Search

Since 2010, the introduction of an effective serogroup A meningococcal conjugate vaccine has led to the near-elimination of invasive Neisseria meningitidis serogroup A disease in Africa’s meningitis belt. However, a significant burden of disease and epidemics due to other bacterial meningitis pathogens remain in the region. High-quality surveillance data with laboratory confirmation is important to monitor circulating bacterial meningitis pathogens and design appropriate interventions, but complete testing of all reported cases is often infeasible. Here, we use case-based surveillance data from 5 countries in the meningitis belt to determine how accurately estimates of the distribution of causative pathogens would represent the true distribution under different laboratory testing strategies. Detailed case-based surveillance data was collected by the MenAfriNet surveillance consortium in up to 3 seasons from participating districts in 5 countries. For each unique country-season pair, we simulated the accuracy of laboratory surveillance by repeatedly drawing subsets of tested cases and calculating the margin of error of the estimated proportion of cases caused by each pathogen (the greatest pathogen-specific absolute error in proportions between the subset and the full set of cases). Across the 12 country-season pairs analyzed, the 95% credible intervals around estimates of the proportion of cases caused by each pathogen had median widths of ±0.13, ±0.07, and ±0.05, respectively, when random samples of 25%, 50%, and 75% of cases were selected for testing. The level of geographic stratification in the sampling process did not meaningfully affect accuracy estimates. These findings can inform testing thresholds for laboratory surveillance programs in the meningitis belt.

Background The MenAfriNet Consortium supports strategic implementation of case-based meningitis surveillance in key high-risk countries of the African meningitis belt: Burkina Faso, Chad, Mali, Niger, and Togo. We describe bacterial meningitis epidemiology in these 5 countries in 2015–2017. Methods Case-based meningitis surveillance collects case-level demographic and clinical information and cerebrospinal fluid (CSF) laboratory results. Neisseria meningitidis, Streptococcus pneumoniae, or Haemophilus influenzae cases were confirmed and N. meningitidis/H. influenzae were serogrouped/serotyped by real-time polymerase chain reaction, culture, or latex agglutination. We calculated annual incidence in participating districts in each country in cases/100 000 population. Results From 2015–2017, 18 262 suspected meningitis cases were reported; 92% had a CSF specimen available, of which 26% were confirmed as N. meningitidis (n = 2433; 56%), S. pneumoniae (n = 1758; 40%), or H. influenzae (n = 180; 4%). Average annual incidences for N. meningitidis, S. pneumoniae, and H. influenzae, respectively, were 7.5, 2.5, and 0.3. N. meningitidis incidence was 1.5 in Burkina Faso, 2.7 in Chad, 0.4 in Mali, 14.7 in Niger, and 12.5 in Togo. Several outbreaks occurred: NmC in Niger in 2015–2017, NmC in Mali in 2016, and NmW in Togo in 2016–2017. Of N. meningitidis cases, 53% were NmC, 30% NmW, and 13% NmX. Five NmA cases were reported (Burkina Faso, 2015). NmX increased from 0.6% of N. meningitidis cases in 2015 to 27% in 2017. Conclusions Although bacterial meningitis epidemiology varied widely by country, NmC and NmW caused several outbreaks, NmX increased although was not associated with outbreaks, and overall NmA incidence remained low. An effective low-cost multivalent meningococcal conjugate vaccine could help further control meningococcal meningitis in the region.

Laboratories play critical roles in bacterial meningitis disease surveillance in the African meningitis belt, where the highest global burden of meningitis exists. Reinforcement of laboratory capacity ensures rapid detection of meningitis cases and outbreaks and a public health response that is timely, specific, and appropriate. Since 2008, joint efforts to strengthen laboratory capacity by multiple partners, including MenAfriNet, beginning in 2014, have been made in countries within and beyond the meningitis belt. Over the course of 10 years, national reference laboratories were supported in 5 strategically targeted areas: specimen transport systems, laboratory procurement systems, laboratory diagnosis, quality management, and laboratory workforce with substantial gains made in each of these areas. To support the initiative to eliminate meningitis by 2030, continued efforts are needed to strengthen laboratory systems.

