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Resume La resection complete des lesions, associee a un traitement par albendazole pendant deux ans representent le traitement le plus efficace de l’echinococcose alveolaire hepatique (EAH). Seulement un petit nombre de patients peuvent beneficier d’une hepatectomie conventionnelle du fait de l’infiltration extensive des lesions hepatiques d’EAH et pour les autres patients un traitement par albendazole avec ou sans allotransplantation ou un traitement interventionnel non chirurgical doivent etre envisages. Bien que la transplantation soit consideree comme une option legitime pour des cas aussi avances, la penurie de donneurs d’organes, la necessite d’un traitement immunosuppresseur postoperatoire a vie et une possible recidive due aux effets secondaires des traitements medicaux, les chirurgiens ont ete motives pour chercher une modalite alternative possible. C’est dans cette optique que la resection « ex vivo » des lesions hepatiques suivie par l’autotransplantation du foie residuel sain (ELRA) a ete entreprise pour la premiere fois chez un patient avec une echinococcose alveolaire (EA) au stade terminal par les auteurs en 2011 et realisee a ce jour chez 94 patients avec des resultats cliniques prometteurs. Les donnees actuellement disponibles chez les 69 premiers patients, confirment que la resection ex vivo suivie d’autotransplantation pour les lesions d’EAH au stade terminal est une option emergente en cas de lesions non resecables par chirurgie classique avec une mortalite globale de 7 % a 30 jours et une survie sans recidive de 100 %. La selection minutieuse des patients, l’evaluation precise du volume et de la qualite du foie restant sont les cles de la reussite du geste chirurgical. Des cohortes complementaires avec un nombre plus eleve de patients et un suivi a plus long terme devraient confirmer ces resultats.

Background In T3 rectal cancer (RC), preoperative chemoradiotherapy [5-fluorouracil (5-FU–RT)] reduces local recurrences, but does not affect overall survival. New therapeutic options are still necessary to improve clinical outcomes. Patients and methods This randomized, noncomparative, open-label, multicenter, two arms, phase II study was conducted in MRI-defined locally advanced T3 resectable RC. In arm A, patients received 12-week bevacizumab plus 5-FU, leucovorin and oxaliplatin (Folfox-4) followed with bevacizumab–5-FU–RT before total mesorectal excision (TME). In arm B, patients received only bevacizumab-5-FU–RT before TME. Primary end point was pathological complete response (pCR) rate. Results Forty-six patients were randomized in arm A and 45 patients in arm B. In arm A, the rate of pCR was 23.8% [95% confidence interval (CI) 12.1% to 39.5%] statistically superior to the defined standard rate of 10%, P = 0.015. In arm B, the rate of pCR of 11.4% (95% CI 3.8% to 24.6%) was not different from 10%, P = 0.906. No death occurred during the study period, from the start until 8 weeks following surgery. Postoperative fistulas were reported for 16 patients (7 in arm A and 9 in arm B). Conclusion Even if the addition of bevacizumab induced manageable toxicities including an increased risk of postoperative fistula and no treatment-related death, arm B did not achieve the expected pCR rate in the population of patients included. Induction bevacizumab–Folfox-4 followed by bevacizumab–5-FU–RT is promising. It is however necessary to continue investigations in the management of locally advanced RC. Clinical Trials.gov Identifier NCT 00865189.

Vascular renal anomalies are frequent, multiple and well described and result from errors in vessel embryogenesis between the 6th and 10th week of gestation. Historically, variations are described in anatomic dissection and currently mostly in image interpretation. We report an anatomic variation concerning the right renal vein which, to our knowledge, has never been described in the literature either by dissection or by radiological examination. This variation was discovered during the routine dissection of an embalmed male body. It consists of a Y-shaped right renal vein and is associated with multiple retroperitoneal variations: a bilateral accessory renal artery, a trident ending of the right renal artery and a left testicular vein variation. Venous and arterial renal anatomy and its variations are fundamentally important in renal surgery, especially concerning living donor renal grafts. These variations may be diagnosed thanks to injected tomodensitometry which has a good sensitivity and specificity for anomalies. Preoperative diagnosis of an anatomic vascular renal variation may reduce morbidity during surgery, which is why precise examination of injected tomography should be mandatory.

Resume Introduction La decouverte d’un cancer vesiculaire sur piece de cholecystectomie est frequente. En raison du risque important de greffe tumorale sur les orifices de trocarts, il est recommande de les resequer au cours de la re-intervention. L’objectif de cette etude etait d’evaluer l’interet de l’exerese des orifices de trocarts au cours d’une re-intervention. Methodes Les patients ayant un cancer vesiculaire sur piece de cholecystectomie pris en charge entre 1998 et 2008 etaient retrospectivement collectes dans une base de donnees nationale multicentrique. Les patients ayant eu une l’exerese des orifices de trocarts etaient compares aux patients reseques sans exerese des orifices de trocarts. Les donnees demographiques, histologiques et de survie etaient analysees. Resultats Parmi les 218 patients ayant un cancer vesiculaire sur piece de cholecystectomie, il y avait 68 hommes et 150 femmes (âge median : 64 ans [46–86]). Parmi les 148 patients ayant une re-intervention a visee curative, 54 (36 %) ont eu une exerese des orifices de trocarts alors que les 94 autres patients n’ont pas eu d’exerese des orifices de trocarts. Les deux groupes etaient comparables en termes de donnees demographiques (sexe masculin 28 vs. 35 %, p = 0,33, âge > 70 ans 22 vs. 22 %, p = 0,50 et co-morbidites), procedures chirurgicales (curage ganglionnaire 87 vs. 86 %, p = 0,07, resection de la voie biliaire principale 37 vs. 46 %, p = 0,35) et postoperatoire (morbidite 30 vs. 41 %, p = 0,29). Dans le groupe avec exerese des orifices de trocarts, le stade tumoral etait T1b (n = 3), T2 (n = 25), T3 (n = 26), comparable au groupe sans exerese des orifices de trocarts (p = 0,97). L’envahissement histologique de l’exerese des orifices de trocarts etait observe chez un patient (2 %) ayant une tumeur T3, qui est decede 15 mois apres la re-resection d’une carcinose peritoneale. L’exerese des orifices de trocarts n’ameliorait pas la survie globale (77 %, 58 %, 21 % a un, trois, cinq ans, respectivement), comparativement aux patients sans exerese des orifices de trocarts (78 %, 55 %, 33 % a un, trois et cinq ans, respectivement, p = 0,37). Huit pour cent des patients avec exerese des orifices de trocarts ont developpe une eventration. Conclusion Chez les patients avec un cancer vesiculaire sur piece de cholecystectomie, l’exerese des orifices de trocarts n’ameliorait pas la survie globale et ne devrait pas etre consideree comme systematique au cours de la re-intervention a visee curative.

