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Thermal ablation is a minimally invasive technique used to induce a controlled necrosis of malignant cells by increasing the temperature in localized areas. This procedure needs an accurate and real-time monitoring of thermal effects to evaluate and control treatment outcome. In this work, a hyperspectral imaging (HSI) technique is proposed as a new and non-invasive method to monitor ablative therapy. HSI provides images of the target object in several spectral bands, hence the reflectance/absorbance spectrum for each pixel. This paper presents a preliminary and original HSI-based analysis of the thermal state in the in vivo porcine liver undergoing laser ablation. In order to compare the spectral response between treated and untreated areas of the organ, proper Regions of Interest (ROIs) were chosen on the hyperspectral images; for each ROI, the absorbance variation for the selected wavelengths (i.e., 630, 760, and 960nm, for deoxyhemoglobin, methemoglobin, and water respectively) was assessed. Results obtained during and after laser ablation show that the absorbance of the methemoglobin peaks increases up to 40% in the burned region with respect to the non-ablated one. Conversely, the relative change of deoxyhemoglobin and water peaks is less marked. Based on these results, absorbance threshold values were retrieved and used to visualize the ablation zone on the images. This preliminary analysis suggests that a combination of the absorbance information is essential to achieve a more accurate identification of the ablation region. The results encourage further studies on the correlation between thermal effects and the spectral response of biological tissues undergoing thermal ablation, for final clinical use.

The aim of the study was to evaluate the feasibility of a longitudinal non-invasive monitoring of rat pancreatic ductal adenocarcinoma (PDAC) using microCTscans (μCT). The identification of the pancreatic gland on (μCT) was performed at first using contrast products (Fenestra LC and VC, v/v) at a dosage of 0.5 ml/Kg of body weight. Then orthotopic PDAC developed in adult Lewis rat was detected and monitored. In vivo μCT measurement of tumor was compared to actual size ex vivo in 12 rats. Gemcitabine treatment of PDAC was monitored at two week intervals until defined endpoints (liver metastasis or ascitis) in 10 rats versus 10 controls. μCT had a 100% positive predictive value in the detection of orthotropic PDAC. Regression analysis showed a linear correlation between ex vivo and in vivo μCT tumor measurements. Longitudinal evaluation of tumor progression showed a reduction in tumor growth (P

Einfuhrung Divertikelerkrankungen sind in westlichen Gesellschaften sehr haufig. Allerdings gibt es eine Tendenz dazu, die Indikation fur eine chirurgische Therapie der Divertikulitis seltener zu stellen. Minimal-invasive Operationen bieten viele potenzielle Vorteile fur Patienten bei der Divertikulitisbehandlung und konnen zur Optimierung chirurgischer Indikationen fuhren.

Once in a few decades in science or medicine, an idea emerges that is so powerful that it changes forever how we think about that field. Natural Orifices Translumenal Endoscopic Surgery (NOTES) has the potential to break the physical barrier between bodily trauma and surgery. At the dawn of surgery, excellence was associated with big incisions: “big scar - big surgeon”. In the 80s, minimally invasive surgery was born representing one of the greatest surgical evolutions of the 20th century. After Kalloo's first report in 2004 on transgastric peritoneoscopy in a porcine model, the interest in natural orifice transluminal endoscopic surgery (NOTES) has blossomed. Theoretically the same operation performed laparoscopically could be carried out through natural orifices without any abdominal incision avoiding pain and scarring. The lesson learned from the advent of laparoscopic surgery, thought us that we could be witnessing the birth of another surgical revolution. Since 2004 many abdominal procedures that use a NOTES approach have been successfully performed in animal models. However, the initial excitement for NOTES has been somewhat tempered by the reality that a NOTES procedure in human without laparoscopic assistance has not been performed by most groups. Indeed, a major issue is the lack of stable operative platform and flexible instruments that allow retraction and exposure of the organs, such as appendix or gallbladder. Will this issue change the future of NOTES?

Resume Kodamaea ohmeri est une levure rarement isolee en pathologie humaine. Depuis le premier cas de fongemie decrit en 1998, une quinzaine d’infections locales ou disseminees impliquant cette levure ont ete decrites. Nous rapportons le cas d’une patiente de 91 ans hospitalisee pour une alteration de l’etat general. Devant la suspicion d’une ischemie intestinale, elle subit une laparotomie exploratrice et une colostomie. Au dix-huitieme jour d’hospitalisation, elle developpe une embolie pulmonaire, puis presente, les jours suivants, une fievre fluctuante, une cyanose des extremites et une hyperleucocytose. Une aspiration tracheale, un prelevement urinaire, puis une hemoculture revelent la presence d’une levure tout d’abord identifiee comme Candida albicans sur milieu chromogene. Une relecture des primocultures, au bout de 96 heures, met en evidence une modification de l’aspect des colonies et remet en cause l’identification initiale. Des tests biochimiques complementaires et un sequencage moleculaire permettent finalement d’identifier K. ohmeri . L’etat respiratoire de la patiente se degrade progressivement et elle decede au vingt-cinquieme jour d’hospitalisation.

