Laparoscopic pancreaticoduodenectomy for tumors of the head of pancreas; 10 cases for a single center experience.

OBJECTIVE: The tumors of the head of the pancreas are one of the leading causes of cancer-related death in Western countries. The current gold standard for these tumors is a Whipple procedure. This procedure did not change in its surgical steps since when it was initially introduced in 1935. More recently, a laparoscopic approach with similar outcomes has been described. The aim of this paper is to describe the laparoscopic surgical technique performed in our unit, reporting single center postoperative outcomes. PATIENTS AND METHODS: From the 1st January 2013 to the 31st December 2015 a database was created. Data about patients who underwent a laparoscopic pancreaticoduodenectomy (LPD) were collected prospectively. All patients were preoperatively assessed with blood samples, tumor markers, CT chest abdomen and pelvis and/or MRI pancreas. Only patients with specific characteristics were considered eligible for an LPD: performance status 0, body mass index (BMI) less than 30 kg/m2, a small neoplastic lesion (< 3.5 cm) confined to the pancreas, the absence of infiltrated organs and/or blood vessels (T1 or T2). Postoperative data and complications were recorded and described according to the Clavien-Dindo classification and the international study group of pancreatic surgery definitions. RESULTS: In a time interval of 36 months, 31 patients with an initially considered resectable pancreatic cancer were referred. 11 patients were found to have metastasis during the preoperative workout. Only 10 patients were considered eligible for a LPD. Six of them were men (60%). The mean BMI was 25.01 kg/m2 (19.6-29.8). 5 patients, who underwent to LPD did not have any comorbidities. An overall 50% of all patients were jaundice at the time of diagnosis with a mean bilirubin level of 181.3 µmol/L (119.7-307.8). All patients with a direct bilirubin greater than 250 µmol/L underwent a preoperative percutaneous biliary drainage. In the majority of the LPD performed (50%), the histology reported a pancreatic adenocarcinoma. Other postoperative histology described were: IPMN (20%), ampullar neoplasia (20%) and neuroendocrine tumor (10%). Neo-adjuvant chemotherapy was never considered indicated. The reported postoperative complications were: 1 anastomotic bleeding, 2 pancreatic fistula, 1 infected intra-abdominal collection and 1 delay gastric emptying. The pancreatic fistulas were considered grade A and grade B. One fatality after LPD occurred because of an uncontrollable, diffuse severe hemorrhagic gastritis associated with a GJ anastomosis bleeding in the POD 25. The mean hospital stay was 12.3 days (8-25). The mean operative time was 224 min (170-310). There were no intraoperative complications. The main intraoperative blood loss was 220 ml (180-400) and intraoperative blood transfusions were not required. The resection margins were negative (R0) in 100% of cases and the mean lymph nodes harvested were 24 (18-40). The LPD is still a not common practice. Our results are comparable with those reported in literature about the open technique. These remarkable surgical outcomes are probably related to the extremely careful preoperative patient selection performed. The indication for a laparoscopic vs. an open pancreaticoduodenectomy was based on a CT scan pancreas performed less than 30 days before the planned date of surgery and a careful preoperative assessment. A low complication rate and a relative short stay in hospital were associated to a good quality of life in the early postoperative period and an early referral for postoperative chemotherapy. Good clinical outcomes were associated with outstanding oncological results. CONCLUSIONS: Laparoscopic pancreaticoduodenectomy is a feasible surgical procedure. Remarkable oncological and surgical outcomes can be achieved with a morbidity and mortality rate in line with the data reported by the large series of open procedures.

[Frequency and epidemiology of primary epiploic appendagitis on CT in adults with abdominal pain]. / Fréquence et épidémiologie descriptive de l'appendicite épiploïque primitive par l'exploration tomodensitométrique des douleurs abdominales de l'adulte.

