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Resume Jusqu’en 2013, la formation pratique des internes inscrits au DES/DESC de chirurgie viscerale et digestive en France n’etait pas standardisee. Depuis 2017, le troisieme cycle des etudes medicales a ete restructure autour de deux axes : connaissances theoriques et competences techniques et non-techniques. Celui-ci comporte notamment un programme de formation pratique par simulation, hors bloc operatoire, national, structure, uniformise et standardise. Le developpement de ce programme de formation est le fruit d’un travail de consensus national sous l’egide du college francais de chirurgie viscerale et digestive permettant d’offrir un guide de formation a tous les futurs chirurgiens de la specialite. Quatre seances de conference de consensus reunissant une commission de 8 membres ont abouti a la redaction du « Livret de l’Interne pour l’Enseignement Pratique en Chirurgie Viscerale et Digestive ». Ce referentiel detaille en 272 pages les objectifs (phase I), les moyens d’apprentissage de chaque competence (phase II) et enfin les methodes d’evaluation (phase III) pour les phases socles et des phases d’approfondissement du DES de chirurgie viscerale et digestive. En complement de ce livret, nous avons mene une reflexion sur la structuration et la mise en place de ce programme a l’echelle nationale a compter de novembre 2017 qui est detaille a la fin de cet article.

International audience; Background Diagnosis and treatment of colorectal peritoneal metastases at an early stage, before the onset of signs, could improve patient survival. We aimed to compare the survival benefit of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC), with surveillance, in patients at high risk of developing colorectal peritoneal metastases. Methods We did an open-label, randomised, phase 3 study in 23 hospitals in France. Eligible patients were aged 18-70 years and had a primary colorectal cancer with synchronous and localised colorectal peritoneal metastases removed during tumour resection, resected ovarian metastases, or a perforated tumour. Patients were randomly assigned (1:1) to surveillance or second-look surgery plus oxaliplatin-HIPEC (oxaliplatin 460 mg/m(2), or oxaliplatin 300 mg/m(2) plus irinotecan 200 mg/m(2), plus intravenous fluorouracil 400 mg/m(2)), or mitomycin-HIPEC (mitomycin 35 mg/m(2)) alone in case of neuropathy, after 6 months of adjuvant systemic chemotherapy with no signs of disease recurrence. Randomisation was done via a web-based system, with stratification by treatment centre, nodal status, and risk factors for colorectal peritoneal metastases. Second-look surgery consisted of a complete exploration of the abdominal cavity via xyphopubic incision, and resection of all peritoneal implants if resectable. Surveillance after resection of colorectal cancer was done according to the French Guidelines. The primary outcome was 3-year disease free survival, defined as the time from randomisation to peritoneal or distant disease recurrence, or death from any cause, whichever occurred first, analysed by intention to treat. Surgical complications were assessed in the second look surgery group only. This study was registered at ClinicalTrials.gov, NCT01226394. Findings Between June 11, 2010, and March 31, 2015, 150 patients were recruited and randomly assigned to a treatment group (75 per group). After a median follow-up of 50.8 months (IQR 47.0-54.8), 3-year disease-free survival was 53% (95% CI 41-64) in the surveillance group versus 44% (33-56) in the second-look surgery group (hazard ratio 0.97, 95% CI 0.61-1.56). No treatment-related deaths were reported. 29 (41%) of 71 patients in the second-look surgery group had grade 3-4 complications. The most common grade 3-4 complications were intra-abdominal adverse events (haemorrhage, digestive leakage) in 12 (23%) of 71 patients and haematological adverse events in 13 (18%) of 71 patients. Interpretation Systematic second-look surgery plus oxaliplatin-HIPEC did not improve disease-free survival compared with standard surveillance. Currently, essential surveillance of patients at high risk of developing colorectal peritoneal metastases appears to be adequate and effective in terms of survival outcomes. Copryright (C) 2020 Elsevier Ltd. All rights reserved.

Resume Introduction La simulation en tant que moyen d’enseignement pratique pour les internes en chirurgie doit etre evaluee de facon objective et doit permettre de mettre en valeur l’acquisition de performance de l’etudiant. Les objectifs de cet article sont la publication de nos grilles d’evaluation et leur validation, ainsi que la mesure de satisfaction des etudiants. Methode Une plateforme d’enseignement pratique sur modele porcin a ete creee en 2009 pour 7 centres hospitaliers universitaires francais. Trois fois par an, 31 internes du DESC de chirurgie viscerale effectuaient 5 exercices chronometres : placement des trocarts (trocarts), test de convergence des instruments (convergence), nœuds intracorporels (nœuds), derouler l’intestin grele pour trouver une lesion (deroule) et realiser un surjet de fermeture du peritoine (surjet). L’evaluation etait realisee de facon prospective par 2 experts sur des grilles (HuFEG) specialement concues et validees pour ces exercices. Le temps, les scores des echelles d’evaluation, l’interet et la satisfaction des internes ont ete analyses. Resultats Les donnees pour 31 internes entre mai 2011 et mars 2012 ont ete analysees. Les echelles d’evaluation etaient statistiquement valides et correlees (K > 0,69) pour chaque exercice. Les temps realises par les internes les plus experimentes etaient significativement plus court dans tous les exercices sauf le deroule du grele (p = 0,2). Apres 4 sessions, les temps etaient significativement ameliores avec une meilleure qualite (moins de fautes et scores moyens eleves [> 88 %]), independamment de l’experience de l’interne. Parmi les apprenants, 92 % etaient satisfaits, 86 % pensaient que ces sessions amelioraient leurs qualites techniques et 74 % pensaient que cela avait un impact favorable sur leur pratique clinique. Conclusion Cette etude montre que l’amelioration des techniques chirurgicales par simulation est plebiscitee par les internes et que nos grilles HuFEG sont valides.

