Increasing ambulatory surgery potential by non-medicalized accommodation: matched comparison of the 2011 national hospital activity data to 66 local stays.

INTRODUCTION: Several policy and cultural factors still hinder the development of ambulatory surgery (AS) in France. Our surgery unit developed a day-surgery approach with extension of a non-medicalized post-operative stay in a hotel-like structure within the hospital, called an "ambulotel". The present study aims to evaluate the potential of this approach in increasing the possibilities of ambulatory surgery by comparing our stays to those of a nationwide database. PATIENTS AND METHODS: We matched 66 patients according to seven criteria in our one-day ambulotel program to the 2011 DRG national database and then compared their characteristics. RESULTS: Of the 10,428 patients in the database with one-night stays in a traditional surgery unit, more than half (52%) would probably have been eligible for ambulatory surgery with a potential theoretical savings estimated at €12,806,568. CONCLUSION: This estimated amount of savings represents a major medical and economic issue. The savings could contribute to increased ambulatory surgery activity in France by creating new dedicated Ambulatory Units, pooling conventional beds, or using night accommodation in non-hospital nursing homes, for example.

Day surgery: Results after restructuration of a university public general surgery unit.

INTRODUCTION: Nowadays, in France, development of the ambulatory surgery has stalled. This is probably related to the fact that ambulatory surgery is restricted by the law to the "day surgery" in 12 hours, and only 17 procedures are referenced for this surgery. Thus, conventional hospitalization remained the rule after surgery. In January 2010, our university general surgery unit was restructured. It evolved from a conventional unit to a predominantly ambulatory unit. Otherwise, our unit adjoins a hotel, even inside our institution, which accommodates patients, patient visitors and tourists. AIM: The aim of this retrospective study was to compare the postoperative accommodation modalities between two groups of patients. The first group consisted of patients admitted before January 2010, at the time of conventional activity, whereas the second group consisted of patients admitted after January 2010 in a restructured unit. METHODS: Inclusion of patients admitted from April 1, 2008 to March 31, 2009 (conventional hospitalization period) and from April 1, 2010 to March 31, 2011 (ambulatory management period), scheduled for one single surgical procedure excluding emergency. RESULTS: A total of 360 patients were retained: 229 for the conventional period and 131 for the ambulatory period, with a median age of 55 (range 15-87). No statistically significant difference was noted between the two groups as concerned median age, gender or ASA status. The number of postoperative nights varied significantly between the two groups with a mean of 3.8 nights (median three nights, range 0-32) for the conventional period versus 0.4 nights (median 0 night, range 0-10) for the ambulatory period (P<0.0001 by the unadjusted Mann-Whitney test and P<0.0001 by the Wald test [with adjustment]). DISCUSSION: Our results show that it is clearly possible to distinguish the need for care of the need for accommodation and significantly reduce postoperative conventional accommodation. They also raise the question of extending the legal period of 12 hours to 24 hours in order to expand the list of the referenced procedures.

Cure of inguinal hernias with large preperitoneal prosthesis: Experience of 2,312 cases.

It is clear that the recurrence rates after nonprosthetic methods for the repair of inguinal hernias, like McVay, Bassini or Shouldice techniques, are high (6-10%). Since 20 years, we are convinced, in the GREPA-EHS group, about the advantages of the use of a prosthetic mesh in majority of patients for repairs of primary or recurrent inguinal hernias and incisional hernias. We describe our typical technique for the cure of all inguinal hernias. We place a large supple mesh, by open inguinal route, posterior to the transversalis fascia and anterior to the peritoneum. We have made a double modification in the initial technique of Rives - the use of a very large unsplit prosthesis (15 × 17 cm) and the parietalization of the spermatic cord helped by a wide opening of the Fruchaud's orifice by diversion of the epigastric vessels. The positioning of the mesh is about the same as in the TEP technique but with the advantages of reduction in the vital laparoscopic risks and reinforcement of the wall by a short tension-free McVay technique.For this prospective study, we repaired 2,312 consecutive hernias in 1,828 patients, 284 of which were recurrent. We present our results in terms of quality of repairs, recurrence rates (0.4%), morbidity rate (8%), and mortality rate (0.8%).This technique involves the placement by an open incisional route of a large preperitoneal sheet of mesh for initial treatment of all inguinal hernias - including scrotal, giant or femoral - to ensure a definitive solid muscular wall, even for recurrent hernias.

[Carcinoid tumor from the small bowel]. / Tumeur carcinoïde de l'intestin grêle.

