[Hiking and useful advices to patients: part II]. / Randonnée: conseils utites aux patients (2e partie).

The attraction of walking as a pastime has grown enormously in Switzerland over the past few years. Synonym of health and wellbeing, this activity carries some risks which more and more patients are questioning; answering these questions is not always obvious, so we wanted to tackle the subject. This second section concerns risks linked to food which can be found in the forest. Echinococcosis is an underestimated parasite which affects a large proportion of foxes in Switzerland. This infectious disease can also affect man following contamination which usually occurs through eating berries. Prevention is the most effective way to avoid poisoning by mushrooms. In case of poisoning, the physician must try and determine the toxidrome. The key element is the length of time before symptoms develop. Treatment is always symptomatic, using activated charcoal.

Rhizomucor hepatosplenic abscesses in a patient with renal and pancreatic transplantation.

Fungal infections are generally observed in immunosuppressed patients only, with a diagnostic challenge due to non-specific symptoms. For this reason, appropriate management may be delayed. This case report concerns a 36-year-old man with history of pancreas and kidney transplantation. He had chemotherapy for post-transplant B-cell lymphoma and presented with left upper abdominal pain and fever. Multiple investigations led to a final diagnosis of disseminated abdominal mucormycosis with multiple Rhizomucor abscesses in the liver, spleen and kidney transplant. Treatment was antifungal therapy and laparotomy with splenectomy, wedge resection of two fungal abscesses in segments II and IVb, and segmental left colic resection.

Biological impact of an enhanced recovery after surgery programme in liver surgery.

BACKGROUND: The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery. METHODS: A retrospective analysis of patients undergoing liver surgery (2010-2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP. RESULTS: A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P < 0.001) and major resection (47.5 versus 38.1 per cent; P = 0.035) in the ERAS group. Patients in the ERAS group showed attenuated ΔWBC (2.00 versus 2.75 g/l; P = 0.013), ΔCRP (60 versus 101 mg/l; P <0.001) and Δalbumin (12 versus 16 g/l; P < 0.001) compared with those in the no-ERAS group. Subgroup analysis of open resection showed similar results. Multivariable analysis identified ERAS as the only independent factor associated with high ΔWBC (odds ratio (OR) 0.65, 95 per cent c.i. 0.43 to 0.98; P = 0.038), ΔCRP (OR 0.41, 0.23 to 0.73; P = 0.003) and Δalbumin (OR 0.40, 95 per cent c.i. 0.22 to 0.72; P = 0.002). CONCLUSION: Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.

[Management of hepatocellular carcinoma]. / Prise en charge du carcinome hépatocettulaire en 2010.

Hepatocellular carcinoma (HCC) is one of the most frequent malignant tumors worldwide and its incidence has increased over the last years in most developed countries. The majority of HCCs occur in the context of liver cirrhosis. Therefore, patients with cirrhosis and those with hepatitis B virus infection should enter a surveillance program. Detection of a focal liver lesion by ultrasound should be followed by further investigations to confirm the diagnosis and to permit staging. A number of curative and palliative treatment options are available today. The choice of treatment will depend on the tumor stage, liver function and the presence of portal hypertension as well as the general condition of the patient. A multidisciplinary approach is mandatory to offer to each patient the best treatment.

[The management of an incidental liver lesion]. / Prise en charge d'une lésion hépatique découverte fortuitement.

The widespread use of abdominal imaging technologies has led to an increase in the incidental finding of liver tumors. Most of these lesions are asymptomatic and will not require any treatment. With the use of contrast-enhanced radiological studies, most of the tumors can be reliably diagnosed by non-invasive means. In case of diagnostic uncertainty, patients should not undergo percutaneous biopsy but rather complete resection of the lesion for an unequivocal diagnosis. Such pathologies must be taken charge of in centers with expertise by interdisciplinary teams.

[Trends in surgery]. / Chirurgie.

