The relationship between MIB-1 proliferation index and outcome in pancreatic neuroendocrine tumors.

The expression of the cell-cycle-associated Ki-67 antigen by MIB-1 monoclonal antibody was retrospectively assessed in 35 surgically resected neuroendocrine tumor specimens of the pancreas embedded in paraffin. The MIB-1 proliferation index was correlated with the classification of the neuroendocrine tumors of the pancreas proposed by Klöppel et al. Four prognostic factors showed a significant correlation with MIB-1: local invasion, metastases, tumor differentiation, and production of insulin. However, analysis by the Cox Proportional Hazards Regression Model showed that only local invasion was an independent predictor of outcome. Finally, our study showed a statistically significant increase in the number of deaths and a statistically significant decrease in survival time when the MIB-1 proliferation index was higher than 4%. We conclude that MIB-1 proliferation index is a simple and reliable tool to predict the clinical outcome of the neuroendocrine tumors of the pancreas. The index might be useful for determining the prognosis for an individual because of the significant decrease in survival when the index is higher than 4%.

Interest of PS100 assay when (99m)Tc sestamibi scintigraphy failed to identify lymph node metastases of melanoma.

The study evaluated the contribution of serum PS100 assay to the detection of lymph node metastases during the follow-up of patients previously treated for a malignant melanoma, in addition to (99m)Tc sestamibi (MIBI) scintigraphy and investigation for gene MDR1, in order to detect chemoresistance phenomena. The study included 37 patients with a clinically questionable lymph node around basin lymphatic areas of the previously surgically-treated malignant melanoma. The sensitivity and specificity of PS100 assay were 91% and 86.5%, respectively. The sensitivity and specificity of MIBI scintigraphy were 95% and 85%, respectively. Overexpression of gene MDR1 was observed in six cases. In the event of negative scintigraphic findings, the concomitant analysis of PS100 levels and the scintigraphic result enabled the metastatic MDR+ patients to be distinguished from the non-metastatic patients. PS100 assay may therefore be proposed for the follow-up of malignant melanoma.

[Primary adenocarcinoma of the ileostomy after total proctocolectomy for ulcerative colitis]. / Adénocarcinome primitif sur iléostomie après proctocolectomie totale pour rectocolite ulcéro-hémorragique.

A 61-year-old man developed primary adenocarcinoma with skin invasion, at the ileostomy site 33 years after a proctocolectomy for ulcerative colitis. A total of eleven patients with ileostomy adenocarcinoma have been reported in the literature. Ten patients were treated surgically for ulcerative colitis and the other for adenomatous polyposis coli. The diagnosis of stomal malignancy was made 9 to 36 years after the ileostomy (mean interval, 22 years). The pathogenesis of the malignant growth is uncertain and several possibilities are discussed: stasis, severe chronic inflammation, colonic metaplasia and severe dysplasia of the ileal mucosa. When an ileostomy requires late revision for inflammatory changes, careful pathologic examination of the entire stoma and surrounding skin is essential.

[Marion's calibrated latero-lateral portacaval anastomosis: a truncular shunt maintaining hepatopetal portal blood flow?]. / L'anastomose porto-cave latéro-latérale calibrée de Marion: une dérivation tronculaire maintenant un flux portal hépatopète?

The authors report the hemodynamic study of 22 cases of calibrated side-to-side portacaval shunts performed in patients with liver cirrhosis. In all patients, hepatopetal portal blood flow was present before the operation. According to the data obtained by scintiangiography and angiography, hepatopetal portal flow was maintained in 70 p. 100 of the patients immediately after the operation. After one year there was a discrepancy between the results of scintiangiography and those of conventional angiography: while portal flow seemed to be hepatopetal on the scintigraphy in 11 of controlled patients, it decreased or disappeared on the angiography in 6 other controlled patients. These results are comparable to those of selective shunts and suggest that the calibrated side-to-side portacaval shunt is a valuable procedure in maintaining hepatopetal portal flow. A controlled trial would be useful to assess the place of this operation in the treatment of portal hypertension due to cirrhosis.

[Bilateral post-traumatic adrenal hemorrhage. Report of a case with acute adrenal insufficiency]. / Hémorragie surrénalienne bilatérale post-traumatique. A propos d'un cas avec insuffisance surrénale aiguë.

Bilateral adrenal haemorrhage of traumatic origin is rarely observed or possibly missed in severely multi-traumatised patients. It can lead to a potentially fatal adrenal shock. Its emergency diagnosis is made by imaging techniques, usually by CT-scan. Early substitution therapy has to be done. This complication emphasizes the importance of an immediate abdominal morphological exploration in multi-traumatized patients when this is feasible.