La incidencia de complicaciones de la ulcera gastroduodenal ha disminuido de forma significativa gracias al conocimiento de la fisiopatologia de la enfermedad ulcerosa y a la erradicacion de la bacteria Helicobacter pylori. La endoscopia permite un diagnostico preciso de las complicaciones de la enfermedad ulcerosa, el control de las hemorragias ulcerosas en mas del 90% de los casos y la dilatacion de las estenosis piloricas. Por ello cada vez es menos frecuente recurrir a una intervencion quirurgica. No obstante, hay que saber cuando ha llegado el momento de la cirugia, que sigue estando indicada en el tratamiento de las perforaciones ulcerosas en la mayoria de los casos, para controlar una hemorragia grave y para derivar las estenosis piloricas resistentes a la dilatacion y al tratamiento medico. El tratamiento quirurgico de la enfermedad ulcerosa en la misma intervencion quirurgica cada vez se encuentra mas discutido, debido a la eficacia del tratamiento medico, a las dificultades de esta cirugia en un contexto urgente y a la morbilidad de una vagotomia carente de utilidad. El acceso laparoscopico ha adquirido un lugar preponderante para la realizacion de estas tecnicas y la urgencia o la presencia de una peritonitis ya no se consideran contraindicaciones.

L’incidenza delle complicazioni dell’ulcera gastroduodenale si e significativamente ridotta grazie alla conoscenza della fisiopatologia della malattia ulcerosa e all’eradicazione dell’«Helicobacter pylori». L’endoscopia permette una diagnosi precisa delle complicazioni della malattia ulcerosa, il controllo delle emorragie ulcerose in piu del 90% dei casi e la dilatazione delle stenosi piloriche. Il ricorso alla chirurgia si e fatto quindi sempre piu raro. Si deve comunque saper non mancare l’indicazione alla chirurgia, che resta attuale per il trattamento delle perforazioni ulcerose nella maggior parte dei casi, per controllare un’emorragia maggiore e per derivare stenosi piloriche resistenti alla dilatazione e al trattamento medico. Il trattamento chirurgico della malattia ulcerosa nello stesso tempo operatorio e sempre piu oggetto di controversia a causa dell’efficacia del trattamento medico, delle difficolta di questa chirurgia in urgenza e della morbilita di una vagotomia inutile. L’accesso laparoscopico riveste ormai uno spazio preponderante nella realizzazione di questi interventi, dato che ne l’urgenza ne la presenza di peritonite sono piu considerate delle controindicazioni.

Resume Les contusions et plaies de l’abdomen sont classiquement regroupees dans la meme entite car les grands principes de leur traitement se superposent. Ils visent a restaurer un etat hemodynamique satisfaisant, a realiser un bilan lesionnel aussi rapide et precis que possible, et enfin a traiter de facon optimale chaque lesion. La prise en charge de ces traumatises debute par leur « ramassage » et leur transfert en unite specialisee. La, une etroite collaboration entre plusieurs specialistes (anesthesiste, reanimateur, chirurgien, radiologue) est necessaire pour assurer le diagnostic et le traitement des lesions. La prise en charge de ces blesses est en constante evolution, prenant en compte les apports les plus recents de la technique : echographie, scanners et angiographies diagnostiques et interventionnelles facilement disponibles dans les centres les mieux equipes ; laparoscopie diagnostique et therapeutique pour les praticiens les mieux formes. Il s’y ajoute une modification de certains concepts, en particulier la chirurgie « ecourtee » ou le pronostic immediat prime sur le traitement definitif des lesions et l’approche mini-invasive et conservatrice face a de nombreux traumatismes hemorragiques. Cette mutation ameliore la survie des patients tout en diminuant les complications et sequelles liees au traitement des lesions.

Resume Les contusions et plaies de l’abdomen sont classiquement regroupees dans la meme entite car les grands principes de leur traitement se superposent. Ils visent a restaurer un etat hemodynamique satisfaisant, a realiser un bilan lesionnel aussi rapide et precis que possible, et enfin a traiter de facon optimale chaque lesion. La prise en charge de ces traumatises debute par leur « ramassage » et leur transfert en unite specialisee. La, une etroite collaboration entre plusieurs specialistes (anesthesiste, reanimateur, chirurgien, radiologue) est necessaire pour assurer le diagnostic et le traitement des lesions. La prise en charge de ces blesses est en constante evolution, prenant en compte les apports les plus recents de la technique : echographie, scanners et angiographies diagnostiques et interventionnelles facilement disponibles dans les centres les mieux equipes ; laparoscopie diagnostique et therapeutique pour les praticiens les mieux formes. Il s’y ajoute une modification de certains concepts, en particulier la chirurgie « ecourtee » ou le pronostic immediat prime sur le traitement definitif des lesions et l’approche mini-invasive et conservatrice face a de nombreux traumatismes hemorragiques. Cette mutation ameliore la survie des patients tout en diminuant les complications et sequelles liees au traitement des lesions.