Background Meningococcal serogroup A conjugate vaccine (MACV) was introduced in Chad during 2011–2012. Meningitis surveillance has been conducted nationwide since 2003, with case-based surveillance (CBS) in select districts from 2012. In 2016, the MenAfriNet consortium supported Chad to implement CBS in 4 additional districts and real-time polymerase chain reaction (rt-PCR) at the national reference laboratory (NRL) to improve pathogen detection. We describe analysis of bacterial meningitis cases during 3 periods: pre-MACV (2010–2012), pre-MenAfriNet (2013–2015), and post-MenAfriNet (2016–2018). Methods National surveillance targeted meningitis cases caused by Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae. Cerebrospinal fluid specimens, inoculated trans-isolate media, and/or isolates from suspected meningitis cases were tested via culture, latex, and/or rt-PCR; confirmed bacterial meningitis was defined by a positive result on any test. We calculated proportion of suspected cases with a specimen received by period, and proportion of specimens with a bacterial meningitis pathogen identified, by period, pathogen, and test. Results The NRL received specimens for 6.8% (876/12813), 46.4% (316/681), and 79.1% (787/995) of suspected meningitis cases in 2010–2012, 2013–2015, and 2016–2018, respectively, with a bacterial meningitis pathogen detected in 33.6% (294/876), 27.8% (88/316), and 33.2% (261/787) of tested specimens. The number of N. meningitidis serogroup A (NmA) among confirmed bacterial meningitis cases decreased from 254 (86.4%) during 2010–2012 to 2 (2.3%) during 2013–2015, with zero NmA cases detected after 2014. In contrast, proportional and absolute increases were seen between 2010–2012, 2013–2015, and 2016–2018 in cases caused by S. pneumoniae (5.1% [15/294], 65.9% [58/88], and 52.1% [136/261]), NmX (0.7% [2/294], 1.1% [1/88], and 22.2% [58/261]), and Hib (0.3% [1/294], 11.4% [10/88], and 14.9% [39/261]). Of specimens received at the NRL, proportions tested during the 3 periods were 47.7% (418), 53.2% (168), and 9.0% (71) by latex; 81.4% (713), 98.4% (311), and 93.9% (739) by culture; and 0.0% (0), 0.0% (0), and 90.5% (712) by rt-PCR, respectively. During the post-MenAfriNet period (2016–2018), 86.1% (678) of confirmed cases were tested by both culture and rt-PCR, with 12.5% (85) and 32.4% (220) positive by culture and rt-PCR, respectively. Conclusions CBS implementation was associated with increased specimen referral. Increased detection of non-NmA cases could reflect changes in incidence or increased sensitivity of case detection with rt-PCR. Continued surveillance with the use of rt-PCR to monitor changing epidemiology could inform the development of effective vaccination strategies.

To assess the value ofMalignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy.Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen.Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. TheIn this study

In 2010, Burkina Faso completed the first nationwide mass-vaccination campaign of a meningococcal A conjugate vaccine, drastically reducing the incidence of disease caused by serogroup A meningococci. Since then, other strains, such as those belonging to serogroups W, X and C, have continued to cause outbreaks within the region. A carriage study was conducted in 2016 and 2017 in the country to characterize the meningococcal strains circulating among healthy individuals following the mass-vaccination campaign. Four cross-sectional carriage evaluation rounds were conducted in two districts of Burkina Faso, Kaya and Ouahigouya. Oropharyngeal swabs were collected for the detection of Neisseria meningitidis by culture. Confirmed N. meningitidis isolates underwent whole-genome sequencing for molecular characterization. Among 13 758 participants, 1035 (7.5 %) N . meningitidis isolates were recovered. Most isolates (934/1035; 90.2 %) were non-groupable and primarily belonged to clonal complex (CC) 192 (822/934; 88 %). Groupable isolates (101/1035; 9.8 %) primarily belonged to CCs associated with recent outbreaks in the region, such as CC11 (serogroup W) and CC10217 (serogroup C); carried serogroup A isolates were not detected. Phylogenetic analysis revealed several CC11 strains circulating within the country, several of which were closely related to invasive isolates. Three sequence types (STs) were identified among eleven CC10217 carriage isolates, two of which have caused recent outbreaks in the region (ST-10217 and ST-12446). Our results show the importance of carriage studies to track the outbreak-associated strains circulating within the population in order to inform future vaccination strategies and molecular surveillance programmes.

