Predicting the Severity of Pancreatic Fistula after Pancreaticoduodenectomy: Overweight and Blood Loss as Independent Risk Factors: Retrospective Analysis of 277 Patients.

Background: Risk factors for pancreatic fistula (POPF) occurrence after pancreaticoduodectomy (PD) are mostly known. Identifying those that are linked to clinically relevant POPF (Grades B and C) (CR-POPF) is critical, as CR-POPF is associated with more complications and a higher mortality rate. Methods: From 2004 to 2016, 270 consecutive patients who underwent PD in two academic centers were compared retrospectively according to the occurrence of CR-POPF. Results: A series of patients with a median age of 64.5 years (range 30.6-88.7 years) underwent PD. They were allocated to two groups: CR-POPF (Grades B and C)(n = 74; 27.4%) and without clinically relevant POPF (cr-POPF) (no fistula formation or Grade A) (n = 196). Pancreatic ductal adenocarcinoma was the main indication for the procedure (58.5%). Post-operative complications Clavien-Dindo I/II and Clavien-Dindo III/IV and in-hospital death occurred in 109 (40.4%), 67 (24.8%), and 18 (6.7%) patients, respectively. After univariate analysis, CR-POPF was associated with a Body Mass Index (BMI) >25 kg/m2 (p < 0.0001), pancreatic duct diameter <3 mm (p = 0.047), soft pancreas texture to palpation (p = 0.037), and peri-operative transfusion (p < 0.001). After multivariate analysis, high BMI (p = 0.026), transfusion (p < 0.001), length of hospital stay (p < 0.0001), and in-hospital death (p = 0.004) were associated with CR-POPF. Conclusions: In-hospital death and length of hospital stay after PD are related to CR-POPF. A BMI >25 kg/m2 and peri-operative blood transfusion are objective risk factors for CR-POPF.

El trabajo de somatización / Le travail de somatisation / The somatizing process

El autor sintetiza los desarrollos del pensamiento de Pierre Marty y delos principales representantes de la Escuela de París de Psicosomática, a laque él ha añadido diferentes conceptos, sobre todo la idea de trabajo. Este texto es una continuación de una hipótesis anterior expresada en «Duelo, melancolía y somatización», en donde muestra que la somatización es un trabajo que se realiza cuando otras modalidades de trabajo psíquico fracasan. (AU)

The author provides a synthesis of the developments in the thought of Pierre Marty and the principal representatives of the Paris Psychosomatic School, including his own conceptual contributions, such as the notion ofa somatizing process. This paper is a continuation of a hypothesis set outin “Mourning, Melancholia and Somatization” which shows that somatization is a process that occurs when other modalities of psychic work fail. (AU)

L´auteur fait la synthèse des développements de la pensée de PierreMarty et des principaux représentants de l´Ecole de Paris de Psychosomatique, à laquelle il a ajouté différents concepts, surtout l´idée de travail. Ce travail est une continuation d´une hypothèse antérieure expriméedans «Deuil, mélancolie et somatisation» où il montre que la somatisation est un travail qui a lieu quand d´autres modalités de travail psychique échouent. (AU)

Innovation in Surgery: Qualitative Analysis of the Decision-Making Process and Ethical Concerns.

BACKGROUND: Surgical innovation from surgeon's standpoint has never been scrutinized as it may lead to understand and improve surgical innovation, potentially to refine the IDEAL (Idea, Development, Exploration, Assessment, Long-term Follow-up) recommendations. METHODS: A qualitative analysis was designed. A purposive expert sampling was then performed in organ transplant as it was chosen as the ideal model of surgical innovation. Interviews were designed, and main themes included the following: definition of surgical innovation, the decision-making process of surgical innovation, and ethical dilemmas. A semistructured design was designed to analyze the decision-making process, using the Forces Interaction Model. An in-depth design with open-ended questions was chosen to define surgical innovation and ethical dilemmas. RESULTS: Interviews were performed in 2014. Participants were 7 professors of surgery: 3 in liver transplant, 2 in heart transplant, and 2 in face transplant. Saturation was reached. They demonstrated an intuitive understanding of surgical innovation. Using the Forces Interaction Model, decision leading to contemporary innovation results mainly from collegiality, when the surgeon was previously the main factor. The patient is seemingly lesser in the decision. A perfect innovative surgeon was described (with resiliency, legitimacy, and no technical restriction). Ethical conflicts were related to risk assessment and doubts regarding methodology when most participants (4/7) described ethical dilemma as being irrelevant. CONCLUSIONS: Innovation in surgery is teamwork. Therefore, it should be performed in specific specialized centers. Those centers should include Ethics and Laws department in order to integrate these concepts to innovative process. This study enables to improve the IDEAL recommendations and is a major asset in surgery.