Peritoneal dissemination is a common end-stage complication of pancreatic cancer for which novel therapeutic modalities are actively investigated, as there is no current effective therapy. Thus, we evaluated, in a mouse model of pancreatic peritoneal carcinomatosis, the therapeutic potential of a novel nonviral gene therapy approach consisting of bis-guanidinium-tren-cholesterol (BGTC)-mediated lipofection of a combined suicide gene system. Human BxPC-3 pancreatic cells secreting the carcinoembryonic antigen (CEA) tumor marker were injected into the peritoneal cavity of nude mice. After 8 days, intraperitoneal (i.p.) lipofection was performed using BGTC/DOPE cationic liposomes complexed with plasmids encoding the two prodrug-activating enzymes Herpes Simplex Virus thymidine kinase and Escherichia coli cytosine deaminase, the latter being expressed from a bicistronic cassette also encoding E. coli uracil phosphoribosyltransferase. Administration of the lipoplexes was followed by treatment with the corresponding prodrugs ganciclovir and 5-fluorocytosine. The results presented herein demonstrate that BGTC/DOPE liposomes can efficiently mediate gene transfection into peritoneal tumor nodules. Indeed, HSV-TK mRNA was detected in tumor nodule tissues by semiquantitative reverse transcription-polymerase chain reaction analysis. In addition, green fluorescent protein (GFP) fluorescence and X-gal staining were observed in the peritoneal tumor foci following lipofection of the corresponding EGFP and LacZ reporter genes. These expression analyses also showed that transgene expression lasted for about 2 weeks and was preferential for the tumor nodules, this tumor preference being in good agreement with the absence of obvious treatment-related toxicity. Most importantly, mice receiving the full treatment scheme (BGTC liposomes, suicide genes and prodrugs) had significantly lower serum CEA levels than those of the various control groups, a finding indicating that peritoneal carcinomatosis progression was strongly reduced in these mice. In conclusion, our results demonstrate the therapeutic efficiency of BGTC-mediated i.p. lipofection of a combined suicide gene system in a mouse peritoneal carcinomatosis model and suggest that BGTC-based prodrug-activating gene therapy approaches may constitute a potential treatment modality for patients with peritoneal carcinomatosis and minimal residual disease.

Whole-body imaging of green fluorescent protein (GFP) can be used to test the efficiency of gene carriers for in vivo transduction. The aim of the current study was to determine the sensitivity and the accuracy of a GFP imaging procedure by in vivo investigation of GFP-expressing tumor cells. An improved method of whole-body GFP imaging made use of a laser excitation source and band-pass filters matched specifically to GFP and constitutive tissue fluorescence emission bands. Processing of the primary GFP fluorescence images acquired by the CCD camera subtracted background tissue autofluorescence. Our approach achieved 100% sensitivity and specificity for in vivo detection of 10%-transfected BxPc3 pancreatic tumor after subcutaneous grafting or orthotopical implantation in the pancreas of nude mice. It also detected less transfected tumors (i.e., 1 to 5%) but with a loss in sensitivity (50% of cases). The system was employed over a 5-week period to monitor the persistence of GFP expression in 10%-transfected BxPc3 tumors orthotopically implanted in the pancreas of two nude mice, allowing the direct visualization of tumor progression and spread. In facilitating the temporal–spatial follow-up of GFP expression in vivo, the optimized laser-induced fluorescence imaging device can support preclinical investigations of vectors for therapeutic gene transduction through regular, harmless, real-time monitoring of theirin vivo transductional efficacy and persistence.

Introduction: A novel technique for secure placement of the anvil for mechanical stapled anastomosis in the proximal colon without exteriorization of the bowel is described. Methods: After standard laparoscopic segmental colonic mobilization, a needle-cannula from a percutaneous endoscopic gastrostomy kit is passed under direct endoscopic vision transparietally into the colon at the site intended for anvil placement. A wire passed through the cannula into the colon is then withdrawn endoscopically per ano. The stapler anvil is fixed to the wire and pulled back along the intestine before being positioned by traction through the needle puncture site. After distal specimen transection, a standard stapled anastomosis is performed. Results: The technique is illustrated in 2 patients undergoing laparoscopic sigmoidectomy by either a single port or a multiport procedure with transanal specimen extraction. Conclusion: By positioning the anvil without colon exteriorization, this technique enables pure intraperitoneal colonic anastomoses that may advance natural orifice operating.

Resumen La incidencia del cancer de estomago ha disminuido en los ultimos 50 anos (de 250 a 100 por cada 100 000 habitantes), pero sigue siendo un cancer con una evolucion preocupante y una supervivencia global inferior al 10 % a 5 anos. El adenocarcinoma gastrico es un cancer con extension local y ganglionar cuyo unico tratamiento potencialmente curativo es quirurgico. El aumento de la supervivencia esta relacionado con una deteccion mas precoz de los canceres. La estrategia quirurgica depende del tipo y del estadio evolutivo del cancer. En el cancer gastrico superficial puede ser util un tratamiento conservador o miniinvasivo. Los canceres mas avanzados se tratan mediante gastrectomia, siempre completada mediante linfadenectomia. Desde los anos sesenta, la Japanese Research Society for Gastric Cancer propugna la realizacion de vaciamientos ganglionares ampliados. Esta actitud esta justificada ante los resultados prometedores de las primeras series publicadas. No obstante, algunos estudios recientes constatan un incremento significativo de la morbimortalidad secundaria a los vaciamientos ganglionares y han cuestionado su realizacion sistematica. Actualmente, la gastrectomia, a menudo parcial y asociada a vaciamiento de proximidad, es una opcion razonable en el arsenal terapeutico, incluso si las resecciones con vaciamientos mas radicales pueden ser aceptables en determinadas indicaciones. En este articulo se presentan las bases quirurgicas de las resecciones gastricas y de las linfadenectomias, asi como los medios de restablecimiento de la continuidad tras una reseccion gastrica ampliada.