PURPOSE: Advances in medical imaging have improved the presurgical diagnosis of isolated epiploic appendagitis. The authors assess its relative frequency and define its main epidemiological criteria. PATIENTS AND METHODS: Study of an adult population presenting with abdominal pain and evaluated by CT over a 3 year period. Evaluation for the presence of an isolated fat density paracolic mass with hyperdense periphery. A review of the literature was performed as well. RESULTS: The frequency of epiploic appendagitis is estimated at 1.3% and its incidence at 8.8 cases/million/year. The typical patient profile is a young to middle aged male presenting with left flank and lower quadrant pain. Obesity, GI symptoms, fever, and leukocytosis are characteristically absent while elevation of the CRP is typical. CT shows the lesion along the anterolateral margin of the descending or sigmoid colon. Spontaneous resolution usually occurs within 8 days. CONCLUSION: Our results confirm epidemiological data from the literature. Knowledge of the imaging features of epiploic appendagitis will ensure conservative patients management and avoid unnecessary surgery.

[Mesenteric hematoma: Unusual complication of a long term oral anticoagulation therapy]. / Hématome mésentérique: rare complication d'un traitement anticoagulant oral au long cours.

Authors report a case of a 77 years old man who developed a small bowel mesenteric hematoma as consequence of an unusual complication from a long term oral anticoagulation treatment. Computed tomoangiography helpfully suggests diagnosis of a mesenteric hematoma and refuts an organic cause as vascular anomalies, by an equivalent method to conventional angiography, noninvasely. In our case report, patient's deterioration justified an emergency surgery corroborating medical imager findings. Authors review the rare cases previously reported.

[MR imaging in the evaluation of blunt pancreatic trauma]. / L'IRM dans la prise en charge des lésions traumatiques du pancréas.

Pancreatic injuries caused by blunt trauma are unusual but associated with a high morbidity and a high mortality because of a delay in diagnosis. Clinical and laboratory findings are non-specific. Accurate grading of blunt pancreatic injury with identification of pancreatic duct disruption helps to define practical treatment guidelines. Computed tomography does not allow direct visualization of the pancreatic duct and may result in low accuracy for the detection of ductal injury. Endoscopic retrograde pancreatography is the "gold standard" but invasive (3-5% complication rate, mainly pancreatitis) and may not be possible in up to 30% of patients, or requested after surgery. Endoscopic retrograde pancreatography may be used as a therapeutic modality (stenting of the main pancreatic duct). Magnetic resonance cholangiopancreatography is non invasive and preliminary results are promising. Magnetic resonance cholangiopancreatography detects pseudocysts, has multiplanar capability and complemented with conventional MR imaging allows evaluation of the pancreatic parenchyma.

[Gastric necrosis from acute dilatation without underlying psychiatric disorder]. / Nécrose gastrique sur distension aiguë sans contexte psychiatrique.

Acute gastric dilatation with necrosis is a rare and severe complication associated with anorexia nervosa, bulimia, and psychogenic polyphagia. The Authors report an unusual case without underlying psychiatric context. Gastric necrosis was suspected based on imaging findings (plain radiograph and computed tomography). The detection of these imaging signs in an appropriate clinical setting, even without underlying psychiatric context, is important to avoid any delay in diagnosis and reduce mortality.

[Characterization of adrenal incidentaloma discovered with tomography. General review]. / Caractérisation des incidentalomes surrénaliens découverts sur tomodensitométrie, revue générale.

The detection of an incidentaloma at abdominal Computed Tomography (CT), except CT features that permit a specific diagnosis (hemorrhage, myelolipoma or cyst), become a problem to differentiate adenomas from "non adenomas" (primary or secondary malignancy) incidentalomas. A density of ten Hounsfield units or less with a nonenhanced CT is a feature of benign incidentaloma (essentially lipid-rich adrenal adenomas). There are two limitations of this characterization: incidentalomas initially detected at enhanced CT and lipid-poor adrenal adenomas. The relative enhancement washout on enhanced CT, by using a threshold of 50% washout, permit then to characterized as adenomas or "non adenomas" incidentalomas on a 10-minute-delayed enhanced CT. Limitations of this characterization are only for benign pheochromocytomas and atypical adrenal cortical carcinomas.

[Primary epiploic appendicitis: an etiology of acute abdomen revealed by CT scan]. / Appendicite épiploïque primitive: une étiologie d'abdomen aigu révélée par la tomodensitométrie.