De lo afectivo a lo somático. El negativo del afecto / From the effective to the somatic. The negative od affect / De l'affectif au somatique. Le négatif de l'affect

El autor, siguiendo a Freud, trata de mostrar cómo un principio económico, de transformación, mueve la evolución desde lo somático a los psíquico. Así construido el afecto, este está sometido a movimientos evolutivos y contraevolutivos (regresivos). Freud creó la concepción teórica de la construcción desde lo somático a lo psíquico, y Pierre Marty la concepción teórica del movimiento contraevolutivo desde lo psíquico a lo somático, la desorganización psicosomática. En estos recorridos, dos autores aparecen con una especial relevancia: Michel Fain con su concepción tomada de Freud sobre la inhibición, y André Green con su teoría sobre el trabajo del negativo. El autor entiende la somatización como una expresión del negativo del afecto

Following on from Freud, the author attempts to show how an economic principle, that of transformation, shifts the evolution from the somatic to the psychic. Affect, thus constructed, is subject to evolutionary and counter-evolutionary (regressive) movements. Freud laid the theoretical foundations of the construction from the somatic to the psychic, and Pierre Marty the idea of the counter-evolutionary movement from the psychic to the somatic, psychosomatic disorganisation. Along this trajectory, two authors feature prominently: Michel Fain, who takes his understanding of inhibition from Freud, and André Green with his theory on the work of the negative. The author understands somatization as an expression of the negative of affect

L' auteur, en suivant Freud, essaye de montrer comment un principe économique, de transformation, provoque l' évolution du somatique au psychique. Une fois l'affect construit, il est soumis a des mouvements évolutifs et contrévolutifs (régressifs). Freud créa la conception théorique de la construction du somatique au psychique, et Pierre Marty le mouvement de la conception théorique du mouvement contrévolutif du psychique au somatique, la désorganisation psychosomatique. Dans ces parcours, deux auteurs se sont spécialement signifiés: Michel Fain avec sa conception empruntée a Freud sur l'inhibition, et André Green avec sa théorie sur le travail du négatif. L'auteur comprend la somatisation comme une expression du négatif de l' affect

Consequences of metabolic syndrome on postoperative outcomes after pancreaticoduodenectomy.

AIM: To analyze immediate postoperative outcomes after pancreaticoduodenectomy regarding metabolic syndrome. METHODS: In two academic centers, postoperative outcomes of patients undergoing pancreaticoduodenectomy from 2002 to 2014 were prospectively recorded. Patients presenting with metabolic syndrome [defined as at least three criteria among overweight (BMI ≥ 28 kg/m²), diabetes mellitus, arterial hypertension and dyslipidemia] were compared to patients without metabolic syndrome. RESULTS: Among 270 consecutive patients, 29 (11%) presented with metabolic syndrome. In univariable analysis, patients with metabolic syndrome were significantly older (69.4 years vs 62.5 years, P = 0.003) and presented more frequently with soft pancreas (72% vs 22%, P = 0.0001). In-hospital morbidity (83% vs 71%) and mortality (7% vs 6%) did not differ in the two groups so as pancreatic fistula rate (45% vs 30%, P = 0.079) and severity of pancreatic fistula (P = 0.257). In multivariable analysis, soft pancreas texture (P = 0.001), pancreatic duct diameter < 3 mm (P = 0.025) and BMI > 30 kg/m² (P = 0.041) were identified as independent risk factors of pancreatic fistula after pancreaticoduodenectomy, but not metabolic syndrome. CONCLUSION: In spite of logical reasoning and appropriate methodology, present series suggests that metabolic syndrome does not jeopardize postoperative outcomes after pancreaticoduodenectomy. Therefore, definition of metabolic syndrome seems to be inappropriate and fatty pancreas needs to be assessed with an international consensual histopathological classification.