Background In 2010, Niger and other meningitis belt countries introduced a meningococcal serogroup A conjugate vaccine (MACV). We describe the epidemiology of bacterial meningitis in Niger from 2010 to 2018. Methods Suspected and confirmed meningitis cases from January 1, 2010 to July 15, 2018 were obtained from national aggregate and laboratory surveillance. Cerebrospinal fluid specimens were analyzed by culture and/or polymerase chain reaction. Annual incidence was calculated as cases per 100 000 population. Selected isolates obtained during 2016–2017 were characterized by whole-genome sequencing. Results Of the 21 142 suspected cases of meningitis, 5590 were confirmed: Neisseria meningitidis ([Nm] 85%), Streptococcus pneumoniae ([Sp] 13%), and Haemophilus influenzae ([Hi] 2%). No NmA cases occurred after 2011. Annual incidence per 100 000 population was more dynamic for Nm (0.06–7.71) than for Sp (0.18–0.70) and Hi (0.01–0.23). The predominant Nm serogroups varied over time (NmW in 2010–2011, NmC in 2015–2018, and both NmC and NmX in 2017–2018). Meningococcal meningitis incidence was highest in the regions of Niamey, Tillabery, Dosso, Tahoua, and Maradi. The NmW isolates were clonal complex (CC)11, NmX were CC181, and NmC were CC10217. Conclusions After MACV introduction, we observed an absence of NmA, the emergence and continuing burden of NmC, and an increase in NmX. Niger’s dynamic Nm serogroup distribution highlights the need for strong surveillance programs to inform vaccine policy.

The sequential FOLFOX7–FOLFIRI combination is not superior to FOLFOX4 in colorectal cancer patients with resectable metastases. Patients with synchronous metastases preferably received perioperative chemotherapy, while patients with metachronous metastases were given postoperative chemotherapy in preference. We observed the highest long-term survival rates ever reported in this setting. Background Perioperative FOLFOX4 (oxaliplatin plus 5-fluorouracil/leucovorin) chemotherapy is the current standard in patients with resectable metastases from colorectal cancer (CRC). We aimed to determine whether a sequential chemotherapy with dose-dense oxaliplatin (FOLFOX7) and irinotecan (FOLFIRI; irinotecan plus 5-fluorouracil/leucovorin) is superior to FOLFOX4. The chemotherapy timing was not imposed, and was perioperative or postoperative. Patients and methods In this open-label, phase III trial, patients with resectable or resected metastases were randomly assigned either to 12 cycles of FOLFOX4 (oxaliplatin 85 mg/m2) or 6 cycles of FOLFOX7 (oxaliplatin 130 mg/m2) followed by 6 cycles of FOLFIRI (irinotecan 180 mg/m2). Randomization was done centrally, with stratification by chemotherapy timing, type of local treatment (surgery versus radiofrequency ablation with/without surgery), and Fong's prognostic score. The primary end point was 2-year disease-free survival (DFS). Results A total of 284 patients were randomized, 142 in each treatment group. Chemotherapy was perioperative in 168 (59.2%) patients and postoperative in 116 (40.8%) patients. Perioperative chemotherapy was preferentially proposed for synchronous metastases, whereas postoperative chemotherapy was more frequently used for metachronous metastases. Two-year DFS was 48.5% in the FOLFOX4 group and 50.0% in the FOLFOX7–FOLFIRI group. In the multivariable analysis, more than one metastasis [hazard ratio (HR) = 2.15] and synchronous metastases (HR = 1.63) were independent prognostic factors for shorter DFS. Five-year overall survival (OS) rate was 69.5% with FOLFOX4 versus 66.6% with FOLFOX7–FOLFIRI. Conclusions FOLFOX7–FOLFIRI is not superior to FOLFOX4 in patients with resectable metastatic CRC. Five-year OS rates observed in both groups are the highest ever reported in this setting, possibly reflecting the pragmatic approach to chemotherapy timing. Clinical trials number NCT00268398.

