Acute esophageal necrosis: Case report of an unknown entity.

INTRODUCTION: Acute Esophageal Necrosis Syndrome (AENS) is a rare and unknown clinical entity, defined as a diffuse circumferential black-appearing friable esophageal mucosa going from the distal esophageal mucosa to the gastroesophageal (GE) junction. Esophagogastroduodenoscopy (EGD) remains the gold standard in making diagnosis. PRESENTATION OF CASE: We report here the case of a 45-year-old man with necrosis of the esophagus treated conservatively. Regression of the lesion but persistence of ulcerations were seen on the endoscopic follow-up. Distal esophageal stenosis was then diagnosed and treated by endoscopic dilation. DISCUSSION: Diagnosis of AENS must be considered when an old patient, with multiple comorbidities, presents an upper digestive hemorrhage. Upper endoscopy is mandatory. Treatment is in most of the cases conservative. Esophageal stenosis is a frequent complication. CONCLUSION: Although AENS is a rare clinical entity, it should not be dismissed by doctors, avoiding useless surgical management. This pathology remains nevertheless associated with a considerable mortality rate.

Can machine learning predict resecability of a peritoneal carcinomatosis?

BACKGROUND: Approximately 20% of initially eligible patients in a HIPEC procedure eventually underwent a simple surgical exploration. These procedures are called 'open & close' (O & C) representing up to 48% of surgery. The objective of this study was to predict the resecability of peritoneal carcinomatosis using a machine-learning model for decision-making support, for eligible patients of HIPEC. METHODS: The study was conducted as an intention to treat based on three databases including a prospective, between January 2000 and December 2015. A propensity score allowed us to obtain two groups of comparable and matched patients. Subsequently, several algorithm models of classification were studied (simple classification, conditional tree, support vector machine, random forest) to determine the model having the best performance and accuracy. RESULTS: Two groups of 155 patients were obtained: one group without resection and one group with resection. Nine criteria of non-resecability reflecting the organ involvement have been retained. They were coded according to their importance. Five classification algorithms were tested. The training data included 218 patients and 92 test data. The random forest model exhibited the best performance with an accuracy of close to 98%. Only two errors of predictions were observed. DISCUSSION: The largest number of patients will allow us to improve the precision prediction. Gathering more data such as biologic, radiologic, and even laparoscopic features, should improve the knowledge of the disease and decrease the number of 'O & C' procedures.

Pancreatico-gastric fistula complicating an intraductal papillary mucinous neoplasm.

Fistula as a complication of pancreatic intraductal papillary mucinous neoplasms (IPMN) is rare and may involve different adjacent organs, sometimes, several organs at the same time. Our patient had a pancreatico-gastric fistula, discovered at work-up for IPMN, which required extensive surgery.

The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center.

INTRODUCTION: Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations. METHOD: We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum. RESULTS: Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France. CONCLUSION: As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

Bone metastasis from endometrioid ovarian carcinoma: a case study and literature review.

INTRODUCTION: Bone metastases from epithelial ovarian carcinoma are rare, usually discovered postmortem. The survival of these patients is poor. Furthermore, only two cases of endometrioid ovarian carcinoma with metastasis to the skeletal structures have been described in the literature. CASE REPORT: We present the case of a 58-year-old woman with a lytic metastasis in the left iliac ramus from endometrioid ovarian carcinoma that occurred seven years after the initial diagnosis. DISCUSSION: A review of the literature since 1966 on bone metastasis of ovarian cancer is also presented. In patients suffering from a neoplasm that rarely metastasises to bone, histological proof should be obtained to diagnose uncommon sites of disease relapse.

The magic of the hypoxia-signaling cascade.

All organisms respond to changes in their environment by activating complex signaling cascades. The "hypoxia-signaling cascade" is activated in response to low oxygen availability and this activation is central to maintaining oxygen homeostasis and hence to survival. By regulating the transcriptional complex hypoxia-inducible factor, hypoxia is associated with several physiopathological processes. Several strategies, based on the targeting of the hypoxia-signaling cascade, have been developed to treat these pathologies. Our review summarize different aspects of the hypoxic pathway.

Characterization of Bacillus and Pseudomonas strains with suppressive traits isolated from tomato hydroponic-slow filtration unit.