Resumen La cirugia de exeresis gastrica por cancer implica un conocimiento perfecto de la anatomia, tanto vascular como linfatica. Con el impulso de las escuelas japonesas, esta cirugia ha evolucionado de forma considerable y requiere actualmente una metodologia rigurosa, tanto para la realizacion de la intervencion quirurgica como en la presentacion de las piezas para anatomia patologica, cuyo analisis permite hacer un pronostico preciso de la enfermedad. Este articulo describe la anatomia vascular del estomago y determina la anatomia quirurgica de los 16 grupos ganglionares que componen los elementos de los distintos niveles de vaciamientos ganglionares gastricos. La estandarizacion de su identificacion y su analisis individual deberian permitir la correcta comparacion de las series quirurgicas europeas y japonesas de exeresis del cancer gastrico.

Background Proficiency in minimally invasive surgery requires intensive and continuous training, as it is technically challenging for unnatural visual and haptic perceptions. Robotic and computer sciences are producing innovations to augment the surgeon's skills to achieve accuracy and high precision during complex surgery. This article reviews the current use of robotically assisted surgery, focusing on technology as well as main applications in digestive surgery, and future perspectives. Methods The PubMed database was interrogated to retrieve evidence-based data on surgical applications. Internal and external consulting with key opinion leaders, renowned robotics laboratories and robotic platform manufacturers was used to produce state-of-the art business intelligence around robotically assisted surgery. Results Selected digestive procedures (oesophagectomy, gastric bypass, pancreatic and liver resections, rectal resection for cancer) might benefit from robotic assistance, although the current level of evidence is insufficient to support widespread adoption. The surgical robotic market is growing, and a variety of projects have recently been launched at both academic and corporate levels to develop lightweight, miniaturized surgical robotic prototypes. Conclusion The magnified view, and improved ergonomics and dexterity offered by robotic platforms, might facilitate the uptake of minimally invasive procedures. Image guidance to complement robotically assisted procedures, through the concepts of augmented reality, could well represent a major revolution to increase safety and deal with difficulties associated with the new minimally invasive approaches.

Resumen La gastrectomia es una intervencion que consiste en una reseccion gastrica de extension variable. La principal indicacion de la gastrectomia por lesion benigna era el tratamiento radical de la enfermedad ulcerosa (antrectomia y gastrectomia de las dos terceras partes del estomago). La vagotomia, los antagonistas de los receptores H 2 de la histamina (anti-H 2 ) y los tratamientos destinados a erradicar Helicobacter pylori redujeron enormemente las indicaciones de la gastrectomia por enfermedad ulcerosa. El tratamiento medicamentoso de la enfermedad ulcerosa fracasa en menos del 5 % de los pacientes. Por esa razon, menos del 1 % de las intervenciones por ulcera corresponden a gastrectomias. Las indicaciones quirurgicas de reseccion gastrica, tipica o atipica, por tumores benignos o trastornos funcionales tambien son excepcionales. En efecto, las publicaciones en las que se refieren resecciones gastricas por ulcera se limitan generalmente a pocos casos. La cirugia de invasion minima ha mostrado sus posibilidades terapeuticas y sus beneficios en la realizacion de gastrectomias tipicas y atipicas para estas indicaciones, fuera de la enfermedad cancerosa. Esta tecnica quirurgica es en la actualidad una practica frecuente para la reseccion de tumores benignos. Dada la disminucion significativa de las indicaciones de gastrectomias tipicas y atipicas con acceso convencional, este articulo se limita a la descripcion de las gastrectomias por lesiones benignas y se presentan principalmente los procedimientos basicos mas utilizados para las gastrectomias parciales y las gastrectomias atipicas.

