Search

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.

Isolated primary human hepatocytes are a well accepted system for evaluating pharmacological and toxicological effects in humans. However, questions remain regarding how culturing affects the liver-specific functions of the hepatocytes. In addition, cryopreservation could also potentially affect the differentiation state of the hepatocytes. The first aim of the present study was to compare gene expression in freshly isolated primary hepatocytes to that of the liver of origin and to evaluate the expression changes occurring after cryopreservation/thawing, both when maintained in suspension and after plating. The second aim of the present study was to evaluate gene expression in hepatocytes after cold storage of suspensions up to 24 h compared with freshly isolated hepatocytes in suspension. Our results show that the gene expression in freshly isolated human hepatocytes in suspension after isolation is similar to that of the liver of origin. Furthermore, gene expression in primary human hepatocytes in suspension is not affected by hepatocyte cold storage and cryopreservation. However, the gene expression is profoundly affected in monolayer cultures after plating. Specifically, gene expression changes were observed in cultured relative to suspensions of human hepatocytes that are involved in cellular processes such as phase I/II metabolism, basolateral and canalicular transport systems, fatty acid and lipid metabolism, apoptosis, and proteasomal protein recycling. An oxidative stress response may be partially involved in these changes in gene expression. Taken together, these results may aid in the interpretation of data collected from human hepatocyte experiments and suggest additional utility for cold storage and cryopreservation of hepatocytes.

To describe the safety, complications, and liver regeneration associated with the left liver after embolization of the right portal vein (PV) in patients with hepatocellular carcinoma (HCC) developed in the setting of advanced liver fibrosis and cirrhosis.Forty patients (31 men, nine women; mean age, 62 years) with HCC underwent PV embolization over a 4-year period. Embolization was performed from a left PV percutaneous access with use of n-butyl cyanoacrylate (NBCA) mixed with iodized oil. Computed tomography (CT) volumetry was performed before and 1 month after PV embolization to measure the left lobe volume as well as the functional liver ratio defined by the ratio between the left lobe and the total liver volume minus tumoral volume. PV pressure and liver enzyme levels were compared before and 1 month after the procedure and complications were registered. Factors potentially affecting regeneration (age, sex, diabetes, chemoembolization, functional liver ratio before PV embolization, and Knodell histologic score) were evaluated by one-way and stepwise regression analysis.PV embolization could be achieved successfully in all cases. Two patients had partial PV thrombosis on the 1-month follow-up CT and two patients developed transient ascites after PV embolization. The left lobe volume increase was 41% +/- 32% after PV embolization and the functional liver ratio increased from 28% +/- 10% to 36% +/- 10% (P.0001). Hypertrophy of the left lobe was greater in patients with a low functional liver ratio before PV embolization and those with an F3 fibrosis score. Other factors had no influence on left lobe regeneration.PV embolization with use of NBCA is feasible in patients with advanced fibrosis and cirrhosis. Hypertrophy of the left lobe of the liver after PV embolization has a statistically significant correlation with lower functional liver ratio and lower degrees of fibrosis.

L'agénésie isolée de la vésicule biliaire (AVB) est une anomalie rare. Vingt-trois pour cents des porteurs de cette malformation présentent des douleurs de l'hypochondre droit accompagnées de nausées et d'intolérance aux graisses dont l'étiologie reste souvent inexpliquée. Que la méthode d'investigation initiale soit un ultrason ou une cholangiographie intraveineuse, le diagnostic retenu à tort est dans la grande majorité des cas celui d'une vésicule exclue ou scléro-atrophique. Il résulte de cette erreur une indication chirurgicale inutile avec un risque accru de lésion des voies biliaires. Le but de ce travail et de déterminer s'il est possible, malgré les pièges de l'imagerie radiologique, d'obtenir un diagnostic préopératoire et de préciser la marche à suivre en cas de découverte pré ou peropératoire d'une AVB. A partir de deux cas isolés que nous présentons dans ce travail, nous avons effectué une revue de la littérature. C'est en fait la méconnaissance de cette pathologie et sa non-évocation dans le diagnostic différentiel qui conduit à une prise en charge chirurgicale inutile et dangereuse. L'absence de structures anatomiques normales et l'impossibilité de réaliser une traction sur l'infundibulum afin de mener la dissection du triangle de Calot représente un risque accru de lésion des voies biliaires. L'évocation de ce diagnostique par le radiologue ou le chirurgien est essentielle lors de l'interprétation de l'imagerie radiologic. En cas de doute on réalisera une cholangiographie-IRM. Une transmission héréditaire de l'AVB a été observée. Les membres d'une même famille doivent être investigués.