Primary epiploic appendicitis are considered to be a rare cause of acute abdomen. We reported 2 cases in which computed tomography CT suggested the diagnosis. Primary epiploic appendicitis shows characteristic CT findings that allow the diagnosis and follow-up. This entity resolves spontaneously and CT helps in avoiding unnecessary surgery.

[Enterolith ileus: a rare complication of small bowel diverticulosis]. / Iléus par entérolithe: une complication rare de la diverticulose de l'intestin grêle.

An elderly patient with subacute small bowel obstruction due to an enterolith that evolved within a small bowel diverticulum is reported. Presence of small bowel diverticulum is not rare. But small bowel obstruction secondary to an enterolith formed within a small bowel diverticulum is a rare complication. Enterolith ileus closely resembles gallstone ileus in its clinical presentation. Diagnosis can be established only by documenting the absence of aerobilia and the presence of small bowel abnormality causing stasis, like small bowel diverticulosis.

[Radiologic appearance of epiploic appendages and their complications]. / Imagerie des appendices épiploïques et de ses complications.

A wide spectrum of pathologic processes can involve epiploic appendages, and primary epiploic appendagitis is the most frequent. Pathologic processes are today more frequently identified with the increased use of radiological assessment (ultrasound and computed tomography) of patients presenting with acute abdominal pain. Recognition of specific imaging abnormalities of complications enables the radiologist to make the diagnosis, thus allowing appropriate treatment.

[Ischemic cholangitis after ligation of the hepatic artery: a case report]. / Cholangite ischémique après ligature de l'artère hépatique: à propos d'un cas.

We report a case of ischemic cholangitis that occurred after ligation of the hepatic artery performed to remove a celiac neurofibroma. At seven weeks in a septic setting, the patient developed ischemic cholangitis. Ligation of the hepatic artery and dissection of the hepatic hilum to remove a neurofibroma have played a role in the development of ischemic cholangitis. Our case demonstrates that supplying peribiliary arteries are important for the biliary vascularization of the epithelium.

[Morbidity and mortality of acute pancreatitis. Prospective study in a French university hospital]. / Morbidité et mortalité de la pancréatite aiguë. Evaluation prospective dans un centre hospitalier universitaire français.

OBJECTIVE: According to certain learned societies, acute pancreatitis mortality should not exceed 10%. The aim of our work was to review the etiology, severity and mortality of acute pancreatitis in a prospective series of patients admitted to a regional university hospital in France, using standardised collection of data assessing the medico-surgical habits in the management of acute pancreatitis. METHODS: From February to September 1999, 86 patients (54 men and 32 women with a mean age of 58.5 years) were admitted for 88 episodes of acute pancreatitis. Data was collected from all the patients on admission and permitted measurement of the severity and prognosis scores and the study of the etiology, complications and management of the latter and the mortality with acute pancreatitis. RESULTS: Ranson's score was a mean of 2.4. Balthazar's score was superior or equal to D in 45% of cases. The respective prevalence of lithiasis, alcoholism, tumors, others or undetermined was of 41%, 37.5%, 7%, 5.5% and 9%. Acute pancreatitis was severe (multi organ failure, pseudo-cyst, systemic or necrotic infection and occlusive syndrome) in 32% of cases. Complications were: infection (22%), pseudo-cyst (14%), pleural effusion (12.5%) and occlusive syndrome (3.5%). Fever of more than 38.5 degrees C was noted in more than half of the patients. The median duration of hospitalisation was of 11 days (range: 1-86 days). Global hospital mortality was of 13.6% (12/88), and of 43% (12/28) in cases of severe acute pancreatitis. Six deaths occurred within the first 8 days of acute pancreatitis, and 6 after 8 days. Seven deaths (59%) were due to multi organ failure, 4 (33%) to infectious causes and one to another cause. CONCLUSION: The standardized collection of clinical and progressive data used in this study permitted assessment of the medico-surgical habits in a regional university hospital.

[Isolated gallbladder contusion following blunt trauma: a case report]. / Contusion vésiculaire isolée post-traumatique: à propos d'un cas.

We report a case of isolated gallbladder contusion with hemobilia. Isolated gallbladder injury following blunt trauma is rare and early diagnosis is difficult. However, ultrasonography and computed tomography are valuable for investigating gallbladder injuries.