Resume Le syndrome hepatopulmonaire est caracterise par une hypertension portale avec ou sans cirrhose, une augmentation du gradient alveolo-arteriel en oxygene en air ambiant superieure ou egale a 15 mmHg, et des dilatations vasculaires intrapulmonaires au niveau des vaisseaux capillaires. Chez les malades cirrhotiques, la prevalence du syndrome hepatopulmonaire est estimee a 20 %. Le diagnostic est fait par l’echographie cardiaque de contraste. La physiopathologie du syndrome hepatopulmonaire ferait intervenir essentiellement une augmentation de la production pulmonaire de monoxyde d’azote. L’hypoxemie s’aggrave progressivement et augmente la mortalite. Une surveillance rapprochee des patients hypoxemiques est necessaire pour envisager une transplantation hepatique dans des conditions optimales. En effet, les principaux facteurs de mortalite postgreffe sont une PaO2 inferieure ou egale a 50 mmHg seule ou associee a un shunt isotopique superieur a 20 %. Nombreux sont les medicaments qui ont ete testes dans le syndrome hepatopulmonaire, mais les resultats probants sont rares : la poudre d’ail et, plus recemment, les aerosols d’iloprost pourraient ameliorer de facon prolongee l’oxygenation des patients avant et apres la transplantation hepatique.

Alveolar echinococcosis is caused by the larva of the cestode Echinococcocus (E.) multilocularis. Carnivores, typically foxes, but also domestic dogs and cats are definitive hosts, harbouring the small adult tapeworms in their intestine. Many species of rodents act as intermediate hosts, allowing the liver development of the metacestode (larval stage) of E. multilocularis. Human is an aberrant host for the metacestode. Contamination occurs either by eating vegetables or wild berries tainted by the infected feces of the carnivores, or by touching these animals. This disease is observed only in the temperate northern hemisphere. The main endemic area are Alaska, Japan, China, Russia , Central Asia, Western Turkey and Central Europe. New factors seem to currently modify the epidemiology of alveolar echinococcosis and to cause an extension of the disease in new areas. Increasing fox populations, invasion of cities by foxes, probably contribute to these changes. The role of cellular immunity in the immune response against E. multilocularis larvae has been clearly established. A spontaneous secretion of IL-10 by the peripheral blood mononuclear cells and within the periparasitic granuloma is the immunological hallmark of patients with progressive forms of the disease. Genetic correlates of resistance or susceptibility to human alveolar echinococcosis have been indicated by analysis of human leucocyte antigen markers in a large group of European alveolar echinococcosis patients. Human alveolar echinococcosis is a potentially fatal, chronically progressive hepatic disease, that is characterized by a long asymptomatic period in which development of an invasive-tumour-like multi-vesiculated lesion occur. Vascular and biliary structures as well as adjacent organs may be involved in the parasitic process. There is, in addition, a risk of hematogenous spreading resulting in distant metastases. Unusually for a parasitic helminth infection, it is a life-threatening disease. Efficient drugs able to destroy the larva are currently lacking. A partial surgical resection is the only curative treatment in case of a rather limited disease, a situation which becomes more frequent due to the large use of abdominal ultrasonography. In case of large unresectable lesions, long-term administration of the parasitostatic benzimidazole derivates, albendazole or mebendazole and use of interventional radiology procedures are now able to stabilize the patients. Liver transplantation had been undertaken in some patients with very severe alveolar echinococcosis, mainly due to biliary complications. This ultimate therapeutic option must be preceded by a meticulous evaluation to identify extra-hepatic extension and need to be associated with long term benzimidazole therapy. Finally, the better comprehension of the immunopathogenesis of this disease allows to consider therapeutic immunomodulation for alveolar echinococcosis in the future.

Intraperitoneal positioning of conventional parietal mesh provides efficient reconstruction but causes visceral adhesion formation in 80-100% of the cases. The purpose of this clinical trial was to assess the performance and tolerance of a new generation of polyester mesh protected by a hydrophilic resorbable film. Eighty patients were included in a prospective multicenter clinical trial. Patients were treated for ventral hernia via an open approach (64%) or laparoscopically (36%). All meshes were implanted in a midline intraperitoneal location. The main objective was to evaluate the anti-adhesive capability of the mesh in relation to the viscera. In order to assess the absence of visceral adhesion objectively, an ultrasound (US) specific examination was initially validated (pre-operative prediction vs. per-operative findings) and then used during the follow-up. The usual clinical parameters were also collected to follow the patients on a period up to 4 years. Pre-operative US prediction vs. per-operative macroscopic findings: sensitivity 79%, overall accuracy 76%, negative predictive value 85%. After 12 months, 86% of the patients were ultrasonically adhesion free. Early post-operative complications were: seroma/hematoma (16%), subcutaneous infection (4%), cutaneous necrosis (1%) and occlusions (outside the mesh) (2.5%). No mortality was reported. Clinically, after 12-month follow-up, no complication related to post-operative adhesions to the mesh was noted: (occlusion 0%, fistula 0%). Late complications were: mesh sepsis (1%), new defects (4%) and recurrence (2.5%). Finally, 56 patients (75.7%) were clinically evaluated with a mean follow-up of 48+/-6 months. One direct recurrence was noted while six patients experienced new defect outside the mesh. No long-term severe complication such as occlusion or enterocutaneous fistula was observed. Based on a mean clinical follow-up of 4 years, the results of this prospective multicenter clinical trial demonstrate the safety and the efficiency of this composite mesh in the intraperitoneal treatment of incisional and umbilical hernia. In particular there was no early or long-term main complication due to the intraperitoneal location of the mesh.