AIM: Extrahepatic portal venous obstruction (EHPVO) is a relatively rare disease in adults. The clinical significance of shunt surgery for EHPVO in adult cases remains unclear. METHODS: We retrospectively analyzed the patient characteristics and the results of shunt surgery in 13 adult cases of EHPVO treated between March 1995 and March 2013 at a tertiary care hospital in Switzerland. The indication for shunt surgery was recurrent bleeding after endoscopic treatment. To update the outcomes of shunt surgery in adult cases of EHPVO, we performed a systematic review of published work to examine this issue. RESULTS: The mean age of the 13 patients in the present case series was 41.8 years (range, 20-68), and the mean follow-up duration after surgery was 4.4 years (range, 1-16). The types of shunt surgery performed were mesocaval shunt (n = 8), portacaval shunt (n = 2), splenorenal shunt (n = 1) and mesorenal shunt (n = 2). Two patients (15%) developed postoperative rebleeding, which was successfully treated by endoscopic treatment. None of the patients developed postoperative hepatic encephalopathy. No operative-related deaths occurred in this series. Six studies, including our own, were identified in the published work. The overall mortality rate was 0-3.7%, and no cases of encephalopathy were observed. The rebleeding rate ranged 2.5-23%. CONCLUSION: Shunt surgery for EHPVO in adults after the failure of endoscopic treatment is feasible, with acceptable outcomes at specialized centers. This surgical procedure should always be taken into consideration when managing adult cases of EHPVO.

Introduction: Le syndrome de l'anse borgne désigne classiquement les complications des montages chirurgicaux en cul-de-sac de l'intestin grêle (stase entérale, prolifération microbienne, anémie mégaloblastique par malabsorption de la vitamine B12). Le but de ce travail est d'attirer l'attention sur d'autres étiologies, plus rares. Patients et méthode: Ces 20 dernières années, nous avons opéré 9 malades: 5 après anastomose latéro-latérale iléo-iléale et 4 après iléo-transversostomie termino-latérale (2) ou latéro-latérale (2). Leur résection de l'intestin grêle avait été motivée dans 8 cas par l'infarcissement d'une anse grêle sur une bride post-opératoire (appendicectomie 7 fois, opération gynécologique 1 fois) et dans 1 cas par une tumeur. Les manifestations cliniques du syndrome de l'anse borgne ont été: douleurs abdominales en crampes, vomissements, amaigrissement important, diarrhées, asthénie, anémie, altération de l'état général. Le diagnostic a été très tardif, posé en moyenne 18 ans après la résection intestinale. Résultats: Tous les patients ont été traités par antibiothérapie au long cours, résection de leur anastomose latéro-latérale ou termino-latérale et rétablissement termino-terminale de la continuité digestive. Conclusion: Une anastomose iléo-iléale ou iléo-transverse latéro- ou termino-latérale peut créer un cul-de-sac responsable d'une stase fécale avec pullulation bactérienne. Outre une antibiothérapie, le traitement doit rétablir une continuité intestinale termino-terminale.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant vascular tumor, slow growing and often discovered late. Clinical presentation depends on the level of the IVC involved and diagnosis relies mostly on imaging methods. Two hundred and eighteen cases have been reported in the literature. The authors present the case of a 56-year-old man who underwent surgery for removal of a leiomyosarcoma of the medial caval segment. The procedure involved a radical excision with reconstruction of the IVC and reimplantation of the right renal vein. Clinical presentation, diagnosis and therapeutic modalities are discussed.

Background: Laparoscopy is used increasingly for the management of acute abdominal conditions. For many years, previous abdominal surgery and intestinal obstruction have been regarded as contraindications to laparoscopy because there is an increased risk of iatrogenic bowel perforation. The role of laparoscopy in acute small bowel obstruction remains unclear. Methods: Since 1995, data from patients undergoing laparoscopic surgery have been entered prospectively into a database. Patients who underwent surgery before 1995 were added retrospectively to the same database. The charts of all patients treated surgically for mechanical small bowel obstruction were reviewed. Univariate analysis was performed to identify factors associated with success or failure, especially intraoperative complications, conversion, and postoperative morbidity. Stepwise logistic regression was used to assess for independent variables. Results: This study included 83 patients (56 women and 27 men) with a mean age of 56 years (range, 17–91 years). Conversion was necessary in 36 cases (43%). Laparoscopy alone was successful in 47 patients (57%). Intraoperative complications were noted in 16% and postoperative complications in 31% of the patients. Eight reoperations (9%) were necessary. Mortality was 2.4%. Duration of surgery (p < 0.001) and a bowel diameter exceeding 4 cm (p= 0.02) were predictors of conversion. No risk factor for intraoperative complication was identified. Accidental bowel perforation (p= 0.008) and the need for conversion (p= 0.009) were the only independent factors associated with an increased risk of postoperative complications. Conclusions: Laparoscopic management of small bowel obstruction is possible in roughly 60% of the patients selected for this approach. Morbidity is lower, resumption of a normal diet is faster, and hospital stay is shorter than with patients requiring conversion. No clear predictor of success or failure was identified, but intraoperative complications must be avoided. If the surgeon is widely experienced in advanced laparoscopic surgery and there is a liberal conversion policy, laparoscopy is a valuable alternative to conventional surgery in the management of acute small bowel obstruction.

