What are the predictive factors of caecal perforation in patients with obstructing distal colon cancer?

AIM: In the presence of large bowel obstruction, the choice of treatment is determined by the patient's general status, the tumour characteristics and the perceived risk of caecal perforation. This study was designed to evaluate the predictive factors of impending caecal perforation, and also investigated the use of caecal volumetry. METHOD: From January 2011 to June 2016, patients with obstructive distal colon cancer undergoing emergency laparotomy, for whom a pretreatment CT scan was available, were included in this retrospective, case-control, two-centre study. Two patient groups were defined: patients with and without impending caecal perforation. The primary end-point of the study was a determination of predictive factors for caecal perforation. RESULTS: A total of 72 patients (45 men, 62.5%) were included. Univariate analysis revealed that the presence of pericaecal fluid (P < 0.0001), caecal pneumatosis (P < 0.0001), mean maximum caecal diameter (P = 0.001), mean caecal diameter at the ileocaecal junction (P = 0.0001) and mean caecal volume (P = 0.001) were associated with caecal perforation. Receiver operating characteristic curve analysis revealed that a caecal volume greater than 400 cm3 (P < 0.0001), a maximum caecal diameter > 9 cm (P = 0.002) and a caecal diameter at the ileocaecal junction > 7.5 cm (P = 0.001) were associated with impending caecal perforation. In multivariate analysis, only caecal volume > 400 cm3 (P = 0.001) was correlated with the risk of impending caecal perforation. CONCLUSION: Caecal volumetry is an easy and useful tool to predict impending caecal perforation in patients with large bowel obstruction.

Distinguishing fecal appendicular peritonitis from purulent appendicular peritonitis.

INTRODUCTION: Fecal appendicular peritonitis (FAP) is a poorly studied, rare form of acute appendicitis, corresponding to peritoneal inflammation with the presence of feces secondary to ruptured appendix. The purpose of this study was to describe FAP and to compare FAP with purulent appendicular peritonitis (PAP). PATIENTS AND METHODS: This single-center, retrospective study was conducted in consecutive patients to compare the FAP group and the PAP group. The primary endpoint was the 30-day postoperative morbidity and mortality according to the Clavien-Dindo classification. The secondary endpoints were description and comparison of intraoperative data (laparoscopy rate, conversion rate, type of procedure and the mean operating time), and short-term outcomes (types of complications, length of stay, readmission rate, and reoperation rate), comparison of intraoperative bacteriological samples of FAP and PAP as well as the rate of resistance to amoxicillin and clavulanic acid, used as routine postoperative antibiotic therapy. RESULTS: Between January 2006 and January 2016, 2.2% of appendectomies were performed for FAP. Patients of the FAP group reported a longer history of pain than patients of the PAP group (mean: 58 h [range: 24-120] vs 24 h [range: 6-504], p = 0.0001) and hyperthermia was more frequent in the FAP group than in the PAP group (72% vs 26%, p = 0.0001). Mean preoperative CRP was also higher in the FAP group than in the PAP group (110 mg/L [range: 67-468] vs 37.5 mg/L [range: 3.1-560], p = 0.007). Significantly less patients were operated by laparoscopy in the FAP group (89.7% vs 96.6%, p < 0.0001). Mean length of stay was significantly longer in the FAP group than in the PAP group (10 days [range: 3-24] vs 5 days [range: 1-32], p = 0.001). The overall 30-day complication rate was significantly higher in the FAP group than in the PAP group (62.1% vs 24.7%, p = 0.0005). The readmission rate was not significantly different between the two groups (14% vs 11.2%, p = 0.2), but the reoperation rate was higher in the FAP group than in the PAP group (31% vs 11%, p = 0.01). No significant difference was observed between the FAP and PAP groups in terms of the positive culture rate (75.9% vs 65.6%, p = 0.3). No significant difference was observed between the two groups in terms of resistance to amoxicillin and clavulanic acid (18.2% vs 20.5%, p = 0.8). CONCLUSION: FAP is associated with significantly more severe morbidity compared to PAP. Clinicians must be familiar with this form of appendicitis in order to adequately inform their patients.

Ruptured Pancreaticoduodenal Artery Aneurysms Associated with Celiac Stenosis Caused by the Median Arcuate Ligament: A Poorly Known Etiology of Acute Abdominal Pain.