The aim of the present study was to analyse, retrospectively on a large panel of patients (149), the influence of the donor liver characteristics on the outcome of human hepatocyte isolation obtained from resected liver biopsies from surgical waste after hepatectomy. Among the pre-operative parameters, the type of disease, age and sex of the patient, previous chemotherapy, alcohol or tobacco consumption did not affect the yield, viability, attachment rate and function of the isolated human hepatocytes. Pre-operative biological and anatomopathological data indicated that, while mild steatosis ( 10% steatotic hepatocytes) tended to decrease hepatocyte yield. Cholestasis, as assessed by gamma-glutamyl transferase serum values, significantly negatively correlated with the percentage of digested liver and the yield of viable cells. Intra-operative clamping time, that is, warm ischaemia, longer than 30 min was found to decrease both the percentage of digested liver and cell yield. Among the post-operative parameters, the percentage of digested liver decreased when biopsy weights were higher than 100 g, the use of glue tended to increase both the percentage of digested tissue and the yield of viable cells.In conclusion, human diseased livers appear to be a valuable source of isolated functional human hepatocytes. We recommend, for an optimal isolation, to use liver biopsies weighing less than 100 g, to glue the section surfaces of the biopsies and to avoid the use of moderate steatotic livers (>10% steatotic hepatocytes) and cholestatic livers, as well as livers undergoing warm ischaemia or clamping during resection due to the decrease in cell yield.

The total mesorectal excision allows the marked increase of the local control rate in rectal cancer. Therefore, the mesorectal space is the usual field for the spread of rectal cancer cells. It could therefore be considered as the clinical target volume in the preoperative plan by the radiation oncologist. We propose to identify the mesorectum on anatomical structures of a treatment-position CT scan.

Aim To study drug metabolism in patients before and after liver transplantation using caffeine as a probe drug. Forty-five patients undergoing liver transplantation for various liver diseases and who had well documented dossiers were selected for the study. Before the liver transplantation and 1 month, 1 year, and 6 years after liver transplantation, they were given 200 mg of caffeine by the oral route in the morning after voiding their bladder. Twenty-four-hour urine samples were collected and caffeine and metabolites were determined by HPLC: 1-methylurate (1U), 1-methylxanthine (1X), 1.7-dimethylurate (17U), 1.7-dimethylxanthine (17X), 7-methylxanthine (7X), 3-methylxanthine (3X), 1.3-dimethylurate (13U), 3.7-dimethylxanthine (37X), 1.3-dimethylxanthine (13X), 1.3.7-trimethylxanthine = caffeine (137X). Indices of enzyme activities were calculated from the following urinary elimination ratios: (AFMU+1U+1X)/17U for CYP1A2, 17U/17X for CYP2A6, 1U/1X for xanthine oxidase (XO), AFMU/(AFMU+1U+1X) for N-acetyltransferase (NAT-2). Results Compared with results obtained in a group of 70 healthy subjects, caffeine metabolism before liver transplantation was deeply depressed with a decreased elimination rate in the case of all metabolites and a decreased CYP1A2 activity. Caffeine metabolism began to return to the control values one month after transplantation. One year and 6 years after liver transplantation, quantitatively, the metabolism of caffeine was stable and not different from control, but with qualitative modifications. CYP1A2 activity was decreased with reduced urinary elimination rates of 1X and 17X. XO and CYP2A6 activities and 1U and 17U urinary elimination rates were increased. Immunosuppressive treatment was possibly responsible for the metabolic pathway changes. Almost the same modifications were observed in 9 patients after bone marrow transplantation who had been treated with the same immunosuppressive drugs, cyclosporine and azathioprine. During severe rejection phases in 6 of the liver transplant patients, caffeine metabolism was progressively decreased when the usual liver function tests showed moderate but uniform changes. Conclusion Despite an apparent normal drug-metabolic function, immunosuppressive treatment induces stable variations in drugmetabolic pathways after liver transplantation which can be detected from the changes in caffeine metabolism.

Complete and rapid cellular ingrowth is the necessary condition of an ideal parietal mesh. However, this property obtained with conventional meshes induces visceral adhesion formation in 80 to 100% of the cases when the mesh is intraperitoneally implanted. In order to combine both cellular ingrowth on one side and adhesion prevention on the other, a new generation of polyester mesh protected by a hydrophilic absorbable film has been developed. The purpose of this study was to assess the performance and tolerance of this mesh in clinical use. 80 patients (mean age: 58 ± 12 y) were included in a prospective multicenter clinical trial: 75% for incisional hernia, 25% for umbilical hernia. Patients were treated via an open approach (64%) or laparoscopically (36%). All meshes were implanted in a midline intraperitoneal location. The main outcome was to evaluate the antiadhesive capability of the mesh as regards the viscera. In order to objectively assess the absence of visceral adhesion, a specific ultrasound (US) examination was firstly validated (preoperative prediction vs. operative findings) and secondly used during follow-up as well as usual the clinical parameters. Pre-op US prediction vs. per-op macroscopic findings: sensitivity 77%, specificity 74%, overall accuracy 75%, negative predicive value 84% (probability illustrating that a negative test really identified an adhesion-free patient). After two months, 80% of the patients were ultrasonically adhesion-free (88% in the laparoscopic group, 76% in the open surgery group, 77% in the incisional hernia group, 88% in the umbilical hernia group). Early postoperative complications were: seroma/hematoma 16.25%, subcutaneous infection 3.7%, cutaneous necrosis 2.5% and obstructions (outside the mesh) 2.5%. No mortality was observed. Clinically, after 10 months, no complication related to postoperative adhesions to the mesh was observed: (obstruction 0%, fistula or sepsis 0%). The observed recurrence rate was 2.5%. The intermediate results obtained in this prospective multicenter clinical trial demonstrated the safety and efficiency of this composite mesh in the intraperitoneal treatment of both incisional and umbilical hernia.