Resume But de l'etude Cette etude prospective initiee par l'AFCE a pour but d'analyser les indications, la voie d'abord et les resultats de toutes les surrenalectomies realisees au cours de l'annee 1997 dans 17 centres ayant une activite importante ou exclusive de chirurgie endocrinienne. Patients et methodes En 1997, une surrenalectomie a ete realisee chez 247 patients, 149 hommes et 98 femmes (âge moyen: 51 ans). La lesion siegeait a droite dans 116 cas, a gauche dans 99; elle etait bilaterale dans 28 cas et ectopique dans quatre. Les pheochromocytomes ( n = 61), les adenomes de Conn ( n = 50) et les adenomes ou hyperplasies bilaterales a l'origine d'un syndrome de Cushing ( n = 48) ont ete les lesions le plus souvent rencontrees. La surrenalectomie a ete realisee sous cœlioscopie chez 172 patients (70%) par voie intraperitoneale dans tous les cas sauf un, et par une operation traditionnelle chez 75 patients (30%). Resultats Chez les patients operes par cœlioscopie, la duree operatoire moyenne a ete de 132 minutes, il y a eu une complication peroperatoire dans 15 cas (8, 7%) le plus souvent hemorragique et le taux de conversion a ete de 7%. Dans les suites operatoires, il y a eu deux deces (1,16%), l'un precoce chez un patient reopere pour hemorragie, l'autre tres tardif par pancreatite aigue necrosante. La duree moyenne d'hospitalisation a ete de 5,8 jours. La taille moyenne de la tumeur etait de 49 mm. Chez les patients traites en ≪ chirurgie ouverte ≫, la duree operatoire moyenne a ete de 148 minutes. Il y a eu une complication peroperatoire chez huit patients (10,6%) le plus souvent hemorragique. Il y a eu deux deces peroperatoires par hemorragie incontrolable. La duree moyenne de l'hospitalisation a ete de 11 jours. La taille moyenne de la tumeur etait de 72 mm. Conclusion La cœlioscopie a pris une part predominante dans l'exerese des tumeurs surrenaliennes. Certaines complications observees dans cette serie correspondent pour plusieurs groupes a leur periode d'apprentissage. La cœlioscopie constitue la voie d'abord de choix pour les tumeurs benignes uni ou bilaterales, ne depassant pas 6 ou 7 cm de diametre. La chirurgie ≪ ouverte ≫ reste indiquee dans les tumeurs malignes, surtout les corticosurrenalomes et dans toutes les tumeurs volumineuses.

Nitric oxide (NO), an endogenous free radical, has been implicated in a wide range of biological functions. NO is generated enzymatically from the terminal guanidinonitrogen of L-arginine by nitric oxide synthase (NOS). Despite intensive investigations, the role of NO--either as the primary product of the L-arginine/NOS pathway or provided from the NO donor sodium nitroprusside (SNP)--in carcinogenesis and tumour cell growth remains unclear and controversial. The objective of this study was to examine the growth effects of NO on a ductal pancreatic adenocarcinoma in the rat and on a human pancreatic tumour cell line (HA-hpc2). In vivo, both SNP and endogenous induction of NO by endotoxins [lipopolysaccharide (LPS)] plus L-arginine significantly reduced the tumour growth. To investigate the mechanisms of NO anti-tumour growth action, the effects of either the SNP or L-arginine/NOS pathway were analysed on the HA-hpc2 cell line. Nitrite/nitrate production, NOS activity and iNOS expression [assessed by reverse transcription-polymerase chain reaction (RT-PCR)] were tested and related to growth (assessed by [3H]thymidine incorporation assay) and apoptosis (assessed by internucleosomal DNA cleavage). SNP exerted a dual effect on tumour cells: stimulation of the proliferation up to 1 mM and inhibition at higher concentrations. These effects were related to NO production. Both proliferative and cytostatic responses were inhibited by NO scavenger 2-phenyl-4,4,5,5-tetramethyl-hemidazoline-1-oxyl3-oxide (carboxy-PTIO). The marked apoptotic DNA fragmentation induced by SNP was also abolished by PTIO association. Unlike macrophages, the human pancreatic tumour cells did not seem to express intrinsically the L-arginine/NOS pathway. Macrophages were activated by HA-hpc2 cells as well as by LPS plus cytokines [interleukin (IL)-1beta plus tumour necrosis factor (TNF)-alpha and interferon (IFN)-gamma]. In HA-hpc2/macrophage co-cultures, NOS activity and inducible NOS (iNOS) transcription were stimulated, whereas an antiproliferative response was observed. These effects were related to both macrophage amount and NO production. Addition of LPS plus cytokines to co-cultures doubled iNOS activity, nitrite/nitrate production and tumoricidal effect. These data suggest the involvement of NO in pancreatic tumour growth and support the fact that generation of high levels of NO with potential production of endogenous reactive nitrogen intermediates may contribute to induction of apoptosis and tumour growth inhibition. Images Figure 2 Figure 5 Figure 6 Figure 7

Resume Les simulateurs de chirurgie apparaissent de plus en plus comme un des aspects essentiels de la chirurgie du futur, que ce soit pour l'entrainement au geste operatoire ou pour la planification chirurgicale. Ils permettront ainsi de reduire les risques de complications operatoires ainsi que les durees d'hospitalisation. Dans cet article, nous decrivons les caracteristiques principales du prototype de simulateur developpe a IWRIA. Nous detaillerons plus particulierement la modelisation de l'environnement virtuel ainsi que les solutions retenues pour interagir en temps reel avec le modele et disposer de retour de force.