Objectives: Pulmonary sequestration is a continuum of lung anomalies for which no single embryonic hypothesis is yet available. The aim of this study was to assess the diagnostic tools and treatment for the rare condition, pulmonary sequestration, in an unspecialised centre. Methods: We performed an analysis of 26 cases of pulmonary sequestration (paediatric and adult) operated at the Centre Hospitalier Universitaire Vaudois between May 1959 and May 1997. A review of the extralobar and intralobar types of sequestrations is discussed. Angiography is compared to other diagnostic tools in this condition, and treatment is discussed. Results: Twenty-six cases of pulmonary sequestrations, a rare congenital pulmonary malformation, were operated on in the defined time period. Seventy-three percent (19) of the cases were intralobar and 27% (seven) extralobar. Extralobar localisation was basal in 71% and situated between the upper and the lower lobe in 29%. In six cases, the diagnosis was made by exploratory thoracotomy. In the other 20 cases, diagnosis was evoked on chest X-ray and confirmed by angiography. Lobectomy (46%) was the most common treatment procedure. Segmental resection was performed in 30% of the cases and bilobectomy in 4%, Post-operative morbidity was low. The most significant complications were pleural empyema, haemothorax and haemopneumoperitoneum in case of extralobar sequestration. There was no evidence of metaplasia or pre-neoplastic changes. Conclusions: Despite its rarity, some radiological features are sufficiently suggestive of diagnosis of pulmonary sequestration. Investigations are necessary in order to avoid unexpected pathology at the time of operation. Resection of the involved lung leads to excellent results and the long-term outcome is highly favourable.

769 Background: Metastasectomy and radiofrequency ablation (RFA) are currently use for treatment of colorectal cancer (CRC) liver metastasis aiming for total tumor ablation with sparing liver parenchyma. Literature is lacking of studies comparing results and risk of recurrence between both techniques. We aim to compare recurrence rate after RFA and metastasectomy for CRC liver metastasis and to define which lesion is the best candidate for each treatment. Methods: By a lesion-by-lesion analysis, we reviewed 121 metastases treated by metastasectomy (43 patients, median follow up 798 days) and 110 metastases treated by RFA (60 patients, median follow up 590 days). Rate of local recurrence (LR) and hepatic recurrence (HR) were compared. We analyzed patients and primary tumor characteristics, looked for predictive factors for recurrence in metastasis data: size, deepness in liver, distance to hepatic veins, pathological resection margins in case of surgery. Analysis were performed using Chi Square and logistic regression in uni and multivariate analysis. Results: Patients and primary tumor characteristics were similar. Metastasis size was larger in metastasectomy group (18mm, range 2-90mm and 15mm, range 3-55mm; p = 0.03). Lesions were located deeper in the liver parenchyma in RFA group (20mm, range 3-51mm and 26mm, range 6-59mm; p < 0.001). Rate of LR and HR were nearly statistically different in favor of RFA: LR was 19% for metastasectomy group and 10% for RFA group (p = 0.06, delay: 245 and 289 days, p = 0.56), HR were 78% for metastasectomy and 66% for RFA (p = 0.054, delay: 226 and 235 days, p = 0.81). Predictive factors for recurrence in metastasectomy group: R1 status (p = 0.03) and metastasis deepness (p = 0.02). Metastasis deepness and proximity to hepatic veins increased risk for R1 (p = 0.04 and p < 0.001 respectively). We found no predictive factor for recurrence in RFA group. Conclusions: Pending proper selection (small lesions visible under imaging guidance), RFA tends to have a lower recurrence rate than metastasectomy. Lesions localized in depth in the liver parenchyma, close to hepatic veins are at risk of LR after metastasectomy.

Infection of an intervertebral disk is a serious condition. Diagnosis often is elusive and difficult. It is imperative to obtain appropriate microbiological specimens before initiation of treatment. The authors describe a 51-year-old woman with lumbar spondylodiscitis that was because of infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging confirmed the diagnosis, but computed tomography-guided fine needle biopsy did not provide adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. The authors believe that this minimally invasive procedure should be performed when computed tomography-guided fine needle biopsy does not provide a microbiologic diagnosis in spondylodiscitis.