Total laparoscopic right colectomy: The duodenal window first approach.

BACKGROUND: Total laparoscopic right colectomy (TLRC) is a demanding procedure requiring laparoscopic skills and expertise in surgical oncology. Identifying the correct plane of dissection may be difficult. A correct management of ileocecal and right colic vascular pedicles is pivotal to achieve an oncological resection and the adequate blood supply of ileal and colic stumps. METHODS: We describe a technique for TLRC with a duodenum-first approach. Using three ports, dividing the "duodenal window", ileocecal and right colic vascular pedicles, and the right ureter are easily identified. The procedure is completed with an intracorporal stapled side-by-side anastomosis. RESULTS: In 2014, 19 patients underwent TLRC using this technique. The median operative time was 178 min (132-237 min) and median intraoperative blood loss reached 60 mL (10-400). Conversion rate was 15.8%. No urinary tract, vascular, duodenal injury or anastomotic fistula were reported. Fifteen patients (79%) underwent a colectomy for cancer with a median of 16 (7-27) harvested lymph-nodes and 100% of R0-resection. Minor morbidity (Clavien-Dindo I-II) was 52.6% mainly related to cardiopulmonary complications (26.3%). Severe morbidity (Clavien-Dindo ≥ III) was 10.5% (two patients), including one reoperation (due to a sepsis related to an intra-abdominal abscess) and one death (due to complications of an aortic aneurism). Median hospital stay was 7 days (2-23 days). Long-term outcomes are unremarkable. CONCLUSIONS: Using three trocars, the "duodenal window" approach to TLRC is technically feasible and safe, with good outcomes. The early access to the duodenum and the exposure of ilea-cecal and right colic pedicles rationalizes the procedure.

Pancreaticoduodenectomy in the presence of a common hepatic artery originating from the superior mesenteric artery. Technical implications.

Pancreaticoduodenectomy (PD) is considered a technically demanding task. Anatomic variations in duodenopancreatic vascularization [celiac axis and the superior mesenteric artery (SMA)] may carry a risk of potentially life-threatening vascular injury. We retrospectively report a modified PD technique performed in two patients presenting with a Common Hepatic Artery (CHA) originating from SMA. The CHA anatomical pattern was known prior surgical procedure. The main modification consisted in cutting pancreas prior dividing the CHA and the gastroduodenal artery. No intraoperative incident was reported. Perioperative outcomes were unremarkable, no vascular injury or hepatic ischemia was reported. Surgeons planning a PD must analyze in depth imaging (CT-scan with 3D angiography) and try to find these patterns. Furthermore, some rare arterial variations may be met and change typical surgical plan. Knowing prior procedure the arterial pattern and keeping in mind expendable or vital vessels allow to accomplish unusual but effective operations.

Liver resection and metabolic disorders: an undescribed mechanism leading to postoperative mortality.

AIM: To investigate the mechanism leading to perioperative mortality in patients undergoing major liver resection and presenting with metabolic disorders. METHODS: The link between Metabolic Syndrome and non-alcoholic fatty liver disease is currently demonstrated. Various metabolic disorders and the Metabolic Syndrome (the association of ≥ 3 metabolic disorders) have been recently described as a risk factor of perioperative mortality in major liver resection. Patients who passed away during perioperative course of major liver resection and presenting with the association of ≥ 2 metabolic disorders without any other known cause of liver disorders were reviewed. RESULTS: From January 2001 to May 2010 in a tertiary centre, ten patients presenting with ≥ 2 metabolic disorders without any other known cause of liver disorders died during perioperative course of major liver resection. The same four-consecutive-steps sequence of events occurred, including jaundice. The analysis of this series suggested a rapidly deteriorating congestive liver resulting in an increased portal hypertension leading to hepatorenal syndrome and lately to multiorgan failure (mimicking septic collapse) as the mechanism leading to exitus. The acute portal hypertension is mainly related to the surgical procedure. The chronic portal hypertension is indeterminate. Patients with ≥ 2 metabolic disorders should be considered as potentially presenting with portal hypertension possibly evolving towards hepatorenal syndrome; thus, they should be considered as having a high perioperative risk and should be carefully evaluated before undergoing major liver resection. CONCLUSION: As fibrosis was not present or marginal in liver specimens, the real cause of portal hypertension in patients with multiple metabolic disorders should be investigated with further studies.