Carcinoid tumors are non-pancreatic digestive neuroendocrine tumors well differentiated. Most of time they are developed from enterochromaffin cells of the digestive tract. Most of them are localized in ileum, rectum, stomach and appendix. Only bronchi are a frequent extra-digestive localization (20 to 25%). Most of these tumors are asymptomatic and discovered incidentally during a laparotomy or secondary to the exploration of a carcinoid syndrome. From a case report and a recent review of literature, diagnosis, histology and treatment of small bowel carcinoid tumors are summarized.

[Suspected acute appendicitis. Role of enhanced helical computed tomography. Prospective study of 100 patients]. / Suspicion d'appendicite aiguë. Intérêt de l'examen tomodensitométrique hélicoïdal. Etude prospective chez 100 patients.

AIM OF STUDY: To assess the diagnosis accuracy of helical computed tomography (CT) in patients with suspected appendicitis. PATIENTS AND METHODS: This prospective study included 100 consecutive patients hospitalized for suspected appendicitis. There were 57 men and 43 women with a median age of 30 years (range: 17-91). An enhanced helical CT was performed at admission, without digestive opacification. Four criteria were interpreted as positive signs for appendicitis: appendix enlarged > or = 7 mm, right lower quadrant inflammation, stercorolith, and peri-appendicular collection. The patient was managed by the surgeon without knowing the result of CT. The final diagnosis was made pathologically. RESULTS: Eighty-one patients were operated on laparoscopically for suspected appendicitis. Intraoperative diagnosis was corrected in three cases and 78 appendectomies were performed (73 histological appendicitis, six normal appendix). Final diagnosis was a medical disease in 19 patients. The findings of 67 CT were interpreted as positive (63 true positive and four false positive) and the findings of 33 CT were interpreted as negative (24 true negative, nine false negative). Sensitivity was 87%, specificity was 86%, positive predictive value was 94%, and negative predictive value was 73%. If the nine false negative cases with minimal lesions at pathological examination were considered as true negative, the rates would be 100%, 89%, 94%, 100%, respectively. CONCLUSION: Enhanced helical CT is a good imaging diagnostic tool for suspected appendicitis. It may reduce the number of patients admitted for observation and decrease the rate of negative appendectomy.

[Androgenic alopecia revealing an androgen secreting ovarian tumor]. / Alopécie androgénétique révélant une tumeur ovarienne androgéno-secrétante.

INTRODUCTION: Androgen-producing tumors of the ovary are rare in postmenopausal women and are revealed by severe virilization. Leydig hilus cell tumors are the most frequent postmenopausal virilizing tumors. In this report, an unusual and rare cause of alopecia due to Leydig cell hyperplasia within the wall of a simple cyst and in the ovarian hilus is described. OBSERVATION: An 80 year-old woman complained of a 10-year history of severe androgenic alopecia associated with very mild facial hirsutism, without others signs of virilization. Hormonal blood levels showed markedly elevated testosterone. Computed tomographic scan of the adrenals and the ovaries revealed an enormous left ovarian cystic mass. Bilateral hystero-ophorectomy was performed. Histological examination demonstrated bilateral Leydig cell hyperplasia within the wall of the cyst and in the right ovarian hilus. Two months postoperative hormonal evaluation demonstrated dramatically decreased plasma levels of testosterone. COMMENTARY: The clinical, X ray and histologic aspects of this case, although rare, show that the presence of virilization should lead to a search for an androgen-secreting ovarian or adrenal tumor.

Atmospheric input of anthropogenic phosphorus to the northwest Mediterranean under oligotrophic conditions.

Phosphorus (P) concentration in the atmospheric aerosol was measured at a northwestern Mediterranean coastal site. Airborne P ranged between 25 and 85 ng m(-3) (geometric mean: 51 ng m(-3)). Due to a significant contribution (about 90%) of anthropogenic land-based source emissions, dry deposition velocities of 0.1-0.5 cm s(-1) were used to estimate a dry flux of 0.15-0.7 micromol P m(-2) day(-1). The theoretical impact of the dry flux on primary production (0.1-0.4 mg C m(-2) day(-1)) is 50-200-fold lower than that of a single significant wet event. The incineration plant of the Nice district is identified as a possible major source of airborne anthropogenic P. As the implementation of waste plants is currently expanding along the western European shores, the importance of the P atmospheric source to the western Mediterranean is likely to increase with time.

[Laparoscopic treatment of perforated duodenal ulcer]. / Traitement laparoscopique de l'ulcère duodénal perforé.