Research involving α/β hydrolases, including α-amino acid ester hydrolase and cocaine esterase, has been limited by the lack of an online high throughput screening assay. The development of a high throughput screening assay capable of detecting α/β hydrolase activity toward specific substrates and/or chemical reactions (e.g., hydrolysis in lieu of amidase activity and/or synthesis instead of thioesterase activity) is of interest in a broad set of scientific questions and applications. Here we present a general framework for pH-based colorimetric assays, as well as the mathematical considerations necessary to estimate de novo the experimental response required to assign a ‘hit’ or a ‘miss,’ in the absence of experimental standard curves. This combination is valuable for screening the hydrolysis and synthesis activity of α/β hydrolases on a variety of substrates, and produces data comparable to the current standard technique involving High Performance Liquid Chromatography (HPLC). In contrast to HPLC, this assay enables screening experiments to be performed with greater efficiency.

Background The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease. Methods Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics. Results Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017). Conclusion NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

Resume Introduction. – Les lesions ampullaires ou peri-ampullaires sont le plus souvent traitees par duodenopancreatectomie cephalique (DPC). Toutefois la morbidite et les sequelles fonctionnelles eventuelles de cette intervention peuvent paraitre injustifiees en cas de lesions benignes. L’ampullectomie chirurgicale peut constituer dans cette situation une alternative interessante. But du travail. – Le but de ce travail etait de rapporter les resultats de notre serie d’ampullectomies et d’analyser au vu de la litterature, les indications, les resultats et la place de cette intervention. Materiel et methodes. – Depuis 1997, huit ampullectomies avec examen histologique extemporane ont ete realisees pour traiter des lesions sans aucun critere de malignite sur les examens pre-operatoires morphologiques et biopsiques. Resultats. – Aucun deces n’est survenu. En postoperatoire sont survenues une fistule biliodigestive traitee medicalement et quatre poussees de pancreatites aigues benignes toutes gueries medicalement. L’examen anatomopathologique definitif a montre deux ampullomes dont un degenere, une stenose fibreuse benigne de la papille, une duplication duodenale et une choledococele, deux adenomes et une adenomyose ampullaire chez les trois patients porteurs d’une polypose adenomateuse familiale. Au cours du suivi, une recidive de polype duodenal dans le cadre d’une polypose adenomateuse familiale (PAF) et une recidive de stenose papillaire fibreuse ont ete traitees par endoscopie. Les autres patients sont restes asymptomatiques. Conclusion. – Les resultats de l’ampullectomie ici observes confirment ceux des series de la litterature et autorisent sa realisation pour traiter des lesions benignes sous couvert d’un examen histologique extemporane de la piece de resection.

Introduction Les insulinomes sont des tumeurs malignes dans 5 a 10 % des cas. Leurs localisations secondaires sont principalement ganglionnaires et hepatiques. Nous rapportons le cas d’un insulinome avec metastases ovariennes. Observation Une patiente de 67 ans, diabetique de type 2 traitee par Metformine presentait depuis 2 mois des hypoglycemies a repetition. Les taux d’insulinemie, de peptide C et de pro-insuline ont affirme le diagnostic d’hypoglycemie organique. Le scanner abdominal et l’IRM ont identifie un nodule de 25 mm associe a une thrombose portale et un volumineux ovaire droit (7 cm). La ponction sous echo-endoscopie etait en faveur une tumeur neuro-endocrine pancreatique bien differenciee. Les marqueurs tumoraux ovariens etaient negatifs. La TEP-FDG a identifie une fixation du thrombus et une fixation tres moderee pancreatique et ovarienne. La TEP DOTATOC a montre une intense fixation pancreatique, du thrombus et de la masse ovarienne droite. Une splenopancreatectomie gauche avec thrombectomie, tumorectomie du segment IV du foie et annexectomie bilaterale a ete realisee. L’examen anatomopathologique a confirme une tumeur neuro-endocrine de 4 cm assez bien differenciee de la queue du pancreas. Elle s’accompagne d’engainements peri-nerveux, d’emboles neoplasiques intravasculaires, d’un thrombus tumoral porte, d’un envahissement de la paroi gastrique, de metastases ganglionnaires et ovariennes bilaterales (pT4N1M1), et d’une metastase hepatique du segment IV. Le traitement antidiabetique a ete repris. Une surveillance a 3 mois par TEP DOTATOC et scanner abdominopelvien est prevue. Conclusion L’insulinome malin avec localisations ovariennes est exceptionnel. Ce cas illustre l’interet de la TEP DOTATOC qui a permis la detection des localisations metastatiques.