Laser-induced fluorescence (LIF) of pheophorbide-a (Ph-a) was used for imaging of a rat pancreatic tumor. Using a dimensionless function (the ratio of Ph-a fluorescence by bluish autofluorescence), the fluorescence contrasts between excised tumors and their paired pancreas were investigated up to 48 h after a 9 mg kg-1 Ph-a intravenous administration. Among five tested excitation wavelengths, 355 and 610 nm excitations gave the best distinctive contrasts, both 48 h after dye injection. The LIF imaging of six intrapancreatic tumors and six healthy pancreas was carried out in vivo using two laser excitations: 355 nm (Nd:YAG + tripling) for bluish autofluorescence and 610 nm (rhodamine 6G dye) for reddish autofluorescence and dye emission. Images were recorded through bandpass filters at 470 and 640 nm (autofluorescence) and at 680 nm (dye + autofluorescence) with an intensified charged-coupled device camera. Autofluorescence as Ph-a fluorescence images did not allow accurate LIF diagnosis of pancreatic carcinoma. An image processing, including for each pixel a computed division of Ph-a fluorescence (after subtraction of reddish autofluorescence) by bluish autofluorescence intensity generated poorly contrasted tumor images in five of six and false tumor localization in one of three of the tumor-bearing pancreas. A fitting of the digital 640 nm autofluorescence up to the mean 680 nm fluorescence intensity in pancreas prior to subtraction allowed a safe diagnosis to be made with well-contrasted tumor images. To assess automation ability of the processing, a same fitting coefficient (mean of individual values) was applied. In this way, false-negative (one of six) and false-positive (two of six) images were present in tumor-bearing animals as false-positive in one-half of the controls. A successful standardized procedure was then applied with a normalization of 640 and 680 nm pancreas intensities to a same set threshold prior processing. In opposition to thin-layered hollow organs, such as bronchial tube or digestive tract, LIF imaging of carcinoma inserted in a compact organ is exhausting. The use of a dye excitable in the red wavelength range (610 nm for Ph-a) may partly solve this problem, rendering LIF imaging more accurate and potentially automated.

Complicated intra-abdominal infections such as acute appendicitis and complicated diverticulitis represent both diagnostic and therapeutic challenges. Both diseases, although different in many ways, are caused by the obstruction of a blind pouch leading to inflammation, abscesses, and perforation of surrounding tissues. For many decades, acute appendicitis was managed through a conventional surgical incision in the right iliac fossa. As for other diseases, there is a significant tendency to propose less invasive treatments. For many teams, laparoscopy, which leads to less postoperative pain, a shorter hospital stay, and a quicker recovery, represents the standard of care for appendectomy. For selected cases, a medical approach can be proposed with satisfactory outcomes. Additionally, the management of complicated diverticulitis is also quickly moving towards less invasive procedures than the deleterious ‘3-phase surgery', which is Hartmann's procedure, followed by reversal protected with a stoma, and finally stoma closure. Benefiting from the evolution of antimicrobial therapy and interventional radiology, many complicated cases classified as Hinchey stage I and Hinchey stage II complicated diverticulitis are now treated medically. CT images allow the identification of patients requiring radiological drainage of localized abscesses or collections over 5 cm in size. Patients with Hinchey stage III sigmoiditis may benefit from an initial laparoscopic exploration allowing, in some cases, a conservative nonresective approach that will prevent laparotomy and stoma. Major resection leading to temporary or definitive stoma is usually indicated for stage IV complications and is required only in exceptional cases. Although a surgical intervention can be the definitive treatment for complicated intra-abdominal infections, multidisciplinary management including radiology, medical treatment, and laparoscopic surgery may limit the severe consequences of an acute surgical approach in patients suffering from complicated appendicitis and diverticulitis. Today, the ultimate goal of acutely infected abdomen management is to reduce hospital stay, disability, and numerous operations for these patients.

Laparoscopic surgery planning is usually realized on a preoperative image that does not correspond to the operating room conditions. Indeed, the patient undergoes gas insufflation (pneumoperitoneum) to allow instrument manipulation inside the abdomen. This insufflation moves the skin and the viscera so that their positions do no longer correspond to the preoperative image, reducing the benefit of surgical planning, more particularly for the trocar positioning step. A simulation of the pneumoperitoneum influence would thus improve the realism and the quality of the surgical planning. We present in this paper a method to simulate the movement of skin and viscera due to the pneumoperitoneum. Our method requires a segmented preoperative 3D medical image associated to realistic biomechanical parameters only. The simulation is performed using the SOFA simulation engine. The results were evaluated using computed tomography [CT] images of two pigs, before and after pneumoperitoneum. Results show that our method provides a very realistic estimation of skin, viscera and artery positions with an average error within 1 cm.

The aim of this study is to demonstrate the efficacy of wireless capsule endoscopy for preoperative identification of bleeding sources and/or small bowel tumours in surgical patients and to evaluate the feasibility of single-port surgery in the treatment of such pathologies.Five patients presenting with obscure gastrointestinal bleeding or/and mild small bowel obstruction were investigated to diagnose and localize the bleeding source or tumour using capsule endoscopy imaging, and, if necessary, with other investigative modalities. All patients were operated on using single-port surgery for small bowel exploration, lesion confirmation, small bowel resection and anastomosis.Small bowel pathology was successfully detected by video capsule endoscopy in three of four patients, and was further substantiated by contrast CT, double-balloon endoscopy or enteroclysis. Complete small bowel exploration, intra-operative identification and oncological resection of the involved segment and anastomosis (intracorporeal and extracorporeal) was successfully performed in all five patients using single-port access without any complication, morbidity or mortality.This study demonstrates the feasibility and safety of single-port small bowel resection performed after a high-quality preoperative localization of the tumour.

