Single umbilical incision laparoscopic cholecystectomy: results of the prospective trial of the Coelio Club.

AIM: To assess the cosmetic outcome after single umbilical incision laparoscopic cholecystectomies (SILC) performed by the surgeons of the Coelio Club. PATIENTS AND METHODS: Multicenter prospective study concerning 105 consecutive patients operated between December 2009 and February 2011 by SILC for non-complicated gallstones. Perioperative and postoperative parameters were analyzed with a systematic follow-up at 1 and 6months postoperative. RESULTS: Conversion to conventional laparoscopic cholecystectomy (CLC) was required for six patients (5.7%). Conversion rate is higher in case of acute cholecystitis (25%, P<0.001). Cosmetic outcome is found excellent by the patient (in 86% of the cases at 6months) and by the surgeon (in 90% of the cases at 6months) using an EVA scale. An incisional hernia was found in two cases (1.9%) and a superficial wound infection in four cases (3.8%). CONCLUSIONS: The cosmetic outcome after SILC is found excellent. SILC has its place in the surgical management of the non-complicated gallstone. We did not notice higher level of peroperative complications (biliary tract injury) during SILC than during CLC. Postoperative higher level of abdominal wall complications than after a CLC makes the surgeon caution to a careful abdominal wall closure.

Single umbilical incision laparoscopic cholecystectomy: initial experience of the Coelio Club.

AIM: To assess the initial results of single umbilical incision laparoscopic cholecystectomies (SUILC) performed by the members of the Club Coelio. PATIENTS AND METHODS: This multicenter study involved 65 consecutive patients undergoing SUILC between September 2008 and December 2009. The operation was performed with a 0° scope in 35 and with a 30° scope in 30 patients. There were 56 women and nine men with a mean age of 49 ± 14 years and a mean body mass index of 25 ± 4. The main perioperative parameters analyzed were duration of operation, conversion, morbidity and duration of hospitalization. One month after surgery, the esthetic result was assessed by each patient on a visual analogue scale (VAS). A VAS score between 9 and 10 was considered as an excellent result. RESULTS: During laparoscopy, some degree of cholecystitis was seen in 10 patients. Intraoperative cholangiography was performed in 57 patients and the mean duration of operation was 68 ± 22 min. Conversion to conventional laparoscopic cholecystectomy (CLC) was required in eight patients (12%). We noted three complications (4%): two wound abscesses and one hemoperitoneum. The mean hospital stay was 2 ± 1 days. The esthetic result was considered as excellent by 45 patients (69%). Multivariable analysis revealed that duration of operation was shorter after five procedures (61 ± 25 vs. 72 ± 18 min, regression coefficient: -7, P<0.032) and when a 30° scope was used (56 ± 18 vs. 76 ± 20 min, regression coefficient: -14, P<0.011), the conversion rate was higher in cholecystitis (60% [6/10] vs. 4% [2/55], OR: 33, P<0.002) and the percentage of excellent esthetic results was greater in patients who did not required a conversion to CLC (77% [44/57] vs. 12% [1/8], OR: 18, P<0.012). CONCLUSIONS: Our study showed that SUILC is feasible with low morbidity but duration of operation is long and conversion to CLC is frequent in cholecystitis. However, duration of operation decreases with rising experience of the surgeon and when a 30° scope is used. The major value of this technique is cosmetic.

Detoxification of ochratoxin A, a food contaminant: Prevention of growth of Aspergillus ochraceus and its production of ochratoxin A.

The toxicity of ochratoxin A (OTA), a mycotoxin produced by fungi ofAspergillus orPenicillium genera is now well documented. Its nephrotoxicity, immunosuppression, teratogenicity, and carcinogenicity have been widely studied. Physical and biochemical methods have been studied to prevent these toxinogenicAspergillus andPenicillium from producing OTA, and/or to destroy the mycotoxin when already produced in a liquid or a solid medium. Repeated freezing at - 20†C and thawing at + 26†C aleatory reduce OTA production in a liquid medium. Exposure to UV B for different periods of time is efficient in preventing OTA production in a liquid medium. Gamma-irradiation from 2 to 5 kGy gives good results in preventing the production of OTA or destroying it when already produced. Carboxypeptidase is very efficient at 5 units/50 ml in a liquid medium for cleaving the OTA already produced.

Pentamidine-induced dysglycaemia: experimental models in the rat.