OBJECTIVE/BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysm is a rare but clinically important form of vascular disease. A small proportion of these aneurysms are caused by compression of the artery by the median arcuate ligament (MAL). The objective of the study was to establish whether it is feasible and effective to treat ruptured PDA aneurysms without treating the celiac stenosis caused by the MAL. METHODS: From January 2007 to November 2014, 10 patients were included. Standard embolization or surgical procedures were used to treat the ruptured aneurysms, but the celiac stenosis itself was not treated. The primary end point was the feasibility and efficacy of embolization for the treatment of ruptured PDA aneurysms. The secondary end points included clinical data, imaging findings, the success rate of embolization and the outcome during follow up. RESULTS: All patients presented with acute, non-specific epigastric pain with nausea. An abdominal computed tomography scan revealed peri-pancreatic hematoma in all cases, and PDA aneurysms were visible in six patients. The aneurysms ranged from 2 mm to 10 mm in diameter and were variously located on the anterior PDA (n = 1), the posterior PDA (n = 3), and the branch of the dorsal pancreatic artery (n = 6). Surgery was performed in two cases (with one death). Embolization was successful in the other eight cases. The median length of hospital stay was 10 days (range 8-25 days). Over a median follow up period of 11 months (range 5-48 months), none of the PDA aneurysms recurred. CONCLUSION: Rupture of a PDA aneurysm caused by the MAL should always be considered in the differential diagnosis of acute abdominal pain, because the condition requires specific management. Embolization is safe and has a high success rate. Surgery should only be performed when embolization fails.

An extremely uncommon variant of left hepatic artery arising from the superior mesenteric artery.

We report a new variation of the left hepatic artery arising from the superior mesenteric artery. The variant was discovered during radiological examinations in a patient presenting with ruptured hepatocellular carcinoma of the left liver lobe. Anatomical description was based on CT-scan and angiographic analysis. When present the left hepatic artery originates from the left gastric artery, with an incidence of 12-34 %. Knowledge of left hepatic artery anatomy is mandatory to optimize surgical and radiological management in complex clinical situations.

Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature.

AIM: Percutaneous drainage of abdominal and pelvic abscesses is a first-line alternative to surgery. Anterior and lateral approaches are limited by the presence of obstacles, such as the pelvic bones, bowel, bladder, and iliac vessels. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous, transgluteal approach by reviewing our clinical experience and the literature. MATERIALS AND METHODS: We reviewed demographic, clinical and morphological data in the medical records of 30 patients having undergone percutaneous, computed tomography (CT)-guided, transgluteal drainage. In particular, we studied the duration of catheter drainage, the types of microorganisms in biological fluid cultures, complications related to procedures and the patient's short-term treatment outcome. RESULTS: From January 2005 to October 2011, 345 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A transgluteal approach was adopted in 30 cases (10 women and 20 men; mean age: 52.6 [range 14-88]). The fluid collections were related to post-operative complications in 26 patients (86.7 %) and inflammatory or infectious intra-abdominal disease in the remaining 4 patients (acute diverticulitis: n = 2; appendicitis: n = 1; Crohn's disease: n = 1) (13.3 %). The mean duration of drainage was 8.7 days (range 3-33). Laboratory cultures were positive in 27 patients (90 %) and Escherichia coli was the most frequently present microorganism (in 77.8 % of the positive samples). A transpiriformis approach (n = 5) was more frequently associated with immediate procedural pain (n = 3). No major complications were observed, either during or after the transgluteal procedure. Drainage was successful in 29 patients (96.7 %). One patient died from massive, acute cerebral stroke 14 days after drainage. CONCLUSION: When an anterior approach is unfeasible, transgluteal, percutaneous, CT-guided drainage is a safe, well tolerated and effective procedure. Major complications are rare. This type of drainage is an alternative to surgery for the treatment of deep pelvic abscesses (especially for post-surgical collections).

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management.

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

[Embolization of recurrent bleeding jejunal varices]. / Embolisation de varices jéjunales hémorragiques récidivantes.

We report a case of recurrent digestive haemorrhage due to bleeding ectopic jejunal varices complicating portal hypertension in a 51-year-old cirrhotic patient, treated 1 year ago by transjugular intrahepatic porto-systemic shunt (TIPS) for the same problem. Successful embolisation with coils, of ectopic varices, was performed using original transjugular and trans-TIPS route, without complication, and no recurrence during a follow-up of 24 months.

[A case of pancreatic schwannoma successfully treated by enucleation]. / Schwannome pancréatique traité avec succès par énucléation : à propos d'un cas.

