Elective surgery for tumours of the splenic flexure: a French inter-group (AFC, SFCD, FRENCH, GRECCAR) survey.

BACKGROUND: In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location. METHODS: Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire. RESULTS: A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed. CONCLUSIONS: There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

Laparoscopic enucleation of pancreatic neoplasm.

BACKGROUND: Enucleation is an alternative procedure for treating benign and borderline neoplasms of the pancreas, which preserves healthy parenchyma and pancreatic function. This study aimed to evaluate the postoperative and long-term results after laparoscopic enucleation. METHODS: Data collected prospectively from 23 consecutive patients who underwent laparoscopic pancreatic enucleation were analyzed. RESULTS: Laparoscopic enucleation was achieved successfully for 21 patients (91.3%). One death (4%) occurred. A postoperative pancreatic fistula was observed in three cases (13%), and was clinically significant in one case (4%). Enucleation was performed for endocrine neoplasm in 15 patients (65%) and for cystic neoplasm in eight patients (35%). All the patients had benign tumors at the final histopathologic diagnosis. During a median follow-up period of 53 months, no patient experienced tumor recurrence or new-onset exocrine or endocrine insufficiency. CONCLUSION: Laparoscopic enucleation is a safe and effective procedure for the radical treatment of benign and borderline pancreatic tumors. The laparoscopic approach seems to be associated with a decrease in operative time, hospital stay, and pancreatic fistula after enucleation. Laparoscopy should become the standard approach in the future for enucleation of presumed benign lesions.

[The old man and the syrup]. / Le vieil homme et le sirop.

Intoxication by glycyrrhizin is a rare cause of hypokalemia. We describe a patient with severe hypokalemia caused by long-term consumption of syrup containing liquorice. The physiopathological mechanism of the intoxication and the differential diagnosis are presented.

Rotation thromboelastometry detects thrombocytopenia and hypofibrinogenaemia during orthotopic liver transplantation.

BACKGROUND: Orthotopic liver transplantation can be associated with haemorrhage, particularly in patients with severe liver dysfunction. We assessed the value of rotation thromboelastometry (ROTEM) to monitor coagulation in the operating theatre, its correlation with routine laboratory findings, and its ability to guide platelet (Plt) and fibrinogen (Fg) transfusion. METHODS: Twenty-three patients were included in this prospective observational study. Laboratory tests and ROTEM tests (EXTEM, INTEM, FIBTEM, and APTEM) were performed six times during the procedure. Correlations between laboratory findings and ROTEM parameters were sought. Thresholds for ROTEM parameters were determined with receiver-operating characteristic (ROC) curve analysis according to Plt count and Fg levels. RESULTS: Clot amplitude at 10 min (A10) of EXTEM was well correlated with Plt count and Fg levels (R(2)=0.46 and 0.52, respectively, P<0.0001). FIBTEM A10 was correlated with Fg (R(2)=0.55, P<0.0001). ROC analysis showed that EXTEM A10 with a threshold of 29 mm predicted thrombocytopenia with a sensitivity of 79% and a specificity of 60%, and a threshold of 26 mm predicted hypofibrinogenaemia with a sensitivity of 83% and a specificity of 75%. CONCLUSIONS: ROTEM is useful for the global assessment of coagulation in the operating theatre. EXTEM was the most informative for assessing the whole coagulation process and A10 showed value in guiding Plt and Fg transfusion.

How mechanistic modelling supports decision making for the control of enzootic infectious diseases.

Controlling enzootic diseases, which generate a large cumulative burden and are often unregulated, is needed for sustainable farming, competitive agri-food chains, and veterinary public health. We discuss the benefits and challenges of mechanistic epidemiological modelling for livestock enzootics, with particular emphasis on the need for interdisciplinary approaches. We focus on issues arising when modelling pathogen spread at various scales (from farm to the region) to better assess disease control and propose targeted options. We discuss in particular the inclusion of farmers' strategic decision-making, the integration of within-host scale to refine intervention targeting, and the need to ground models on data.

[Surgical excision of subclinical cortisol secreting incidentalomas: Impact on blood pressure, BMI and glucose metabolism]. / Bénéfices tensionnels, anthropométriques et métaboliques de l'exérèse chirurgicale des adénomes cortisoliques infracliniques.