Background Percutaneous computed tomography (CT)-guided aspiration of abdominal collections is performed in necrotizing pancreatitis to detect infection of necrosis, which is an adverse prognostic factor and requires surgical drainage. However, in the case of sterile aspirates, the outcome and the optimum management are subject to debate. This study examined the clinical and bacteriological outcome of patients with severe acute pancreatitis with initially sterile necrosis and assessed the efficiency of percutaneous drainage in this setting. Methods Seventeen patients hospitalized for necrotizing pancreatitis with a septic course underwent a preliminary sterile CT-guided aspiration. Eight patients underwent simultaneous percutaneous drainage of the punctured collection. Supportive therapy was continued unless severe clinical deterioration or proven secondary infection of necrosis indicated the need for necrosectomy and drainage. Results Secondary infection of necrosis was observed in two patients of nine who had only fine-needle aspiration cytology of the collection, and in seven of eight it was drained percutaneously (P=0·01). Only one patient drained percutaneously recovered without surgery. Surgical drainage was required in 12 patients. The hospital mortality rate was 29 per cent and was not significantly affected by the bacteriological status of necrosis. Conclusion Percutaneous drainage of sterile collections predisposed to secondary infection of the necrosis and did not cure the patients. A first sterile percutaneous aspiration did not predict a favourable course and surgery frequently remains necessary.

The area of biocatalysis itself is in rapid development, fueled by both an enhanced repertoire of protein engineering tools and an increasing list of solved problems. Biocatalysts, however, are delicate materials that hover close to the thermodynamic limit of stability. In many cases, they need to be stabilized to survive a range of challenges regarding temperature, pH value, salt type and concentration, co-solvents, as well as shear and surface forces. Biocatalysts may be delicate proteins, however, once stabilized, they are efficiently active enzymes. Kinetic stability must be achieved to a level satisfactory for large-scale process application. Kinetic stability evokes resistance to degradation and maintained or increased catalytic efficiency of the enzyme in which the desired reaction is accomplished at an increased rate. However, beyond these limitations, stable biocatalysts can be operated at higher temperatures or co-solvent concentrations, with ensuing reduction in microbial contamination, better solubility, as well as in many cases more favorable equilibrium, and can serve as more effective templates for combinatorial and data-driven protein engineering. To increase thermodynamic and kinetic stability, immobilization, protein engineering, and medium engineering of biocatalysts are available, the main focus of this work. In the case of protein engineering, there are three main approaches to enhancing the stability of protein biocatalysts: (i) rational design, based on knowledge of the 3D-structure and the catalytic mechanism, (ii) combinatorial design, requiring a protocol to generate diversity at the genetic level, a large, often high throughput, screening capacity to distinguish 'hits' from 'misses', and (iii) data-driven design, fueled by the increased availability of nucleotide and amino acid sequences of equivalent functionality.

Introduction Le cortico-surrenalome est une tumeur neuro-endocrine rare : 0,5 a 2 cas pour un million. Le signe clinique le plus frequent est le syndrome de cushing (50 %), puis l’hyperandrogenie avec virilisation (21 %). Les formes feminisantes sont plus rares : 8 % et sont decrites principalement chez des hommes. Observation La patiente, G1P1, menopausee a l’âge de 56 ans, a consulte a 65 ans, pour des metrorragies intenses, d’apparition brutale. A l’echographie : hypertrophie endometriale de 16 mm (n Au bilan hormonal : estradiol eleve a 722 pmol/L (n Au scanner : masse surrenalienne droite de 5,5 cm de grand axe, heterogene, de densite 87 UH. L’examen anatomopathologique apres surrenalectomie concluait a un cortico-surrenalome de 5 cm, score de Weiss a 7. Apres la chirurgie, les metrorragies se sont spontanement resolues et le bilan hormonal s’est normalise. Un traitement hormonal par mitotane a ete instaure. A trois mois post-operatoire, le PET-scan etait negatif. Discussion Ce cas clinique montre une presentation atypique d’un cortico-surrenalome, se revelant par des metrorragies. Il s’agit d’un cas tres rare car a notre connaissance, seulement deux cas ont ete decrits chez des femmes menopausees.