Multidisciplinary team meeting in digestive oncology: when opinions differ.

In daily oncology, Multidisciplinary Team (MDT) meetings are used worldwide to take every main decision. In order to improve the MDT efficiency, an analysis of decision-making process relying on patients refusing to undergo MDT proposal during presentations, in accordance with their referent specialist, was retrospectively performed in an academic and tertiary center, from 1995 to 2010. Out of 1000 patients, 0.5% refused the MDT proposal because of (1) ignorance of current evidence-based literature, (2) heterogeneous interpretations of the technical feasibility, and (3) the MDT undervaluing patient's specificities and wishes. In order to offset the MDT decision, patient needs to come from a well-off and educated background and to get the uttered support of the referent specialist. MDT conclusion is not customized because of interindividual exceptions and technical evaluations. Clinical Nurse Specialists attending to "blind" MDT meetings may help to back oncologic patient's specificities and wishes.

Delayed right-sided diaphragmatic rupture and laparoscopic repair with mesh fixation.

Diaphragmatic rupture is usually an immediate, left-sided complication of high-velocity thoraco-abdominal trauma. Here we present a rare case of delayed, right-sided diaphragmatic rupture and its laparoscopic mesh repair.

A função desobjetalizante na obra de André Green: um modelo para a psicossomática / La función desobjetalizante en la obra de André Green: un modelo para la psicosomática / The deobjectalizing function in André Green’s work: a model for psychosomatic theory

Os autores expõem a sua compreensão da contribuição de André Green para uma teoria psicossomática. Esta adquire seu significado na aproximação entre os fatos psicossomáticos e os estados-limites. O marco conceitual dentro do qual André Green propõe sua compreensão dos transtornos psicossomáticos é o trabalho do negativo. Foi dentro desse marco que ele expôs suas hipóteses acerca dos processos psicossomáticos: todas elas repousam na ação da pulsão de morte e de sua função desobjetalizante. Podemos encontrar entre Green e Marty um parentesco de pensamento, mas também divergências teóricas que expomos aqui.

The authors expose their understanding of André Green’s contribution for psychosomatic theory. It acquires its meaning in the proximity of psychosomatic facts to the borderline states. The conceptual framework within which André Green proposes his understanding of the psychosomatic disorders is the work of the negative. It was within this framework that he presented his hypothesis on the psychosomatic processes: they are all based over the action of death instinct and its deobjectalizing function. We may find in Green and Marty parallels in thinking, but also theoretical disagreements which are exposed here.

Los autores exponen su comprensión del aporte de André Green a una teoría psicosomática. Esta adquiere su significado en la aproximación entre los hechos psicosomáticos y los estados límites. El marco conceptual dentro del cual André Green propone su comprensión de los trastornos psicosomáticos es el trabajo de lo negativo. Dentro de ese marco expuso sus hipótesis acerca de los procesos psicosomáticos: todas ellas radican en la acción de la pulsión de muerte y de su función desobjetalizante. Podemos encontrar entre Green y Marty un parentesco de pensamiento, pero también divergencias teóricas que exponemos aquí.

A rare case of appendicitis-like syndrome: prompt laparoscopic diagnosis and management.