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Resume Objectif de l'etude La maladie de Caroli est une dilatation des voies biliaires segmentaires intrahepatiques. Le plus souvent diffuse, elle est beaucoup plus rarement localisee a un seul lobe du foie, essentiellement a gauche. Le diagnostic est souvent porte avec retard a la suite de gestes chirurgicaux ou endoscopiques inadequats. L'objectif de cette etude etait d'analyser une serie de 12 patients atteints d'une forme monolobaire, dont trois a localisation droite et tous traites par hepatectomie. Patients et methodes Une serie de 12 observations a ete recueillie entre 1974 et 1997. Il y avait six hommes et six femmes d'âge moyen 51 ans. L'etude a porte sur les circonstances de decouverte de l'affection. Le delai moyen entre les premiers symptomes et le diagnostic definitif etait de 12,5 ans. Huit des 12 patients avaient eu 22 gestes chirurgicaux ou endoscopiques avant l'intervention d'exerese. Dans cette serie, l'echographie pre-operatoire et/ou la tomodensitometrie ont toujours etabli le diagnostic. Six patients n'avaient pas de lithiase vesiculaire. Resultats Le traitement chirurgical d'exerese a ete une lobectomie gauche (sept cas), une hepatectomie gauche (deux cas) et une hepatectomie droite (trois cas). Une anastomose biliojejunale intrahilaire a ete etablie dans cinq cas. L'examen anatomopathologique des pieces d'hepatectomie montrait dans tous les cas une dilatation kystique des voies biliaires intrahepatiques segmentaires et sous-segmentaires sous forme de cavites kystiques de quelques millimetres a 4 cm contenant des calculs. Il y avait dans deux cas une fibrose hepatique congenitale et dans un cas, une heterotopie pancreatique intrahepatique. Aucune lesion de cholangiocarcinome n'a ete observee. Un patient a developpe dans les suites operatoires une fistule biliaire necessitant une reintervention. A distance, tous ont eu une evolution favorable a l'exception d'un patient decede d'un cancer colique apres trois ans. Conclusion Associee a d'autres malformations, et notamment a une fibrose hepatique congenitale, cette affection habituellement diffuse porte le nom de syndrome de Caroli. La forme monolobaire, localisee le plus souvent a gauche, repond au terme de maladie de Caroli. Les formes monolobaires et les formes diffuses sont revelees par des acces de cholangite et, dans plus de la moitie des cas, par une lithiase de la voie biliaire principale en l'absence de lithiase de la vesicule.

Liver metabolism may be modified after liver transplantation according to the phenotype of the donor and may be influenced by posttransplantation complications. The CYP2D6 phenotype was assessed in 13 patients (group I) before and after liver transplantation using debrisoquine. CYP2D6 activity was also assessed in vitro on microsomes from the liver of the recipients and the donors, using dextromethorphan. Twelve patients were extensive metabolizers both before and after transplantation. One apparently poor metabolizer was transplanted with the liver of another poor metabolizer. The intrinsic clearance of dextromethorphan (CL(int)) measured on recipient liver microsomes was significantly lower than that on donor liver microsomes (p < 0.05). In extensive metabolizers, the debrisoquine metabolic ratio was correlated with CL(int) before (r = 0.78, p < 0.05) and after (r = 0.89, p < 0.0005) transplantation. Debrisoquine phenotype was measured repeatedly in nine additional patients (group II) up to 3 years after liver transplantation. Their phenotype was stable during the follow-up observation, although the variations observed may be clinically relevant. Therefore, no change in CYP2D6 phenotype (extensive/poor metabolizer) was observed because of the liver transplantation, and the debrisoquine log metabolic ratio was largely unaffected by the liver complications observed during the posttransplantation follow-up observation.

International audience; The present study aimed to identify a sub-group of inoperable alveolar echinococcosis (AE) patients undergoing long-term treatment with benzimidazole (BZM) who presented with an evolution suggestive of a parasitocidal effect. An evolution compatible with parasite death was observed in five patients.

To determine the value of multidetector-row CT (MDCT) in the management of sigmoid volvulus.Twenty-three MDCT examinations showing sigmoid volvulus were retrospectively evaluated and analyzed based on the type of volvulus (mesentericoaxial versus organoaxial), degree of rotation (180 degrees or 360 degrees ), maximum diameter of the volvulized sigmoid loop and presence or absence of the northern exposure sign, signs of bowel wall ischemia, and ascitis. A statistical analysis was performed to determine the correlation between patients characteristics, CT findings, type of management, and histological findings when available.In our study, organoaxial volvulus occurred in older patients (p=0.047), had a higher risk of recurrence (p=0.015) and more frequently required urgent surgical management than mesentericoaxial volvulus. A higher degree of rotation was associated with a more distended volvulized sigmoid colon (p=0.033) and more frequently required surgery.In addition to detection of volvulus and signs of bowel wall ischemic, MDCT can characterize the type of volvulus and degree of rotation, findings that may assist in determining the severity of the process and direct towards optimal management, endoscopic or surgical.

Between 185 and 190, 14 consecutive patients were entered into a prospective study of conventional adjuvant post-operative external beam radiotherapy after complete resection for a pancreatic adenocarcinoma. The surgical procedure was a Whipple resection in nine patients, a distal pancreatectomy in four patients and a total pancreatectomy in one patient. There were three T 1b eight T 2 and three T 3 tumours (UICC 1987); nodal involvement was present in five cases. The radiotherapy was delivered using a four-field box technique with a 23 x MV photon beam. All patients received a total dose of 54 Gy to the tumour bed. The mean treated volume was 900 cm 3 . Acute toxicities consisted mainly of weight loss (mean: 2 kg). Two patients had a grade 2 diarrhoea and two patients a grade 2 gastritis. Late effects were minimal and only observed in two patients. The overall locoregional recurrence (LR) rate was 50%. The median disease-free survival was 12 months, and the median survival was 23 months. This post-operative conventional radiotherapy treatment gives results that are comparable to the results of the GITSG-Aduvant study using a combination of split-course radiotherapy and 5-fiuorouracil (5-FU).