In order to analyse further the pathophysiology of pentamidine effects on blood glucose regulation, the following experimental models were established in rats: impairment of the renal function, bile duct ligation, inhibition of the P450 cytochrome enzyme system. In otherwise intact rats, 7.5 mg/day pentamidine was well tolerated whereas doses of 15 mg/day induced severe, relapsing and eventually lethal hypoglycaemia within a few days. Induction of a renal insufficiency of graded severity by treatment with gentamycin, subtotal nephrectomy and total bilateral nephrectomy resulted in repetitive, severe (sometimes lethal) hypoglycaemia, alternating with hyperglycaemia, glucosuria and ketonuria in pentamidine-treated rats (7.5 mg/d). No long-standing insulin-dependent diabetes was observed. In the dysglycemic animals, plasma insulin levels were inappropriate to the concomitant glycaemia; no stimulation was obtained by i.v. glucose. Glucagon levels were higher than normal, suppressible by i.v. glucose, responsive to IV arginine and to hypoglycaemia. Dysglycemic events were more frequent and marked in the rats with the most severe renal functional derangement. They were more frequent in the rats treated with pentamidine mesylate than in those treated with the isethionate salt. Control uremic rats (free of pentamidine) remained euglycaemic. The islets of Langerhans displayed severe vascular congestion and degranulation and necrosis of the B cells, while the non B cells (and particularly the A cells) were intact. Exocrine pancreatitis was occasionally observed in the most severely uremic rats. In contrast with uremic rats, neither surgical ligation of choledocus, nor treatment by P450 cytochrome inhibitors (particularly ketoconazole) precipitated dysglycaemia in the pentamidine-treated rats. These experimental data: 1) strengthen the concept of inappropriate insulin release from pentamidine-lesioned islet B cells due to pentamidine accumulation; 2) indicate a predominant role for renal insufficiency in determining the accumulation of this drug; 3) emphasize the clinical importance of renal insufficiency as a risk factor for pentamidine-induced dysglycaemia. Association with ketoconazole does not appear to be a risk factor.

[Management of a focal hepatic mass: propositions of a workshop]. / Conduite à tenir devant une masse focale hépatique: propositions synthétiques d'un groupe de travail.

Focal hepatic masses are a common problem, due to the expansion of ultrasound. Individuals engaged in the four disciplines involved (hepatogastroenterology, digestive surgery, radiology and pathology) met to summarize the information available, to compare their experience and to make synthetic proposals. The method consisted of an expert report, discussion of the clinical cases, workshop discussion for each discipline around synthetic proposals, reporting of these proposals in full session and discussion. The results, i.e. the synthetic and consensual proposals concerned diagnosis, treatment and monitoring of focal hepatic masses are presented for each discipline.

[Predictive factors of response to chemotherapy in epidermoid cancer of the esophagus. Study apropos of 60 patients and evaluation of a response score]. / Facteurs prédictifs de réponse à la chimiothérapie du cancer épidermoïde de l'oesophage. Etude à propos de 60 patients et élaboration d'un score de réponse.

The aim of this study was to select predictive factors for response to chemotherapy in esophageal squamous cell carcinoma. Sixty patients, aged between 39 and 77 years (mean 61.5) received two initial chemotherapy sessions of 5 FU (1 mg/m2/24 h) and cisplatinum (20 mg/m2/24 h) during four days. Sixteen clinical, endoscopic, biological, and histological factors were collected. The response to chemotherapy was evaluated one month after completion of the second session by means of endoscopic and computed tomographic data. Thirty-two percent (CI: 20-44 percent) of patients had an objective response to chemotherapy (according to WHO criteria). Univariate analysis showed two predictive factors: obstructing pattern of tumor (P less than 0.01) and albuminemia less than 35 g/l (P less than 0.01). A response score was calculated with a stepwise regression model. The score correctly predicted a satisfactory response to chemotherapy with a sensitivity and specificity of 84.2 and 73 percent, respectively. Overall survival of these patients was statistically higher (P less than 0.001) compared with patients without any response. A satisfactory response to chemotherapy in patients with esophageal squamous cell carcinoma can be expected according to certain pretreatment factors.

[Analysis of cellular DNA content by flow cytometry in epidermoid carcinoma of the esophagus]. / Analyse du contenu cellulaire en ADN par cytométrie en flux dans le carcinome épidermoïde de l'oesophage.