A large amount of data is available on hepatocellular carcinoma, cholangiocarcinoma, and liver metastases from colorectal or neuroendocrine origin. During the last decade, a multidisciplinary diagnostic and therapeutic approach has led to a considerable improvement in outcome, especially in high volume centres. Based on a large body of evidence, comprehensive treatment algorithms have recently been defined for these frequent entities [1, 5, 27]. The therapeutic backbone remains surgical resection or liver transplant. This has been complemented by interventional radiology, local ablation and innovative chemotherapy [1, 5, 20, 27]. However, only very little is known about the treatment of rare liver tumours, and this chapter will focus entirely on these neglected rare malignancies. Because of their rarity, no large prospective series are available. Prognostic factors and the optimal treatment still need to be defined. We will review the available data on these “orphans”, including rare epithelial and nonepithelial tumours, primary hepatic lymphoma as well as the veritable curiosities such as solitary fibrous tumour or carcinosarcoma. While treatment strategies are nowadays available for metastases from breast cancer, melanoma, and gastric cancer, rarities such as liver tumours of unknown origin constitute diagnostic and therapeutic challenges that have to be treated on a case-by-case basis [4, 5, 17, 19, 28, 32].

Invariant NKT cells (iNKT cells) recognize glycolipid Ags via an invariant TCR α-chain and play a central role in various immune responses. Although human CD4+ and CD4− iNKT cell subsets both produce Th1 cytokines, the CD4+ subset displays an enhanced ability to secrete Th2 cytokines and shows regulatory activity. We performed an ex vivo analysis of blood, liver, and tumor iNKT cells from patients with hepatocellular carcinoma and metastases from uveal melanoma or colon carcinoma. Frequencies of Vα24/Vβ11 iNKT cells were increased in tumors, especially in patients with hepatocellular carcinoma. The proportions of CD4+, double negative, and CD8α+ iNKT cell subsets in the blood of patients were similar to those of healthy donors. However, we consistently found that the proportion of CD4+ iNKT cells increased gradually from blood to liver to tumor. Furthermore, CD4+ iNKT cell clones generated from healthy donors were functionally distinct from their CD4− counterparts, exhibiting higher Th2 cytokine production and lower cytolytic activity. Thus, in the tumor microenvironment the iNKT cell repertoire is modified by the enrichment of CD4+ iNKT cells, a subset able to generate Th2 cytokines that can inhibit the expansion of tumor Ag-specific CD8+ T cells. Because CD4+ iNKT cells appear inefficient in tumor defense and may even favor tumor growth and recurrence, novel iNKT-targeted therapies should restore CD4− iNKT cells at the tumor site and specifically induce Th1 cytokine production from all iNKT cell subsets.

Surgery offer the only curative treatment for colorectal hepatic metastasis. Nowadays, five-year survival increases up to 58% in selected cases, due to the improvement and combination of chemotherapy, surgery and ablative treatment like embolisation, radio-frequency or cryoablation. Surgery should be integrated in a multi disciplinary approach and initial work-up must take in account patient general conditions, tumor location, and possible extra hepatic extension. Thus, a surgical resection may be performed immediately or after preparation with chemotherapy or selective portal embolization. Management of liver metastasis should be carried out in oncological hepato-biliary centre.

Adult intussusception represents 5% of all intussusceptions and 1% of all bowel obstructions. In adults, it is often associated with a systemic disease, such as acquired immune deficiency syndrome (AIDS), and is usually caused by a focal pathologic process at the point of the intussusceptum. In these patients, diagnosis is often delayed, mainly because of the nonspecific and prolonged nature of the symptoms and because of the extensive differential diagnosis of nonsurgical abdominal conditions. Leucocyte count is rarely increased because of the depressed immune response. We present here the case of a patient with AIDS, who developed an ileocolic intussusception after laparoscopic appendectomy. The clinical and radiographic findings are described.

