Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients.

BACKGROUND: Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores. METHODS: From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration. RESULTS: The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively). CONCLUSION: The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

Fibrin sealant in inguinal hernioplasty: an observational multicentre study in 1,201 patients.

PURPOSE: A prospective, multicentre, observational study was undertaken to assess Tisseel fibrin sealant for atraumatic mesh fixation in inguinal hernia repair throughout France. METHODS: Surgeons recorded data on patients undergoing tension-free inguinal hernioplasty with mesh fixation with Tisseel, regardless of the hernioplasty technique used. Assessments were made at 2 days and 1 month after surgery. Data on local complications, operation times and ease of product use were collected. RESULTS: In total, 1,201 patients were recruited (90% men, mean age 57 years), among which 526 procedures were performed using open techniques and 675 using laparoscopic repairs. Local complications occurred in 4.7% of patients: 3.0% haematoma, 1.4% seroma, 0.3% recurrence. The mean visual analogue scale (VAS)-rated pain scores were 3.2 pre-operatively, 2.3 immediately after surgery and 1.8 at 1 month. Surgeons rated the product as very easy to use. CONCLUSIONS: Tisseel fibrin sealant appears to be a well-tolerated and easy-to-use alternative to traditional, tissue-penetrating devices for mesh fixation in hernia repair techniques.

[Adrenal metastasis: survival following surgical resection]. / Métastase surranélienne: survie après chirurgie d'exérèse.

GOAL: This study aims to determine the post-surgical survival after resection of adrenal metastasis from extra-adrenal primary cancers. PATIENTS AND METHODS: A retrospective study of sixteen patients undergoing surgery for adrenal metastasis between 1995 and 2005 analyzed age, type of primary cancer, interval to detection of adrenal metastasis, type of surgery performed, and survival (Kaplan-Meier curve). RESULTS: The study included 10 men and 6 women with a mean age of 55.5 years (25-74). Adrenal metastasis causes no clinical signs or symptoms. Diagnosis was made on the basis of CT scan in 12 cases and PET scan in 4 cases. The primary cancer site was lung (6), kidney (3), melanoma (2), colorectum (2), esophagus (1), pancreas (1), and B-cell lymphoma (1). Metastasis was confined to the adrenal in 7 cases and associated with other-site metastasis in 9. The interval from diagnosis of the primary cancer to detection of the adrenal metastasis ranged from 9 months to 11 years. Surgery consisted of radical resection in 5 cases, metastasectomy in 10 cases, and biopsy in one case. The overall survival was 12 months (range 2-120 months); when the diagnosis of the metastasis was synchronous with that of the primary, survival was just 8 months. CONCLUSION: The survival after surgery for adrenal metastasis is poor; it is even more dismal when the metastasis is diagnosed synchronously with the primary tumor. Surgical management depends on the primary neoplasm and the extent of metastases.

[Acute intestinal strangulation after Scarpa's triangle cow horn injury]. / Occlusion intestinale aiguë suite à un encornage du triangle de Scarpa.

A 52 year-old man, treated by neuroleptic drugs, presented with a cow horn injury in the right Scarpa's triangle. The surgical management found no injury of femoral vessels. Surgical hemostasis of superficial vessels was performed. An ileal strangulation appeared three days later. At laparotomy, we found an internal parietal wound. Here we explain the mechanism of this strangulation.

[Focal nodular hyperplasia involving portal cavernoma]. / Hyperplasie nodulaire multifocale compliquant un cavernome porte.

Focal nodular hyperplasia is a rare hepatic tumor in children representing only 2% of all pediatric hepatic tumors. We report a case in teen-ager who had a symptomatic portal cavernoma at 9 years of age, and had been treated by porto-mesenteric surgical shunt. At 16 years, liver ultrasounds revealed multiple hepatic nodules. Focal nodular hyperplasia was suggested by CT scan and magnetic resonance imaging. Given the symptoms and the unusual and multiple lesions, diagnosis was confirmed by surgical biopsy. FNH pathogeny is discussed in this context.

[Hepatic haemangioendothelioma: case report and review of literature]. / Hémangioendothéliome épithélioïde du foie: à propos d'un cas clinique et revue de la littérature.