International audience; Introduction Simulation as a method for practical teaching of surgical residents requires objective evaluation in order to measure the student's acquisition of knowledge and skills. The objectives of this article are to publish our evaluation and validation grids and also the measure of student satisfaction. Method A teaching platform based on practical exercises with a porcine model was created in 2009 at seven French University Hospitals. Three times a year, 31 Diplôme d’Études Spécialisées Complémentaires (DESC) surgical residents underwent timed assessment of the performance of five surgical tasks: trocar insertion (trocars) testing the convergence of instruments (convergence), intra-corporeal knot tying (knots), running of the small intestine to find a lesion (exploration), and performance of a running suture closure of the peritoneum (closure). Two experts evaluated performances prospectively on grid score sheets specifically designed and validated for these exercises. We measured time, scores on a rating scale, and the interest and satisfaction of the residents. Results Data for 31 residents between May 2011 and March 2012 were analyzed. Rating scales were statistically validated and correlated (Kappa correlation coefficient K > 0.69) for each task. The performance times of the most experienced residents decreased significantly for all tasks except for small bowel exploration (P = 0.2). After four sessions, times were significantly improved with better quality (fewer errors and higher average scores [> 88%]), regardless of the residents’ experience. Of the participants, 92% were satisfied, 86% thought that the sessions improved their technical skills and 74% thought it had a favorable impact on their clinical practice. Conclusion This study shows that the performance of surgical techniques can be improved through simulation, that HUFEG grids are valid, and that this teaching program is popular with surgical residents

PURPOSE: This study compares open Hartmann's procedure reversal (OHPR) and laparoscopic Hartmann's procedure reversal (LHPR) in patients first treated for peritonitis (Henchey III or IV). METHODS: Fourteen patients who underwent LHPR during a 2-year period were compared with 20 patients who had previously undergone an open procedure at the same institution. RESULTS: Conversion rate was 14.28%. Operating time was shorter for the laparoscopic group [143 (90 to 240) vs. 180 (90 to 350) min, P

Background It was demonstrated that postischemic kidney expresses different factors in a pattern that recapitulates expression of these factors in the developing kidney. We investigated whether peripheral-type benzodiazepine receptor (PBR), which belongs to the mitochondrial permeability transition pore and is essential during development, could be influenced by the ischemia-reperfusion injury process when compared with leukemia inhibitor factor (LIF). Study design PBR, LIF, and LIF receptor messengers and proteins were analyzed in adult normal and ischemic kidney under conditions mimicking cardiac arrest: 18 pigs were studied after 60 minutes of warm ischemia and reperfusion for 7 days and compared with sham-operated (Sham, n=12) and control (CONT, n=12) groups. The same messengers and proteins were assessed in fetal kidneys. Results In normal kidney, PBR was expressed in descending and ascending limbs of Henle and in distal tubules. After ischemia-reperfusion injury, PBR mRNA significantly increased between days 1 and 7 in cortex and outer medulla. PBR protein increased between days 1 and 7, and was transiently expressed in proximal tubules at days 1 and 3 and returned to basal level at day 7. LIF messenger and protein increased rapidly at day 1 in proximal tubules. In turn, LIF receptor messenger and protein were not changed during reperfusion. Conclusions These results suggest that PBR may be implicated in ischemia-reperfusion injury and, particularly, in the regenerative process within proximal tubules with LIF. These new insights open the possibility of novel targets for organ protection and repair.

Background Proton nuclear magnetic resonance spectroscopy can be used to measure organic molecules in biological fluids. In this study, proton nuclear magnetic resonance spectroscopy of bronchoalveolar lavage was assessed to detect cellular damage in lung transplants. Also we evaluated a polyethylene glycol solution in lung preservation. Methods An isolated perfused and working pig lung was used to assess initial pulmonary function after in situ cold flush and cold storage for 6 hours in three preservation solutions: (1) Euro-Collins solution, (2) University of Wisconsin solution, and (3) low potassium solution with polyethylene glycol (PEG). Pulmonary vascular resistance and partial pressure of arterial oxygen were measured during reperfusion. Bronchoalveolar lavage was studied by proton nuclear magnetic resonance spectroscopy and a histologic study of the lungs was done at the harvest after ischemia and after reperfusion. Results Partial pressure of arterial oxygen and pulmonary vascular resistance were significantly better in PEG compared with Euro-Collins solution ( p = 0.011). Interstitial edema was significantly higher in Euro-Collins solution (2.4 ± 0.24; p = 0.02) and University of Wisconsin solution (2.7 ± 0.20; p = 0.0003) than PEG (2 ± 0.16). Mitochondria scale was better in PEG (8.1 ± 0.46) than in Euro-Collins solution (6.2 ± 0.37; p = 0.0001) or University of Wisconsin solution (5.6 ± 1.36; p = 0.0046). In bronchoalveolar lavage proton nuclear magnetic resonance spectroscopy spectra, lactate, pyruvate, citrate, and acetate were only detected after reperfusion, with a significantly reduced production of acetate in PEG. Pyruvate was reduced at the limit of significance in PEG versus University of Wisconsin solution. Conclusions Proton nuclear magnetic resonance spectroscopy seems to be a simple and suitable method for assessment of early injury to the lung transplant. In this experimental study, PEG preserved the lung better than University of Wisconsin solution and Euro-Collins solution in both the proton nuclear magnetic resonance spectroscopy study as well as the physiologic study.