Parastomal herniation of end colostomies can be chronically debilitating for patients and a difficult problem to treat. To prevent parastomal hernia (PSH) formation an extraperitoneal colostomy (EPC) approach has been developed in open colorectal surgery and some studies have suggested a potential advantage to this approach. Here we describe our technique of laparoscopic extraperitoneal stoma formation and present our experience to date.We performed a retrospective analysis of consecutive patients undergoing a laparoscopic abdominoperineal resection between March 1999 and March 2011. We performed the EPC technique as follows: under laparoscopic guidance, a smooth tip instrument was used to gently separate the peritoneum from the posterior aponeurotic plane to create an extraperitoneal tunnel running from the skin incision to the left flank of the abdominal cavity to join the previously dissected paracolic gutter. The colon was exteriorized and the position was checked to ensure the absence of torsion or kinking.Twenty-two patients underwent a standard laparoscopic abdominoperineal resection with total mesorectal excision. Colostomy was constructed extraperitoneally (EPC) or transperitoneally (TPC) in 12 and 10 patients respectively. There were five complications requiring operative intervention: two stomal necrosis and one surgical site infection in the TPC group and two small bowel occlusions in the EPC group. Four patients from the TPC group developed PSH at 24, 36, 48 and 72 months respectively while there were no cases of PSH in the EPC group.Extraperitoneal laparoscopic colostomy showed a potential reduction of PSH in our series of patients.

Biliopancreatic bypass (BPB), a bariatric surgical procedure, leads to a malnutrition-induced general visceral atrophy except for the pancreas. This work investigates the implication of cholecystokinin (CCK) in the exocrine pancreatic adaptive process using a plasma CCK assay and the CCK receptor antagonist CR 1409. No significant reduction in weight and DNA content of the pancreas was noted 36 days after BPB, while a strong decrease in protein, enzymes and RNA contents indicating cellular hypotrophy became apparent. CR 1409 treatment strongly depressed pancreatic weight and its DNA content in BPB animals, suggesting an additional hypoplasia; however, the reduction in pancreatic enzyme content was not aggravated. BPB increased plasma CCK concentrations by 160%, unrelated to CR 1409 treatment. These results indicate that: (1) CCK is involved in the pancreatic adaptive response after BPB in rats, and (2) in the context of a protein malnutrition state, CCK dissociates its pancreatic growth and enzymatic effects, favouring the former.

To assess the current state of the art of transanal specimen extraction in colonic resections.A systematic literature search was conducted including the terms 'transrectal or transanal specimen extraction', 'Natural Orifice Specimen Extraction' and 'laparoscopic colectomy' for the period from 1955 to May 2011. Exclusion criteria were abdomino-perineal resections, pull-through technique, experimental studies and paediatric population.Nineteen studies met the inclusion criteria, representing 154 patients. The overall postoperative complication rate was 10%. The risks of peritoneal contamination and sphincter dysfunction were evaluated by a single study of each.Transanal extraction is a feasible option to minimize incisions in colorectal surgery.

The expected benefit of transvaginal specimen extraction is reduced incision-related morbidity.A systematic review of transvaginal specimen extraction in colorectal surgery was carried out to assess this expectation.The following keywords, in various combinations, were searched: NOSE (natural orifices specimen extraction), colorectal, colon surgery, transvaginal, right hemicolectomy, left hemicolectomy, low anterior resection, sigmoidectomy, ileocaecal resection, proctocolectomy, colon cancer, sigmoid diverticulitis and inflammatory bowel diseases.SELECTION CRITERIA included large bowel resection with transvaginal specimen extraction, laparoscopic approach, human studies and English language. Exclusion criteria were experimental studies and laparotomic approach or local excision. All articles published up to February 2011 were included.Twenty-three articles (including a total of 130 patients) fulfilled the search criteria. The primary diagnosis was colorectal cancer in 51% (67) of patients, endometriosis in 46% (60) of patients and other conditions in the remaining patients. A concurrent gynaecological procedure was performed in 17% (22) of patients. One case of conversion to laparotomy was reported. In two patients, transvaginal extraction failed. In left- and right-sided resections, the rate of severe complications was 3.7% and 2%, respectively. Two significant complications, one of pelvic seroma and one of rectovaginal fistula, were likely to have been related to transvaginal extraction. The degree of follow up was specified in only one study. Harvested nodes and negative margins were adequate and reported in 70% of oncological cases.Vaginal extraction of a colorectal surgery specimen shows potential benefit, particularly when associated with a gynaecological procedure. Data from prospective randomized trials are needed to support the routine use of this technique.