OBJECTIVES: To compare clinical, vascular and metabolic parameters before and after surgery in patients with subclinical cortisol secreting incidentalomas. PATIENTS AND METHODS: Eight patients were investigated before and 12 months after removal of the mass on hemodynamic (blood pressure by MAPA procedure), anthropometric (body weight, body mass index), and metabolic parameters (glucose level, HbA(1c)). RESULTS: In the whole group, 75% of patients displayed decrease in blood pressure (cessation of at least one hypotensive medication) and 33% of them were definitely cured of hypertension. Seventy-one percent of patients lost body weight and 37.5% lost more than 5%. In the whole group of patients, glucose level decreased by 1.1% and medical treatment was discontinuated in two of three diabetic patients. CONCLUSION: Subclinical cortisol secreting adrenal incidentalomas are associated with cardiovascular risk factors that may be corrected after removal of the mass. Therefore, surgery may be an appropriate choice in patients with subclinical Cushing's syndrome to improve hypertension, body weight and impaired glucose level. Controlled studies comparing surgical treatment to a medical follow-up including optimal cardiovascular risk factors treatment are needed to define the usefulness of surgery in hypertensive patients with subclinical cortisol secreting incidentalomas.

[Intragastric migration of adjustable gastroplasty bands]. / Migration intragastrique des anneaux de gastroplastie ajustable.

BACKGROUND: The incidence of morbid obesity is increasing in France; adjustable gastric banding has become the most common surgical treatment. PATIENTS: We report seven cases of patients who presented with gastric erosion as a complication of gastric banding; this occurred at a mean interval of 4 years following the initial bariatric procedure. RESULTS: In six cases, repair was performed laparoscopically; one case required conversion to an open laparotomy approach. There was no mortality but morbidity occurred in 57% of cases: pleural effusion (two) and wound abscess (two). CONCLUSION: Gastric erosion and migration of adjustable gastric rings can occur at a long interval after laparoscopic gastric banding. Long-term follow-up is necessary in all such patients.

Antibiotic use by farmers to control mastitis as influenced by health advice and dairy farming systems.

Mastitis is a bacterial disease common in dairy farms. Although knowledge about mastitis and its optimal technical management and treatment is now available, some dairy farmers still use antibiotics in inappropriate ways. Antibiotic use by farmers can be influenced by personal restraints and motivations, but it can be assumed that external drivers are also influential. The main purpose of this article is thus to analyse the choices of antibiotic and alternative medicine use for mastitis treatment and investigate the possible influence of two unexplored external drivers in dairy farms: (i) the health advice offered to farmers by farm advisors and veterinarians, (ii) the dairy farming system, as defined by combining the market valuation chosen for the milk, the level of intensification, and the perceived pressure related to investments. Research was based on 51 individual semi-structured interviews with farmers and their corresponding veterinarians and farm advisors. Based on verbatim, the use of antibiotics and alternative medicine by farmers for mastitis treatment, the vet-farmers interactions, and the dairy farming systems are described. The advisory relationships between farmers and farm advisors and between farmers and veterinarians influenced the implementation of selective dry cow therapy, but had very little effect on the use of alternative medicines by farmers, who were more willing to experiment alternative medicines than their advisors. The dairy farming system had very little influence on antibiotic use: some misuse of antibiotics was found whatever the farming system. Systematic dry cow therapy was also a widespread habit in all dairy farming systems except organic. The use of alternative medicine was common in all farming systems.

[Laparoscopic treatment of para-esophageal hernias]. / Traitement laparoscopique des hernies hiatales par roulement.

AIM: This retrospective study aims at analyzing the functional results obtained in patients operated by laparoscopy for a para-esophageal hernia. PATIENTS AND METHODS: From 1994 to 2004, 38 patients underwent a laparoscopic procedure for a symptomatic para-esophageal hiatal hernia of at least 3/4 of the proximal stomach: 27 females and 11 males, mean age 65 years (extreme: 22-84). There was no case on emergency, 4 patients had have at least one episode of intrathoracic volvulus. The operation consisted in gastric reduction into the abdominal cavity, excision of the sac, suture of the crura reinforced with a mesh in 6 patients and the construction of a gastric wrap. A postoperative barium swallow was performed on POD 3 in order to confirm the anatomical result. RESULTS: Mean operating time was 157 minutes (75-480), no case was converted into laparotomy. Four postoperative complications were observed (morbidity 10.8%): one gastric perforation diagnosed on POD 1, 2 severe dysphagias linked to the wrap, and one atelectasia. There was no death in this series. Functional results were evaluated by the mean of a questionnaire in 33 patients who had a follow up more than 6 months. Thirty-three questionnaires have been sent, 3 patients were lost and one was dead. Among the 29 patients analyzed, 14 were very satisfied, 11 were satisfied and 3 were deceived by the operation. Best results are obtained in patients with GERD, dysphagia or postprandial cardiothoracic symptoms. CONCLUSION: These results compared to the published data allow us to discuss about indications of surgery, the necessity to removal the hernia sac, and the advantages to reinforce the crura by the mean of a non absorbable mesh.

Laparoscopic adjustable gastric banding results after 2 years with two different band types.