The authors describe a technique of totally preperitoneal videoscopic inguinal hernia repair. This method allows, by cleavages, to obtain a preperitoneal space where can be individualised anatomical structures of the inguinofemoral area: pubis, pectineal ligament of Cooper, epigastric vessels. After squelettisation of the elements of the cord by release of the hernial bag, installation of a not fixed prosthesis largely covers the hernial rings.

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PDD) significantly contributing to post-operative morbidity. Clinical risk factors for DGE occurrence after PDD remain controversial. From January 2004 to December 2011, a total of 132 patients underwent PDD for either malignancies (73.5 %) or benign diseases (26.5 %) in one single universitary center. Post-operative mortality and morbidity were, respectively, 3 and 44.7 %. DGE has been defined in accordance with the International Study Group of Pancreatic Surgery (ISGPS) classification. DGE was distinguished in primary or secondary. Factors associated with grades B and C of DGE, based on severity and clinical impact, were assessed by means of univariate and multivariate analysis. Thirty-eight patients (28.8 %) had clinical DGE grade B or C. Post-operative complications (pancreatic fistula and/or hemorrhage or anastomotic leak) were reported in 25 out of the 38 patients (65.8 %, secondary DGE), while in 13 patients it was not associated to any other complication (34.2 %, primary DGE). Post-operative complications (pancreatic fistula and hemorrhage) appeared to be the most important predictive factor for Grade B or C DGE.

Background. Ischemia-reperfusion injury (IRI) is often responsible for graft rejection and leads to delayed graft function of cadaveric kidneys. We have shown that adding polyethylene glycol (PEG 20M) to the preservation solutions helps protect isolated perfused pig kidneys against cold ischemia and reperfusion injury. Methods. We compared the effects of adding PEG to a simplified high-K 1 perfusion solution of cold-stored kidneys to Euro-Collins or University of Wisconsin solutions on the function of reperfused autotransplanted pig kidneys. The left kidney was cold-flushed with the preservation solutions and stored for 48 hr at 4°C before reimplantation. Creatinine clearance and fractional excretion of sodium were analyzed 2 days before surgery and over 7 days after transplantation. Histological sections were obtained 40 min after reperfusion and on day 7 after surgery. Results. Adding PEG to the perfusate significantly reduced IRI from autotransplanted pig kidneys. Creatinine clearance was significantly higher and fractional excretion of sodium was significantly lower in pigs transplanted with kidneys cold-flushed with PEG-supplemented perfusate than in those flushed with Euro-Collins or University of Wisconsin solutions. PEG supplementation also better preserved the integrity of kidney cells and markedly reduced interstitial cell infiltrates. Conclusion. PEG protects against IRI and reduces early cellular inflammation. PEG may impair the recruitment and migration of leukocytes into retransplanted pig kidneys. Cold preservation of donor organs with PEG-supplemented solutions may therefore help limit IRI in human renal transplantation. Delayed graft function (DGF) is a major problem affecting kidney allografts after transplantation. DGF occurs in 30 ‐ 50% of patients given a first cadaver graft and can be exac

Background. Delayed graft function (DGF) has remained an important complication after renal transplantation. The exact causes of DGF remain to be clarified, particularly the impact of retrieval conditions and preservation factors. In the present investigation, 1HNMR spectroscopy of urine was assessed in order to detect the influence of retrieval condition on renal medulla damage. Methods. The isolated perfused pig kidney (IPK) was used to assess initial renal function from multiorgan donors (MOD) or single organ donors (SOD) after in situ cold flush and 24-h cold storage (CS) preservation with two standard preservation solutions: Euro-Collins (EC) and University of Wisconsin (UW) solutions. Kidneys flushed with cold heparinized saline and immediately perfused were used as the control group. Kidneys were perfused for 90 min at 37.5°C for functional evaluation. During reperfusion, renal perfusion flow rate (PF) was measured. Glomerular filtration rate (GFR), tubular reabsorption of Na+, and lactate dehydrogenase (LDH) and N-acetyl-β- d -glucosaminidase (NAG) excretions were determined. Ischemia–reperfusion impairment was also determined by histological techniques and 1HNMR spectroscopy. Results. PF, GFR, and tubular reabsorption of Na+ were significantly decreased in experimental groups when compared to the control group but there was no significant difference between experimental SOD groups. GFR was significantly greater in UW-MOD than in EC-MOD and tubular reabsorption of Na+ was significantly greater in UW-MOD than in EC-MOD after 45 min of reperfusion. The release of LDH in the effluent and the urinary excretion of NAG were not significantly different after 24-h CS in the various experimental groups. The most relevant resonances determined by 1HNMR spectroscopy were citrate, trimethylamine-N-oxide, lactate, acetate, and amino acids. Excretion of these markers was significantly different when compared to biochemical markers. A resonance (P) detected particularly in EC-MOD after 24-h CS was identified and well correlated to renal dysfunction. Histological study showed that ultrastructural damage and mitochondrial injury were more pronounced in the EC-MOD group. Conclusion. These results show that retrieval condition influences renal medullary damage. NMR spectroscopy, which is a noninvasive and nondestructive technique, is more efficient in assessing renal damage than conventional histology and biochemical analysis.