More than the number of real novelties, trends and preliminary results characterise the annual development in surgery. The wealth and diversity of topics to be covered require arbitrary choices, therefore not necessarily complete. The constant development of choledocolithiasis management, dominated by minimal invasive technology, treatments of unusual nature of two frequent proctological conditions, fistulae and haemorrhoids, the increasing importance of metabolic bariatric surgery, as well as the strict rules of effective melanoma treatment, represent as many directions in which the operating procedure, although unseen, continue to gain quality and security.

[Pancreaticoduodenectomy: indications, results and management of complications]. / Duodénopancréatectomie céphalique: indications, résultats et prise en charge des complications.

Pancreaticoduodenectomy is a major procedure in visceral surgery. Post-operative mortality is around 5% in high-volume hospitals, thanks to improvement in global patients care. Morbidity remains high though. The treatment of complications most often require a multidisciplinary approach. Delayed gastric emptying, intraabdominal abscesses and pancreatic fistulas are the most frequent complications. Post-pancreatectomy hemorrhage, although more rare, is a severe and dreadful event. Despite its morbidity, duodenopancreatectomy significantly improves survival of patients with biliopancreatic cancer. Early recognition of these complications and a prompt treatment increase the safety of this procedure.

[Systemic treatment of metastatic colorectal cancer]. / Traitements systémiques du cancer colorectal métastatique.

Colorectal cancer is the 2nd cause of cancer related death in industrialised countries. 20% of all patients present with metastatic disease at diagnosis and need systemic treatment. Since the introduction of irinotecan and oxaliplatin as part of standard chemotherapy, and recently the new targeted agents bevacizumab, cetuximab and panitumumab, the overall survival for patients suffering from metastatic colorectal cancer (mCRC) has increased significantly and nearly reaches 2 years nowadays. Surgery or radiofrequency ablation has become central in the care of metastatic disease. This article resumes recent therapeutic advances in the field and emphasizes the multidisciplinary concertation between specialists to obtain the best outcome.

[Prevalence of undernutrition in 143 patients before liver transplantation. The Lausanne experience between 1997 and 2005]. / Prévalence de la dénutrition chez 143 adultes en bilan prétransplantation hépatique. Experience lausannoise de 1997 a 2005.

The prevalence of undernutrition was prospectively studied in 143 patients before liver transplantation between 1997 and 2005. Nutritional assessment is a particularly tricky problem in cirrhosis and mid-arm muscle circumference is considered as the best reliable anthropometric tool. In this prospective study, prevalence rate is very high (61%) and undernutrition is more frequent in alcoholic cirrhotic patients. In conclusion, these patients should benefit from an early dietician intervention before liver transplantation.

Predicting the duration of antiviral treatment needed to suppress plasma HIV-1 RNA.

Effective therapeutic interventions and clinical care of adults infected with HIV-1 require an understanding of factors that influence time of response to antiretroviral therapy. We have studied a cohort of 118 HIV-1-infected subjects naive to antiretroviral therapy and have correlated the time of response to treatment with a series of virological and immunological measures, including levels of viral load in blood and lymph node, percent of CD4 T cells in lymph nodes, and CD4 T-cell count in blood at study entry. Suppression of viremia below the limit of detection, 50 HIV-1 RNA copies/mL of plasma, served as a benchmark for a successful virological response. We employed these correlations to predict the length of treatment required to attain a virological response in each patient. Baseline plasma viremia emerged as the factor most tightly correlated with the duration of treatment required, allowing us to estimate the required time as a function of this one measure.

A case of Muir-Torre syndrome associated with mucinous hepatic cholangiocarcinoma and a novel germline mutation of the MSH2 gene.

Muir-Torre syndrome (MTS) is a rare cancer-predisposing syndrome that is autosomal dominantly inherited and characterized by the development of sebaceous skin lesions (adenomas, epitheliomas, basaliomas and carcinomas). These lesions are typically associated with tumors that belong to the spectrum of hereditary nonpolyposis colorectal cancer (HNPCC) (i.e., tumors of the colorectum, endometrium, stomach or ovary). Biliary malignancy in association with MTS has only rarely been reported. We report a case of Muir-Torre syndrome associated with intrahepatic cholangiocarcinoma, a location not previously described, and associated with a novel missense mutation of the MSH2 gene (c.2026T > C), predicted to disrupt the function of the gene.