To determine the benefit of surgery for resectable pancreatic adenocarcinomas (PAs) in elderly patients.From 2004 to 2009, 932 patients with resectable PAs underwent pancreatectomies without neoadjuvant treatment in 37 institutions. The patients were divided into three groups according to age:70 years (control group; n = 580); 70-79 years (70s group, n = 288), and ≥ 80 years (80s group; n = 64). Preoperative, intraoperative, postoperative, and histological data were recorded to assess the postoperative course and survival.Preoperative or intraoperative characteristics, and the histological findings were comparable in the three groups. Postoperative mortality and morbidity rates did not differ in the three groups. Adjuvant therapies were more frequently used in younger patients than in elderly patients (p0.01). The overall 1-year, 3-year, and 5-year survival rates of control group/70's group/80's group were 82.2%/75.7%/75.7%, 49.9%/41.8%/31%, and 38.7%/33.2%/0%, respectively (p = 0.16). The median survival of the control, 70s, and 80s groups was 24 months, 35.3 months, and 30 months, respectively. Four independent prognostic indicators were identified by multivariate analysis: venous invasion (hazard ratio (HR) = 2.12), arterial invasion (HR = 2.96), positive lymph nodes (HR = 2.25), and adjuvant treatment (HR = 0.65).Fit elderly patients with resectable PAs should not be excluded from surgical resection of PA solely because of their real age. Moreover, elderly patients seem to obtain similar advantages from pancreatectomies than younger patients.

A 73-year-old man, who previously underwent laparotomy for pancreatic adenocarcinoma, was admitted in the emergency room for acute small bowel obstruction related to a strangulated Spieghelian hernia. On CT-scan, the hernia was located at the lateral border of the right rectus abdominis muscle below the external oblique muscle, among the transverse abdominis and internal oblique muscles layers. Spieghelian hernias (or hernia of the linea semilunaris) often occur at the level of a weak spot where the linea accurata crosses the linea semilunaris, when the posterior layer of the rectus gain changes its conformation. This weak spot is limited underneath by the inferior epigastric artery. When examining a patient with a previous history of laparotomy presenting with acute small bowel obstruction, it is mandatory to exclude a possible strangulated Spieghelian hernia before concluding to postoperative intra-abdominal adhesions. Spieghelian hernias are asymptomatic in approximately 90% of cases but entail a high risk of strangulation. Consequently, herniorrhaphy through a local approach route or open/laparoscopic mesh repair is always required.

In recent years, autoimmune pancreatitis (AIP) has been increasingly recognized. It can be associated with diabetes mellitus and other systemic autoimmune diseases, or with bile ducts lesions, which are also responsive to steroid therapy as pancreatic lesions. We report the case of a 34-year-old man with a history of a first acute pancreatitis, attributed to an intraductal papillary-mucinous neoplasm of the pancreas (IPMN) with segmental involvement of the main pancreatic duct. A spleno-pancreatectomy was performed, and pathological examination of the specimen diagnosed autoimmune pancreatitis. A treatment with corticosteroids was carried out. To our knowledge, this is the first reported case of AIP mimicking IPMN of the main pancreatic duct.