Flow cytometric DNA analysis was performed in 35 patients with squamous cell carcinoma of the esophagus. The aim of this study was a) to establish a tumoral DNA pattern, b) to determine an objective parameter correlating with tumoral response to chemotherapy (5 FU-cisplatin). DNA analysis was performed in perendoscopic ranged tumoral biopsy specimens to determine the DNA ploidy (DNA index) and S phase fraction. Tumor diameter and length were evaluated by computed tomography (CT) before and after chemotherapy in 24 patients. The relative variation of this product determined a CT index. Before chemotherapy, 82 percent (76/93) of the specimens were available for assessment; 72 percent (26/36) of the tumors were aneuploid. In these tumors, the DNA index ranged from 1.23 to 2.80. Five tumors had two distinct and simultaneous aneuploid populations. CT index values were not significantly different according to the ploidy (diploid, aneuploid), the S phase fraction (low, high), the DNA content modification after chemotherapy (absent, present). In this study, DNA analysis did not allow to select patients with higher response to chemotherapy. The inter- and intratumoral phenotypic heterogeneity may be one of the responsible factors.

[Idiopathic segmental infarction of the greater omentum]. / Infarcissement segmentaire idiopathique du grand épiploon.

Segmental infarction of the omentum is a rare disease, with about 150 published cases, and an unusual cause of "pseudoacute" abdomen. The preoperative diagnosis is difficult because of the rarity and lack of specificity of the syndrome, and it is established after laparotomy, with a few exceptions. The authors report on a personal case and emphasize the importance of systematic exploration in spite of the "innocence" of the organ initially involved, and they describe the few signs that are nontheless suggestive of this provocative and puzzling entity.

[Contusions of the liver in adults. Initial non-operative management with computerized tomography follow-up is a reasonable therapeutic option. Report of 16 cases]. / Contusions du foie de l'adulte. L'abstention opératoire initiale sous contrôle tomodensitométrique est une option thérapeutique raisonnable. A propos de seize observations.

Nonoperative management of blunt liver injury in adults still remains controversial. From February 1985 through September 1989, 27 patients were treated for blunt hepatic trauma: 11 required immediate operation and 16 (59%) were initially managed nonoperatively after evaluation of intraabdominal injury by computerized tomography. All of these 16 patients were hemodynamically stable and had no significant peritoneal signs. CT criteria for nonoperative management included subcapsular and intrahepatic hematoma, capsular tear or unilobar fracture, absence of large hemoperitoneum, absence of large devitalized liver and absence of other intraabdominal organ injuries. Clinical follow-up, repeated radiologic examinations and surgery confirmed the accuracy of CT. Only 2 patients required delayed operation (12.5%). Serial abdominal CT studies are an integral part of the conservative treatment of blunt hepatic injuries and showed complete resolution of hepatic injuries in the fourteen nonoperated patients in less than six months. No death and no delayed septic or biliary complications were noted. Mean hospital stay was seventeen days for all of the patients (multiple injuries or not) and only ten days for isolated blunt liver injury. These good results depend on identification of candidates for nonoperative management on strict clinical and CT criteria. Nonoperative management of adult blunt liver injury based on these findings is a useful alternative in a selected group of hemodynamically stable patients and decreases the rate of non-therapeutic coeliotomy.

[Acute pancreatitis: prognostic value of early x-ray computed tomography coupled with Ranson's criteria and its role in surveillance of the course]. / Pancréatites aiguës: valeur pronostique de la tomodensitométrie précoce couplée aux critères de Ranson et son rôle dans la surveillance de l'évolution.

Fifty nine patients suffering from a first attack of acute pancreatitis were investigated during the first ten days of illness with computerized tomography (CT scan) and biological signs of Ranson. The prognostic value of the combination of these two classes of signs was evaluated. The grading of initial CT scan findings was accorded to the Ranson and Balthazar classification. In addition, the authors evaluated the presence and extent of necrosis and studied phlegmonous extrapancreatic spread. A high risk group of patients was determined: grade C, D, E, with at least three prognostic signs. Twelve of these high risk patients with grade D and E had a glandular necrosis as detected on initial contrast enhanced CT scan. This was an important prognostic value sign (sensibility 100 percent; specificity 92 percent) as all morbidity was 100 percent compared with 8.5 percent among the 47 other patients who did not exhibit this CT sign; mortality was 25 percent compared with 0 percent among the other patients. Phlegmonous extrapancreatic spread in three or more areas also influenced the prognostic but to a lesser extent (sensibility 100 percent; specificity 62 percent). Forty-four patients among the fifty-nine had a morphologic follow-up of the course of lesions by repeated CT scan. Local complications occurred only in patients at high risk: 9 pancreatic abscesses (20.4 percent) and 6 pseudocysts (15 percent). One-third of the twenty-one grade D and E patients had spontaneous resorption of the phlegmonous extrapancreatic areas.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cutaneous closure of peritonitis]. / Fermeture cutanée des péritonites.