BACKGROUND: Hyperpyrexia associated with right iliac fossa pain and tenderness in a young patient is a common finding in an Emergency Department, and is frequently caused by acute appendicitis or genitourinary affliction. Especially in the case of young males, it is debated whether the patient should undergo immediate surgery or be referred for imagery, and, when surgery is finally planned, whether an open incision of the iliac fossa or a laparoscopic approach is preferred. OBJECTIVE: We describe a case of a patient with a twisted, ischemic ileal hemangioma mimicking an acute appendicitis, which was diagnosed and managed laparoscopically. CASE REPORT: A 16-year-old boy was admitted to the Emergency Department with a 2-day history of hyperpyrexia, nausea, right iliac fossa pain, and tenderness. Perioperative computed tomography scan showed a 3-cm image that was interpreted as a periappendicular abscess. At laparoscopy, a twisted ischemic mass adherent to the surrounding ileum was located and removed. The patient's outcome was uneventful. Pathology showed a benign hemangioma of the ileal mesentery. To our knowledge, this is the first case treated by laparoscopic resection. CONCLUSIONS: Rare conditions, such as peduncolated tumors, can mimic common conditions like acute appencitis. Also, due to the aspecificity of symptoms and difficult interpretation of imagery, diagnosis can be difficult to achieve preoperatively and surgery can be challenging. Laparoscopy can allow a diagnosis to be made and the appropriate treatment to be performed without the need for laparotomy. Rare causes of appendicitis-like syndrome represent an argument in favor of a laparoscopic approach, even in the case of young male patients.

Metabolic disorders, non-alcoholic fatty liver disease and major liver resection: an underestimated perioperative risk.

INTRODUCTION: Despite increasing evidence of an association of metabolic syndrome and liver degeneration, little is known about the results of major hepatic resection in patients with metabolic disorders. Following the observation of some unexplained perioperative deaths following uncomplicated right hepatectomy in patients presenting metabolic disorders, we analyzed the perioperative mortality in such population. MATERIAL AND METHODS: A retrospective analysis of immediate outcome was performed of patients undergoing right hepatectomy and affected by two or more metabolic disorders (diabetes mellitus, hypertension, dyslipidemia, obesity/overweight) without any other known cause of liver disease from January 2001 to May 2010. RESULTS: Among 151 patients undergoing right hepatectomy, 30 patients presented two or more metabolic disorders. Perioperative mortality in this group reached 30 % (nine patients). In patients presenting MS (≥3 disorders), mortality reached 54 %. Univariate analysis identified four criteria associated with poor prognosis: MS, perioperative bleeding ≥1,000 mL, middle hepatic vein resection and primary hepatic malignancy. At multivariate analysis, middle hepatic vein resection and underlying primary hepatic malignancy resulted as being related to mortality. CONCLUSIONS: Patients presenting with multiple metabolic disorders should be carefully evaluated before major liver resection, especially when the procedure is planned for hepatocellular carcinoma and when a middle hepatic vein resection is required.

Isolated extrahepatic bile duct rupture: a rare consequence of blunt abdominal trauma. Case report and review of the literature.

A 16-year-old girl suffered blunt abdominal trauma. Clinically, a severe motor impairment with paraesthesia of the legs was found. Posterior osteosynthesis in T10-L1 with laminectomy in T10-T12 and posterolateral arthrodesis in T11-T12 was performed because of a dorsal traumatic vertebral fracture. On hospital day 7, because of an acute abdomen, surgical laparoscopic exploration showed sterile bloody fluid without any evident hemorrhagic injury. On hospital day 11, the patient was reoperated on by the laparoscopic approach for increasing abdominal pain and fever: a peritoneal biliary fluid was aspirated. After conversion to open surgery, cholecystectomy was performed. Intraoperative cholangiography was considered as normal. On arrival at our institution 13 days after injury, the patient was operated on for a biliary peritonitis. Intraoperatively, a trans-cystic cholangiography showed a biliary leakage of the common bile duct; a T-tube was placed into the common bile duct; a subhepatic drainage was placed too. On postoperative day 30, a T-tube cholangiography showed a normal biliary tree, without any leakage, and the T-tube was subsequently removed. The patient had a complete recovery.

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment.

BACKGROUND: In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. METHODS: The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. RESULTS: There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). CONCLUSIONS: Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.

Synchronous pyogenic liver abscess and acute cholecystitis: how to recognize it and what to do (emergency cholecystostomy followed by delayed laparoscopic cholecystectomy).