OBJECTIVE: The aim of this study was to determine if laparoscopic simple closure for perforated duodenal ulcer is possible, efficient and safe. METHODS: Thirty-five consecutive patients with perforated duodenal ulcer and peritonitis were treated by simple closure, peritoneal lavage and omentoplasty. This treatment was performed laparoscopically. RESULTS: Diagnosis was confirmed in all cases. Conversion to laparotomy was necessary in two patients due to a technical problem and poor tolerance to pneumoperitoneum, respectively. Mean operative time was 120 min. Morbidity and mortality rates were 2.8%. Mean hospital stay was 7.8 days. No recurrence was found after eradication of Helicobacter pylori with a long-term follow-up of 38 months. CONCLUSION: Laparoscopic suture of perforated duodenal ulcer is possible and safe. It can avoid laparotomy with septic complications in peritonitis. In emergency there is no place for radical treatment of ulcer disease because of efficiency of medical treatment.

[Non-secreting pheochromocytoma of the broad ligament revealed by appendicular peritonitis]. / Phéochromocytome non sécrétant du ligament large révélé par une péritonite appendiculaire.

BACKGROUND: Non-secreting pheochromocytoma is an endocrine tumor located in the adrenal medulla in 85% of the cases. Extra-adrenal localizations account for the other 15%. A broad ligament localization related to an accessory adrenal gland is exceptional. CASE REPORT: A tumoral formation was observed during computed tomographic exploration of appendicular peritonitis in a 25-year-old patient. The tumor had developed from an ectopic adrenal gland included in the large ligament of the uterus. Pathology reported non-secreting pheochromocytoma confirmed by immunolabeling. DISCUSSION: The broad ligament localization is exceptional for pheochromocytomas and may mislead diagnosis. Resection is the only treatment. Recurrence and metastases have been reported to develop in some cases many years later, particularly after incomplete resection. Pathogenically, this tumor is remnant embryonic chromaffin tissue issuing from the parasympathetic nodes and developing in an ectopic adrenal gland.

[Laparoscopic appendectomy in the adult]. / Appendicectomie laparoscopique chez l'adulte.

AIM OF THE STUDY: The benefits of laparoscopic appendectomy remain controversial. The aim of the study was to evaluate the advantages and disadvantages of this technique. MATERIAL AND METHODS: Four hundred and forty-eight patients operated on for suspected appendicitis during a 5-year period were analysed in a retrospective study. The preoperative diagnosis was corrected in 21.4% of the cases (8.1% for males and 28.7% for females) and the conversion rate was 9.7%. There were 17 patients with generalized peritonitis and 28 with localized peritonitis. During the past year, this surgical method was introduced in another hospital and a prospective study included 92 consecutive patients operated on for appendicitis. The operating time was 53 minutes and the conversion rate was 7.6%. There were five patients with generalized peritonitis and eight with localized peritonitis. RESULTS: There were no postoperative deaths. In the first period, the morbidity rate was 2.3% in the laparoscopic group without conversion. After pathological examination, there was a 14.2% rate of normal appendix. The mean hospital stay was 4.3 days. In the second period, there were only three minor complications and the mean hospital stay was 4.19 days. CONCLUSION: The choice of laparoscopic approach is associated with some advantages: corrections of the diagnosis (mainly in young women) and simplification of the postoperative course, provided that the surgeon has sufficient experience.

Idiopathic thrombocytopenic purpura associated with Crohn's disease.

Besides cytopenia related to treatment, several hematological disorders such as anemia, abnormal platelet activity, thrombosis, presence of anticardiolipin or anti-neutrophil antibodies, cyclic neutropenia, and myelodysplasia, have been reported in patients with Crohn's disease (CD). The case we report here is the first one documenting the association of idiopathic thrombocytopenic purpura (ITP) with CD.

Idiopathic thrombocytopenic purpura as the presenting feature of a primary bilateral adrenal non Hodgkin's lymphoma.

Primary lymphomas arising in the adrenal gland are extremely rare. The presenting symptoms are nonspecific and may be related to lymphoma or to associated adrenal insufficiency. In this report we describe the case of a 61 year old woman with idiopathic thrombocytopenic purpura and primary bilateral non Hodgkin's lymphoma of the adrenals.

Pancreatic transplantation in experimental non-insulin-dependent diabetic rats.