Chylothorax after esophagectomy is a potentially life-threatening complication, with a reported incidence rate of 1-4%. Two cases of postoperative chylothorax successfully managed thoracoscopically are reported.In case 1, a 61-year-old man presenting with an adenocarcinoma of the lower esophagus underwent laparoscopic transhiatal esophagectomy after neoadjuvant chemotherapy. The thoracic duct was identified, and no obvious leaks were detected. The thoracic drain was removed on postoperative day (POD) 6, and chest X-rays were normal. The patient was discharged on POD 10. On POD 20, he was readmitted for acute cardiopulmonary distress. Computed tomography scan showed a massive right collection. After insertion of a chest tube, 8 l of chylous fluid were drained. Once hemodynamic stabilization had been established, the patient was scheduled for surgery. In case 2, a 54-year-old woman presenting with esophageal stenosis after caustic injury refractory to balloon dilation and stenting underwent esophagectomy. Mediastinal dissection was difficult due to fibrotic reaction. On POD 2, the patient presented with a massive chylothorax. In both cases, three trocars were inserted in the right pleural cavity. An incomplete lateral injury of the thoracic duct was found in case 1, and a complete transection proximal to the cervical anastomosis next to the left subclavian was found in case 2. Clips and sutures were used first to seal the duct. Fibrin glue was applied to reinforce the closure. A chest tube was left in place.The operative time was 60 min in case 1 and 55 min in case 2. The chylothorax did not recur, although the postoperative course was longer in case 2 due to associate comorbidities.The thoracic duct is exposed to injuries during esophagectomies, especially in cases of cancer and postcaustic injuries, leading to fibrotic reaction of the surrounding tissue. Early and delayed chylothorax can be managed efficiently by a thoracoscopic approach replicating the sealing techniques used in thoracotomy.

Ultrasonography is the lowest cost no risk medical imaging technique. However, reading an ultrasonographic (US) image as well as performing a good US probe positioning remain difficult tasks. Education in this domain is today performed on patients, thus limiting it to the most common cases. In this paper, we present a cost effective simulator that allows US image practice and realistic probe manipulation from CT data. More precisely, we tackle the issue of providing a realistic interface for the probe manipulation with a basic haptic feedback.

Laparoscopic reversal of Hartmann's procedure is technically demanding. We evaluated the technical aspects and outcome of a standardized approach in a single centre and examined the feasibility of including this into training curricula.The procedure entails a laparoscopy for adhesiolysis and identification and mobilization of the rectal stump. Mobilization of the splenic flexure is performed if necessary, and a colorectal anastomosis is fashioned after introduction of the stapler anvil via the colostomy with intra-abdominal positioning and delivery into the proximal colonic segment to be anastomosed. The stoma is excised as the last step in the operation.Forty-two patients underwent the procedure over an 8-year period with either an expert (n=21) or trainee under expert mentorship (n=21) as first operator. Intra-operative data and postoperative outcomes were evaluated by retrospective review of clinical charts and theatre records. There was a 9.5% conversion rate and 0% mortality. One patient suffered a ureteric injury, while postoperative surgical complications occurred in 7 patients (including one clinical anastomotic leakage). The mean operative time was 117 min. There was no significant difference in intra operative technical parameters or postoperative clinical consequences between procedures performed by a trained surgeon or by a trainee under mentorship.Adherence to a standardized operative protocol and expert mentorship allows this technically demanding operation to be associated with low conversion and complication rates. The absence of any difference between procedures performed by a trainee or trained surgeon suggests that the operation can be included in training programmes for laparoscopic surgery.

Nel corso del ventesimo secolo la medicina e entrata nel mondo dell’informatica con grandi rivoluzioni, tra cui la piu ovvia e senza dubbio rappresentata dallo sviluppo della diagnostica per immagini 3D (TC, RM ed ecografia). La digitalizzazione dei dati del paziente e presente oggigiorno in tutti gli ambiti, incluso quello chirurgico. Questo flusso crescente di dati resta tuttavia complicato da interpretare e utilizzare in maniera adeguata.

We demonstrate localized sigmoidectomy with sentinel node biopsy performed entirely via natural orifice transluminal endoscopic surgery in a porcine model (see Video, Supplemental Digital Content 1, http://links.lww.com/A1170).To perform transluminal endoscopic sentinel node biopsy in the sigmoid mesocolon, a conventional double-channel gastroscope created both the gastrotomy and pneumoperitoneum enabling peritoneoscopy. The sigmoid colon was exposed by an intracolonic magnet under extracorporeal control while intraluminal colonoscopy performed lymphatic mapping via submucosal injection of methylene blue dye. After searching the mesocolon for blue-stained lymph channels, the sentinel nodes were resected and retrieved by the intraperitoneal fiberscope. Immediate thereafter localized sigmoidectomy was performed via an additional transcolonic access just above the rectosigmoid junction. With the circular stapler anvil placed early into the proximal colon, mesenteric dissection and proximal transection were performed using conventional laparoscopic instruments worked through a long standard trocar passed transanally through the colotomy. The specimen was delivered per ano (pull-through technique) and the distal margin cross-stapled extracorporeally, including the colotomy within the specimen. Stapled intestinal anastomosis was fashioned by passing a circular stapler transanally (thus returning the rectal stump to its anatomic position) and mating it with the in situ anvil. The gastrotomy was closed as previously described.The operative duration was 31.4 minutes and technical success was readily achieved. Patency and integrity of the anastomosis was confirmed by sigmoidoscopy.Oncologically propitious surgery for germinal colonic neoplasia may be encompassed by natural orifice transluminal endoscopic surgery. This provocative proposal challenges the conventional treatment paradigm for early stage colonic neoplasia although much further validation of the concepts involved is required.