Background: Endoscopic insertion of biliary stents is a useful treatment for obstructive jaundice resulting from unresectable tumors of the pancreas and biliary tree. The main drawback is the recurrence of jaundice due to clogging. The aim of this study was to establish an experimental model of polyethylene stent clogging in large white pigs. Methods: A straight polyethylene stent of 5F (group I), 7F (group II) or 10F size (group III) was inserted in the common bile duct. Animals were killed at 2 months, or earlier if physical signs suggesting stent clogging occurred. Chemicophysical analysis of stent deposition combined stereomicroscopy and identification of the contents by means of Fourrier transform infrared spectroscopy. Bacteriologic analyses included identification of aerobic and anaerobic bacteria and measurement of β-glucuronidase, lecithinase and lipase activities. Results: Physical signs suggesting stent obstruction or death occurred in 8 of 8 animals in group I, 11 of 12 in group II, and 2 of 8 in group III ( p Clostridium species were associated with the highest enzyme activities. Conclusions: In this model the major component of early stent deposits was mucoprotein, and numerous aerobic and anaerobic bacteria were isolated. Formation of calcium bilirubinate was a late phenomenon and poorly related to bacterial enzymatic activities. (Gastrointest Endosc 2000;51:12-8.)

Ischemia/reperfusion injury leads to delayed graft function, which is a major problem in kidney transplantation. This study investigated the effects of adding trimetazidine (TMZ) to the perfusate of cold-stored kidneys on the function of reperfused autotransplanted pig kidney. The left kidney was removed and cold-flushed with Euro-Collins (EC), or University of Wisconsin (UW) solutions with or without 10 -6 M TMZ and stored for 48 h at 4°C. The kidneys were then autotransplanted and the contralateral kidneys were removed. Several parameters were analyzed over the 14 d after transplantation. The survival rate was 57% in pigs transplanted with kidneys cold-flushed with UW and 43% for those flushed with EC solution; it was 100% for pigs having kidneys cold-flushed with TMZ-supplemented UW and EC solutions. The functions of the transplanted kidneys were also better preserved after cold flush with TMZ-supplemented solutions than with TMZ-free solutions. Creatinine clearance was higher and the urinary excretion of trimethylamine- N -oxide and dimethylamine, used as markers of renal medulla injury, were lower in animals transplanted with kidneys cold-flushed with TMZ-supplemented solutions than with TMZ-free solutions. The cytoprotective action of TMZ also reduced interstitial and peritubular inflammation and the numbers of infiltrating mononuclear CD45 + and CD3 + T cells. These results indicate that the tissue damage due to ischemia/reperfusion injury may be prevented, at least in part, by adding TMZ to preservation solutions.

Background. Initial ischemia-reperfusion injury is associated with organ retrieval, storage, and transplantation adversely affects early graft function and influences the development of chronic graft dysfunction. We have recently shown that the protective agent trimetazidine (TMZ) added to preservation solutions: Euro-collins (EC) and University of Wisconsin (UW) was efficient to protect kidneys from ischemia-reperfusion injury in an isolated perfused kidney model. We extended these observations to investigate the role of this drug in the development and progression of organ dysfunction in the autotransplant pig kidney model. Methods. Five experimental groups were studied. After 48-hr cold preservation, autotransplantation and immediate controlateral nephrectomy was then performed in group EC (EC+placebo (n=8), EC+TMZ (n=8), UW+placebo (n=7), and (UW+TMZ) (n=7) and compared with control group (uninephrectomized, n=4) during 14 days. Blood and urine samples were collected for the measurement of creatinine and blood urea nitrogen on postoperative days 1, 3, 5, 7, 11, and 14. Histological analysis was performed after reperfusion and at day 14. Results. Survivals were 100% in group B and D versus 42% in group A and 57% in group C. Urine production occurred earlier after autotransplantation from TMZ preserved kidneys than in placebo preserved groups. Peak creat and blood urea nitrogen was significantly greater in groups B and D than in groups A and C. TMZ was also efficient both to reduce ischemia-reperfusion injury and to decrease cellular infiltration. Conclusion. These results support the beneficial effect of TMZ against ischemia-reperfusion injury and its early effects on grafts in the form of delayed graft function and decreased graft survival. In addition, TMZ reduces inflammatory cellular infiltration in the renal parenchyma.