BACKGROUND: Laparoscopic surgery during pregnancy is a challenging procedure that most surgeons are reluctant to perform. The objective of this study was to evaluate whether laparoscopic appendectomy and cholecystectomy is safe in pregnant women. The management of these situations remains controversial. We report a single center study describing the successful management of 16 patients during pregnancy. METHODS: More than 3,356 laparoscopic procedures were performed in our institutions between May 1990 and June 2005. Sixteen of these patients were operated on in the second and third trimester between 22 and 32 weeks of estimated gestational age. We performed 11 laparoscopic appendectomies and 5 laparoscopic cholecystectomies. We also reviewed the management and operative technique used in these patients. RESULTS: In this study, the laparoscopic appendectomy or cholecystectomy was performed successfully in all patients. Three patients were in their second trimester, weeks 22, 23, and 25, and 13 were in the third trimester, weeks 27 (three patients), 28 (five patients), 31 (three patients), and 32 (two patients). No maternal or fetal morbidity occurred. Open laparoscopy was performed safely in all patients and all patients delivered healthy babies. CONCLUSION: From our experience laparoscopic management of appendicitis and biliary colic during pregnancy is safe, however the second trimester is preferable for laparoscopic cholecystectomy. Pregnancy is not a contraindication to the laparoscopic approach to appendicitis or symptomatic cholelithiasis. We believe that laparoscopic operations, when performed by experienced surgeons, are safe and even preferable for the mother and the fetus

Isolated agenesis of the gallbladder is a rare anomaly, often asymptomatic. However, one patient out of four presented with right upper abdominal pain, nausea, and fatty food intolerance. The condition is frequently mistaken with an excluded or sclero-atrophic gallbladder, regardless of the imaging modality used. Consequently, AG often leads to unnecessary and potentially dangerous laparoscopic surgery as described in a few case reports over the last 10 years. The aim of this study is to clarify the diagnostic and therapeutic approach of this unusual pathology. Two cases seen in our institutions were retrospectively reviewed, together with a review of the American and European literature. During laparoscopy, the absence of normal anatomical structures and the impossibility of pulling on the gallbladder to expose and dissect the triangle of Callot increases the risk of iatrogenic injury to biliary or portal structures. Depending on the experiment of the surgeon in laparoscopic procedure, this has to be taken into account to decide a conversion to laparotomy. A high index of suspicion is necessary when interpreting the radiological images. In case of doubt, a MRI-cholangiography is mandatory. Because of possible inherited transmission, relatives with a history of biliary symptoms should be investigated.

The treatment of the hepatocellular carcinoma (HCC) is multidisciplinary. Hepatic transplantation offers the best chances of survival for patients with hepatic cirrhosis and HCC. However the indications for transplantation are limited. For patients that do not qualify for liver transplantation, surgical excision and percutaneous ablative treatment can also be curative. Five years survival then reaches 50%. The choice of treatment is based upon the patient's clinical state, the hepatic function and the cancer clinical stage. Follow-up is crucial as recurrences can be treated by following similar algorithms. The efficacy of oncological adjuvant and neoadjuvant treatment is not yet proved.

Immunotherapy is being proposed to treat patients with hepatocellular carcinoma (HCC). However, more detailed knowledge on tumor Ag expression and specific immune cells is required for the preparation of highly targeted vaccines. HCC express a variety of tumor-specific Ags, raising the question whether CTL specific for such Ags exist in HCC patients. Indeed, a recent study revealed CTLs specific for two cancer-testis (CT) Ags (MAGE-A1 and MAGE-A3) in tumor infiltrating lymphocytes of HCC patients. Here we assessed the presence of T cells specific for additional CT Ags: MAGE-A10, SSX-2, NY-ESO-1, and LAGE-1, which are naturally immunogenic as demonstrated in HLA-A2+ melanoma patients. In two of six HLA-A2+ HCC patients, we found that MAGE-A10- and/or SSX-2-specific CD8+ T cells naturally responded to the disease, because they were enriched in tumor lesions but not in nontumoral liver. Isolated T cells specifically and strongly killed tumor cells in vitro, providing evidence that these CTL were selected in vivo for high avidity Ag recognition. Therefore, besides melanoma, HCC is the second solid human tumor with clear evidence for in vivo tumor recognition by T cells, providing the rational for specific immunotherapy, based on immunization with CT Ags such as MAGE-A10 and SSX-2.

Spontaneous subcapsular splenic hematoma formation without rupture in infectious mononucleosis is a very unusual occurrence. Splenic rupture in infectious mononucleosis (Pfeiffer disease, or glandular fever) is a rare but life-threatening complication. A conservative management is successful in those patients in stable condition. We describe the presentation and the clinical progress of a case in whom a sudden enlargement in hematoma's diameter needed a splenectomy to avoid the risk of blood effusion in the abdominal cavity. The contribution of the sonographic examination and follow-up in the diagnosis of infectious mononucleosis is emphasised.

