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International audience; BACKGROUND: Exposure of the surgical team to toxic drugs during hyperthermic intraperitoneal chemotherapy (HIPEC) remains a matter of great concern. During closed-abdomen HIPEC, operating room staff are not exposed to drugs, but the distribution of the heated liquid within the abdomen is not optimal. With open-abdomen HIPEC, the opposite is true. Although the open-abdomen method is potentially more effective, it has not become a standard procedure because of the risk of exposure of members of the team to drugs. METHODS: We present a new technique (closed HIPEC with open abdomen) which ensures protection against potentially contaminating exposure to liquids, vapours and aerosols, and allows permanent access to the whole abdominal cavity. Its principle is to extend the abdominal surgical wound upwards with a sort of "glove-box". The cutaneous edges of the laparotomy are stapled to a latex "wall expander". The expander is draped over a special L-section metal frame placed above the abdomen. A transparent cover containing a "hand-access" port, like those used in laparoscopic surgery, is fixed inside the frame. RESULTS: In 10 patients, this device proved to be hermetic for both liquids and vapours. Intra-abdominal temperature was maintained between 42 and 43 degrees C during most of the procedure. The whole abdominal cavity was accessible to the surgeon, allowing optimal exposure of all peritoneal surfaces. CONCLUSION: This technique allows optimal HIPEC, while limiting the potential toxic effects for the surgical, medical and paramedical teams.

Resume But de l’etude etudier les lesions biliaires iatrogenes en cours de cholecystectomie : les facteurs de risque et les resultats de la reparation, pour en deduire une conduite a tenir. Patients et methode revision de la serie de patients adresses dans notre service dans une periode de 9 ans pour lesion de la voie biliaire au cours d’une cholecystectomie : type de lesion, circonstances, reparation et evolution. Resultats entre 1997 et 2005, 18 patients ont ete pris en charge pour lesion biliaire au cours de cholecystectomie (14 par cœlioscopie et 4 par laparotomie ; 9 femmes et 9 hommes). L’indication operatoire la plus frequente etait des coliques hepatiques (n = 8). Trois patients ont ete operes en urgence. Chez 9 patients il existait une paroi vesiculaire inflammatoire. Une cholangiographie peroperatoire a ete realisee chez 9 patients, ne permettant la decouverte de la lesion biliaire que dans un cas. La plaie laterale de la voie biliaire a ete le type de lesion le plus frequent. Dans 9 cas la lesion a ete decouverte en peroperatoire : un drainage biliaire a ete mis en place, associe a une reparation primaire chez 5 patients ; trois patients ont necessite ulterieurement une chirurgie biliaire. Chez 9 malades la decouverte de la lesion a ete tardive, et 6 ont necessite une derivation bilio-digestive. Deux patients sont decedes, 3 ont presente des episodes d’angiocholite pendant le suivi et 2 ont necessite une cure d’eventration. Conclusion l’inflammation est le principal facteur de risque de lesion de la voie biliaire. La realisation d’une cholangiographie peroperatoire ne met pas a l’abri d’une lesion meconnue de la voie biliaire. Le drainage biliaire pour les lesions detectees en cours d’intervention diminue la morbidite associee et serait un bon choix pour le chirurgien sans experience hepatobiliaire. La morbidite est plus elevee chez les patients avec decouverte tardive de la lesion biliaire.

Few population-based studies investigate obstructing colorectal cancers. This study was designed to describe trends in their frequency and management. Data were obtained for 13,331 colorectal cancers registered by the population-based cancer registry of Burgundy, France, between the years 1976 and 2000. Obstructing cancers represented 8.3 percent of all colorectal cancers. This proportion was stable throughout the study. Resection for cure increased from 54.9 percent (1976–1980) to 71.4 percent (1996–2000; P = 0.011). Using multivariate analysis, site of cancer and period of diagnosis were the only factors significantly associated to a curative resection. Postoperative mortality for obstructing colorectal cancers decreased from 32.6 percent (1976–80) to 15.2 percent (1996–2000; P

Desmoid tumors may occur sporadically or as part of the extraintestinal manifestations of familial adenomatous polyposis. Different phenotypes have been described and some genotype-phenotype correlations have been raised, associated with different sites of germline mutations in the adenomatous polyposis coli (APC) gene. We report on a 42-year-old woman ascertained for a large desmoid tumor of the anterior chest wall with pleural involvement, which persistently recurred despite a decade of treatment including hormone therapy, chemotherapy, and surgery. Spontaneous disappearance of the tumor was later noted after 1 year without any treatment and confirmed after 4 years of regular follow-up. Repeated colonoscopies were normal in the proband and DNA sequencing showed a frameshift mutation due to a single adenosine deletion at position 5772 (codon 1924). This mutation, located in the exon 15 at the 3' end of the APC gene, leads to an unusual and late onset phenotype. The pedigree revealed other isolated or familial adenomatous polyposis-associated cases of desmoid tumors. This family report shows that a molecular analysis of the APC gene should be performed in familial desmoid tumors for accurate genetic counseling and follow-up.