Background. Ischemia caused by cold storage (CS) and reperfusion of the kidney is often responsible for delayed graft function after transplantation. Significant attention has been focused on the cascade of events involved in ischemia-reperfusion injury, with the objective of identifying drugs to ameliorate the functional damage that occurs. Methods. The purpose of this study was to evaluate the renal function of isolated perfused pig kidneys after 48 hr of CS with Euro-Collins (EC) solution plus trimetazidine (EC+TMZ), standard EC solution, or University of Wisconsin (UW) solution. Normothermic isolated perfused pig kidneys were randomized into five experimental groups: (A) control group (cold flush with cold heparinized saline and immediately reperfused ; n=6); (B) cold flush with cold heparinized saline with TMZ (10 -6 M), n=6; (C) 48 hr of CS with EC and reperfusion (n=8); (D) 48 hr of CS with EC+TMZ alone and reperfusion (n=8); (E) 48 hr of CS with UW and reperfusion (n=8). Proton nuclear magnetic resonance spectroscopy and biochemical studies were performed for the functional evaluation during reperfusion. Lipid peroxidation was also determined. Histological examination (optical and electron microscopy) was performed after CS and reperfusion. Results. Using TMZ, the renal perfusate flow rate as well as the glomerular filtration rate and proximal tubular function were significantly improved. This improvement of renal function during reperfusion was correlated with a less significant cellular and interstitial edema. In addition, tubular injury markers were significantly lower in the group preserved with EC+TMZ, and TMZ reduced lipid peroxidation dramatically during reperfusion. Conclusions. The addition of TMZ to the EC solution increased the preservation quality and renal tubular function, and gave protection from reperfusion injury better than EC alone or UW. These results strongly suggest that TMZ has a cytoprotective effect and may therefore be useful for kidney preservation.

The isolated perfused pig kidney (IPK) model was used to mimic the non-heart-beating donor situation. This model was performed to assess initial renal functions after normothermic ischemia, cold flush, and 24 hr cold-storage preservation (CSP) with Euro-Collins and to determine normothermic ischemia and reperfusion impairment by biochemical, histological, and proton nuclear magnetic resonance (NMR) spectroscopy analysis. Twenty-four pig kidneys were used. There were three experimental groups: Group 1 (G1), control kidneys flushed with cold heparinized saline and immediately perfused; Group 2 (G2), cold flush followed by 24 hr CSP and reperfusion; and Group 3 (G3), 30 min of normothermic ischemia followed by cold flush and 24 hr CSP and reperfusion. Kidneys were perfused for 2 hr at 37.5 degrees C for functional evaluation. Perfusate flow rate is significantly different for G3 (P < 0.01). Glomerular filtration rate is less in G3 (P < 0.05). Fractional reabsorptions of sodium (FRNa+) and glucose (Glc) excretion in urine are different in G3 (P < 0.01 and P < 0.05, respectively). Amino acid excretion in NMR spectroscopy was higher in G3 (P < 0.05). Elevated levels of trimethylamine-N-oxide (TMAO) and lactate (Lac) were detected by proton NMR spectroscopy in G2 and particularly G3. A peak is present in G3 and related with poor glomerular and tubular functions and worse histological data. Malondialdehyde tissue level was higher in G3. This study shows that the IPK with proton NMR spectroscopy may be a useful method in the evaluation of kidneys after cold ischemia and transplantation. This model might be suitable for a variety of experimental protocols, particularly to improve functional performance after ischemia and reperfusion.

The aim of this review of the literature was to present and discuss the anatomical and embryological basis of congenital abnormalities of the gallbladder, based on a case of volvulus. In the rare cases of ectopic gallbladder, diagnosis of a biliary disease could be difficult. In such cases surgery can also be dangerous, especially when it is associated with abnormalities of the intra-hepatic biliary and vascular tree. This study, based on the embryology of the extra hepatic bile duct, focused on the most frequent gallbladder abnormalities to keep them in mind.

ALTHOUGH the success of the first cold storage solution was attributed to its intracellular composition with low sodium and high potassium,1,2 the importance of impermeant agents has been shown and the potential deleterious effects of high potassium solutions have been suggested.3–5

The pancreas is an uncommon site of metastasis from renal cell carcinoma, comprising 2% of pancreatic tumors removed in sizable series of operations. To our knowledge the role of operative resection in the setting of metastatic malignancy to the periampullary region has not yet been defined. We reviewed the records of 6 women and 2 men who underwent pancreatic resection due to malignancy and analyzed various prognostic factors.Between 1985 and 1995, 269 patients underwent pancreatic resection for malignancy at our hospitals, including 150 (56%) for pancreatic duct cancer, 65 (24%) for carcinoma of the ampulla, 27 (10%) for distal bile duct cancer, 19 (7%) for duodenal carcinoma and 8 (3%) for renal cell carcinoma metastasis. We reviewed the records of these latter 8 cases, and analyzed demographics, primary tumor type, disease-free interval, resection type, concomitant other organ resection, histological examination of the specimen, morbidity, adjuvant therapy and survival.Pancreatic metastasis of renal cell carcinoma was managed by duodenopancreatectomy in 5 patients and total pancreatectomy in 3. There were no perioperative deaths. Mean tumor size in cases of a solitary pancreatic metastasis was 4 cm. (range 1.5 to 8). In the 3 patients treated with total pancreatectomy there were 2, 5 and 3 pancreatic metastases, respectively. Pathological examination revealed negative lymph nodes in all cases. Mean survival was 48 months. At study end 6 patients were alive at 24, 26, 30, 46, 84 and 88 months, while 2 died at 13 and 70 months, respectively.We advocate aggressive surgical resection when possible. Surgical removal of metastatic lesions prolongs survival but radical lymph node dissection is not mandatory. We also recommend careful long-term followup of patients with a history of renal cell carcinoma.