Between 1986 and 1989, orthotopic liver transplantations were performed in our unit for 17 patients with incurable alveolar echinococcosis. Ten patients had hilar involvement (group I), and seven patients had posterior localization (five of them had chronic Budd-Chiari syndrome) (group II). The delay between diagnosis and the orthotopic liver transplantation was more than 48 mo in group Ia (six patients), less than 24 mo in group Ib (four patients) and less than 48 mo in group II. Previous operations were more common in group Ia than in group Ib and II. Five patients have died-four in group I and one in group II. The actuarial survival rate at 15 mo was 75%. Early reoperations were frequent (69%), mainly caused by rebleeding. Bacterial and fungal infections occurred only in group Ia (four cases) and group II (three cases). In eight patients (palliative group), residual foci of infected nonhepatic tissue occurred after surgery. The titer of specific antibodies decreased during the first 3 mo in all the patients but one. In patients with radical liver transplantation, the complete disappearance of specific antibodies occurred within 2 yr in four cases. In the remaining five patients, specific antibodies remained detectable, but no evidence of recurrence has been obtained up to now. In the palliative group, a peak of specific IgM occurred at 3 mo; an increase of specific IgG was observed later. The growth of residual parasitic foci was relatively slow, and all these patients remained asymptomatic with a mean follow-up of 19 mo. We conclude that orthotopic liver transplantation is feasible in incurable alveolar echinococcosis and could be proposed without delay to patients with parasitic Budd-Chiari syndrome or complicated secondary biliary cirrhosis. In the other cases, the best time to perform an orthotopic liver transplantation is more difficult to determine. Nevertheless, in the perspective of an orthotopic liver transplantation, the management of these patients has to change, and repetitive laparotomies for palliative surgical procedures have to be replaced by interventional radiology.

Unplanned readmission after colorectal surgery is a relatively frequent event, knowledge of which often is inaccurate. This study was designed to examine the incidence and causes of readmissions and to determine the criteria that could predict them. From June to September 2002, 1,421 patients were enrolled in a prospective, multicenter study performed by the Association Francaise de Chirurgie. The goal of the study was to determine mortality and morbidity after colorectal surgery for elective or emergency surgical management of diverticular disease or cancer. In the study, readmissions within three months after discharge were assessed. Of 1,421 patients, 342 patients (27 percent) were readmitted once after a mean period of 53 days. Among the readmissions, 248 (19.5 percent) were planned and 94 (7.5 percent) were unplanned (mainly for septic complications). With the multivariate logistic regression analysis, five independent factors were significantly associated with a higher risk of unplanned readmission (in order of importance): surgical field contamination, long duration of operation, need for an associated surgical procedure, hemoglobin level

Tobacco smoking is associated with a higher risk of developing colorectal cancer. This study was designed to assess the role of smoking in early onset of colorectal pathology. This was a prospective cross-sectional study of 997 patients with colorectal cancer. Age of colorectal cancer diagnosis was studied in two groups of patients, i.e., smokers (>10 pack-years) and nonsmokers. Confounding factors, such as alcohol drinking, obesity, and gender, also were studied using a correlation analysis and multivariate logistic regression analysis. Of the 997 patients, 852 had sufficient data for analysis and were included. Baseline analysis showed that excluded patients had similar demographic characteristics. Smokers (n = 108) reported symptoms related to colorectal cancer at an earlier mean age (64.1 (standard deviation, 11.7) years) than nonsmokers (69.6 (standard deviation, 12.6) years; mean difference, 5.5 (standard deviation, 1.2 years); P < 0.001). Impact of smoking according to the bowel segment involved was significant for slow-transit segments (transverse and sigmoid colon and rectum). Multivariate analysis revealed that tobacco smoking was the only independent risk factor of early onset of colorectal cancers. Tobacco smoking could be a factor of early onset of colorectal cancers especially for slow-transit bowel segments. If these findings are confirmed in larger studies, screening for colorectal cancer should not involve a simple sigmoidoscopy but also an exploration of transverse colon in smokers.

BackgroundThe aim of this study was to compare in-hospital morbidity and mortality rates after elective laparoscopic and open colorectal surgery for sigmoid diverticular disease (SDD).MethodsThis prospective national multicentre observational study included all consecutive patients undergoing open or laparoscopic elective colectomy for SDD in a 4-month period between June and September 2002. Postoperative in-hospital mortality and morbidity in the two groups were compared.ResultsThree hundred and thirty-two consecutive patients undergoing either laparoscopic (163 patients) or open (169 patients) colectomy for SDD were analysed. Overall postoperative mortality and morbidity rates were 0·3 and 23·8 per cent respectively. The morbidity rate was significantly higher in the open than in the laparoscopic group (P < 0·001), leading to a significantly longer hospital stay (P < 0·001). The morbidity rate remained significantly higher in the open group when the patients were matched for age (P = 0·015) or American Society of Anesthesiologists score (P = 0·028). An open procedure (relative risk (RR) 2·13 (95 per cent confidence interval (c.i.) 1·29 to 3·45)), age over 70 years (RR 1·62 (95 per cent c.i. 1·14 to 2·30)) and intraperitoneal contamination (RR 2·54 (95 per cent c.i. 1·18 to 5·50)) were identified as independent risk factors for morbidity.ConclusionA laparoscopic approach to elective treatment of SDD may be associated with reduced postoperative morbidity and hospital stay. A randomized study is required to confirm these results.

Various incubation conditions of human hepatocytes were compared for their accuracy in predicting the in vivo hepatic clearance (CL(H)) of model compounds. The test compounds were the highly cleared, low protein bound naloxone (in vivo CL(H) = 25 ml min(-1) kg(-1); free fraction = 0.6), the medium clearance, highly protein bound midazolam (CL(H) = 12 ml min(-1) kg(-1); free fraction = 0.04) and the low clearance, highly protein bound bosentan (CL(H) = 3.9 ml min(-1) kg(-1); free fraction = 0.02). Each compound was tested in three 'hepatocyte systems', using resections from three donors, in the presence and absence of human serum. Those hepatocyte systems were: conventional primary cultures, freshly isolated suspensions and cryopreserved suspended hepatocytes. Except for a twofold overestimated CL(H) for bosentan from conventional primary cultures, and despite variable cryopreservation recoveries, similar predictions of CL(H) were recorded with all hepatocyte systems. Moreover, the CL(H) values obtained with cryopreserved suspended hepatocytes were similar to those obtained with freshly isolated suspensions. For midazolam and bosentan, the predicted in vivo CL(H) was markedly higher in the presence of serum, whereas serum had little influence on the scaled-up CL(H) of naloxone. In vivo, CL(H) was properly approached for naloxone and bosentan (particularly from experiments in the presence of serum), but it was strongly underestimated for midazolam (particularly in the absence of serum). Additional compounds need to be investigated to confirm the above findings as well as to assess why the clearances of some highly protein-bound compounds are still considerably underestimated.