BACKGROUND: The treatment of synchronous pyogenic liver abscess (PLA) and acute cholecystitis (AC) may be challenging. Moreover, because of the similarity of symptoms and the suboptimal accuracy of ultrasound (US), PLA(s) may be undetected, unless a computer tomography (CT) scan is performed. The aims of this study were (1) to evaluate the results of emergency cholecystostomy (CS) and late laparoscopic cholecystectomy (LC) in such a population and (2) to identify the criteria for selecting patients with AC and a high risk of having synchronous PLA(s) for referral for a CT scan. METHODS: A retrospective analysis of the outcome of 12 patients with AC and PLA(s) treated by emergency CS followed by delayed LC from January 1996 through May 2010 at a tertiary-care university hospital was performed. Clinical, laboratory, and radiological data of patients with synchronous AC and PLA(s) are compared with those of 66 patients with "simple" AC. RESULTS: The association of age >55 years, temperature >38°C, WBC count >12,000/ml, and ASAT >50 UI/l and/or ALAT >75 UI/l allows for the selection of patients at high risk of PLA to undergo a CT scan (sensitivity: 100%; specificity: 86%). All treated patients had a sudden improvement within 24 h following CS. PLA was treated in 10/12 patients (83%). Hospital stay lasted 21.5 ± 3.5 days. Ten patients underwent elective LC 12 ± 4 weeks after CS with no conversion and 30% perioperative morbidity. Operating time was 91 min. Hospital stay was 1.7 days [7 patients (70%) underwent surgery as an outpatient]. CONCLUSIONS: A simple algorithm is presented for the selection of patients with AC to undergo a CT scan to identify synchronous PLA. Emergency CS followed by delayed LC is a viable, first-line treatment option for synchronous PLA and AC.

Hemoperitoneum caused by a ruptured GIST located in the posterior gastric wall managed by endoscopic diagnosis and laparoscopic treatment: case report and literature review.

A case of hemoperitoneum caused by a ruptured gastrointestinal stromal tumor (GIST) of the posterior gastric wall is presented. An otherwise healthy 81-year-old man presented with abdominal pain/tenderness and anemia (hemoglobin: 7.4 g/dL). Computed tomography scan showed hemoperitoneum and a gastric mass of uncertain nature. As the patient was hemodynamically stable, a mini-invasive approach was decided. Esophagogastroscopy revealed an umbilicated mass of the posterior gastric wall, therefore allowing for a correct preoperative diagnosis of GIST and its appropriate treatment by laparoscopic atypical gastrectomy. Laparoscopically, a longitudinal resection of gastric fundus including the tumor was performed in a sleeve gastrectomy fashion, 25 minutes after the induction of pneumoperitoneum. The outcome was uneventful. Pathologic examination confirmed a benign 4 × 3-cm gastric GIST with <1 mitosis per 50 high power field, staining positive for CD117 (C-KIT) and negative for S-100 protein and smooth muscle actin. To our knowledge, it is the first case of a successful laparoscopic resection of an endoscopically diagnosed gastric GIST in an emergency setting. Hemoperitoneum is a rare, potentially severe complication of GIST. As bleeding is rarely severe, most patients may benefit from a mini-invasive approach, even if the tumor is located in the posterior gastric wall.

Conceptual framework from the Paris Psychosomatic School: a clinical psychoanalytic approach to oncology.

This article presents further clinical material from the Paris Psychosomatic School (Aisenstein, 2006). The Freudian foundations of psychosomatics are detailed and post-Freudian developments focusing on the contribution of the Paris Psychosomatic School are outlined, in particular, the somatizing process as a result of regression and the somatizing process as a result of drive unbinding. The authors argue that the latter possibly gives rise to progressive and serious illness leading to death. The relationship of classical psychoanalysis to psychotherapeutic treatment from the angle of the Paris school is commented on. The authors then turn to two clinical presentations of women suffering from breast cancer. The method of evaluating the patients' capacities for undergoing psychotherapeutic treatment and their mental capacity for healing is discussed. The face-to-face psychoanalytic treatment undertaken with the second case is discussed. Finally, the authors recall Freud's insistence after 1920 on the opposition of the life drives and the death drives, which placed self-destruction at the centre of psychic functioning. They conclude that current research in biology and medicine, notably research concerning programmed cell death, will converge with psychoanalytic psychosomatics to illuminate somatizing processes and demonstrate the relevance of psychoanalytic treatment to patients who are capable of mental reorganization in the course of their illness and medical treatment.