A 37 year old-woman complained about persistant pain of right abdominal quadrant. We discovered many hepatic lesions. Histology revealed benign processus. Evolution was marked by peritoneal carcinomatosis. After reexamination of histology we discovered hepatic haemangioendothelioma. The patient died 18 month after diagnosis although chemotherapy.

[Cecal volvulus]. / Les volvulus du caecum.

The cecum is the second most common site of colonic volvulus after the sigmoid. The mechanism is torsion or hyperflexion of the enlarged, poorly-fixed, and hypermobile cecum. It presents clinically as an acute bowel obstruction with strangulation. Diagnosis can be made by plain abdominal X-ray in more than half the cases on the basis of cecal distention (with a classical "teardrop" or "comma" appearance), proximal small bowel distention with air-fluid levels, and a gasless distal colon. Barium enema shows lack of filling of the cecum, often with a "beaked" termination of the column of contrast. CT images are pathognomonic when they reveal a cecal "vortex". After surgical reduction of the torsion, ileo-cecal resection is usually the best therapeutic alternative. Cecopexy may be aDDrouriate in older and debilitated Datients if there is no concomitant cecal necrosis.

[The MDR3 gene mutation: a rare cause of progressive familial intrahepatic cholestasis (PFIC)]. / La mutation du gène MDR3: une cause rare de cholestase familiale.

A 47-year old man complained about persistant pain and cholestasis 12-years after a cholescystectomy. In his family, all his brothers and sisters had cholecystectomy. Genetic explorations revealed a MDR3 gene mutation. All symptoms disappeared with a treatment by ursodesoxycholic acid. MDR3 gene mutation is to be researched in all cases of familial cholestasis.

[Inferior mesenteric arteriovenous fistulas. Report of a case]. / Les fistules artérioportales mésentériques inférieures. A propos d'un cas.

We report a case of postoperative inferior mesenteric arteriovenous fistula. Arteriovenous fistula represents a rare disease. Symptoms are due to portal hypertension and distal ischemy. Treatment of these fistulas is embolization. Surgery is possible by ligature or excision of the fistula because vascularisation is obtained by Riolan arcade and hypogastric artery.

[Spontaneous splenic rupture due to splenic metastasis of lung cancer]. / Rupture spontanée de rate révélatrice d'une métastase splénique d'un cancer du poumon.

We report the case of a patient who underwent splenectomy for spontaneous rupture of the spleen due to splenic metastasis. Pathologic examination revealed diffuse infiltration by carcinoma. Chest X-ray revealed a right lung superior lobe tumor, related to poorly differentiated carcinoma. Total splenectomy is a good option for diagnosis and treatment of splenic metastases.

[Giant diverticulum of the sigmoid colon with jejunal fistula]. / Diverticule géant du côlon sigmoïde fistulisé dans le jejunum.

An 80-year-old woman with sigmoïd diverticula was treated by corticosteroid for Horton disease. She presented abdominal pain, and abdominal mass in left iliac fossa. Radiological examinations revealed a colo-jejunal fistula. At laparotomy it was a giant diverticulum of colon sigmoid with fistula in the jejunum. The pathogeny of giant diverticulum and the role of corticosteroid are discussed.

[Apropos of a case of bilateral axillary supernumerary breasts]. / A propos d'un cas de seins surnuméraires axillaires bilatéraux.

We herein report a case of axillary localization of supernumerary breast. It is a matter of axillary bilateral masses mistaken as lipoma at clinical examination and ultrasonography. We here explain this confusion between lipoma and supernumerary breast. The aim of this work is to specify clinical characters of an axillary mass that must lead to suspect a supernumerary breast.

[Aberrant pancreas: report of five cases]. / Les pancréas aberrants: à propos de cinq cas.

We herein report five cases of heterotopic pancreas localized on common bile duct, gastric antrum, duodenum (two cases including one with cystic dystrophy), and jejunum. The choledocal localization was revealed by jaundice. The duodenal localization with cystic, diagnosed by endoscopic ultrasound, was revealed by onsets of acute pancreatitis. All localizations were treated by resection: antrectomy, bowel resection, and pancreaticoduodenectomy. Postoperative course was uneventful. Review of the literature shows that, even in uncomplicated cases, resection is usually performed.