Bacillus and Pseudomonas spp. are known to be involved in plant pathogenic fungi elimination during the slow filtration process used in tomato soilless cultures. We isolated 6-8 strains of both Bacillus and Pseudomonas from the top, middle, and bottom sections of filters and identified them after 16S rDNA sequencing. Four Pseudomonas strains were identified as Pseudomonas fulva, 5 as Pseudomonas plecoglossicida, and 12 as Pseudomonas putida. The use of specific oligonucleotide polymerase chain reaction primer sets designed from gyrB gene sequences additionally permitted the identification of 17 Bacillus cereus and 3 Bacillus thuringiensis strains. Ribotyping with EcoRI pointed out an important polymorphism within Bacillus and Pseudomonas strains. Molecular characterization did not reveal a correlation between the location of isolates within the filter (top, middle, or bottom) and bacterial identification or riboclusters. Functional aspects assessed by community-level physiological profiling showed marked phenotypic differences between Pseudomonas communities isolated from the top and bottom filter layers; differences were lower between Bacillus communities of different layers and far less noticeable between mixed communities of Bacillus and Pseudomonas. These strains were tested for several suppressive activities. Conversely to most Bacillus, the majority of Pseudomonas strains were auxin producers and promoted the growth of tomato plantlet roots. On the other hand, only Bacillus strains displayed antagonistic activities by inhibiting the growth of pathogenic fungi frequently detected in soilless cultures. Siderophores were produced by nearly all bacteria, but at higher amounts by Pseudomonas than Bacillus strains. The biocontrol agent potentiality of certain strains to optimize the slow filtration process and to promote the suppressive potential of nutrient solution is discussed.

Soil microbial diversity as affected by the rhizosphere of the hyperaccumulator Thlaspi caerulescens under natural conditions.

It is hypothesized that metal hyperaccumulator plants have specific rhizosphere conditions, potentially modifying the bioavailability of soil metals. This article aims to further the knowledge about the rhizosphere of the hyperaccumulator Thlaspi caerulescens, focusing on its microflora isolated from metalliferous soils collected in situ where the plants grow naturally. We characterized the cultivable microbial communities isolated from the rhizosphere of one population of this Ni hyperaccumulator species grown on a serpentine soil. The rhizosphere soil harbored a wide variety of microorganisms, predominantly bacteria, confirming the stimulatory effect of the T. caerulescens rhizosphere on microbial growth and proliferation. We tested the hypothesis that the rhizosphere of T. caerulescens influences (1) the metabolic diversity of the bacterial community and (2) the bacterial resistance to metals. The principal component analysis of the Biolog plate's data confirmed a structural effect of the rhizosphere of T. caerulescens on bacterial communities. The percentage of Ni-resistant bacteria was higher in the rhizosphere than in the bulk soil, suggesting a direct effect of the rhizosphere on Ni tolerance, reflecting a greater bacterial tolerance to Ni in the rhizosphere.

[Bening enterogenital fistulas arising from the digestive tract: three cases]. / Fistules entérogénitales d'origine digestive bénigne: à propos de trois cas.

Fistulas between the female genital tract and the digestive tract occur after obstetrical, oncological, or post-operative complications. We report herein 3 rare cases of enterogenital fistulas: one colouterine fistula and one colotubal fistula in a patient with diverticulitis, and one ileovaginal fistula in a patient with Crohn's disease. Vaginal discharge was frequent and incited patients to consult a gynecologist. Better knowledge of enterogenital fistulas is necessary to enable earlier diagnosis and apply specific treatment. The incidence of colovaginal fistulas is increasing in diverticular disease because of increased prevalences of hysterectomies and diverticular disease.

Open inguinal hernia repair by plug and patch: the value of fibrin sealant fixation.

BACKGROUND: Prosthetic meshes give excellent results in groin hernia repair. However, although recurrence rates are very low, chronic pain remains frequent and mesh fixation may play a role in the occurrence of this complication. The use of fibrin sealant to secure the mesh may represent a useful alternative for the prevention of chronic pain. The aim of this study is to confirm that the mesh may be secured by spraying fibrin sealant and to assess the reduction in the incidence of chronic pain. METHODS: Seventy hernias were operated on in 57 patients and were evaluated on a prospective basis. The procedure involved placement of a plug and patch mesh which was secured with fibrin sealant alone. These patients were compared to a matched retrospective series of 57 patients who underwent the same procedure, except that conventional non-absorbable suture was used to secure the mesh. RESULTS: The two groups were equivalent for inclusion criteria and preoperative data. The complication rate was similar in the two groups. The operative time was shorter in the fibrin sealant group: 7 min for unilateral hernia (p=0.0017) and 16 min for bilateral hernia (p=0.0008). The length of hospital stay was also shorter in the fibrin sealant group (1.8 days vs. 2.5 days: p < 0.0001). There was no recurrence in the fibrin sealant group after a minimum follow-up of 12 months and no recurrence in the suture group after a minimum follow-up of 25 months. Finally, a significant reduction in chronic pain was observed in the fibrin sealant group (3.5% vs. 22.8%: p=0.042). CONCLUSION: This study confirms the effectiveness of fibrin glue in securing prosthetic meshes and reducing chronic inguinal pain.