PURPOSE: Recurrent cytomegalovirus (CMV) disease is a frequent complication of liver transplantation. Visceral leishmaniosis in a transplant recipient is, on the other hand, extremely rare and only two cases of kala-azar have been described after liver transplantation. Immunosuppressed patients are known to be at risk of Legionella infection and the relationship between infection with this organism and hospital water supplies has been well described. These three diseases carry a high mortality rate. Our report examines the potential relationship between these complications. CLINICAL FEATURES: We describe the case of a liver transplant recipient who presented the three complications successively and survived. After reviewing the literature, we explore hypotheses linking these infections and discuss treatment strategies. CONCLUSIONS: In the patient described, infection with leishmania probably occurred months prior to the clinical presentation, a delay that matches the incubation period of kala-azar. The simultaneous onset of leishmaniosis and of a high CMV viremia may have been a coincidence. However, CMV infection has been shown to be an independent predictor of invasive fungal infection in liver transplant recipients. CMV does indeed have a suppressive effect on the humoral and cellular immune response in vitro as well as in vivo. The clinical manifestations of leishmaniosis may, therefore, have been precipitated in this patient by the additive immunosuppressive effect of antirejection drugs and CMV

Laparoscopic cholecystectomy (LC) has been routinely performed since 1989 at our institution, and patients were traditionally admitted for 2 days. In 1996 we implemented a protocol for LC as a day surgery procedure at our center. Although initially reported by others, it has not yet been introduced as routine in Switzerland. The objective of this prospective study was to determine acceptability and safety of LC as an outpatient procedure in a university hospital. Data were collected prospectively for 136 LCs between January 1996 and December 2001. Patients were selected for the study if they wanted to go home within less than 24 hours, had no previous jaundice, and had no anesthetic contraindication. Systematic preoperative liver function tests and hepatic ultrasonography were performed. All patients were admitted on the day of operation. LC was performed using a three-trocar technique. Systematic cholangiography was performed, and all the procedures were completed laparoscopically. There were no common bile duct explorations. Postoperative complications were the following: nausea in seven patients, a minor umbilical hematoma in two. According to patient preference, 101 (74%) were discharged after an overnight stay (less than 24 hours) and 32 (24%) on the same day. The unplanned admission rate was 2%, and none of the patients was subsequently readmitted. The reasons for unplanned admissions were two patients with persistent nausea and one patient for whom an overnight stay was scheduled who presented with a ruptured subcapsular hematoma of the liver. Altogether, 97% of the patients were satisfied with the care they received. Operative costs were not significantly different when comparing inpatient and outpatient LC. The main postoperative savings were in the postoperative costs. Our results confirm that LC as a day surgery procedure is safe, effective, and acceptable to patients and their relatives. These results were achieved by using selection criteria that considered not only the surgical pathology but also the individual and by using appropriate techniques and planned postoperative analgesia.

Background Hepatic portal venous gas (HPVG) in adults is a rare entity. The underlying pathologic condition is usually an intestinal ischemia, but it has been reported in association with a variety of conditions. Hypothesis Miscomprehension of the underlying pathologic conditions has led to some confusion in the literature concerning its etiology, diagnostic methods, and clinical consequences. Setting Centre Hospitalier et Universitaire Vaudois, Lausanne, Switzerland, and District Hospital of Morges, Morges, Switzerland. Method Between February 1, 1995, and May 30, 2000, eleven cases of HPVG were treated. These cases were retrospectively reviewed, together with a review of the literature to define the clinical significance of HPVG, the role of the computed tomographic scan, and the necessity of performing systematic emergency exploratory surgery. Results Two groups have to be distinguished—those who have HPVG with associated pneumatosis intestinalis and those who have HPVG without associated pneumatosis intestinalis. When associated with pneumatosis intestinalis, the cause is usually an intestinal ischemia and in a symptomatic patient it justifies systematic exploratory surgery. An abdominal computed tomographic scan including lung window settings to better identify air in the bowel wall will distinguish between these 2 groups. Pneumatosis intestinalis and HPVG due to bowel ischemia do not allow prediction of the severity of bowel wall damage. Conclusions The cause of HPVG without pneumatosis intestinalis is variable. Good knowledge of the possible causes combined with the clinical picture and the abdominal computed tomographic scan is required to correctly identify the underlying cause of HPVG and to avoid unnecessary surgery.

Idiopathic segmental infarction of the greater omentum is a rare cause of acute abdomen. Patients, typically children or obese males in their fifties, present with abdominal pain located in the right upper or lower quadrant, mimicking cholecystitis and appendicitis. CT scanning and ultrasound imaging both may show a well-circumscribed soft tissue mass. Retrospective review of all patients treated for idiopathic segmental infarction of the greater omentum occurred from January 1993 to December 2001. Nine patients were treated successfully, six surgically and three medically. Conservative management of segmental infarction of the greater omentum can be proposed when correctly diagnosed by ultrasound imaging or CT scanning and the patient's condition is stable. If not, laparoscopic removal of the involved segment of the greater omentum is the treatment of choice.