To investigate the role of increased intra-abdominal pressure (IAP) on the intratumoral accumulation and the antitumor effect of intraperitoneal cisplatin in rats with advanced peritoneal carcinomatosis. To evaluate the tolerance of IAP in pigs, as it is a large animal with a body size equivalent to humans.To investigate if an active convection, driven by a positive IAP, increases cisplatin penetration and antitumor effectiveness in a model of advanced peritoneal carcinomatosis in rats.BDIX rats with macroscopic peritoneal tumors received cisplatin administered as intravenous injection (IV), conventional intraperitoneal injection (IP), or sustained intraperitoneal injection of cisplatin given in a large volume of solvent for maintaining IAP for 1 hour. Platinum tissue concentration was measured by atomic absorption spectroscopy (AAS), and platinum distribution into the tumor nodules was assessed by the particular-induced x-ray emission (PIXE) method. The antitumor effect was assessed in a survival experiment. The hemodynamic, local, and systemic tolerance of IAP, with or without cisplatin, was evaluated in Large White pigs.The maximum tolerated IAP was 22 mm Hg for 1 hour in nonventilated rats. IAP, in comparison with IV or conventional IP injections, resulted in the increased concentration and depth of diffusion of platinum into diaphragm and peritoneal tumor nodules. Consequently, IAP treatment induced an extended survival of rats treated at an advanced stage of carcinomatosis. In 7 50- to 70-kg ventilated pigs, a 40-mm Hg IAP was well tolerated when maintained stable for 2 hours. Renal failure occurred in pigs receiving a total dose of 200 and 400 mg of cisplatin with IAP, but a dose of 100 mg was well tolerated.Intraperitoneal chemotherapy with increased IAP, in comparison with conventional IP or IV chemotherapy, improved the tumor accumulation and the antitumor effect of cisplatin in rats bearing advanced peritoneal carcinomatosis. In preclinical conditions, the tolerance of sustained IAP was manageable in ventilated pigs.

International audience; The analysis of self-excited combustion instabilies encountered in a laboratory-scale, swirl-stabilized combustion system is presented. The instability is successfully captured by reactive large-eddy simulation (LES) and analyzed by using a global acoustic energy equation. This energy equation shows how the source term due to combustion (equivalent to the Rayleigh criterion) is balanced by the acoustic fluxes at the boundaries when reaching the limit cycle. Additionally, an Helmholtz-equation solver including flame-acoustics interaction modeling is used to predict the stability characteristics of the system. Feeding the flame-transfer function from the LES into this solver allows to predict an amplification rate for each mode. The unstable mode encountered in the LES compares well with the mode of the highest amplification factor in the Helmholtz-equation solver, in terms of mode shape as well as in frequency.

Pedicled omentoplasty has been advocated to prevent the formation of lymphocysts and lymphedema after pelvic lymph node dissection, We evaluated the possible benefit of a pediculated omentoplasty placed in the groin for preventing complications after ilioinguinal lymph node dissection.In this pilot study, we report a series of four women and three men with inguinal metastatic lymph nodes. Each was treated with a pediculated omentoplasty after groin dissection. We examined complications such as lymphedema, lymphorrhea, wound breakdown, skin necrosis, and lymphocysts.Only one wound breakdown with skin necrosis was observed, and it healed satisfactorily in 10 days without exposing the femoral vessels. No lymphocele or infectious complications occurred, even though no antibiotic prophylaxis was used. Midthigh circumference increase ranged from 1.5 to 7 cm in four cases but remained asymptomatic. Furthermore, lymphedema of the lower limb decreased in the three remaining patients, who previously had an enlargement of the thigh. No evidence of peritoneal carcinomatosis was noted during the 4-month follow-up.Pedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluids and resulted in less lymphedema in the lower limb even after radiotherapy. Pedicled omentoplasty reduces both short-term and long-term postoperative complications without affecting treatment outcome and could even be considered as a safe and effective therapy for lymphedema of the lower extremity.

Background . Pulmonary resection belongs to a group of surgical procedures with significant morbidity and mortality. The aims of this study were to classify postoperative complications and to identify prognostic factors determining risk group. Methods . In a prospective study 500 patients undergoing lung resection (wedge resection, n=141; lobectomies, n=245; bilobectomies, n=12; and pneumonectomies, n=102) were included. In 178 patients (36%) pulmonary resections were extended to structures or thoracic organs. Sleeve resection of the bronchus to preserve lung parenchyma was performed in 22 patients. Results . Classification of postoperative complications fell into four categories: patients without postoperative complications; patients with moderate complications (n = 137); patients with severe complications (n = 38); and death (n = 33). Factors adversely affecting postoperative complications by multivariate analysis included pulmonary pathology, bronchoplastic technique, forced expiratory volume in 1 second (FEV 1 ), extended resection, type of lung resection, comorbidity indices, and preoperative chemotherapy. Four risk groups were determined. Risk group I (n = 60) with the best prognosis included patients with FEV 1 greater than or equal to 80% undergoing wedge resection for a benign lesion or metastasis. Risk group II (n = 161) included patients with FEV 1 greater than or equal to 80% undergoing major pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV 1 less than 80% undergoing wedge resection for benign lesion or metastasis. Risk group III (n = 233) with a fair prognosis included patients with comorbidity indices less than 4 and FEV 1 greater than or equal to 80% undergoing extended pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV 1 less than 80% and emphysema. Risk group IV (n = 46) with the worst prognosis included patients with FEV 1 less than 80% undergoing an extended lung resection or bronchoplastic procedures for a benign lesion or metastasis or lung cancer, or patients with comorbidity indices greater than or equal to 4 undergoing extended lung resection for lung cancer. Conclusions . In a prospective study, based on these prognostic factors, a practical, easy-to-use risk group system of lung resection is proposed as a tool to aid the decision to perform lung resection.

