[Update in abdominal surgery]. / Evolution en chirurgie abdominale. Avancées techniques, collaboration intra et inter hospitalière.

During the last decade minimal invasive approach progressed in all sectors of abdominal surgery. Technological improvements allowed to perform more complex procedures laparoscopically with increased safety. The implementation of pre-, per- and postoperative protocols with an adaptation of surgical, anesthetic and analgesia methods and the patient's involvement in the healing process led to enhanced recovery after surgery. The centralization of complex esophageal and pancreatic surgery established the CHU of Liège as a tertiary referral institution for complex oncological surgery thanks to a large cooperation with regional hospitals.

La dernière décennie a vu progresser l'approche mini-invasive dans tous les domaines de la chirurgie abdominale. Les améliorations technologiques permettent de réaliser des interventions toujours plus complexes en laparoscopie avec une sécurité accrue. La systématisation de la prise en charge pré-, per- et postopératoire, avec une adaptation des techniques de chirurgie, d'anesthésie et d'analgésie, et une implication du patient dans ce processus ont abouti à une réhabilitation accélérée. La centralisation de la chirurgie complexe de l'oesophage et du pancréas a permis de créer une structure de référence en chirurgie oncologique complexe au CHU de Liège grâce à une large collaboration interhospitalière régionale.

[Cushing's syndrome during pregnancy : diagnostic and therapeutic difficulties]. / Le cas clinique du mois. Syndrome de Cushing au cours d'une grossesse : difficultés diagnostiques et thérapeutiques.

Cushing's syndrome (CS), which is often associated with infertility, exceptionally occurs in pregnancy, and markedly increases maternal and fetal morbidity and mortality. Gestational CS may be challenging. Indeed, symptoms of hypercorticism may overlap with physiological hyperactivity of the hypothalamus-pituitary-adrenal axis in normal pregnancy. This case report describes a pregnant patient that underwent a fertility treatment and developed a gestational CS due to an adrenocortical adenoma. Diagnosis of gestational CS was suspected at 13 weeks by a new onset of hypokalemia and arterial hypertension. A multidisciplinary approach was necessary during follow up. At 24 weeks, laparoscopic surgery retrieved a 4 cm adrenocortical adenoma. Cesarean surgery was successfully practiced at 31 weeks, because of preeclampsia. We discuss the differential diagnosis of hypokalemia and arterial hypertension during pregnancy and the diagnosis and management of gestational CS.

Le syndrome de Cushing (SC), déterminant fréquemment une infertilité, survient exceptionnellement au cours d´une grossesse. La présentation du SC au cours de la grossesse s'accompagne d'une plus grande morbimortalité maternelle et foetale. Son diagnostic représente un véritable défi pour le clinicien, car les symptômes de l'hypercorticisme se superposent aux modifications physiologiques induites par la stimulation de l`axe corticotrope lors de la grossesse. Nous rapportons le cas d'une patiente enceinte après une fécondation in vitro. A 13 semaines de grossesse, un SC gestationnel d'origine surrénalienne est suspecté dans le cadre d'une hypokaliémie et d'une hypertension artérielle inaugurales. Un suivi multidisciplinaire est instauré au cours de la grossesse. Une surrénalectomie gauche par voie laparoscopique est décidée à 24 semaines d'aménorrhée, avec l'exérèse complète d'un adénome cortical, de 4 cm de diamètre. La chirurgie par césarienne est pratiquée avec succès à 31 semaines de grossesse, car la patiente développait une pré-éclampsie. Nous discutons les différents diagnostics différentiels d'une hypokaliémie et d'une hypertension artérielle au cours de la grossesse et les modalités de prise en charge d´un SC gestationnel.

[CONTROVERSIES REGARDING THE ACCURACY AND LIMITATIONS OF FROZEN SECTION IN THYROID PATHOLOGY: AN EVIDENCE-BASED ASSESSMENT]. / INTÉRÊTS ET LIMITES DE L'EXAMEN EXTEMPORANÉ EN PATHOLOGIE THYROÏDIENNE. Revue systématique de la littérature et évaluation fondée sur les preuves.