To study the possible influence of ursodiol (ursodeoxycholic acid), a hydrophilic bile acid, on cyclosporine (CsA) bioavailability.Seven adult liver transplant recipients participated in a randomised cross-over pharmacokinetic study comparing ursodiol (600 mg) with placebo in single doses. Blood concentrations of CsA were measured by HPLC.There was no significant effect of ursodiol on CsA absorption: AUC was 5011 vs 5486 ng.h.ml-1, Cmax was 832 vs 871 ng.ml-1 and tmax was 2 vs 2 h, after ursodiol and placebo, respectively.Although a significant period effect was observed, we conclude that a single dose of ursodiol has little effect on CsA absorption in liver transplant patients and that an interaction in the intestinal lumen between these two drugs is unlikely.

Determine the gain of hospitalization cost using a new intraperitoneal mesh compared to the retro-muscular pre-fascial implantation of a polyester mesh.From January 1998 to June 2000, 52 patients with incisional hernia of the anterior abdominal wall were operated using intraperitoneal Parietex composite Mesh. The cost of surgery, anesthesia and hospitalization in this group were compared to similar data from a group of 21 patient where a Mesrsuture mesh in a prefascial retromuscular position was used.Parietex Composite Mesh in intraperitoneal position allows a significative reduction in surgery time, anesthesia time and hospitalization. The clinical results were confirmed by cost savings.Using new innovative medical device changing surgery technique insures significant cost saving despite its initial additional cost and increases patient's comfort during hospitalization.

The aim of the present study was to analyse, retrospectively on a large panel of patients (149), the influence of the donor liver characteristics on the outcome of human hepatocyte isolation obtained from resected liver biopsies from surgical waste after hepatectomy. Among the pre-operative parameters, the type of disease, age and sex of the patient, previous chemotherapy, alcohol or tobacco consumption did not affect the yield, viability, attachment rate and function of the isolated human hepatocytes. Pre-operative biological and anatomopathological data indicated that, while mild steatosis (/=10% steatotic hepatocytes) did also not affect the outcome of hepatocyte isolation, stronger steatosis (10% steatotic hepatocytes) tended to decrease hepatocyte yield. Cholestasis, as assessed by gamma-glutamyl transferase serum values, significantly negatively correlated with the percentage of digested liver and the yield of viable cells. Intra-operative clamping time, that is, warm ischaemia, longer than 30 min was found to decrease both the percentage of digested liver and cell yield. Among the post-operative parameters, the percentage of digested liver decreased when biopsy weights were higher than 100 g, the use of glue tended to increase both the percentage of digested tissue and the yield of viable cells.In conclusion, human diseased livers appear to be a valuable source of isolated functional human hepatocytes. We recommend, for an optimal isolation, to use liver biopsies weighing less than 100 g, to glue the section surfaces of the biopsies and to avoid the use of moderate steatotic livers (10% steatotic hepatocytes) and cholestatic livers, as well as livers undergoing warm ischaemia or clamping during resection due to the decrease in cell yield.

Gastrointestinal stromal tumours (Gist) are mesenchymal tumour with uncertain prognosis occurring in the gastrointestinal tract wall. For clinicians, these tumours raise two problems: to establish the diagnosis and to determinate the future behaviour for the choice officient therapeutics. For the diagnosis the new marker c-KIT is useful. A new treatment with an inhibitor of c-KIT has given encouraging results. currently there is no consensus on specific cut-points to distinguish as low or high risk (i.e., malignant) Gist. For metastases-free Gist, the prominent histopronostic markers are size, mitotic index and localization of the tumour. The small intestine Gist have the reputation to be more aggressive than in other localization. Skenoid fibers in small intestine Gist could be a marker of good prognostic. The authors reported three cases of small intestine Gist with skenoid fibers. The discussion point out the significance of this particular morphological aspect.

Abdominal actinomycosis is an unusual peritoneal disease due to actinomyces, which are Gram-positive bacillus bacteria. Those saprophytes pathogens of digestive tract and genital mucous, can appear accidentally in the peritoneum cavity, in tumor form, simulating a neoplasic disease. We report the case of a 43-year old woman, with abdominal actinomycosis, revealed by feverish bowel obstruction. During laparotomy, several nodes were removed. Their histologic study permitted the diagnosis. Long-term antibiotics treatment allowed patient recovery.

Background: Alveolar echinococcosis (AE) of the liver, caused by the larval stage of the fox tapeworm Echinococcus multilocularis, has the characteristics of a slow-growing liver cancer. It is one of the rare parasitic diseases for which a parasitolytic drug is not yet available, and AE is lethal in the absence of appropriate therapeutic management. Complete surgical resection of the parasite at an early stage of infection provides favourable prospects for cure, but, due to a long clinical latency, many cases are diagnosed at an advanced stage, so that partial liver resection can be performed in only 35% of patients. Benzimidazole (BZM) treatment is given in inoperable cases but these compounds are only parasitostatic, and lifelong therapy is required. During the past 20 years some centres have considered liver transplantation (LT) for the treatment of incurable AE. Methods: Our review summarizes the results of this experience based on a series of 47 European patients who received transplants between 1985 and 2002, tries to specify the real place of LT for AE, and underlines the measures that could be undertaken in the future to improve the results. Results: Five-year survival was 71%. Five-year survival without recurrence was 58%. Major technical difficulties related either to previous laparotomies or to the loco-regional involvement were observed. The nine early deaths concerned AE patients with a long past-history of symptomatic AE (iterative cholangitis, secondary biliary cirrhosis). Five late deaths were directly related to ongoing AE, located in the brain in three cases, a very rare AE location that was not investigated before LT in these patients. Conclusions: In general, the pre-LT screening for distant AE metastases appeared insufficient in this series. Heavy immunosuppressive schemes, absence or delayed re-introduction of BZM after LT have clearly played a role in this unfavourable course. This unique experience indicates that, despite major technical difficulties, LT for incurable AE is feasible and could be discussed in very symptomatic cases. Before LT, interventional radiology should be preferred to repeated laparotomies. Pre-LT and post-LT BZM treatment is mandatory. A careful evaluation of possible distant metastases should be done before the decision for LT is made. After LT, the possibility of an ongoing AE must be permanently kept in mind. This could be reduced by lightening the immunosuppressants, carefully following the specific circulating antibodies, and applying a systematic radiological evaluation, not only to the graft but also to the lungs and the brain