Ischemic stroke and ST-elevation myocardial infarction revealing infective endocarditis.

In this clinical scenario, we report the case of a patient who presented multiple embolic complications due to mitral infective endocarditis (IE). A 68-year-old woman had extended right hepatectomy for hilar cholangiocarcinoma. Unfortunately, she had multiple postoperative complications and had to be transferred to the Intensive Care Unit. During this stay, we have diagnosed an Enterococcus faecium IE after the occurrence of multiple embolic complications (myocardial infarction, ischemic stroke, digital emboli, splenic emboli, and renal emboli). The case is presented hereunder with illustrative imagings. While embolism is a known complication of IE, the presence of multiple emboli in various organs is rare.

[Rupture of hepatic focal nodular hyperplasia. About two cases]. / Rupture d'une hyperplasie nodulaire focale. A propos de deux cas.

The diagnostics of focal nodular hyperplasia is reached through the use of imaging. When the diagnostic is certain, surgical abstention is the rule. Nevertheless, we were confronted with two cases of a rare complication; that of intraperitoneal rupture. In this situation, we suggest to first do an arteriography to control the bleeding, then to perform surgery when the patient has reached hemodynamic stability. Spontaneous rupture as a complication of benign nodular hyperplasia remains a rare event and only five cases were reported in litterature.

[Complications of liver cirrhosis: oesophageal varices, ascites and hepato-cellular carcinoma]. / Les complications de la cirrhose hépatique: varices oesophagiennes, ascite et carcinome hépato-cellulaire.

The principal treatment for bleeding oesophageal varices is endoscopic ligation. Non-cardioselective beta-blockers are the gold-standard of primary prophylaxis. The principal treatment for ascites is a salt-free diet and diuretics, mainly spironolactone, if necessary associated with a loop diuretic. In refractory ascites, paracentesis or installation of a transjugular intrahepatic portosystemic shunt (TIPS) are two possible treatment options. Cirrhosis patients are at higher risk of developing hepato-cellular carcinoma. Surgery is only possible in a small number of cases. Percutaneous destruction techniques have nearly the same survival rate as that obtained by surgery and should be proposed to patients where surgery is not an option.

Immunological and virological responses in HIV-1-infected adults at early stage of established infection treated with highly active antiretroviral therapy.

OBJECTIVE: To evaluate the immunological and virological responses to highly active antiretroviral therapy (HAART) in blood and lymphoid compartments of HIV-1-infected patients at an early stage of infection. DESIGN: An open-label, observational, non-randomized, prospective trial of outpatients attending the Centre of Clinical Investigation in Infectious Diseases, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Switzerland. SUBJECTS: Forty-one antiretroviral-naive HIV-1-infected adults with 400 CD4 T cells/microl or greater and 5000 plasma HIV-1-RNA copies/ml or greater were enrolled, and 32 finished the study. Forty-nine HIV-negative individuals were included as controls. All subjects gave written informed consent. INTERVENTIONS: All patients received abacavir 300 mg by mouth every 12 h and amprenavir 1200 mg by mouth every 12 h for 72 weeks. MAIN OUTCOME MEASURES: The extent of immune reconstitution in blood and lymph nodes after 72 weeks of HAART was evaluated, and compared with immunological measures of 49 HIV-negative subjects. RESULTS: Virus replication was effectively suppressed (-3.5 log10 at week 72). Substantial increments of CD4 T cell count in blood and percentage in lymph nodes were observed over time, and these measures were comparable to HIV-negative subjects by week 24 in blood and by week 48 in lymph nodes. The increase was equally distributed between naive and memory CD4 T cells. Recovery of HIV-specific CD4 responses occurred in 40% of patients. CONCLUSION: The initiation of HAART at an early stage of established HIV infection induces systemic quantitative normalization of CD4 T cells, a partial recovery of HIV-specific CD4 cell responses, and effective and durable suppression of virus replication.