Benign pancreatic schwannoma is a very rare cystic and solid tumor, which poses a diagnostic and therapeutic challenge. Herein, we present a case of 4-cm solitary benign schwannoma of pancreatic uncinate process, with pancreas divisum, incidentally discovered in a 53-year-old woman. Preoperative diagnosis was established by endoscopic ultrasound and fine needle aspiration. Simple enucleation of the tumor from the surrounding parenchyma was successfully performed. No complications were found after the operation.

[Late complications from abdominal wall surgery: report of three cases of mesh migration into hollow viscus]. / Complications tardives de la chirurgie pariétale abdominale: à propos de trois cas de migration de prothèse dans un organe creux.

Laparoscopic mesh repair of ventral abdominal wall hernias is routinely performed. Mesh detachment and migration within the abdominal cavity is a late complication of this procedure. Symptoms are non-specific and imaging diagnosis is difficult to achieve because this complication is rare and overlooked.

Elective (planned) colectomy in patients with colorectal obstruction after placement of a self-expanding metallic stent as a bridge to surgery: the results of a prospective study.

INTRODUCTION: Acute malignant colorectal obstruction (CRO) can be satisfactorily dealt by the placement of a self-expanding metallic stent (SEMS). The aim of this prospective study was to evaluate the rate of elective (planned) colectomy (EPC) in patients with CRO after SEMS placement as a bridge to surgery on an intention-to-treat (ITT) basis. METHOD: From 2002 to 2007, 30 SEMS were placed as a bridge to surgery in 30 CRO patients (median age 73 +/- 12 years). The obstructing lesions were located in the right (n = 1), transverse (n = 1) or left colon (n = 24) or the upper third of the rectum (n = 4). RESULTS: The SEMS was placed successfully in 25 (83%) patients. Five patients underwent Hartmann's procedure (n = 2) or a diverting colostomy (n = 3). The SEMS was functionally operational in 23 (92%) of the 25 patients. A diverting colostomy was avoided in 23 (77%) of the 30 patients (placement failure n = 5, clinical failure n = 2). There were no complications in 17 (80%) patients. On an ITT basis, 70% of the patients (21 out of 30) underwent an EPC. CONCLUSION: On an ITT basis, SEMS placement in CRO patients enabled EPC in 70% of patients.

[Hepatic Epithelioid hemangioendothelioma: a rare liver tumor]. / L'hémangioendothéliome épithélioïde du foie: une tumeur hépatique rare.

Epithelioid hemangioendothelioma of the liver is a rare primary malignant tumor of vascular origin. It most frequently occurs in middle age adults and clinical findings are non-specific. Histological diagnosis may be difficult to achieve with lesions containing a large myxoid component, and immunohistochemical staining is required. A few imaging features may suggest the correct diagnosis, and radiologists should be familiar with these findings. We will illustrate the potential role of PET-CT at the time of initial presentation. Prognosis is variable and optimal management is based on a case by case analysis, ranging from clinical and imaging follow-up to liver transplantation.

Transitioning to Transradial Access for Cerebral Aneurysm Embolization.

BACKGROUND AND PURPOSE: Despite several retrospective studies showing the safety and efficacy of transradial access for cerebral angiography, neurointerventionalists are apprehensive about implementing TRA for neurointerventions. This reluctance is mainly due to anatomic factors, technical factors, and a long learning curve (relative to transfemoral access). We present here our experience of TRA transition for cerebral aneurysm embolization. Our aim was to demonstrate the feasibility and safety of radial access for consecutive embolizations of ruptured and unruptured cerebral aneurysms. MATERIALS AND METHODS: We performed a retrospective review of a prospective data base on cerebral aneurysm embolizations. Between April and December 2018, radial access was considered for all consecutive patients referred to our institution for cerebral aneurysm embolization. Technical success was defined as radial access with insertion of the sheath and completion of the intervention without a crossover to conventional femoral access. The primary safety end point was the in-hospital plus 30-day incidence of radial artery occlusion. Secondary end points included intraoperative complications and neurologic complications at discharge and in the following 30 days. RESULTS: Seventy-one patients with a cerebral aneurysm underwent 73 embolization procedures at our institution. The first-choice access route was the radial artery in 62 patients (87.3%) and the femoral artery in 9 (12.6%). Thirty-four embolizations were performed using coils, 22 used a balloon-assisted coil technique, 6 used a stent-assisted coil technique, and 2 used a flow diverter. Crossover to femoral access was observed in 2 patients (3.1%). Four patients developed coil-induced thrombi requiring intra-arterial tirofiban injections. In 1 case, an aneurysm ruptured during the operation but did not have a clinical impact. No cases of radial artery occlusion or hand ischemia were observed. CONCLUSIONS: A transition to radial access for cerebral aneurysm embolization is feasible and does not increase the level of risk associated with the procedure.