The effect of pancreatic transplantation on noninsulin -dependent diabetes mellitus (NIDDM) had not been evaluated in animal models. We assessed its impact by the insulin-glucose clamp study in experimental diabetic rats. NIDDM was induced in Lewis female rats by streptozocin at the age of 5 days (n5-STZ). To determine its effect on insulin sensitivity, we measured the glucose turnover rate and performed euglycemic hyperinsulinemic clamp studies, evaluating hepatic glucose production (HGP) and glucose uptake. This assessment was conducted on 5 groups of 6 female Lewis rats: 2 groups n5-STZ tested at the age of 10 and 14 weeks, respectively; 2 normal age-matched groups; and a fifth group (n5-STZ) transplanted at 10 weeks of age and tested at 14 weeks. Heterotopic pancreaticoduodenal transplantation was performed, using an end-to-side anastomosis between the donor celiac artery and portal vein to the recipient infrarenal aorta and vena cava, respectively. Pancreatic drainage was achieved by an end-to-side duodenojejunostomy. At 10 weeks of age, diabetic n5-STZ rats showed decreased body weight, hyperglycemia, moderate insulinopenia, a significantly higher basal HGP as compared with normal controls (28.5 +/- 10 vs. 10.7 +/- 4 mg/kg/minute, P<0.05), and ineffective suppression of the HGP by the insulin infusion. Glycemia, body weight, and basal HGP were normalized in the transplanted group and were statistically similar to age-matched normal controls. HGP was totally suppressed by the insulin infusion. However, the blood insulin level remained significantly higher than in the normal groups (P<0.05). We conclude that n5-STZ is a reliable model of NIDDM and that pancreatic transplantation, without immunosuppressive drugs in this isogenic line, corrects all tested parameters of glucose homeostasis and improves insulin sensitivity.

[Is there a role for pancreas transplantation in the treatment of type II diabetes mellitus? Experimental study]. / Y a-t-il une place pour la transplantation pancréatique dans le traitement du diabète du type II? Etude expérimentale.

There is no experimental basis for transplantation of the pancreas in patients with non-insulin-dependent diabetes mellitus. We compared results in normal and grafted non-insulino-dependent Lewis rats. A heterotopic pancreatico-duodenal graft was implanted with end-to-side anastomosis of the coeliac artery and the portal vein of the donner on the infrarenal aorta and inferior vena cava of the recipient. The diabetic rats showed weight loss, high blood glucose levels (3.30 +/- 1.25 milligrams), moderate insulinopenia and significantly elevated liver production of glucose. Glycaemia, weight and liver production of glucose were the same as those in the group of normal animals. We concluded that transplantation of the pancreas in an isogenic model without immunosuppression can correct glucose levels and insulino-resistance. It could be suggested in man.

A cost-benefit comparison of intensive diabetes management with implantable pumps versus multiple subcutaneous injections in patients with type I diabetes.

OBJECTIVE: To investigate if intraperitoneal (IP) insulin infusion via programmable implantable pumps is a potential alternative to subcutaneous (SC) insulin via multiple injections. RESEARCH DESIGN AND METHODS: We compared the cost-benefits of the two methods using a randomized, prospective, 6-month, crossover design in 10 adult type I diabetic patients. RESULTS: When judged on the last month of IP versus SC periods in the nine patients who completed the study, metabolic data showed better glycemic control (HbA1c: 7.2 +/- 0.2 IP vs. 8.5 +/- 0.7% SC, mean +/- SE, P = 0.02), reduced glycemic fluctuations (SD of capillary glucose values: 3.4 +/- 0.2 IP vs. 4.6 +/- 0.2 mM SC, P < 0.01), and fewer mild hypoglycemic events (5.7 +/- 2.0 IP vs. 10.0 +/- 3.1 events/month SC, P = 0.02). Quality of life, judged by Diabetes Control and Complications Trial questionnaires, was unaffected by pump therapy. Direct costs, including pump acquisition, implantation, and follow-up, were 2.6-fold higher with IP than with SC delivery. CONCLUSIONS: The implantable pump is more effective in the short term, equally accepted, but more costly than multiple injections and should be limited to patients with unsatisfactory glycemic control despite intensive diabetes management with SC insulin. In addition, longer-term, larger-scale, and comparative evaluation is required.

[Cost benefits of intensive insulin therapy using injections, external pumps and implantable pumps]. / Coût-bénéfice de l'insulinothérapie intensive par injections, pompe externe et pompe implantable.

Since feasibility is now proven, cost-efficacy of external sub-cutaneous (EXT) and implantable programmable (IMP) insulin pumps needs to be compared to those of intensified conventional insulin therapy (CONV). Only metabolic efficacy and short-term direct costs are easily evaluable. We (WHO-CSII Study) and others have shown that glycemic control and severe hypoglycemia risk are slightly improved, while ketoacidosis risk and costs are aggravated with EXT vs CONV. We (CEDIT Study) and others have shown that glycemic control, mild and severe hypoglycemic risks are improved, with no increase in ketoacidosis rates although a doubling in costs with IMP vs CONV. Rigid interpretation of the above data would limit indications of insulin pumps to patients experiencing frequent hypoglycemias while on intensified conventional insulin therapy.