Palpable thyroid nodules are present clinically in 4-7% of the population and their prevalence increases to 50%-67% when using high-resolution neck ultrasonography. By contrast, thyroid carcinoma (TC) represents only 5-20% of these nodules, which underlines the need for an appropriate approach to avoid unnecessary surgery. Frozen section (PS) has been used for more than 40 years in thyroid surgery to establish the diagnosis of malignancy. However, a controversy persists regarding the accuracy of FS and its place in thyroid pathology has changed with the emergence of fine-needle aspiration (FNA). A PubMed Medline and SpringerLink search was made covering the period from January 2000 to June 2012 to assess the accuracy of ES, its limitations and indications for the diagnosis of thyroid nodules. Twenty publications encompassing 8.567 subjects were included in our study. The average value of TC among thyroid nodules in analyzed studies was 15.5 %. ES ability to detect cancer expressed by its sensitivity (Ss) was 67.5 %. More than two thirds of the authors considered PS useful exclusively in the presence of doubtful ENA and for guiding the surgical extension in cases confirmed as malignant by FNA; however, only 33% accepted FS as a routine examination for the management of thyroid nodules. The influence of FS on surgical reintervention rate in nodular thyroid pathology was considered to be negligible by most studies, whereas 31 % of the authors thought that FS has a favorable benefit by decreasing the number of surgical re-interventions. In conclusion, the role of FS in thyroid pathology evolved from a mandatory component for thyroid surgery to an optional examination after a pre-operative FNA cytology. The accuracy of FS seems to provide no sufficient additional benefit and most experts support its use only in the presence of equivocal or suspicious cytological features, for guiding the surgical extension in cases confirmed as malignant by FNA and for the identification of other potentially confusing intraoperative findings.

[Amiodarone and the thyroid]. / L'amiodarone et la thyroid.

Amiodarone is an antiarrhythmic agent among the I most powerful and the most frequently used for the control of recurrent ventricular tachycardia and the secondary prevention of recurrent atrial fibrillation. Its use is not without risk. Although highly effective, it may induce various, sometimes severe, side effects, particularly at the thyroid level.In patients receiving amiodarone, one can encounter biological changes without clinical repercussion. Some may present a true thyroid disease, either hyper- or hypothyroidism. In this literature review, we will see how to prevent, diagnose, and treat these complications,if required.

Cardiac paraganglioma: diagnostic work up and review of the literature.

Paraganglioma of the heart are potentially invasive, highly vascularized tumors for which complete resection may be curative. Derived from the cardiac wall in most instances, resectability can be assessed after integration of the data provided by MRI in T2 sequence, and coronarography. A fully documented case of a large cardiac pheochromocytoma of the left atrium and AV groove is reported and the pertinent literature on the subject is here presented.

[Current opinion on primary aldosteronism]. / Concepts actuels de l'hyperaldostéronisme primaire.

In recent years, a greater interest has been focused on primary aldosteronism (PA), which shows a higher prevalence rate than previously thought. The consequences of PA are life threatening such as a refractory hypertension with serious cardiovascular damages.The evaluation of a suspected PA should follow a step-by-step approach (screening test, then confirmatory test and, in some cases, adrenal venous sampling). This protocol may seem tedious, but it allows an accurate etiologic diagnosis that leads to an appropriate therapy with better blood pressure control,improvement of quality of life, and, in some cases even,cure of hypertension.

Effects of oral preoperative carbohydrate on early postoperative outcome after thyroidectomy.

BACKGROUND: Preoperative carbohydrate (CHO) reduces perioperative insulin resistance and improves preoperative patient comfort. We tested the hypotheses that preoperative CHO reduces the risk of postoperative nausea and vomiting (PONV) and improves early postoperative patient comfort. METHODS: Two hundred women scheduled for thyroidectomy were randomly allocated to drink 50 g CHO in 400 ml of water or 0.5 g aspartam in 100 ml of water 2 h before surgery. The incidence and the severity of PONV, pain scores, and analgesic consumption were recorded postoperatively. Intensity of thirst, hunger, anxiety, fatigue were recorded on 100-mm visual analog scales just before the induction of anesthesia, 2, 6, and 24 h postoperatively. RESULTS: The incidence and severity of PONV were similar in both groups. Patients from the CHO group reported significantly less thirst (P = 0.007), hunger (P = 0.04), and fatigue (P = 0.01) than patients from the control group. Postoperative pain scores did not differ significantly between both groups (P = 0.34). However patients from the CHO group requested less acetaminophen during the first 24 postoperative h: 3 g vs. 2 g (median, P = 0.002). CONCLUSIONS: Oral carbohydrate before thyroidectomy improves pre- and postoperative patient comfort, as well as postoperative analgesia, but has no effect on the PONV.