Postoperative chylous ascites is a classical but uncommon complication following extensive retroperitoneal or near the root of the mesentery dissection with an incidence ranging from 1.2 to 3%. Only 6 cases of chylous ascites have been described after ulcer surgery with troncal vagotomy associated with pyloroplasty and only 1 after gastrectomy. We report the second case of chylous ascites after a D2 distal gastrectomy. A 56-year-old female underwent a D2 distal gastrectomy and gastro-duodenostomy with omentectomy for a prepyloric T1N0M0 moderately differentiated adenocarcinoma. The patient was treated conservatively by both of parenteral nutrition and a fat free diet. By the end of 2(nd) postoperative week, the effusion became serous again and the output gradually ceased. The drain could be removed on the 20(th) postoperative day. Normal enteral nutrition was resumed, no recurrence of chylous ascites occurred. This conservative treatment proved to be effective as it as already be reported with resolution in almost 60% of the patients and remains the first choice option.

A well circumscribed nodular mass discovered on routine chest ray examination, in the left inferior lobe of an otherwise healthy 49-year-old male. Histopathologically the lesion corresponded to a typical so called sclerosing hemangioma. The clinical and histopathological features are described. The sclerosing hemangioma of the lung is a rare benign tumor. Its histogenesis has not been explained yet. Following the electron-microscopic and immunohistochemical researches the opinions have been still unhomogeneous. Therefore, it is concluded that is a tumor of epithelial, endothelial, mesenchymal and even mesothelial origin. This study deals with this tumor, its immunohistochemical analysis points at its epithelial character.

BACKGROUND: Robot surgery is a further step towards new potential developments in minimally invasive surgery. Surgeons must keep abreast of these new technologies and learn their limits and possibilities. Robot-assisted laparoscopic cholecystectomy has not yet been performed in our institution. The purpose of this report is to present the pathway of implementation of robotic laparoscopic cholecystectomy in a university hospital. METHODS: The Zeus(R) robot system was used. Experimental training was performed on animals. The results of our experimental training allowed us to perform our first two clinical cases. RESULTS: Robot arm set-up and trocar placement required 53 and 35 minutes. Operative time were 59 and 45 minutes respectively. The overall operative time was 112 and 80 minutes, respectively. There were no intraoperative complications. Patients were discharged from the hospital after an overnight stay. CONCLUSION: Robotic laparoscopic cholecystectomy is safe and patient recovery similar to those of standard laparoscopy. At present, there are no advantages of robotic over conventional surgery. Nevertheless, robots have the potential to revolutionise the way surgery is performed. Robot surgery is not reserved for a happy few. This technology deserves more attention because it has the potential to change the way surgery is performed.

Acute appendicitis is the most common acute surgical infection during pregnancy. Although usually pyogenic in origin, parasitic infections account for a small percentage of cases. Despite the relatively high prevalence of acute appendicitis in our environment, it is not commonly associated with schistosomiasis. We report here the association of pregnancy and appendicitis caused by Schistosoma haematobium. Schistosomiasis is very common complication of pregnancy in hyperendemic areas. Schistosome egg masses can lodge throughout the body and cause acute inflammation of the appendix, liver and spleen. Congestion of pelvic vessels during pregnancy facilitates passage of eggs into the villi and intervillous spaces, causing an inflammatory reaction. Tourism and immigration make this disease a potential challenge for practitioners everywhere.

BACKGROUND: Laparoscopic enucleation for neuroendocrine pancreatic tumors has become a feasible technique, with a reported incidence of pancreatic fistula ranging from 13 to 29 %.1 (-) 3 This report describes the first successful case of laparoscopic pancreatic enucleation with resection of the main pancreatic duct followed by end-to-end anastomosis. METHODS: A 41-year-old woman was admitted to the authors' hospital for repeated syncope. Hypoglycemia also was noted. A contrast-enhanced computed tomography examination showed a highly enhanced tumor measuring 22 mm in diameter on the ventral side of the pancreatic body adjacent to the main pancreatic duct. The patient's blood insulin level was elevated, and her diagnosis was determined to be pancreatic insulinoma. Laparoscopic pancreatic enucleation was performed. Approximately 2 cm of the main pancreatic duct was segmentally resected, and a short stent (Silicone tube: Silastic, Dow Corning Corporation, Midland, MI) was inserted. The direct anastomosis of the main pancreatic duct was performed using four separate sutures with an absorbable monofilament (6-0 PDS). RESULTS: The operation time was 166 min, and the estimated blood loss was 100 mL. The postoperative course was uneventful, and the patient was discharged from hospital on postoperative day 7. The pathologic findings showed a well-differentiated insulinoma and a negative surgical margin. A computed tomography examination performed 1 month after the operation showed a successful anastomosis with a patent main pancreatic duct. CONCLUSIONS: Laparoscopic segmental resection of the main pancreatic duct and end-to-end anastomosis can be performed safely with the insertion of a short stent. This technique also can be used for a central pancreatectomy.