Surgical resection remains today the standard treatment of ampullary and papilla tumours. Whether pancreaticoduodenectomy (PD) or ampullectomy is indicated for presumed benign lesions remains debated. The feared potential post-operative morbidity of ampullectomies is balanced by the functional sequelae of PD.This work reports our experience of ampullectomies for presumed benign lesion of the ampulla and papilla and analyses the indications and results of ampullectomies, considering both our series and published series of the literature.Since 1997, eight ampullectomies with frozen section have been performed for presumed benign lesions, taking account of morphologic criteria and pre-operative endoscopic biopsies.Post-operative mortality was nil. Post-operative morbidity included one bilio-enteric fistula and four acute pancreatitis, all treated conservatively. Final pathological examination showed one benign and one malignant ampullomas, one benign fibrous stenosis of the papilla, one duodenal duplication and one choledococele, two adenomas and one adenomyomatosis of the papilla in patients with familial adenomatous polyposis (FAP). During follow-up, one de novo duodenal adenoma in FAP and one benign stenosis of the papilla were observed and treated endoscopically. All other patients remain asymptomatic.Ampullectomy with accurate intra-operative frozen section appears adequate for presumed benign lesion of the papilla and ampulla.

To report a new series of medial pancreatectomy (MP), with analysis of early and long-term results.From 1990 to 1999, 11 patients (mean age = 53 years, extremes: 28-70)--including 10 non-diabetic--underwent MP for neuroendocrine tumor (n = 5), intraductal papillary mucinous tumor (IPMT) (n = 3), serous cystadenoma, metastasis from renal cell carcinoma, and focal pancreatitis. The procedure included medial resection of variable extent, frozen section, and suture of the cephalic stump. The caudal stump was either anastomosed to the posterior gastric wall (n = 9), or closed when atrophic or very small (n = 2).The mean length of resection was 7 cm (extremes: 4-15). The diagnosis suspected preoperatively was confirmed in 10 cases. In one patient, a suspected adenocarcinoma was actually a focal pancreatitis. No postoperative death occurred. Seven patients experienced complications: one delayed gastric emptying and 6 pancreatic fistulas (54%), including 3 associated with intraabdominal collection. Two patients were reoperated to drain a pancreatic fistula. The mean hospital stay was 14 days (extremes: 10-21) without complications, and 30 days (extremes: 11-90) after complications. After a mean follow-up of 45 months (extremes: 7-130), only one patient initially non-diabetic experienced post-operative diabetes and needs enzyme therapy after a 15 cm-resection for IPMT. No patient developed isolated intrapancreatic recurrence.MP preserves efficiently pancreatic function and is associated with a low risk of intrapancreatic recurrence. Conversely, MP is associated with an high risk of pancreatic fistula.

To report the results of a pancreaticojejunostomy in the treatment of chronic pancreatitis, and to assess the role of residual cephalic ductal obstruction in pain recurrence.Thirty seven patients with painful chronic pancreatitis whose pancreatic duct diameter exceeded 6 mm were treated by lateral pancreaticojejunostomy and were retrospectively studied. Deobstruction of the cephalad portion of the main pancreatic duct was complete in 21 patients (group A), while residual obstruction was noted in 16 patients (group B).One patient died post-operatively (2.7%) and 6 patients underwent complications (16%) that were treated without reoperation. With a median follow-up of 52 months, 26 patients were pain free (70%). Pain recurrence occurred in 3 patients in group A (14%) who were treated medically, versus in 8 patients in group B (50%) of whom 4 needed iterative surgery. Ongoing alcoholic addiction did not influence pain recurrence, which onset significantly altered the weight increase observed after pancreaticojejunostomy.Lateral pancreaticojejunostomy has a low morbidity rate and offers long lasting pain relief in 86% of patients whose cephalad main pancreatic duct is completely deobstructed.

In the treatment of adenocarcinoma of the cardia and lower oesophagus, the choice of the approach (with or without thoracotomy) to perform a proximal oesogastrectomy (POG) is still debated. The aim of this retrospective study was to compare mortality, morbidity and long-term survival in a series of patients operated on with or without thoracotomy.From January 1991 to June 1997, 59 patients (mean ages: 65 +/- 10 years, range: 30-83) underwent POG through a transthoracic (n = 31) or a transhiatal approach (n = 28). All patients underwent both coeliac and left gastric lymphadenectomy. A mediastinal subaortic lymphadenectomy was only performed in patients who had a transthoracic approach. Both groups were comparable concerning age, weight and height, and tumoral staging according to preoperative imaging and pathologic examination. The transhiatal group included more high-risk patients (respiratory insufficiency, ASA score = 3) (NS).Resection was palliative in four patients in the transthoracic group and two patients in the transhiatal group. Operative mortality was 9% in the transthoracic group and 0% in the transhiatal group (NS). Pulmonary complications were as frequent with and without thoracotomy (35% versus 32% respectively). Global (curative and palliative resections) 3-year actuarial survival was similar in both groups (transthoracic: 39% versus transhiatal: 46%, NS), as well as survival after curative resection (44% versus 49% respectively, NS). The operative approach did not influence survival in patients N+ (22% versus 17% respectively, NS) and in patients N- (86% versus 77% respectively, NS).These results suggest that, for adenocarcinoma of the cardia and lower oesophagus, the theoretical carcinologic benefit of mediastinal lymphadenectomy can be balanced with an higher operative risk related to the transthoracic approach.