Isolated human hepatocytes have been shown to represent a valuable in vitro model to investigate the metabolism and cytotoxicity of xenobiotics. In addition, human hepatocyte transplantation and artificial liver support systems using isolated human hepatocytes are currently investigated as treatment for acute and chronic hepatic failure. In this regard, human hepatocyte banking by cryopreservation would be of great interest. In the present study, freshly isolated hepatocytes from resected liver biopsies of 28 separate donors (viability: 88 +/- 2%; plating efficiency: 79 +/- 5%) were cryopreserved using two different protocols, stepwise freezing (SF) or progressive freezing (PF), in combination (PF(+), SF(+)) or not (PF(-), SF(-)) with a 30 min preincubation in culture medium at 37 degrees C. Total recovery was higher after PF (38 +/- 3%) than after SF (12 +/- 2%). Preincubation prior to SF had no effect on plating efficiency of thawed hepatocytes (SF(-): 38 +/- 6% versus SF(+): 46 +/- 7%) while preincubation prior to PF increased plating efficiency of thawed hepatocytes (PF(-): 42 +/- 6% versus PF(+): 64 +/- 4%, p0.05). In attached cultured human cryopreserved/thawed hepatocytes (CH) from the PF(+) group, albumin production and glutathione content were not significantly different from those of the freshly isolated hepatocyte (FIH) cultures. Cells in CH monolayers appeared smaller than cells in FIH monolayers. In addition, the pattern of cytochrome P450- and UDP-glucuronosyl transferase-dependent isoenzyme activities and GST activity were different, suggesting a variability in the resistance to cryopreservation of the various liver hepatocyte populations. Taken all together, the results of the present study suggest that recovery of human hepatocytes after isolation prior to progressive freezing should allow human hepatocyte banking for use in pharmacotoxicology and cell therapy research purposes.

Endoscopic ultrasonography is considered a highly accurate procedure for diagnosing small pancreatic tumors and assessing their locoregional extension.To evaluate the impact of endoscopic ultrasonography on the management of pancreatic adenocarcinoma in clinical practice.Sixty-four consecutive patients (mean age 70.5 plus/minus 11.9 years) hospitalized for staging or diagnosis of pancreatic adenocarcinoma were retrospectively (from January 1995 to November 1997) or prospectively studied (from December 1997 to August 1999).Group 1 consisted of 52 patients with pancreatic adenocarcinoma which was discovered using computerized tomography scanning and/or ultrasound. Endoscopic ultrasonography was utilized for staging purposes only in patients who were considered to be operable and the tumor to be resectable based on computerized tomography scanning criteria. Group 2 consisted of 12 patients who were diagnosed as having a pancreatic adenocarcinoma using endoscopic ultrasonography whereas computerized tomography scanning and ultrasound was negative.The impact of endoscopic ultrasonography was analyzed on the basis of the number of patients requiring endoscopic ultrasonography as a staging procedure (Group 1) and by evaluating the performance of endoscopic ultrasonography in determining resectability (Groups 1 and 2) based on the surgical and anatomopathological results.Endoscopic ultrasonography was performed in 20 out of 64 patients (31.3%): 8/52 in Group 1 (15.4%) and all 12 patients of Group 2. Endoscopic ultrasonography correctly assessed an absolute contraindication to resection in 11 cases. Resection was confirmed in 8 of the 9 cases selected by endoscopic ultrasonography. The positive predictive value, negative predictive value and overall accuracy of endoscopic ultrasonography for determining resection were 89%, 100%, and 95%, respectively.The impact of endoscopic ultrasonography seems especially relevant for the detection of pancreatic tumors after negative computerized tomography scanning, and for the prevention of unnecessary laparotomies as complementary staging after ultrasonography and computerized tomography scanning.

The total mesorectal excision allows the marked increase of the local control rate in rectal cancer. Therefore, the mesorectal space is the usual field for the spread of rectal cancer cells. It could therefore be considered as the clinical target volume in the preoperative plan by the radiation oncologist. We propose to identify the mesorectum on anatomical structures of a treatment-position CT scan.

Only limited data are available on comparative genomic hybridization (CGH) in hepatocellular carcinoma (HCC). They concern mainly B virus related HCC. Therefore, we used CGH to detect chromosomal imbalances in 16 non-B virus related HCC in alcoholic cirrhosis in 7 cases (HA1 to HA7), in C virus cirrhosis in 7 cases (HC1 to HC7), in non-cirrhotic liver in 2 cases (NC1, NC2), and in 9 non-malignant cirrhotic tissues. The most frequent imbalances in HCC were gains of whole chromosomes or chromosomal regions 7 or 7q (10/16, 62%), 1q (9/16, 56%), 5 or 5q (9/16, 56%), 8q (8/16, 50%), 6p (6/16, 37%), 15q (5/16, 31%), 20 or 20q (5/16, 31%), and losses of 17p (6/16, 37%), and 8p (5/16, 31%). High-level gains were identified in HCC on 1q (2/16), 3q (1/16), 7q (1/16), and 8q (3/16). No chromosomal imbalances were detected in any of the cirrhotic tissues. Most of the gains, losses, and amplifications detected in this CGH study corresponded well to those identified in previous studies, except for gains of whole chromosome 5 or 7 and/or of chromosome arms 5q or 7q and losses on 4q. Our results suggest that other chromosomal regions are involved in hepatocarcinogenesis.