BACKGROUND: Laparoscopic gastric banding is the most common operation in Europe for morbid obesity. Many devices from different companies are now available. The aim of this study was to compare the results over a 2-year period of 2 types of band: the Lap-Band and the Minimizer band. METHODS: In a non-randomized study, 2 consecutive groups were prospectively analyzed. Group A consisted of 120 patients who received the Lap-Band, and group B consisted of 68 patients who received the Minimizer band which contains eyelets. All the bands were placed above the lesser sac by the perigastric approach. RESULTS: 4 early complications were observed in group A (1 phlebitis, 1 pneumopathy and 2 early displacements of the band); and 1 in group B (1 retention of urine). After a follow-up of 2 years, the displacement rate of the band was 10.8% in group A and 0% in group B. One gastric erosion was observed in group B, but not in group A. After 2 years, the average loss of excess weight was 50% in both groups. CONCLUSION: With the Minimizer band, we did not observe any slipping, and the efficacy with respect to weight loss was equivalent to the Lap-Band.

[Value of surgical ampullectomy in the management of benign ampullary tumors]. / Intérêt de l'ampullectomie chirurgicale dans la prise en charge des lésions bénignes de l'ampoule de Vater.

AIM OF THE STUDY: To report the results of transduodenal excision (TDE) for tumors of the ampulla of Vater. PATIENTS AND METHODS: From 1998 to 2003, 10 patients underwent a transduodenal excision for presumed benign tumors of the ampulla of Vater. After resection, frozen sections were performed to ensure negative margins. RESULTS: There was no operative mortality. A postoperative pancreatitis occurred in one patient. For nine patients the postoperative course was uneventful. The mean duration of hospital stay was 18 +/-11 days. The final pathology showed adenoma in 8 patients, an adenocarcinoma in one patient and inflammatory lesions in other one. With a mean follow-up of 20 months, endoscopy did not show any recurrence in patients with benign lesion. Patient with an invasive cancer developed recurrence. CONCLUSION: Transduodenal excision is safe and effective treatment for benign ampullary tumors. TDE should be the operation of choice for patients with histologically-proven benign ampulloma, staged as uT1 by endoscopic ultrasound. This approach could reduce the rate of pancreaticaduodenoctomy performed for benign ampullomas.

[Surgical management of obstructed colonic cancer]. / Prise en charge du cancer colique en occlusion.

INTRODUCTION: Management of obstructed colonic carcinomas is a surgical challenge because it happens more often in elderly patients. The aim of our study is to assess mortality and morbidity rates of procedures performed in emergency for this pathology. PATIENTS AND METHOD: Between January 1st, 1998 and December 31st 2003, 22 patients underwent an emergency procedure for obstructive colonic obstruction due to an adenocarcinoma. Obstruction was defined as an emesis, distension on examination, no gas or stool since 24 hours and confirmatory plain radiograph film. RESULTS: Twenty patients (91%) underwent surgical procedure and two others received a colonic stent. Eleven patients (50%) underwent left colonic resection and intraoperative colonic cleansing was undertaken in 3 of these patients. One patient underwent a lateral colostomy, three patients (14%) underwent a right colectomy. A Hartmann's procedure was performed in six cases (27%). Morbidity occurred in 23% (50% were from anastomotic complication). Mortality rate was 27% (44% if aged more than 75 years old) (one superior mesenteric ischemia, and five heart and respiratory failures). Two-year survival rate was 61% and five year survival rate was 47%. Median survival was 24 months. CONCLUSION: Our study confirms that obstructed colonic cancer has a bad prognosis because it happens in elderly and not healthy patients. Priority must be given to the restoration of colonic permeability.

[Technics, main advantages and best indications of quick plastic embedding (author's transl)]. / Techniques, principaux avantages et indications préférentielles des inclusions rapides en résine plastique.

Three recent progresses allow to perform plastic embedding of moderate or large samples of tissue in limits of time close to those of the paraffin embedding and to obtain slices between 1 and 2,5 mu on which all current histochemical or even histo-immunological reactions are possible. These technics prevent the retraction of the tissues, give a good preservation of the structure of the cells and permit a good analysis of the tiny lesions of all kinds of tissues. From our experience about 1362 varied biopsies, the best indications seems to be in order : kidney, hepatic, lung, medullary and nodes biopsies. It seems now justified to introduce these technics as a routine one, inside laboratories which have to detect tiny lesions on particular tissues or on experimental samples.

[Laparoscopic pancreatectomy: report of 22 cases]. / Les pancréatectomies laparoscopiques. A propos d'une expérience de 22 cas.