Influence of cold-storage conditions on renal function of autotransplanted large pig kidneys. Background The consequences of ischemia/reperfusion injury (IRI) on delayed graft function (DGF) and graft survival for kidney recipients remain a matter of debate. Several strategies have been proposed to reduce IRI. We have shown that adding the anti-ischemic drug trimetazidine (TMZ) to different preservation solutions had beneficial effects on the function of reperfused rat and pig kidneys. Methods We analyzed the renal parameters of reperfused, autotransplanted large pigs following transplantation. The left kidneys were first removed and cold flushed with Euro-Collins (EC) and University of Wisconsin (UW) solutions (with or without 10 -6 mol/L TMZ) and were stored for 48 hours at 4°C. The kidney was then autotransplanted, and the contralateral kidneys were removed. Creatinine clearance, natriuresis, proteinuria, the degree of interstitial fibrosis, the number of CD4, CD8, and macrophage-positive cells, and the amount of vascular cell adhesion molecule-1 were analyzed on kidney biopsies taken at 2, 4 to 5, and 10 to 12 weeks after surgery. Results The functions of the transplanted kidneys were better preserved after cold flushing with TMZ-supplemented solutions than with TMZ-free solutions. Creatinine clearance was higher, and proteinuria was lower in animals transplanted with kidneys cold flushed with TMZ-supplemented solutions than with TMZ-free solutions. The cytoprotective action of TMZ also reduced interstitial fibrosis and the numbers of infiltrating CD4- and CD8-positive cells. Conclusion These results indicate that the condition of cold preservation may influence long-term kidney graft functions and suggest that, to a certain extent, TMZ reduces the degree of interstitial fibrosis.

ISCHEMIA-reperfusion injury after organ transplantation is a major cause of delayed graft function. The pathogenesis of ischemia-reperfusion injury are well correlated with alterations in mitochondrial function, namely, decrease in ATP synthesis, NAD(P)H level, and mitochondrial membrane potential and generation of mitochondrial permeability transition. A previous study has demonstrated that the pretreatment with trimetazidine (TMZ) prevented these ischemia-reperfusion deleterious effects at both the cellular and mitochondrial level. The aim of this study was to assess the effect of TMZ added to University of Wisconsin Solution (UW) during cold preservation in an isolated perfused pig kidney model against lipid peroxidation and renal medulla damage. After cold preservation (CP), kidneys were perfused as previously described.

The laboratory piglet is currently the preferred animal for experimental digestive surgery. In order to ensure optimal perioperative analgesic control with motor blockade during surgery together with rapid postoperative recovery, epidural anesthesia techniques were developed in this animal. We report the anatomo-radiologic studies (10 animals) and clinical experiments (51 transplantations of the liver and the small intestine) which led to the refinement of this anesthesia. In laboratory piglets, epidural anesthesia by distal transsacral (S4-S5) or sacrococcygeal approach is possible in a reproducible manner. The localization of the injection site is simple and epidural space catheterisation is easy without risk for the dural sac which ends at S1-S2.

We report, in an adult, an asymptomatic association between cystic dilatation of the bile duct (type IV A in Todani’s classification) and anomalous pancreatico-biliary ductal union (APBD) with stones in a long common channel. In APBD, the connection between the common bile duct and the main pancreatic duct is located outside the duodenal wall and is therefore not under the influence of the sphincter of Boyden. An abnormally long common channel is in excess of 15 mm. Two types of convergence anomalies are defined according to whether the bile duct opens into the main pancreatic duct (BP) or the main pancreatic duct into the bile duct (PB). In APBD, there is probably a reverse pressure gradient between the bile and pancreatic ducts, with regurgitation of pancreatic juice into the bile duct, repeated attacks of cholangitis, stenosis and cystic dilatation. A long common channel is associated with a higher incidence of carcinoma of the gall bladder or the bile duct.

IN RENAL transplantation, delayed graft function remains a major problem and increases the posttransplant morbidity and hospital costs. Trimetazidine (TMZ), an antiischemic drug, was introduced several years ago and used as an antianginal agent whose main effect is to be devoid of hemodynamic effects. TMZ is a cytoprotective drug that counteracts the metabolic disorders occurring at the level of ischemic cells. Several experimental results have suggested direct actions of the drug on mitochondrial function, intracellular acidosis, and calcium intracellular accumulation. 1,2 The aim of this study was to assess beneficial effect of TMZ during cold storage (CS) with Euro-Collins solution (EC) and normothermic reperfusion on energetic status of the kidneys.