The authors report results of prospective study about skin closure of peritonitis. Two groups are compared: Group A: continuous suture + suction drain VS Group B: simple suture at wide intervals of 4 cm. 93 patients have been included with a mean age of 53.2 +/- 23.9 and just before surgery randomized. Two groups are homogeneous. The postoperative parietal complications were respectively 12% in group A versus, 29% group B. There is a significant difference of 5% in favor of group A. Because the little size of groups, the authors conclude that closure of the skin peritonitis with "continuous suture" is not forbidden. This procedure doesn't increase morbidity.

Reproducible high yields of rat islets of Langerhans.

Isolation of islets of Langerhans from the pancreas by action of collagenase, a major breakthrough for physiological studies in vitro, has long appeared empirical, and the results were sometimes unpredictable. Isolation yields (number of islets obtained per pancreas) and their reproducibility, purification from exocrine remnants and vitality of the islets obtained, can improve owing to precise techniques, adapted to the architecture of collagen in the pancreas. We have tested four isolation-purification techniques in the rat pancreas. The best results were obtained by combining intra-ductal collagenase injection, with complete but moderate distension of the gland, avoiding leakage, multistep digestion (in situ and then in vitro), followed by purification on a discontinuous bovine serum albumin (BSA) gradient. Average yields were 670 +/- 40 islets per pancreas (range 570-800), versus 170 +/- 9 (range 40-350) with the technique used initially. The use of BSA discontinuous gradient improved the purification yield: 90-96% of islets obtained were concentrated in the 26/29% BSA interface. Furthermore, this technique shortened the duration of purification step: 1 hr (centrifugation gradient) vs 3 hrs (handpicked). It was verified that islets were morphologically free of exocrine tissue. Islet structure was well preserved either in conventional histology or insulin and glucagon immunoperoxidase staining. Islet vitality, as assessed by trypan blue exclusion test, was 100% of freshly isolated islets, and 89% after 24 hrs culture. Insulin secretory responses to a given stimulus were stronger than in the case of islets isolated by former techniques: 10-12 times the basal release (vs 5 times) with clear dose-response proportionality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bilateral abscess of the psoas with aero-anaerobic digestive flora in advanced tuberculosis]. / Abcès bilatéral du psoas à flore digestive aéro-anaérobie lors d'une tuberculose évolutive.

The authors report a case of bilateral psoas abscess without spondylodiscitis, occurring in the course of an advanced pleuro-pulmonary tuberculosis. The dual bacteriological composition of the pus with an aero-anaerobic flora on direct examination, and mycobacterium tuberculosis in the culture, as well as the presence of an obstructive appendicitis noticed during the surgery, open the discussion of its pathogenesis.

[Obstruction of the extrahepatic bile ducts by tumor debris and/or clots in primary cancer of the liver. Diagnostic and therapeutic problems. Apropos of 9 personal cases and review of the literature]. / Obstruction des voies biliaires extra-hépatiques par débris tumoraux et/ou caillots dans les cancers primitifs du foie. Problémes diagnostiques et thérapeutiques. A propos de neuf observations personnelles et revue de la littérature.

The onset of jaundice in patients with primary liver cancer is sometimes caused by intra ductal biliary system tumor casts, free floating debris or hemobilia. The diagnosis of this complication is now possible by E.R.C.P. or P.T.C. We report 9 cases of unrecognized primary liver tumor revealed by intra biliary system migration of tumor casts or free floating debris. In three patients the diagnosis was operative, but for the last six cases the E.R.C.P. data in addition with U.S., C.A.T. Scan and/or hepatic angiography were helpful in determining the nature of the hepatic and biliary changes, the operability (size, location, extent). A curative surgery was not indicated in our 8 operated patients: liver resection and biliary decompression. With the palliative procedures, bilio enteric by pass (2 cases) T tube (1 case) trans hepatic uni or bilateral tubes. The survey was not longer than 11 months. Three patients died in post operative course. Only 56 patients among 117 observations of the literature have been operated: 10 liver resections including the main hepatic junction in two cases were performed with one hospital death, two patients were alive over 2 years with recurrence and three patients were disease free with a follow up less than one year. The operative mortality with palliative procedures was 34.4%; the one-two years survival was 23%; the two longest survivors lived 41 and 61 months.