Natural history of percutaneous drainage of postoperative collection following colorectal surgery: in which patients can follow-up imaging be dispensed with before drain removal?

INTRODUCTION: Colorectal surgery is complicated by postoperative collections in up to 25% of cases depending on local conditions. The aim of this study was to identify predictive factors of success of percutaneous drainage of collections in order to avoid follow-up imaging. PATIENTS AND METHODS: All consecutive patients between January 2009 and December 2016, who had undergone elective or emergency colorectal surgery (colorectal surgery and appendectomy) complicated by a postoperative collection treated by percutaneous drainage with follow-up imaging prior to drain removal, were included in this single-center and retrospective study. The primary objective was to assess predictive factors of success of the first attempt of percutaneous drainage of collections. Secondary objectives were to describe the natural history of percutaneous drainage of postoperative collections after colorectal surgery and the overall success rate of percutaneous drainage. RESULTS: Fifty-three patients underwent percutaneous drainage of a postoperative collection during the study period and were included in this study. Complete resolution of the collection was observed on the first follow-up radiological examination in 36 patients (58%). In multivariate analysis, post-appendectomy collections (OR = 3.19 (1.14-9.27), p = 0.002) and reduction of the leukocyte count (OR = 3.22 (1.28-8.1), p = 0.013) were significantly associated with success of percutaneous drainage. CONCLUSION: This is the first study to address that follow-up imaging prior to drain removal might not be necessary in patients undergoing drainage of post-appendectomy collections and/or with more than 30% reduction of the leukocyte count at the first follow-up examination.

Surgical conservative treatment of recurrent bleeding duodenal ulcer.

BACKGROUND/AIMS: Endoscopic hemostasis and proton pump inhibitors (PPI) have decreased the incidence of rebleeding and reduced the need for surgery for bleeding duodenal ulcer (BDU). The gold standard surgical treatment of BDU remains vagotomy-antrectomy. Currently, no recommendation is made on the best procedure when emergency surgery is necessary. The aim of this study was to assess the results of a systematic conservative treatment (CT): under-running bleeding gastroduodenal artery (GDA) and ulcer suture through a duodenotomy with (CT+L group) or without (CT group) GDA double ligation along with continuous intravenous PPI. METHODOLOGY: From 1995 to 2006, 22 consecutive patients (11 per group) underwent emergency surgery for BDU. Mean age was 63 +/- 18 years, ASA score 2.64 +/- 0.7. Ten patients (45%) presented collapse. Mean transfusion number was 11 +/- 9, number of therapeutic endoscopies 1.7 +/- 1, and Rockall score 6 +/- 2. RESULTS: Overall, 2 patients (9%) had rebleeding and 5 patients (22%) died. No death was reported secondary to rebleeding. In the CT+L group, 9 patients (82%) had intravenous PPI, no patient had rebleeding and 2 patients died (22%). CONCLUSIONS: Surgical CT of BDU with continuous PPI is effective, with a low rate of rebleeding. The standard use of vagotomy-antrectomy is questionable.

[Surgical management of resectable hilar cholangiocarcinoma]. / Prise en charge chirurgicale du cholangiocarcinome hilaire résécable.

Hilar cholangiocarcinoma is a cancer with a poor long-term survival rate (20% at five years), even after curative resection (R0: surgical margins free of tumour). Recent advances have been made in the preoperative management of these patients: clinical imaging, such as magnetic resonance cholangiography, biliary drainage according to the type of hilar obstruction or laparoscopic assessment before portal vein embolization. Extended hemihepatectomy has recently been recognized as the standard curative treatment for hilar bile-duct cancer with concomitant resection of the portal-vein bifurcation as a radical resective procedure. Neoadjuvant-photodynamic therapy could be a new approach to treating hilar cholangiocarcinoma decreasing tumour margins, which is a major prognostic factor.

[Inflammatory fibroid polyp, a rare tumor of the appendix]. / Le polype fibroïde inflammatoire, une tumeur rare de l'appendice.