[Detection of lymphatic metastasis from malignant melanoma after identification of the sentinel node by preoperative lymphoscintigraphy and intraoperative radioisotopic detection]. / Recherche des métastases ganglionnaires des mélanomes malins après isolement du ganglion sentinelle par lymphoscintigraphie préopératoire et détection radio-isotopique peropératoire. Résultats préliminaires.

OBJECTIVES: The aim of this study was to evaluate the detection of the first lymph node draining the primary tumour site, using a radioisotopic mapping alone and to determine whether a preoperative lymphoscintigraphy using technetium sulfur colloid and a hand-held gamma detecting probe could improve the detection of the sentinel lymph node (SLN) in melanoma. PATIENTS AND METHOD: From January to December 1998, 36 patients with a cutaneous melanoma larger than 0.75 mm, stage I TNM were included in this prospective study. Mean Breslow was 1.85 mm. The distribution of melanoma was head and neck (n = 9), trunk (n = 7), upper extremities (n = 4), lower extremities (n = 16). Preoperative lymphoscintigram and intraoperative detection were used. The first hot lymph node was supposed to be the SLN. RESULTS: In all cases, a lymph node was found and nine patients had more than one SLN (average number of SLN per patient: 1.25). Aberrant drainages were found in seven patients (19.4%): 1 in-transit lymph node, three paradoxical bassins, three bypasses). Four out of 36 patients had lymph node metastases and underwent elective lymph node dissection. CONCLUSION: The radio-isotopic technique used alone for the identification of the SLN is efficient in melanoma with a 100% detection rate in this short series.

[Colonic pseudo-obstruction caused by digestive amyloidosis in a chronic hemodialyzed patient. Apropos of a case]. / Pseudo-obstruction colique par amylose digestive chez l'hémodialysé chronique. A propos d'un cas.

A case of intestinal pseudo-obstruction by amyloidosis, occurring after 20 years of dialysis in a 72-year-old woman is reported. Although acute intestinal complications of intestinal amyloidosis, such as ischemia, colonic obstruction or haemorrhage are well known, colonic pseudo-obstruction is more unusual. It gradually results in, it carries out an intestinal obstruction with colonic and gastric distension. The diffuse topography of amyloid deposits throughout the gastrointestinal tract carries a poor prognosis and surgery cannot be curative.

[Carney's triad]. / La triade de Carney.

The triad described by J.A. Carney in 1977 is characterized by the successive or concomitant occurrence of three rare tumours of different origin: gastric leiomyoblastoma, functioning extra-adrenal paraganglioma and pulmonary chondroma. It is found mainly in young female patients with prevalent blood group A and may be incomplete, with only two of the three tumours occurring. The case of a young woman who developed gastric leiomyoblastoma and, six years later, pelvic paraganglioma is reported; she died of metastases from the paraganglioma with malignant hypertension. The 16 cases already published are reviewed. The authors insist upon the severity of paragangliomas and the need for a systematic search for the other tumours in patients who present with one tumour of the triad. A histogenetic interpretation relating the tumours to pathology of the neural crest is suggested.

[Postoperative respiratory function and cholecystectomy by laparoscopic approach]. / Fonction respiratoire postopératoire et cholécystectomie par voie coelioscopique.

Open cholecystectomy is associated with characteristic changes in pulmonary function showing a restrictive pattern. Laparoscopic cholecystectomy without opening of the peritoneal cavity could be an alternative in reducing postoperative respiratory dysfunction. Having given their informed consent, 13 healthy ASA1 patients (age: 41 +/- 18 yrs) undergoing laparoscopic cholecystectomy were enrolled in this study, in order to assess their postoperative pulmonary function tests (forced vital capacity [FRC], forced expiratory volume [FEV1], functional residual capacity [FRC]) before operation (T0) and 4 h (T4), 24 h (T24), 48 h (T48) after surgery. Anaesthesia technique was the same associating propofol-atracurium-fentanyl, 50% N2O/O2. Ventilation was adapted to maintain end-tidal carbon dioxide pressure up to 30-35 mmHg. Postoperative analgesic regimen consisted of paracetamol-ketoprofen. Mean length of surgery was 84 +/- 15 min; mean duration of anaesthesia was 110 +/- 24 min. An immediate and harmonious restrictive breathing pattern developed postoperatively. Postoperative FVC measured 65% (T4), 63% (T24), 72% (T48) of preoperative function (p < 0.025); postoperative FEV1 measured respectively 60, 66 and 75% of preoperative function (p > 0.001), without change in FEV1/CV and FRC; a significant hypoxia occurred (T0: 86 mmHg, T4: 80 mmHg, T24: 75 mmHg, T48: 81 mmHg [p < 0.05]). Laparoscopic cholecystectomy resulted in less postoperative respiratory dysfunction than conventional cholecystectomy, as previously reported; this restrictive pattern observed without changes in FRC was similar to that following lower abdominal surgery.