Treatment of synchronous peritoneal carcinomatosis and liver metastases from colorectal cancer.

AIM: To report our experience of peritoneal carcinomatosis (PC) discovered during abdominal exploration in patients with liver metastases (LM). METHODS: Liver resection plus cytoreductive surgery were combined in 24 patients with LM and moderate PC from colorectal origin treated with a curative intent between January 1993 and November 2003. RESULTS: The mean operative time was 357+/-112 min and median blood loss was 719 ml. One postoperative death occurred and postoperative morbidity was 58%. The mean hospital stay was 21.4+/-4.2 days. Three-year overall and disease-free survival rates were respectively 41.5% (confidence interval [CI]: 23-63) and 23.6% (CI: 11-45). Seven patients are disease-free with a mean follow-up of 27.8 months after their last surgery, 3 having a repeated hepatectomy. Three patients developed a peritoneal recurrence and 13 had recurrence in the liver. The only significant prognostic factor was a number of LMs of less than 3 (p < 0.01). CONCLUSION: A combined treatment of LM plus PC is feasible and is beneficial in selected patients presenting three or fewer metastases.

Trans-metastasis hepatectomy: results of a 21-case study.

AIM: The aim of this study was to report the feasibility and efficiency of a new approach, called post-RF trans-metastasis hepatectomy (PRFTMH). This technique consists in using RF to first ablate an ill-located liver metastasis (LM) along the planned hepatectomy resection line, the only one possible for volumetric reasons, and then to perform the hepatectomy passing via this initially ablated LM. MATERIAL AND METHODS: Twenty-one patients were treated with PRFTMH between January 2000 and May 2004. Thirteen of them had a primary colorectal tumour, four had a primary endocrine tumour and four had miscellaneous primaries. The mean number of LMs per patient was 13.8 (10.7 for primary colorectal tumours and 22.2 for primary endocrine tumours). Pre-operative hypertrophy of the future remaining liver was obtained by selective portal vein embolisation in 11 patients. RESULTS: One patient died post-operatively (4.7%) and five developed complications (24%). No local recurrence has occurred at the site of PRFTMH after a median follow-up of 19.4 months (range: 47-7), demonstrating the efficacy of this technique. All patients, except the patient who died post-operatively, are currently alive, and the median survival rate has not yet been attained, after a median follow-up of 19.4 months. CONCLUSION: PRFTMH combining RF ablation and trans-metastasis hepatectomy is a new and safe technique, allowing a curative approach to be proposed to some patients with unresectable bilateral LMs.

Mediastinal cystic lymphangioma: is resection always necessary?

Mediastinal cystic lymphangiomas are rare tumours. Usually asymptomatic, they can be complicated by a chylopericardium or/and chylothorax. We report a case of a left lesion infiltrating through the supra-aortic vessels complicated with a iatrogenic left chylothorax managed by bilateral video-assisted thoracoscopy at the same time. First, on the right, the chylous inflow was stopped by suturing the thoracic duct; then, on the left, a fenestration was done to confirm the diagnosis and treat the lesion while preserving the adjacent structures.

[Evaluation of the TVT technique according to age]. / Evaluation selon l'âge de la technique TVT.

OBJECTIVE: To compare efficacy and long-term morbidity of the TVT between patients younger than 70 years and patients older than 70 years. METHOD: Retrospective monocentric study from January 2000 to May 2001. A postal questionnaire was sent to patients to evaluate their satisfaction and their functional status after surgery. RESULTS: The study included 154 patients, and 137 (89%) answered the questionnaire. Seventy-two were less than 70 years old (52.5%) and 65 were more than 70 years old (47.5%). The satisfaction rate in the total population was 88.3%. Amongst the patients younger than 70 years, 97.5% were cured or improved, versus 78.5% of the oldest patients (p=0.001). The study within age groups showed that the satisfaction rate between 70-74 years was higher (92.6%) than in the total population and lower after 75 years (66.7%). This difference is linked to the rates of de novo and persistent urge incontinence, which increase after 75 years. CONCLUSION: The TVT seems to be a good treatment for urinary incontinence in women younger than 75 years. Patients should be warned that preoperative urge incontinence may persist after surgery.