Impaired insulin response after oral but not intravenous glucose in heart- and liver-transplant recipients.

BACKGROUND: The prevalence of diabetes is high after transplantation. We hypothesized that liver transplantation induces additional alterations of glucose homeostasis because of liver denervation. METHODS: Nondiabetic patients with a heart (n=9) or liver (n=9) transplant and healthy subjects (n=8) were assessed using a two-step hyperglycemic clamp (7.5 and 10 mmol/L). Thereafter, an oral glucose load (0.65 g/kg fat free mass) was administered while glucose was clamped at 10 mmol/L. Glucose appearance from the gut was calculated as the difference between glucose appearance (6,6 2H2 glucose) and exogenous glucose infusion. Plasma insulin, glucagon-like peptide (GLP)-1 and gastric inhibitory polypeptide(GIP) concentrations were compared after intravenous and oral glucose. RESULTS: After oral glucose, the glucose appearance from the gut was increased 52% and 81% in liver- and heart-transplant recipients (P<0.05). First-pass splanchnic glucose uptake was reduced by 39% in liver-transplant and 64% in heart-transplant patients (P<0.05). After oral but not intravenous glucose, there was an impairment of insulin secretion in both transplant groups relative to the controls. Plasma concentrations of GIP and GLP-1 increased similarly in all three groups after oral glucose. CONCLUSIONS: First-pass hepatic glucose extraction is decreased after heart and liver transplant. Insulin secretion elicited by oral, but not intravenous glucose, is significantly reduced in both groups of patients. There was no difference between liver- and heart-transplant recipients, indicating that hepatic denervation was not involved. These data suggest an impairment in the beta-cell response to neural factors or incretin hormones secondary to immunosuppressive treatment.

Video-assisted thoracic surgery diagnosis of thoracic spinal tuberculosis.

Tuberculous spondylitis is rare in economically well-developed countries. MRI is the most sensitive radiologic method of diagnosis. CT-guided fine needle aspiration can be an appropriate method for obtaining samples for culture, with positive cultures in 25 to 89% of cases. However, it can take >6 weeks for specimens to grow, and it is essential to have adequate culture and sensitivity studies for the diagnosis and treatment of mycobacterial diseases. We propose a minimally invasive diagnostic approach that ensures that adequate surgical specimens are obtained prior to initiating treatment.

Penetrating thoracic trauma in arrow injuries.

Arrow wounds are very rare. We present herein a case of hilar penetrating thoracic trauma caused by an arrow, and a review of the literature, to clarify the management of these cases and their indications for surgery. Depending on the type of arrowhead, the tissue elasticity can narrow the wound track around the shaft of the arrow, sometimes causing a tamponade effect. In the mediastinal or hilar area, an arrow should not be removed before an injury to the major blood vessels or the heart has been ruled out.

Ruptured subcapsular hematoma after laparoscopic cholecystectomy attributed to ketorolac-induced coagulopathy.

Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. However, gastrointestinal bleeding is a risk associated with its perioperative administration. A 23-year-old woman was admitted for elective laparoscopic cholecystectomy. Her medical history was unremarkable except for a complaint of intermittent right upper quadrant pain for several months. The operative procedure was uneventful. Thirty milligrams of ketorolac were given intravenously just prior to termination of surgery. Eighteen hours after surgery, the patient developed right upper quadrant pain associated with tachycardia and hypotension. Abdominal computed tomography (CT) scan demonstrated a large subcapsular hematoma of the liver. A few hours later, the hemodynamic condition worsened, and the patient was taken to the operating room. Laparoscopic exploration showed a ruptured subcapsular hematoma with active bleeding. No evidence of parenchymal injury of the gallbladder bed was found. The hematoma was evacuated and hemostasis was performed laparoscopically. Ketorolac has a strong antiplatelet activity and further acts by the inhibition of platelet function, which may last as long as 24 h after the last administration. Surgeons and anesthesiologists should be aware that ketorolac may cause or aggravate bleeding.