Intraductal papillary and mucinous tumors of the pancreas (IPMT) have been recently well defined histologically. Recent reports have described their diagnostic and therapeutic modalities. The malignant potential of these lesions warrants their surgical resection. The main difficulty of their management is the pre-operative assessment of ductal extension and grade of dysplasia. Despite the use of various imaging modalities (ultrasound, endoscopic ultrasonography, CT scan, retrograde pancreatography, pancreatic MRI), examination of the pancreatic margin on frozen section remains mandatory to ensure complete resection of epithelial lesions. This usually requires partial pancreatic resection. The long-term outcome is favourable for lesions with no invasive component. Recurrence in case of invasive malignant transformation appear to be more frequent than previously reported.

Experimental in vitro studies support a theory which attributes a key role to pancreatic lipase in the physiopathology of acute pancreatitis. Pancreatic lipase would hydrolyse triglycerides either in circulation or in tissues, releasing Free Fatty Acids (F.F.A.). These F.F.A. would contribute to the genesis of necrotizing lesions by their detergent properties. This experimental work, tried to confirm this theory in vivo in rats, using the cerulein-induced pancreatitis model (four injections 20 micrograms/kg of cerulein subcutaneously). It has been demonstrated first that a five-times increase of circulating plasma F.F.A. (3.02 +/- 0.28 mmol/l versus 0.75 +/- 0.05 mmol/l in control) dit not worsen cerulein-induced pancreatitis and were rather protective than deleterious. Furthermore, F.F.A. levels did not increase either in portal and aortic plasma during these pancreatitis, despite a major lipase release. There was also no increase of pancreatic content of F.F.A., measured by organic extraction performed on pancreatic homogenates. The role commonly attributed to F.F.A. in acute pancreatitis, based on in vitro experiments seems questionable in vivo.

The purpose of this study was to compare efficiency of polyamide mesh externally applied to the skin and intraperitoneal resorbable mesh of polyglactine 910, for the prevention of wound dehiscence. Two consecutive and homogenous groups of 100 patients, operated by the same surgical team and presenting one or more risk factors of evisceration, were retrospectively compared. Use of intraperitoneal polyglactine mesh, significantly reduced rate of wound dehiscence (4% vs 13%), lowered frequency of reoperation in eviscerated patients (25% vs 61%), but did not improve prognosis of this complication (50% mortality). Potential effect of resorbable mesh on late fascial disruption remains controversial.

Fulminant hepatitis of unknown origin remain a significant cause of mortality, for which liver transplantation is often considered as the only therapeutic option. In retrospective studies, human herpesvirus 6 (HHV-6) infections have been associated with such diseases, but the diagnosis of HHV-6 infection of the liver is rarely established during the acute phase of liver failure. Using real-time polymerase chain reaction (PCR), we diagnosed two cases of severe acute liver failure (ALF) related to HHV-6 occurring in immunocompetent young adults. Both cases had a favourable outcome, one after valganciclovir therapy, one after liver transplantation associated with ganciclovir. Viral origin was evidenced in each case by the detection of high amounts of HHV-6 DNA in liver tissue by the PCR assay. The decrease of intrahepatic viral load after therapeutic intervention was also monitored by quantitative PCR and paralleled in the two cases the clinical improvement. Diagnosis of HHV-6 infection must be systematically evoked in case of unexplained ALF, since it might lead to specific therapeutic interventions, in addition of liver transplantation.