HIGH resolution protin nuclear magnetic resonance (NMR) spectroscopy can be used for the rapid multicomponent analysis of low molecular weight metabolites in biologic fluids such as plasma and urine. Citrate (Cit) is an organic acid normally found in human urine. Reduced urinary Cit excretion has been described in HgCl2 and p-aminophenol intoxication.1 The mechanism is impairment of the Krebs cycle. Trimethylamine-N-oxide (TMAO) is an osmolyte molecule synthesized in the medullar cells of the kidney.2 In plasma and urine, TMAO is not usually detected. Its excretion may be related to leakage from the renal medulla cells after intense medullar ischemia. The aim of this study was to assess Cit and TMAO excretion after prolonged cold storage (CS) with two standard solutions. These markers are precisely detected by proton NMR spectroscopy.

In order to assess the tolerance induced by hepatic transplantation in a multivisceral graft, a model of a transplant combining the liver and small intestine was developed in the pig, using animals of Large White Isogroup O, typed in the system of major incompatibility as "Swine lymphocyte antigen" (SLA), whose weight varied from 30 to 40 kg. In order to limit the duration of warm ischemia, dissection of the graft was performed on the donor animal with respect for the following anatomic features: absence of intestinal attachment to the posterior parietal peritoneum, anti-clockwise torsion of 360 degrees of the intestine around the superior mesenteric a. with the small intestine convolutions on the right and the colonic helix on the left. The bifid pancreas follows this rotation and its resection must respect the vascularisation of the proximal small intestine; the hepatic a. arises from a common trunk with a gastrosplenic branch of the aorta between the crura of the diaphragm and travels sagittally from behind forward toward the liver pedicle, which it reaches ar the upper border of the duodenum; the hepatic a. and its branches are dorsal in relation to the portal vein; the hepatic arterial distribution follows a right-left and antero-posterior systematisation for the six hepatic lobes of this quadruped animal.

International audience

La cholecystectomie laparoscopique est le traitement chirurgical de reference de la lithiase vesiculaire symptomatique. La strategie therapeutique a adopter devant une lithiase de la voie biliaire principale (LVBP) decouverte lors d’une cholecystectomie laparoscopique reste encore debattue. Apres plusieurs approches sequentielles, la tendance actuelle est au traitement en un temps de la lithiase choledocienne et vesiculaire. Ainsi plusieurs strategies therapeutiques ont emerge en cas de suspicion de LVBP. Le traitement laparoscopique en un temps implique l’abord choledocien transcystique voire une choledocotomie, avec la difficulte de l’abord de la voie biliaire par laparoscopie. Une autre voie semble seduisante. Elle est basee sur la combinaison des deux methodes laparoscopique et endoscopique, le traitement de la LVBP se faisant par sphincterotomie endoscopique (SE) par voie retrograde avant ou apres la cholecystectomie laparoscopique, mais au cours de la meme anesthesie. Entre janvier 2003 et juin 2009, 1451 cholecystectomies ont ete realisees au Centre hospitalo-universitaire de Poitiers. Parmi ces patients, le diagnostic de LVBP avait ete pose 24 fois en pre-operatoire ou 73 fois devant la decouverte d’une image lacunaire lors de la cholangiographie peroperatoire. Au total, 97 patients ont beneficie du traitement combine pour LVBP. La SE a pu etre realisee pour 84 patients pendant la meme anesthesie, soit 86,6 %. Pour les 13 autres patients, la SE a ete realise en postoperatoire dans un delai moyen de 5 jours (extremes de 1 a 29). Sept patients ne presentaient pas de lithiase au moment de la SE. Le taux d’extraction est de 92 % (89 patients). Un echec d’extraction a conduit a une derivation bilio-digestive. Il n’y a eu aucun deces. Quatorze patients ont presente des complications, dont 3 ont necessite un traitement chirurgical (2 hemorragies, 1 fuite biliaire). La duree moyenne d’attente de l’endoscopiste a ete de 35 minutes (extremes de 0 a 100). La realisation d’une SE peroperatoire allonge la duree moyenne d’intervention de 57 minutes (extremes de 15 a 130). La duree moyenne de sejour des patients ayant beneficie du traitement combine en un temps est 6,7 (2 a 24) jours contre 9,3 (5 a 18) lorsque la SE etait realise en postoperatoire. Le traitement de la LVBP en un temps par la cholecystectomie laparoscopique et SE peroperatoire semble donc une alternative interessante au traitement de la LVBP « tout coelioscopique » avec un faible risque et de bons resultats. L’efficacite de cette methode est par contre etroitement liee a la collaboration avec le service d’endoscopie, necessitant la presence et la disponibilite d’operateurs experimentes en endoscopie biliaire therapeutique. Lithiase de la voie biliaire principale : cholecystectomie laparoscopique et sphincterotomie endoscopique en un temps.