[An unusual complication of perforated sigmoid diverticulitis: gas in the portal vein with miliary liver abscesses]. / Une complication exceptionnelle de la sigmoïdite diverticulaire perforée: l'aéroportie avec abcès miliaires du foie.

A patient presented with gas in the portal vein and miliary liver abscesses due to perforation of a sigmoid diverticulitis abscess. The outcome was favorable after surgical treatment. Gas in the portal vein, a sign of extreme seriousness, is generally the result of intestinal necrosis from ileo-mesenteric artery infarction, responsible for more than 75% of deaths. Diagnosis of this exceptional complication, suggested from a straight abdominal film, was confirmed by hepatic ultrasound and scan imaging. Urgent surgical intervention can hopefully, as in the present case, result in the patient's survival.

[Treatment of large abdominal eventrations with an intraperitoneal stapled plate. Apropos of a series of 27 patients]. / Traitement des grandes éventrations abdominales par plaque intra-péritonéale agrafée. A propos d'une série de vingt-sept patients.

Treatment of 27 large abdominal eventrations by intra-peritoneal prothesis fixed by staples is reported. Only one recurrence (3.5%) in the post-operative period, the good results observed, absence of grave complication, and great simplicity of this procedure lead the authors to recommend the use of intraperitoneal prosthesis in the treatment of post-operative eventration with major loss of parietal substance.

[Tubular grafts of the inferior vena cava for portacaval shunts. Principle, technic and preliminary clinical results]. / Plasties tubulées de la veine cave inférieure pour dérivations porto-caves. Principe, technique et résultats cliniques préliminaires.

A technique for performance of portocaval shunt operations using tubular inferior vena cava grafts is proposed. The aim of this method is to avoid prosthetic or venous interposition with their risk of thrombosis. It is based on results of cadaver experimental studies and a clinical case. Different possible grafts are described, including useful sizes, advantages and inconveniences and clinical indications. Two types are selected: that resected from left surface of subhepatic vena cava for portocaval anastomosis and that obtained from anterior surface of infrarenal vena cava for mesentericocaval anastomosis.

[Endoluminal protection of colorectal anastomosis by Coloshield. Apropos of 14 cases]. / Protection endoluminale des anastomoses colo-rectales par Coloshield. A propos de quatorze cas.

Ideal exeresis with immediate anastomosis protected by an endoluminal shield (Coloshield) was performed in a series of 14 patients with left colic lesions for which the classical treatment would have been exeresis without anastomosis. No post-operative anastomotic fistulas were observed; one case of secondary stenosis of the anastomosis was treated successfully by endoscopic dilatation. The results of this series suggest that this technique is a reliable method of internal intestinal by-pass which offers real progress by allowing left colon exeresis with immediate anastomosis even in case with unfavourable local conditions.

[Tubular gastrostomy]. / Les gastrostomies tubulées.

Development and generalization of the use of mechanical suturing apparatuses has led to re-evaluation of tubular gastrostomy. Use of the 1AG clamp ensures gastric tubulization under good safety conditions (quality of the suture and absence of opening of the gastric tube). The choice of location of the tube depends upon the size of the stomach. The main indication is for feeding gastrostomies of long duration, particularly cases with irreversible lesions of the esophagus or in the ENT sphere. The quality of the apparatus and the facility with which it can be employed has transformed survival in these patients. A further possible indication is in acute necrotic pancreatitis, its use suppressing complications of classical gastrostomies (Fontan type) (gastric fistulae, disinsertions, difficulties with the apparatus). The only inconvenience of this procedure, minimal in regard to the benefits obtained, is the need for surgical closure.

[The treatment of villous tumors of the rectum by cryosurgery. A report of 10 cases (author's transl)]. / Le traitement des tumeurs villeuses du rectum par la cryochirurgie. A propos de 10 observations.