Exploration and management of adrenal incidentalomas. French Society of Endocrinology Consensus.

The French Society of Endocrinology convened a multidisciplinary panel of endocrinologists, radiologists, nuclear physicians and surgeons to address the appropriate evaluation and treatment of adrenal incidentalomas. The panel conducted a systematic review of medical literature on the following issues: epidemiology, natural history, radiological and scintigraphic evaluation, endocrine assessment, surgical management and appropriate follow-up. The following text reports the recommendations of experts on behalf of the French Society of Endocrinology. The authors emphasize the paucity of published scientific data that hampers evidence-based medicine recommendations. The crucial points of the French consensus are: the usefulness of CT-scanning evaluation of adrenal incidentalomas, the systematic screening for pheochromocytoma, the usefulness of the 1mg overnight dexamethasone test to screen for latent hypercortisolism, the difficulty to interpret mild biological abnormalities of the HPA axis, the consensus to remove surgically most of tumours greater than 4cm, the necessity to follow clinically glucorticoid tissular targets in the follow-up of non operated benign adrenocortical incidentalomas.

Adrenal ganglioneuroma. A neoplasia to exclude in patients with adrenal incidentaloma.

OBJECTIVE: To determinate the MRI and CT scanning appearance of adrenal ganglioneuroma and correlate the imaging with histological features. SUMMARY BACKGROUND DATA: In the last 10 years, eight patients with a pathologically proven adrenal ganglioneuroma were operated on in our department of endocrine surgery. To our knowledge, these patients represent one the largest reported cohorts of adrenal ganglioneuroma treated in a single institution. METHODS: All these eight patients had a comprehensive hormonal work up and underwent CT and/or MRI. Biological data, radiological features and histological findings were thoroughly reviewed in order to further characterize these tumours. RESULTS: The most relevant characteristics of adrenal GN resected in our patients were: No hormonal hypersecretion, Presence of calcifications; no vessel involvement; and a non-enhanced attenuation of less than 40 HU on CT, A low non-enhanced T1W signal, a slightly high and heterogeneous T2W signal, a late and gradual enhancement on dynamic MRI, especially if associated with a whorled pattern. CONCLUSIONS: Even if many aggressive tumours, mainly adrenal carcinoma, may share some of these radiological features, the presence of all or most of them must made the clinician evoke the diagnosis of GN.

Surgical management of adrenal tumours. Lessons from a 10 years personal experience.

OBJECTIVE: To review our personal experience of the last 10 years with adrenal surgery in order to define the indications of laparoscopic adrenalectomy (LA) and open adrenalectomy (OA), respectively. PATIENTS AND METHODS: From November 1993 to June 2003, we performed 105 adrenalectomies on 97 patients (29 males and 68 females). The lesions resected were preoperatively considered non-secreting in 47 cases (45%) and hormonally active in 58 cases (55%). In 78 patients (80%), LA was performed and 84 adrenal glands were resected. In 19 patients (20%), OA was considered the best modality of resection and 21 adrenal glands were resected. The average tumour size was 37.2 mm (range 25-90) in LA group and 82.6 mm (30-260) in the OA group. All the LA were performed using a trans-peritoneal approach. Depending on the particularities of the lesions and of the patients, the OA were performed by anterior or lumbar incisions. RESULTS: There was no mortality. Conversion from LA to open surgery was necessary in two patients. Mean operating time was 110 minutes for LA and 135 minutes for OA. Two (2.6%) patients suffered complications after LA and 4 (19%) after OA. CONCLUSIONS: In our experience, trans-peritoneal LA proved to be a safe and reliable procedure for benign adrenal disease. In our institution, it has become the gold standard technique for the resection of adrenal tumours, except for those suspected or proven malignant.

[Hypertension due to primary aldosteronism]. / Comment j'explore ... l'hypertension artérielle par excès de minéralocorticoïdes.

Primary aldosteronism is a rare cause of hypertension. However, its incidence seems to be underestimated. It is important to identify this syndrom since the disease is potentially curable. In the present paper, we depict different forms of primary aldosteronism as well as the diagnostic procedures. When the diagnosis is suspected (hypertension associated to spontaneous or diuretic-induced hypokaliemia), the more efficient screening test is the determination of the aldosteron/renin ratio. Saline infusion or posture tests can thereafter confirm the diagnosis. Differential diagnosis between bilateral and unilateral forms of primary aldosteronism can be made by CT-scanner and the response of aldosterone to the posture test. Such a complex assessment leads to the identification of patients who can be surgically treated. This treatment consists in a unilateral adrenalectomy which can be realised by laparoscopy.