International audience; BACKGROUND: Intraperitoneal (i.p.) epinephrine was shown to increase the accumulation of i.p. cisplatin in tumours, and thus its antitumour effect in a model of peritoneal carcinomatosis in rats. METHODS: To determine the tolerance to i.p. epinephrine with cisplatin, 18 patients with recurrent ovarian carcinoma were intraoperatively treated in this phase 1 study. After maximal cytoreductive surgery, the peritoneal cavity was filled twice for 1 h with 30 mg/l of cisplatin and increasing concentrations of epinephrine (0, 1, 2, 3 mg/l) in 3 l of saline solution at 37 degrees C. RESULTS: No deaths occurred. Three patients were treated at each of the 0, 1 and 2 mg/l epinephrine levels without adverse events. Two of the three patients who received 3 mg/l epinephrine experienced cardiac intolerance. Six additional patients received 2 mg/l of epinephrine without toxicity. A relationship between the serum concentration of epinephrine and occurrence of cardiac toxicity was established. A 60% decrease in serum area under the curve of platinum was calculated in patients receiving i.p. epinephrine compared with i.p. cisplatin alone. Renal toxicity from cisplatin was not increased by epinephrine. No haematological or neurological toxicity was recorded. The other grade 3-4 adverse events [thromboembolism (5), peritonitis (1), abdominal bleeding (1), bowel fistula (1)] occurred as often as usually reported for this heavy surgical procedure. CONCLUSION: The combination of i.p. epinephrine with cisplatin as intraoperative chemotherapy after optimal cytoreductive surgery is feasible. The recommended concentration for further studies is 2 mg/l for i.p. epinephrine.

BACKGROUND: The trunk of a car occupant can be injured by a frontal or lateral impact. Lesions can be either intrusion injuries or due to the effects of deceleration alone. The aim of this study conducted with human cadavers was to explore the effects of deceleration on the liver during frontal or lateral deceleration. METHODS: Trunks previously instrumented with accelerometers in three sites, the left and right lobes of the liver and the retrohepatic inferior vena cava, were subjected to substantial deceleration in three orientations: frontal, left, and right lateral. The anatomic consequences and deceleration data were measured. A deceleration ratio was defined as a peak deceleration measured in the liver divided by peak deceleration imposed on the trunk. RESULTS: Peak deceleration imposed on the trunks was up to 60 g, which caused peak deceleration up to 26 g in the liver. No anatomic injury was observed. For each orientation, deceleration ratios were not significantly different among the three sites (p = 0.64) or between left and right lateral decelerations (p = 0.12). Deceleration ratios were significantly different (p = 0.001) between frontal (3 sites combined) and lateral (3 sites of left and right lateral orientations combined) decelerations: 39.4% (+/-6) versus 48.4% (+/-11). CONCLUSIONS: In conclusion, at tested decelerations, under the hepatic injury threshold, cadaveric liver seemed to be subjected to higher deceleration when the trunk was decelerated in lateral than in frontal direction, without terminal impact. Language: en

The aim of this study is to classify patients into risk groups for mediastinal lymph node metastases. Three hundred and thirty-seven patients underwent lung resection for lung cancer. The nodal status was pN0 in 181 patients, pN1 in 62 and pN2 in 94. The presence of the involvement of one mediastinal compartment (superior or inferior) or two mediastinal compartments (superior and inferior) was considered to be the main end point. One mediastinal compartment was involved in 65 patients and two mediastinal compartments in 29 patients. Two variables (visceral pleural invasion and the primary tumor location) were retained in the model. The regression tree analysis categorized patients into 3 risk groups for the involvement of two mediastinal compartments. The low-risk group included 118 patients with a tumor located in the left side and no visceral pleural invasion. The intermediate-risk group included 160 patients with a tumor located in the right side and no visceral pleural invasion. The high-risk group included 59 patients with visceral pleural invasion and a tumor located in the right side or left lower lobe. A practical, easy-to-use risk grouping system is proposed to aid the decision making and to simplify mediastinal lymphadenectomy procedure.

International audience; A new methodology to assess the effect of the flame/acoustics coupling on the stability of the modes without combustion is presented. An asymptotic method is used to account for the acoustic flame transfer function. The efficiency and accuracy of the approach is demonstrated on an academic case similar to a Rijke tube configuration.