The outcome of 31 patients with severe radiation enteritis treated by total parenteral nutrition (TPN) was analyzed. Before initiation of parenteral nutrition, 18 of the patients had not had abdominal surgery, while 13 had either a resection or an intestinal bypass for radiation enteritis. Median follow-up was 2 1/2 years (range: 1 month to 12 years) from the time of initiation of parenteral nutrition. Surgery was required in 15 cases because parenteral alimentation could not be continued. Only eight of these 15 were able to resume a normal oral intake. Total parenteral nutrition allowed oral feeding to be resumed in 11 (36%) after a median follow-up of 40 months (range: 6-142 months). In general, total parenteral nutrition was well tolerated and was associated with low morbidity. Eighteen patients died, 13 of complications due to radiation therapy, four of cancer recurrence, and one of an unrelated cause. Survival probability was 58% at one year and 36% at five years. When possible, prognostic factors present either before or at initiation of total parenteral nutrition were analyzed. Age, predisposing vascular factors (hypertension, diabetes mellitus, or vascular disease), and enteric fistula and/or perforation were found to have prognostic value. The probability of clinical radiation enteritis recurrence was 34% at one year and 47% at two years. A clinical recurrence of symptoms was more frequent but not significantly so after parenteral nutrition as compared to surgical therapy of radiation enteritis. Although TPN corrected denutrition and allowed deferred surgery in some patients, severe radiation enteritis remains a poorly predictable progressive disease with numerous relapses.

PRIMARY dysfunction or nonfunction of liver graft is still an important problem in liver transplantation despite surgical progress. The determination of new markers of graft viability and metabolic activities seems to be an important challenge to assess the early graft function. Proton nuclear magnetic resonance spectroscopy (NMRp) has previously demonstrated its interest in the evaluation of renal allograft dysfunction after ischemia reperfusion in isolated perfused pig kidney. For the kidney, NMRp study determines specific markers of function like TMAO and citrate. The aim of this study was to assess liver graft function in an isolated perfused rat liver model after 24 hours of preservation in Euro-Collins (EC) or University of Wisconsin (UW) solution.

DAMAGE sustained by the allograft during the process of transplantation has been shown to be influenced by cold ischemia-reperfusion injury, which is one of the principal “antigen-independent” factors. A previous study demonstrated that tissue injury occurs within isografts as compared to allografts, in the absence of alloantigen stimulation. In a rat model, a recent report suggests that molecules involved in T-cell costimulation may play a key role in ischemia-reperfusion in the kidney, independent of any alloimmune stimuli. The aim of this study was to assess the effect of the length of cold ischemic time in an autotransplant pig kidney model on delayed graft function and inflammatory cell infiltration.

PRIMARY and early allograft dysfunction remains a challenge for the nephrologist. Usually, the assessment of renal graft dysfunction following transplantation is based on nonspecific measurement of renal function or an invasive method such as transplant biopsy. A rapid diagnosis is necessary because a delay in treating early rejection deteriorates the prognosis of the allograft function. In addition, the antirejection treatment based on a mere clinical diagnosis of rejection could improve delayed graft function caused by acute tubular necrosis or cyclosporine damage through possible side effects of antirejection treatment. In the present study, we wanted to assess whether proton nuclear magnetic resonance (HNMR) spectroscopy can detect ischemic damage and predict acute tubular necrosis after pig kidney preservation in two preservation solutions (Euro-Collins: EC and University of Wisconsin: UW).

Between January 1985 and January 1989, 13 patients underwent femorotibial bypass using a polytetrafluoroethylene graft with a remote distal arteriovenous fistula. Indications for operation were gangrene in six patients, rest pain in five patients, and nonhealing ulcer in two patients. No patient had a usable autogenous saphenous vein. Eight patients had a previous failed femorodistal bypass. Standard femorotibial bypass was performed using a 6 mm thin-walled polytetrafluoroethylene graft. The distal remote arteriovenous fistula was done on the same artery. Warfarin was given postoperatively. Graft patency was assessed by duplex scan and digital arteriography. There was no postoperative mortality. All grafts and fistulas remained patent initially with improvement in symptoms and limb salvage. In the follow-up period there was continued graft patency in all but two patients who had a below-knee amputation. Three patients died with a patent graft. In two additional patients the graft remained patent but the fistula closed. We believe that in selected situations, the remote distal arteriovenous fistula is a potentially valuable adjunct for obligatory polytetrafluoroethylene femorotibial bypass.

The cases of 6 patients with coeliac disease of adults presenting as small bowel occlusion or abdominal mass and who underwent exploratory laparotomy are reported. Surgeons should consider a diagnosis of CD in the presence of mesenteric lymph node cavitation, « inflammatorystenosis or small bowel dilatation without obstacle.

This study had 4 objectives: first, to define the place of the Cooper ligament in hernial repairs by recalling its anatomic importance within the inguinal region; second, to describe our technique using the Cooper ligament, a technique based on suture of the conjoined tendon to the Cooper ligament without a relaxing incision into the rectus sheath and also to describe other authors' variants; third, to report the results obtained for 1,040 patients operated on by our technique from 1970 to 1978; fourth, to define the value and limits of these herniorrhaphy methods in repairs of groin hernias. These methods are inexpensive and virtually exclude the risk of serious infections because no foreign material is used. The procedures can be used in most patients. The only limits are suture tension during the repair and the presence of parietal deterioration. In such situations, it is necessary to perform a prosthetic repair or to reinforce the herniorrhaphy with prosthetic mesh.