Hypnoanesthesia for endocrine cervical surgery: a statement of practice.

OBJECTIVES: To assess the feasibility of endocrine cervical surgery under hypnoanesthesia as a valuable, safe, efficient, and economic alternative to general anesthesia. METHODS: Between April 1994 and June 1997, 197 thyroidectomies and 21 cervical explorations for hyperparathyroidism were performed under hypnoanesthesia (HYP) using Erikson's method. Operative data and postoperative course of this initial series were compared to a contemporary population of patients (n = 119) clinically similar except that they declined HYP or were judged unsuitable for it, and who were therefore operated on under general anesthesia (GA). RESULTS: The surgeons all reported better operating conditions for cervicotomy using HYP. Conversion from hypnosis to GA was needed in two cases (1%). All patients having HYP reported a pleasant experience and, keeping in mind that the GA group is not a randomly assigned control group, both had significantly less postoperative pain and analgesic use. Hospital stay was also significantly shorter, providing a substantial reduction in the costs of medical care. The postoperative convalescence was significantly improved after HYP and a full return to social or professional activity was significantly quicker. CONCLUSION: From this study, we conclude that HYP is an effective technique for providing relief of intraoperative and postoperative pain in endocrine cervical surgery. The technique results in high patient satisfaction and better surgical convalescence. This technique can therefore be used in most well-chosen patients and reduces the socioeconomic impact of hospitalization.

Videoendoscopic adrenalectomy: multicentric study from the Belgian Group for Endoscopic Surgery (BGES).

This paper reports the experience of five Belgian surgical teams with 18 videoendoscopic adrenalectomies performed on 16 patients between October 1993 and May 1995. The adrenal gland diseases were pheochromocytoma (4 patients), primary hyperaldosteronism (2 cases), Cushing's adenoma (2 cases), Cushing's disease (1 case), nonfunctional adenoma (3 cases), single metastasis from adenocarcinoma (2 cases), functional adenoma with dehydro-epiandrostenedione (DHEAS) and cortisol hypersecretion (1 case), ACTH secreting metastases from a thymoma (1 case) Two patients underwent bilateral adrenalectomies. Eleven left and three right adrenal glands were removed in 14 other patients. The eight women and eight men range in age from 17 to 72 years (median 47). Six patients demonstrated a body mass index greater than 30. Median tumor size was 3 cm (range 1.3 - 5). Laparoscopic adrenalectomy was successful in 14 patients (87%). The median duration of the procedure was 132 minutes (range 59-360). The median postoperative stay was 6 days (range 2-13). No patient required blood transfusion. We conclude that the videoscopic approach can safely be used for surgical removal of adrenal lesions. However this approach should be performed by surgeons well versed in the techniques of open adrenalectomy for endocrine disorders, but also well trained in videoendoscopic surgery.

Prediction of malignancy in solitary thyroid nodules: value of preoperative explorations.

The thyroid nodule is a topic in clinical medicine which remains controversial because any thyroid disease can virtually turn up a thyroid nodule. The reliability of the diagnostic techniques for making the distinction between a benign and a malignant lesion varies. The various techniques for the assessment of a solitary nonfunctional thyroid nodule are described and their comparative values in establishing the nature of the nodule, identifying patients with low likelihood of malignancy--making it possible to defer surgery or to avoid it altogether--are analyzed. According to the results and for several reasons, controversy over the best approach of solitary cold nodule management can remain. We propose an alternative approach and provide a personal guideline for the use of these tests.

New challenges in the treatment of early breast cancer or surgery for early breast cancer ... can less be more?

Breast cancer is a major public health problem of great interest and importance to physicians in a variety of specialities. The incidence of the disease has increased dramatically, heightening concern among physicians and women in general. In addition, long-term results are now available from clinical trials initiated in the 1970s and 1980s to evaluate the usefulness of early detection with mammography and physical examination, breast-conserving treatment with limited breast surgery and irradiation, and adjuvant systemic therapy with hormonal therapy and chemotherapy. Furthermore, in the light of newly gained knowledge, new strategies for addressing this problems have been proposed. In this review, we will summarize the evidence evaluating the strategies for diagnosis and therapy initiated in the 1970s and 1980s, and will describe the prospects for prevention and for more specific treatments bases on evolving biologic knowledge. Our review will only focus on early breast cancer, discussing the following topics: Breast Cancer screening: Who should be screened and how often?; New technologies in Breast Cancer Diagnosis; Selection of patients for Breast-conserving therapy; Management of the axilla in primary breast cancer or "Is sentinel lymph node biopsy useful?"; Expanded use of adjuvant systemic therapy; Genetic predisposition for Breast Cancer; Clinical options for Women at high-risk for Breast Cancer.