We report the rare occurrence of an inflammatory fibroid polyp of the appendix. The lesion was diagnosed in a 33-year-old woman presenting with abdominal pain, fever and localized tenderness in right iliac fossa on abdominal palpation. CT-scan showed an 8 cm appendiceal mass and a laparoscopic appendectomy was consequently performed. On microscopic examination, the tumor consisted of spindle cells dispersed in a loose fibromyxoid stroma containing numerous blood cells and inflammatory cells with abundant eosinophils. On immunohistochemistry, the spindle tumor cells were positive for vimentin, fascin and focally for CD34 and CD35. They were negative for smooth muscle actin, desmin, CD21, CD23, CD117 and S100 protein. Inflammatory fibroid polyp is a rare benign mesenchymal tumor of the gastrointestinal tract rarely reported in the appendix. This tumor shares some common pathologic features with the myofibroblatic inflammatory tumor but they are two different entities. The pathogenesis of this tumor remains unclear but fascin and CD35 immunoreactivity of the tumor cells suggests a probable dendritic cell origin.

[Gastric calcifying fibrous pseudotumor, a rare mesenchymal tumor of the stomach]. / La pseudotumeur fibreuse calcifiante gastrique, une tumeur rare de l'estomac.

We report a case of calcifying fibrous pseudotumor fortuitously discovered on abdominal CT-scan in a 50 year-old woman presenting with metrorragia. CT-scan showed a 2 cm hypodense nodular tumor of the gastric wall with granular calcifications. Upper endoscopy showed a nodular tumor along the lesser curvature of the gastric body, covered by normal gastric mucosa and biopsies were negative. A diagnosis of gastric stromal tumor was suspected and a partial gastrectomy was performed. On gross examination surgical specimen showed a firm, whitish nodular tumor measuring 2 cm in diameter. On microscopic examination the tumor was composed of whorls of dense hyalinized collagen bundles with a few fibroblasts. There were psammomatous calcifications and nodular aggregates of mononuclear inflammatory cells. Immunohistochemically, spindle cells stained for vimentin. They did not stain for smooth muscle actin, desmin, CD34, CD117, S100 protein, Ki-67 and ALK-1. Surgical resection of the tumor was complete. Patient has no evidence of disease with a follow-up of 12 months. Only seven cases of gastric calcifiying fibrous pseudotumors have been reported in the literature. These benign tumors are usually incidentally discovered. They have characteristic imaging and microscopic features and appear as a distinct clinicopathologic entity different from stromal tumors.

Colorectal carcinoma with potentially resectable metastases: factors associated with the failure of curative schedule.

BACKGROUND: The management of patients with colorectal cancer (CRC) and synchronous liver metastases (SLM) depends on the primitive tumor, resectability of the metastatic disseminations and the patient's comorbid condition(s). Considering all patients with potentially resectable primary CRC and SLM, curative resection (R0) will be possible in some patients, although in others surgery will never be performed. The purpose of our study was to identify factors of failure of the curative schedule in these patients. METHODS: We reviewed the data of patients with CRC and SLM between January 2002 and March 2007. Two groups were defined: group R0 when complete metastatic and primary tumor resection was finally achieved after one and more surgical stages and group R2 when curative resection was not possible at the end of the schedule. Clinical, pathologic and outcome data were retrospectively analyzed as well as preoperative management of SLM (chemotherapy, radiofrequency, portal vein embolization). RESULTS: Forty-five patients were included. Curative resection (group R0) was performed in 31 patients (69%) with 48% undergoing major hepatic resection. Mortality of hepatic resection was 0% although it was 9% for primitive tumor. Portal vein embolization was performed preoperatively in eight patients and radiofrequency ablation in 13. Median follow-up was 21 months. Overall survival was 86% at one year and 39% at three years. Survival in group 1 was 97 and 57% at one and three years respectively. Disease-free survival was 87 and 40% at one and three years. Tumor recurrence was noted in 61% of resected patients. At multivariate analysis, number of hepatic metastases superior than three and complicated initial presentation of primitive tumor were found to be significant and predictors of failure of hepatic resection. CONCLUSION: Aggressive management with curative resection of SLM may enable long-term survival. More than three SLM and complicated initial presentation of primitive tumor are factors predictive of failure of the curative schedule.

[Acinar cell carcinoma of the pancreas: a rare tumor with particular clinical and paraclinical presentation]. / Carcinome à cellules acineuses du pancréas : une tumeur rare avec des caractéristiques cliniques et paracliniques particulières.

Acinar cell carcinoma of the pancreas is a rare tumour with specific clinical and paraclinical presentation. Its management is not well codified resulting from its low frequency.