[Unexpected discovery of a bladder tumor during a TVT operation]. / Découverte fortuite d'une tumeur vésicale au cours d'une opération de TVT.

With the common use of the tension-free vaginal tape (TVT) procedure, we will probably be facing more and more pathologies that will require a transurethral treatment. We report an intra-operative discovery of a bladder tumor during a cystoscopic TVT procedure. The tumor was easily treated by several transurethral resections without any consequences on the result of the TVT procedure.

Anatomy of the presacral venous plexus: implications for rectal surgery.

The presacral venous plexus results from anastomoses between the lateral and median sacral veins, and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum. The presacral venous plexus is not directly visible during rectal surgery, and injuries to this plexus may be life-threatening. Dissection of the retrorectal plane or anchoring of the rectum to the sacral promontory as in rectal prolapse surgery exposes the patient to the risk of injury to the presacral venous plexus. The aim of this study was to identify some avascular areas in the anterior aspect of the sacrum in order to lower the occurrence of such injuries during rectal surgery. The pelvis of 10 fresh cadavers was dissected after injection of a colored resin into the inferior vena cava, and the presacral venous plexus was studied. Four avascular tetragonal areas were common to all the specimens. The corners of a square with a side of 3 cm, centered on the anterior aspect of the body of sacrum, were always contained in the avascular areas. The upper side of this square was parallel to a line passing through the sacral promontory, at a 3 cm distance from it. Staples or sutures should be placed in the avascular areas to avoid injuries to the presacral venous plexus.

[Colostomy vs self-expanding metallic stents: comparison of the two techniques in acute tumoral left colonic obstruction]. / Colostomie de décharge vs endoprothèse colique autoexpansive: comparaison des deux techniques dans l'occlusion colique gauche aiguë par obstacle tumoral.

UNLABELLED: Self-expanding metallic stents is an alternative treatment to colostomy that is the treatment of choice in acute tumoral left colonic obstruction. AIM OF THE STUDY: To compare morbidity, mortality, length of hospital stay and treatment performed after desobstruction using the two methods. PATIENTS AND METHODS: Thirty-three patients admitted for acute obstruction of the left colon were retrospectively separated in two groups depending on the type of intervention performed to treat the obstruction ("colostomy" group: 17 patients and "self-expanding stent group": 16 patients). We studied complications after desobstruction, hospital courses and surgical strategy performed after the acute phase. RESULTS: Time between desobstruction and colectomy was shorter in the "self-expanding stent group" than in the "colostomy group" (18.5 days versus 73 days). Age superior than 75 years and colostomy were the two main factors predicting the risk of definitive colostomy (P < 0.05). Global mean hospital stay was longer in the colostomy group (32.7 days versus 19.3 days, P = 0.02). Two perforations and one local recurrence occurred in the "self-expanding stent group". CONCLUSIONS: Self-expanding metallic stent can decrease the permanent colostomy rate and the number of interventions. The recurrence rate seems to be theoretically increased with the stenting method. Then, colostomy must be done for patients in curative situation. The self-expanding metallic stent should be used as a palliative care.

Influence of maize mucilage on the diversity and activity of the denitrifying community.

In order to understand the effect of the maize rhizosphere on denitrification, the diversity and the activity of the denitrifying community were studied in soil amended with maize mucilage. Diversity of the denitrifying community was investigated by polymerase chain reaction (PCR) amplification of total community DNA extracted from soils using gene fragments, encoding the nitrate reductase (narG) and the nitrous oxide reductase (nosZ), as molecular markers. To assess the underlying diversity, PCR products were cloned and 10 gene libraries were obtained for each targeted gene. Libraries containing 738 and 713 narG and nosZ clones, respectively, were screened by restriction fragment analysis, and grouped based on their RFLP (restriction fragment length polymorphism) patterns. In all, 117 and 171 different clone families have been identified for narG and nosZ and representatives of RFLP families containing at least two clones were sequenced. Rarefaction curves of both genes did not reach a clear saturation, indicating that analysis of an increasing number of clones would have revealed further diversity. Recovered NarG sequences were related to NarG from Actinomycetales and from Proteobacteria but most of them are not related to NarG from known bacteria. In contrast, most of the NosZ sequences were related to NosZ from alpha, beta, and gammaProteobacteria. Denitrifying activity was monitored by incubating the control and amended soils anaerobically in presence of acetylene. The N2O production rates revealed denitrifying activity to be greater in amended soil than in control soil. Altogether, our results revealed that mucilage addition to the soil results in a strong impact on the activity of the denitrifying community and minor changes on its diversity.