A study of 10 cases of villous tumors treated by cryosurgery shows that this is a simple, benign, and conservative method which can be repeated if need be. It is possible to associate this method with other methods, in particular radiotherapy. The first results obtained suggest that cryosurgery can take its place amongst all the other non-invasive methods but requires, like them, a careful and continuous surveillance of the result which involves repeated endoscopy. The follow up time and the number of patients involved is not large enough to state definitely its long term efficacy but the results of this series are encouraging and optimistic for the future use of this method.

[A new concept of dressing: silastic foam]. / Une conception nouvelle du pansement "la mousse silastic".

The authors report their experience, still short, of a new type of dressing based upon Silastic foam used in general surgery. They emphasise the considerable progress achieved in the everyday care of their patients with easy to manage dressings and the virtual disappearance of pain. This has transformed the patients' existence and has made early physiotherapy possible in certain of them. The simplicity of use of this dressing leads to savings in time and cost and if the patient is cooperative the possibility of widespread use at home by the patient himself. The properties of this foam form the basis for a wide range of indications going beyond general surgery, with applications in ENT, dermatology, rehabilitation centres, etc. Results are satisfactory in 90% of cases, the only failures being due to a failure to obey the basic principles of care: doubtful indication (inadequate disinfection of wounds), neglect of concomitant pathology (diabetes, nutritional state) or lack of patient cooperation.

[Crohn's disease. Apropos of 72 surgical cases]. / La maladie de Crohn. A propos de 72 cas opérés

The authors report a series of 72 cases of Crohn's disease, and discuss the clinical and pathological aspects, the surgical treatment and results. A critical study of the operations in view of the requirements of the disease showed that incomplete resection was mainly responsible for the recurrences. In most cases, the word relapse was more suitable to describe the poor results noted. Immediate radical removal gives such good results that these outweigh the functional disadvantages.

[Present role of Hartmann's operation. Apropos of 50 cases]. / La place actuelle de l'opération de Hartmann. A propos de 50 cas.

Of 50 Hartmann's operation conducted, 22 (including 19 for sigmoid diverticulitis) were for non-neoplastic lesions. Emergency surgery was necessary for lesions complicated by perforation, abscess, or occlusion in 34 cases, the indications for operation being local and general conditions, where immediate re-establishment of colorectal continuity was not possible, in the other 16 patients. Overall mortality was 22 p. cent, being much higher in cancer cases (32 p. cent) than in those with sigmoiditis (52 p. cent). Postoperative morbidity was marked, and was dominated by parietal complications and those due to the colostomy, and by thromboembolic complications particularly in the sigmoiditis cases. Secondary re-establishment of intestinal continuity was possible in 19 patients (6 cancers and 13 benign lesions) with a single postoperative death. Whereas the employ of Hartmann's operation in cancer would appear to be justified only in urgent complicated cases it is certainly a valid procedure in the acute phase of sigmoid diverticulitis, where its mortality is relatively low. Current mechanical suturing techniques, by facilitating secondary re-establishment of continuity, reduce the classical inconveniences of Hartmann's operation, suggesting its wider use for the emergency treatment of complicated lesions of the colon.

[Rupture of the left subclavian artery associated with fracture of the 1st rib]. / Rupture de l'artère sous-clavière gauche associée à une fracture de la première côte.

Treatment in a case of partial rupture of the subclavicular artery, provoking subacute ischemia of the upper limb and associated with a fracture of the first rib, was by sternoclavicular disinsertion and resection-suture. The importance of systematic investigation of possible subclavicular lesions in patients with fractured first ribs is emphasized, both during the initial and follow-up examinations. The presence of a fracture of this type has little influence on the classical surgical attitude adapted, apart from the possible need for resection of the first rib.

[Difficult diagnosis of a rapidly developing post-traumatic tumor of the thymus region. Encysted hematoma or intracystic hemorrhage?]. / Diagnostic difficile d'une tumeur post-traumatique de la loge thymique d'évolution rapide. Hématome enkysté ou hémorragie intrakystique?

We report a case of rapidly developing (subacute) post-traumatic mediastinal haematoma which initially suggested a malignant tumour of the thymus region. The lesion, discovered on the basis of non-specific signal symptoms 2 months after a mild chest injury, consisted of a voluminous tumour of the thymus region associated with pericardial effusion. At angiography, the mass proved to be extravascular. CT scans of the thorax showed that it surrounded, but did not compress, the mediastinal vessels. Surgery revealed an organized encysted haematoma of the thymus region that had ruptured into the pericardial cavity containing a blood collection. The possibility of an intracystic haemorrhage in a cystic tumour preexisting to the trauma is discussed, but a more likely diagnosis would be chronic haematoma, especially since a similar case independent of any injury has already been published.