[Nephro-uretero-sigmoidectomy for colonic carcinoma associated with destruction of kidney after ureterosigmoidostomy: a case report]. / Néphro-urétéro-sigmoïdectomie pour cancer colique avec destruction rénale après urétéro-sigmoïdostomie: à propos d'un cas.

A patient underwent at his birth, an ureterosigmoidostomy for exstrophic bladder. Fifty-six years later, she presented a carcinoma on the right ureterosigmoidostomy associated with chronic urinary infection. She underwent a right ureteronephrectomy and sigmoidectomy. Chronic alterations of the colic mucin by urines lead to carcinoma.

[A case of right liver atrophy]. / A propos d'un cas de sagittalisation des voies biliaires droites.

The authors report a case of right liver atrophy. This rare anomaly was suspected during post-operative period on abnormalities of cholangiogram. This biliary tract anomaly was diagnosed by CT scan. This congenital abnormality may be associated with biliary tract abnormalities, portal hypertension and other congenital abnormalities.

Right hepatectomies without vascular clamping: report of 87 cases.

BACKGROUND/PURPOSE: Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping. METHODS: From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 +/- 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava). RESULTS: There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 +/- 2.7 units. The mean operative length was 280 +/- 60 min and the mean hospital stay was 12.8 +/- 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week. CONCLUSIONS: In our experience with major liver resections, vascular clamping is not necessary.

Development of colonic stenosis following severe acute pancreatitis.

BACKGROUND: Colonic necrosis after acute pancreatitis is rare. When it does occur, it is commonly due to ischaemia or inflammation and may necessitate early colonic resection. CASE OUTLINE: A 72-year-old man developed colonic necrosis 6 weeks after severe acute pancreatitis. CT scan revealed a bulky mass near the left colon. Barium enema and colonoscopy revealed stenosis of the left colonic flexure, and this segment of bowel was successfully resected. DISCUSSION: Severe acute pancreatitis must be recognised as a cause of colonic ischaemia and necrosis. The possible pathogenic mechanisms include severe local inflammation and an ischaemic process. This complication is associated with a very poor prognosis despite surgical intervention, but a timely resection may prevent further problems.

Laparoscopic liver resection of benign liver tumors.

OBJECTIVE: The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic liver resection for benign liver tumors in a multicenter setting. BACKGROUND: Despite restrictive, tailored indications for resection in benign liver tumors, an increasing number of articles have been published concerning laparoscopic liver resection of these tumors. METHODS: A retrospective study was performed in 18 surgical centres in Europe regarding their experience with laparoscopic resection of benign liver tumors. Detailed standardized questionnaires were used that focused on patient's characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. RESULTS: From March 1992 to September 2000, 87 patients suffering from benign liver tumor were included in this study: 48 patients with focal nodular hyperplasia (55%), 17 patients with liver cell adenoma (21%), 13 patients with hemangioma (15%), 3 patients with hamartoma (3%), 3 patients with hydatid liver cysts (3%), 2 patients with adult polycystic liver disease (APLD) (2%), and 1 patient with liver cystadenoma (1%). The mean size of the tumor was 6 cm, and 95% of the tumors were located in the left liver lobe or in the anterior segments of the right liver. Liver procedures included 38 wedge resections, 25 segmentectomies, 21 bisegmentectomies (including 20 left lateral segmentectomies), and 3 major hepatectomies. There were 9 conversions to an open approach (10%) due to bleeding in 45% of the patients. Five patients (6%) received autologous blood transfusion. There was no postoperative mortality, and the postoperative complication rate was low (5%). The mean postoperative hospital stay was 5 days (range, 2-13 days). At a mean follow-up of 13 months (median, 10 months; range, 2-58 months), all patients are alive without disease recurrence, except for the 2 patients with APLD. CONCLUSIONS: Laparoscopic resection of benign liver tumors is feasible and safe for selected patients with small tumors located in the left lateral segments or in the anterior segments of the right liver. Despite the use of a laparoscopic approach, selective indications for resection of benign liver tumors should remain unchanged. When performed by expert liver and laparoscopic surgeons in selected patients and tumors, laparoscopic resection of benign liver tumor is a promising technique.