Introduction Les programmes de rehabilitation amelioree apres chirurgie (Enhanced Recovery After Surgery, ERAS®) permettent de reduire significativement les complications, la duree de sejour et les couts de la chirurgie colorectale. L’objectif est d’evaluer l’applicabilite de tels programmes a la chirurgie pancreatique. Methodes Les recommandations ERAS® publiees recemment pour la chirurgie pancreatique ont ete implantees de maniere structuree et ont ete appliquees de maniere systematique chez chaque patient opere d’une duodenopancreatectomie cephalique des octobre 2012. Les patients traites selon ERAS® jusqu’a decembre 2013 ont ete compares aux patients controles traites precedemment. Toutes les donnees ont ete collectees de maniere prospective. Observation Les 43 patients ERAS® avaient les memes caracteristiques demographiques, operatoires et pathologiques que les 43 patients du groupe controle. La morbidite postoperatoire etait a 63 % dans le groupe ERAS par rapport a 79 % dans le groupe controle (p = 0,128). La survenue de complications severes s’elevait respectivement a 35 % et 44 % (p = 0,51). La duree du sejour hospitalier etait raccourcie de 6 jours, passant d’une mediane de 20 jours a 14 jours apres l’introduction d’ERAS (p = 0,0027). Conclusion La mise en route d’un programme ERAS® s’est averee sure et a permis de reduire la duree du sejour hospitalier. Ces resultats sont prometteurs et devront etre confirme par des etudes plus etendues.

All manner of foreign bodies have been extracted from the bladder. Introduction into the bladder may be through self-insertion, iatrogenic means or migration from adjacent organs. Extraction should be tailored according to the nature of the foreign body and should minimise bladder and urethral trauma. We report a case of a bullet injury to the bladder, which finally presented as a gross hematuria after remaining asymptomatic for four years. We present here an alternative to suprapubic cystostomy with a large bladder foreign body treated via a combined transurethral unroofing followed by removal using a grasper passed through a suprapubic laparoscopic port.

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.

We review our cases of a rare pathology, intrathoracic tumours in von Recklinghausen's neurofibromatosis, involving 6 patients operated upon in our Surgery Department for intrathoracic neurogenic tumors. All had had a positive history of von Recklinghausen's neurofibromatosis prior to thoracic surgery. The management of this rare condition is discussed. We describe the presentation of the symptoms, the operative technique and the long-term outcome, when obtainable. Our results are compared with those of other authors, and the management of these cases is reconsidered. In conclusion, we recommend that thoracic surgery should only be considered when the patient becomes symptomatic, since malignant changes in the tumour are possible due to operative trauma.

Gastric neurofibroma associated with von Reklinghausen's disease is a rare clinical entity. We report a case of gastric neurofibroma with gastrointestinal bleeding and severe anaemia. Surgical resection is the treatment of choice. The recommended follow-up is an annual complete cell blood count and stool testing for occult blood.

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.

Totally extraperitoneal laparoscopic hernia repair is an efficient but technically demanding procedure. As mechanisms of hernia recurrence may be related to these technical difficulties, we have modified a previously described double-mesh technique in an effort to simplify the procedure. Extraperitoneal laparoscopic hernia repairs were performed in 82 male and 17 female patients having inguinal, femoral, and recurrent bilateral hernias. A standard propylene mesh measuring 15 x 15 cm was cut into two pieces of 4 x 15 cm and 11 x 15 cm. The smaller mesh was placed over both inguinal rings without splitting. The larger mesh was then inserted over the first mesh and stapled to low-risk zones, reinforcing the large-vessel area and the nerve transition zone. The mean procedure duration was 60 minutes for unilateral and 100 minutes for bilateral hernia repair. Patients were discharged from the hospital within 48 hours. The mean postoperative follow-up was 22 months, with no recurrences, neuralgia, or bleeding complications. Over a 2-year period, this technique was found to be satisfactory without recurrences or significant complications. In our hands, this technique was easier to perform: it allows for a less than perfect positioning of the meshes and avoids most of the stapling to crucial zones.