Verneuil's disease (hidradenitis suppurativa) is a chronic inflammatory, suppurating and fistulizing disease of apocrine sweat gland-bearing skin. The aim of this study was to describe the surgical treatment, conducted in 15 patients suffering from this disease.We retrospectively analyzed 15 observations (9 men, 6 women, mean age 38.6). The mean delay between beginning of the symptoms and diagnosis was 55.5 months. Surgery was conducted at the stage of abscesses, fistulization and keloids in all patients. The first surgical step was wide and deep excision of affected skin and subcutaneous fat. The second step was secondary intention healing, or ideal suture, Z plasty or dorsalis major flap.Only four patients had complications: two axillary strictures, one anal margin stenosis and one hypertrophic scarring. Three relapses occurred, treated by excision under local anesthesia.Surgical treatment seems to be the only definitive treatment of Verneuil's disease.

To assess toxicity and long-term results of preoperative chemoradiotherapy in rectal cancer.Between 1989 and 1997, as a phase II study, 66 patients with T3 M0, rectal cancer received preoperatively a 45 Gy dose pelvic radiotherapy (XRT) combined with two 5-day chemotherapy courses (CT) of 5-Fluorouracil (5-FU) and Leucovorin (LV) delivered the first and fifth week of XRT. For each CT course, LV:20 mg/m2/d1-d5,. While the 5-FU dose was variable from 450 to 350 mg/m2/d first course and 370 to 350 mg/m2/d second course. Surgery was planned 3 weeks later.XRT-CT was stopped in 1 patient due to progressive disease. CT was stopped in 1 patient due to toxicity. Grades 2 and 3 diarrhea were observed in 8 and 3 patients, respectively. One patient died from acute diarrhea due to deviation from recommendations; 60 patients went to surgery. Among the 58 patients operated on for cure, 5 had an R1-resection. After a 4.5-year median follow-up, the 5-year pelvic disease-free survival was 92% for the whole group and 96% in the R0-resection group.Preoperative combined XRT-5-FU-LV is feasible if optimal XRT and patients are carefully managed. The recommended 5-FU daily dose is 350 mg/m2 for both CT courses. This approach is currently tested in a large EORTC phase III trial.

Neuroendocrine tumors of the ampulla of Vater are rare (less than 100 cases reported). We report here a new case characterized by histamine secretion, a hitherto unreported feature. Clinical presentation is similar to that of other tumors of the ampulla of Vater. In our observation, the patient had noticed urticaria on the right forearm for several months. Tumor of the ampulla was confirmed by endoscopic ultrasonography, while neuroendocrine characterization was assessed on biopsies after endoscopic sphincterotomy. Histamine concentration in blood was the only elevated neuroendocrine marker and returned to normal after surgical resection. Histology showed a neuroendocrine tumor with extension to lymph nodes. On immunohistochemical analysis, production of histamine was confirmed, and the diagnosis of mastocytoma was eliminated. In view of the literature, neuroendocrine tumors of the ampulla of Vater are associated with a good prognosis (5 year-survival rate: 90%) despite early lymph node involvement.

Between 1986 and 1991, 21 patients received liver grafts in our center for incurable alveolar echinococcosis (AE). The aim of this study was to analyze the long-term results in 15 of these 21 patients who survived more than 1 year after undergoing a liver transplantation (LT). The follow-up, mainly aimed at the diagnosis of recurrence, consisted of repeated radiological and specific immunological investigations. The role of pre- and post-LT benzimidazole (BZM) therapy was also evaluated. Among the 15 patients, 8 patients had a palliative LT related to previously known pulmonary AE metastases and/or inextirpable abdominal parasitic foci. In the 7 remaining patients, LT was considered curative. In June 1998, the mean follow-up duration was 96 months (range: 28-138 months). Five late deaths occurred, 2 of them were directly related to residual AE. A reinfection of the graft was observed in 4 patients. Preoperative BZM therapy seemed useful in preventing or delaying the parasitic recurrence. Post-LT BZM was able to stabilize and even to reduce residual AE. The anti-Em2 enzyme-linked immunosorbent assay (ELISA), which is the standard test used in patient follow-up after partial liver resection for AE, did not appear useful in detecting recurrence here; however, an ELISA, using a crude heterologous antigen (Echinococcus granulosus) allowed early diagnosis of residual AE. In conclusion, primary disease recurrence is not rare after LT for AE. Immunosuppressive therapy may favor larval growth in extrahepatic sites; therefore, an extensive extrahepatic radiological check-up has to be performed before LT. BZM therapy seems to stabilize residual foci. Anti-Eg immunoglobulin G (IgG) follow-up is the most useful test for early diagnosis of parasite recurrence.

Alcoholic cirrhosis is the most common cause of liver transplantation in US males. The limited number of donor livers calls for "prioritisation", favouring those patients who will benefit most. The aim was to assess the efficacy of liver transplantation in patients with alcoholic cirrhosis.We compared the survival of 169 transplanted patients with two conservatively treated control groups, one of 169 patients matched for prognostic factors (age, cirrhosis severity, bleeding history) and one of 169 simulated patients.The probability of survival to 5 years in the transplanted group was 66% (95% confidence interval 58-74%) vs. 52% (44-60; p = 0.03) in the matched group and 54% (51-57; p = 0.01) in the simulated controls. Transplantation was associated with survival (relative risk = 1.51; p = 0.02), independently of risk score (risk = 2.07; p0.001), indication, period of inclusion, centre experience, and alcohol abstinence. Patients with severe disease (Pugh C11-15) benefited most in terms of 5-year survival: 58% (44-72) vs. 31% (17-45; p = 0.008) in the matched and 35% (30-40; p0.001) in the simulated control groups. For patients at lower risk there was no significant difference.Liver transplantation increases the 5-year survival of patients with severe alcoholic cirrhosis. In patients at lower risk, efficacy of transplantation should be confirmed by longer follow-up or by randomised trial.