The value of immunoscintigraphy in the detection of recurrent colorectal cancer.

The aim of this prospective study was to determine whether anti-carcinoembryonic antigen (anti-CEA) scintigraphy is a useful additional technique in the diagnosis recurrence of colorectal cancer. Forty patients with suspected recurrence of colorectal cancer, underwent immunoscintigraphy (IS) and helical computed tomography (CT) in the 2 weeks before surgery. Surgical findings were used to evaluate the performance of the imaging techniques. Suspected areas on IS and CT were systematically explored. Helical CT was found to be superior to IS for the liver, the sensitivity and specificity of CT being 100% and 90%, respectively, vs 53% and 100% for IS. However, IS was better than CT for the detection of extra-hepatic abdominal recurrence: sensitivity and specificity of IS were 100 and 82% respectively vs 33 and 82% for CT. Seven cases of peritoneal carcinomatosis were overlooked by helical CT. Our results indicate that IS improves detection of extra-hepatic abdominal recurrence of colorectal cancer. Immunoscintigraphy is valuable as a guide to the treatment strategy and operative procedures.

Risk factors for immediate complications after progressive pneumatic dilation for achalasia.

OBJECTIVE: The aim of this retrospective study was to determine the risk factors of early complications after progressive pneumatic dilation for achalasia. METHODS: Five hundred four dilations were performed in 237 consecutive achalasic patients between 1980 and 1994 with the same technique: low-pressure pneumatic dilation every other day with balloons of increasing diameter until success criteria were obtained (depending on manometric examination and esophageal x-ray transit performed 24 h after each dilation). Clinical, radiographical, endoscopical, and manometrical data as technical procedure characteristics for patients with perforations or other early complications were compared with those without complications. RESULTS: We observed 15 complications (6% of patients): 7 perforations (3%), 3 asymptomatic esophageal mucosal tears, 4 esophageal hematomas, and 1 fever. Perforations occurred in 6 of 7 patients during the first dilation. The mean age was 68.5 yr in the group with complications versus 56.4 yr for the remainder (p < 0.05). Two deaths occurred in patients older than 90 yr. Instability of the balloon during dilations was noted in 8 of 15 cases of complications versus 57 of 222 patients (p < 0.05). No other data differed significantly. CONCLUSIONS: This study showed a low prevalence of early complications using this progressive technique. Patients with hiatal hernia, esophageal diverticulum, or vigorous achalasia may safely undergo progressive pneumatic dilation. Only patients older than 90 yr should be referred for progressive pneumatic dilation with caution. Most of perforations arose during the first dilation, but there was no predictive pretherapeutic factor of perforation.

[Aneurysm of the portal vein associated with aneurysm of the splenic artery]. / Anévrysme de la veine porte associé à un anévrysme de l'artère splénique.

Portal vein aneurysm is very rare. A case of portal vein aneurysm without symptoms of portal hypertension is described. Ultrasonography demonstrated a hypoechoic mass at the isthmic region of the pancreas. Computed tomography demonstrated the vascular origin of the mass. Angiography showed a portal vein aneurysm, measuring 3 cm in diameter, at the junction of portal vein trunk and splenic vein. The association with a splenic artery aneurysm and absence of portal hypertension lead us to suggest that our case is congenital. Non-invasive diagnostic methods are useful to recognize the pathology of portal vein aneurysm and prevent complications especially those related to a possible portal hypertension.

Role of computed tomography in vertebrobasilar ischemia.

Precise delineation of vertebrobasilar ischemia by computed tomography (CT) appears difficult due to the numerous variations in distribution of the posterior fossa arterial supply. While pontine and upper brainstem infarctions can be readily demonstrated, medullary infarction remains beyond the scope of present CT scanners. CT findings in cases of basilar artery occlusion include bilateral pontine infarction or extensive brainstem ischemia, associated with cerebellar and posterior cerebral vascular damage. Demonstration of basilar artery occlusion using routine CT is only rarely achieved. In cerebellar ischemia, CT, in conjunction with clinical syndromes, helps in the recognition of the arterial territory involved. CT provides useful guidelines for the treatment of cerebellar stroke, leading to surgery in cases of massive cerebellar infarction.