Evaluation of the ultrasonic dissector in thyroid surgery. A prospective randomised study.

BACKGROUND: The use of ultrasonic dissectors in endoscopic surgery has proved to be of value, particularly for the prevention of bleeding and the reduction of electrical internal burns. This prospective randomised study was performed in order to evaluate the efficacy, security and cost of using the ultrasonic hook in thyroid surgery. METHODS: Thirty-four consecutive euthyroid patients with multinodular goitre for whom a total thyroidectomy was indicated, were randomly assigned either to group I, Ultracision or to group II, conventional hemostasis. Pre-, peri-, and postoperative biochemical, clinical, surgical and economical variables were compared between both groups. RESULTS: The use of the ultrasonic hook resulted in a significant reduction in operating time, blood loss, and maybe in "transitory hypoparathyroidism"; postoperative analgesic consumption was also reduced in this group. Considering the cost, the ultrasonic hook was no more expensive than conventional hemostasis, as long as a minimum of 15 patients shared the initial unit cost of the device. CONCLUSION: Even if the use of the ultrasonic dissector is not of major interest in terms of patient management or cost-saving in the context of total thyroidectomy, essential advantages reside in significant reductions of operating time, blood loss and organ injury, (particularly parathyroid). The reduced operating time undoubtedly represents a positive feature of the ultrasonic dissection technique.

The inferior non recurrent laryngeal nerve: a major surgical risk during thyroidectomy.

It is now widely established that systematic intraoperative location and diligent dissection of the recurrent inferior laryngeal nerve during thyroidectomy are the keystones to assure its anatomic and functional preservation. The possibility of abnormal routes, like a non-recurrent cervical course of the inferior laryngeal nerve is an additional major argument for its systematic identification to avoid surgical damage. In 2517 cervicotomies performed between 1992 and 1997 for at least right thyroid lobe excision or parathyroid glands exploration, 20 cases of non recurrent laryngeal nerve were identified (0.79%). The embryological nature of such a nervous anatomical variation results originally from a vascular disorder, named arteria lusoria in which the fourth right aortic arch is abnormally absorbed, being therefore unable to drag the right recurrent laryngeal nerve down when the heart descends and the neck elongates during embryonic development. The surgeon must be aware of the possibility of a non recurrent laryngeal nerve, which arises directly from the cervical vagus and therefore represents a severe potential pitfall during thyroidectomy. Given the absence of reliable clinical symptoms and signs or investigations indicating preoperatively the possibility of a non recurrent nerve, guidelines are given to prevent intraoperatively this major surgical risk.

Laparoscopic adrenalectomy in pheochromocytoma and Cushing's syndrome. Reflections about two case reports.

Laparoscopic adrenalectomy is possible as well on the left as on the right side using a percutaneous transabdominal approach. The exposure of the glands seems better than it could be achieved with an open method. In combination with intraoperative infusion of nicardipine, a calcium-channel blocker, the laparoscopic removal of a pheochromocytoma was performed safely and under stable conditions. In case of Cushing's syndrome, the laparoscopic approach reduces the problems related to poor healing. In all cases of laparoscopic adrenalectomy, this approach could offer the clear advantages of smaller incisions, reduced postoperative pain and incisional discomfort as well as complications related to large and invasive procedure and finally allows quicker recovery. Moreover, conversion to open surgery remains always possible, if needed.

Laparoscopic live donor nephrectomy: initial experience.

Transplanting a kidney graft harvested from a live donor has been proposed and used to shorten the waiting time of kidney transplant candidates and to increase the graft pool. Live donor renal transplants have demonstrated better results in term of graft survival rates, compared to renal transplants harvested from brain dead donor. Recently, laparoscopic live donor nephrectomy has been introduced to reduce the live procurement morbidity. This lower morbidity may result in increased acceptance of the donor operation. We initiated a program of laparoscopic live donor nephrectomy in January 1997 and up until June 1998, three cases were successfully performed in our department. The purpose of this paper was to report the first case of this program and its first year of follow-up.