suspected before laparotomy in only one case. 12 patients had a superficial lesion, 21 had a wirsung disruption (14 in the left pancreas, 7 in the right pancreas), 2 had a diffuse pancreatitis. For the 30 patients operated in emergency, 20 had a conservative treatment, 10 had a resection. 5 patients died (14.2%), from exsanguination (2 cases), missed diagnosis or inadequate treatment (2 cases), sepsis after adequate management (1 case). Our experience suggests that an aggressive diagnosis management in emergency, with pre or pre-operative wirsungography, could determined with precision the type of the lesion and permit an adequate management, to decrease mortality.

Single umbilical incision laparoscopic cholecystectomy: results of the prospective trial of the Coelio Club.

AIM: To assess the cosmetic outcome after single umbilical incision laparoscopic cholecystectomies (SILC) performed by the surgeons of the Coelio Club. PATIENTS AND METHODS: Multicenter prospective study concerning 105 consecutive patients operated between December 2009 and February 2011 by SILC for non-complicated gallstones. Perioperative and postoperative parameters were analyzed with a systematic follow-up at 1 and 6months postoperative. RESULTS: Conversion to conventional laparoscopic cholecystectomy (CLC) was required for six patients (5.7%). Conversion rate is higher in case of acute cholecystitis (25%, P<0.001). Cosmetic outcome is found excellent by the patient (in 86% of the cases at 6months) and by the surgeon (in 90% of the cases at 6months) using an EVA scale. An incisional hernia was found in two cases (1.9%) and a superficial wound infection in four cases (3.8%). CONCLUSIONS: The cosmetic outcome after SILC is found excellent. SILC has its place in the surgical management of the non-complicated gallstone. We did not notice higher level of peroperative complications (biliary tract injury) during SILC than during CLC. Postoperative higher level of abdominal wall complications than after a CLC makes the surgeon caution to a careful abdominal wall closure.

Surgical management of ileosigmoid fistulas in Crohn's disease: role of preoperative colonoscopy.

PURPOSE: Surgical treatment of ileosigmoid fistulas in Crohn's disease remains controversial and can be radical (resection of both segments) or conservative (ileal resection with suture or wedge resection of the sigmoid). At our institution, the sigmoid defect is sutured if the sigmoid is not affected by primary Crohn's disease or by important stricture; otherwise, the sigmoid is resected. We reviewed our experience to evaluate our results with this procedure. METHODS: Thirty patients with ileosigmoid fistulas underwent operation. Among them, 15 had a preoperative colonoscopy, whereas others had no endoscopic work-up. In nine patients, the sigmoid was thought to be affected by Crohn's disease (n = 7) or stricture (n = 2) and was resected. In 21 patients, the sigmoid was thought to be affected by proximity, and a simple suture (n = 15) or wedge resection (n = 6) was performed. Eleven patients had a temporary stoma (37 percent). One had coloprotectomy. RESULTS: One patient died postoperatively. One patient had postoperative sigmoidocutaneous fistula after conservative treatment. Histology of the sigmoid specimen showed Crohn's disease in 8 patients (27 percent), including 5 of 9 resected specimens, and 3 of 21 conservative procedures. All patients with Crohn's misdiagnosis did not have preoperative colonoscopy. Nine of 11 stomas were closed in a median delay of four months. With a median delay of nine years, four patients have again undergone surgery for recurrent colonic Crohn's disease, all of whom underwent surgery initially without preoperative colonoscopy. CONCLUSION: Preoperative endoscopic assessment of the colon is a reliable guide to use when choosing between sigmoid resection or a conservative approach and can result in reduced morbidity and improved long-term results.

Long-term seton drainage for high anal fistulas in Crohn's disease--a sphincter-saving operation?

METHODS: Forty-one consecutive patients with Crohn's disease who underwent long-term seton drainage for high transsphincteric, suprasphincteric, or extrasphincteric anal fistula from 1985 to 1993 were reviewed. The subsequent associated procedure was simple seton removal (18), secondary fistulotomy (7), rectal flap advancement (3), and proctectomy (2). Eleven patients still had the seton in place. RESULTS: Recurrence developed in seven patients (39 percent) undergoing simple seton removal and in one patient undergoing rectal flap advancement. None of the patients treated by secondary fistulotomy developed a recurrence. At the end of follow-up, five patients (12 percent) required proctectomy mainly for severe proctitis, and five patients (12 percent) developed anal incontinence, which was severe in two. CONCLUSION: Long-term seton drainage for high and fistula in Crohn's disease is efficacious in both treating sepsis and preserving anal sphincter function.

Metastatic endocrine tumors: medical treatment, surgical resection, or liver transplantation.

We reviewed our experience with 34 patients with metastatic endocrine tumors (METs) who were treated by different modalities. Eight patients were treated by chemotherapy or chemoembolization because of stable disease or surgical contraindications. Seventeen patients underwent curative or cytoreductive surgical resection. Nine patients received grafts based on the following criteria: no extrahepatic spread on imaging workup and nonresectable symptomatic metastatic disease. Of the eight medically treated patients, the five patients with initial stable clinical condition are alive 32 to 56 months after referral. Of the 17 patients treated by liver resection, 13 are alive 6 to 108 months after surgery, and 7 are disease-free. After curative resection, the 5-year actuarial survival and disease-free survival rates were 62% and 52%, respectively. Of the nine grafted patients, three patients grafted for carcinoid tumor are alive at 15, 24, and 62 months, one of whom has a late recurrence. Our results indicate that therapeutic indications for METs should be based on age, clinical symptoms, histologic type, and tumor extension: Patients with stable MET may benefit from surgical restraint; liver resection in patients with aggressive MET may provide good long-term palliation and possibly cure one-third of the patients; liver transplantation should be restricted to young patients with nonresectable carcinoid MET but remains a high-risk operation because of previous surgery and chemoembolization.