OBJECTIVE: To evaluate results of laparoscopic pancreatectomy for benign lesions of the pancreas. Peri-operative data, surgical outcomes and techniques are presented. PATIENTS AND METHODS: Eighteen women and four men underwent laparoscopic pancreatectomy and were collected retrospectively from 1999 to 2003. RESULTS: Laparoscopic pancreatectomy was attempted in 22 patients and completed successfully in 18: 10 enucleations, three distal pancreatectomies, four left pancreatectomies and one total pancreatectomy for endocrine and cystic tumors. Left and distal pancreatectomies were performed with preservation of the spleen. Four patients were converted (one enucleation, one whipple procedure and two left pancreatectomy). There was no mortality; the post-operative morbidity included two pancreatic leaks and one case of half splenic infarction. The median length of hospital stay was 12 days. CONCLUSION: Patients appear to benefit from laparoscopic pancreatectomy for pancreatic benign tumors.

[Horton's disease in the course of chronic hepatitis C]. / Maladie de Horton au cours d'une hépatite C chronique.

BACKGROUND: Vascularitis is a well-known extrahepatic manifestation of chronic hepatitis C. Mixed cryoglobulinemia is the most common form. To our knowledge, the present case is the first report associating chronic hepatitis C and temporal arteritis. CASE REPORT: A 56-year-old man with chronic hepatitis C in the precirrhogenic phase presented with fever and weight loss. The patient complained of pain of the scapular and pelvic girdles and headache and physical examination revealed claudication of the jaw and abolition of the upper limb pulses. Biopsy of the temporal artery confirmed the diagnosis of Horton's disease. The patient also had bilateral stenosis of the sub-clavian arteries. DISCUSSION: This observation of Horton's disease involving large vessels in a patient with chronic hepatitis C suggests that an infectious factor might trigger vascularitis.

Vesicoovarian fistula on an endometriosis abscessed cyst.

We report the case of a patient who developed a vesicoovarian fistula on an endometriosis abscessed cyst. The patient presented with an advanced endometriosis stage IV complicated with a right ovarian abscessed cyst of 10 cm. A first coelioscopy with cystectomy was realized. After surgery, a voiding cystography highlighted a fistula between the ovarian abscess and the bladder. A second surgery by median laparotomy was realized with the resection of the right ovarian abscess and the resection of vesical fistula.

Evaluation and validation of two microbiological tests for screening antibiotic residues in honey according to the European guideline for the validation of screening methods.

Two microbiological kits based on Bacillus stearothermophilus (Eclipse 50® and Premi®Test) have been evaluated and validated according to the European guideline for the validation of screening methods (January 2010) and in relation to the concentrations recommended by the EU-RL in 2007. Both tests are robust, a fast method and easy to implement. Both tests are applicable to a very large variety of honeys from different floral and geographical origins (rosemary, lavender, scrub, heath, alder, forest, lemon, acacia, chestnut, raspberry, mountain and flowers) as well as honey of different colours (from blank honey to brown honey, including yellow and orange honey). A satisfactory false-positive rate of 5% was obtained for the Eclipse 50® test. The observed detection capabilities CCß of the Eclipse 50® kit were: chlortetracycline (>75 µg kg(-1)), oxytetracycline (≤200 µg kg(-1)), tetracycline (>100 µg kg(-1)), cloxacillin (≤40 µg kg(-1)), tylosin (≤200 µg kg(-1)), desmycosin (>400 µg kg(-1)), sulfadiazine (≤300 µg kg(-1)), sulfadimethoxine (≤250 µg kg(-1)), sulfamerazine (>300 µg kg(-1)), sulfamethazine (>1000 µg kg(-1)), sulfamethizole (>75 µg kg(-1)), sulfamethoxazole (≤25 µg kg(-1)), sulfanilamide (>>1000 µg kg(-1)), sulfaquinoxaline (>75 µg kg(-1)), sulfathiazole (≤250 µg kg(-1)) and lincomycin (>1500 µg kg(-1)). These levels were all higher than the recommended concentrations where they exist. Due to its lack of sensitivity, it cannot be recommended for reliable routine use. The observed CCß of the Premi®Test kit were: chlortetracycline (10 µg kg(-1)), oxytetracycline (>10 µg kg(-1)), tetracycline (≤10 µg kg(-1)), cloxacillin (≤5 µg kg(-1)), tylosin (≤10 µg kg(-1)), desmycosin (≤15 µg kg(-1)), sulfadiazine (≤25 µg kg(-1)), sulfadimethoxine (≤25 µg kg(-1)), sulfamerazine (≤25 µg kg(-1)), sulfamethazine (≤25 µg kg(-1)), sulfamethizole (≤25 µg kg(-1)), sulfamethoxazole (≤10 µg kg(-1)), sulfanilamide (≤25 µg kg(-1)), sulfaquinoxaline (≤10 µg kg(-1)), sulfathiazole (25 µg kg(-1)) and lincomycin (≤25 µg kg(-1)). The Premi®Test kit could be recommended for reliable use in routine control due to its low detection capabilities (except for aminoglycosides), but the disadvantage is a high false-positive rate of 14%.