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Summary Introduction Burnout syndrome (BOS) affects all professional categories, particularly in the medical sector. Perceived deterioration of working conditions in university hospital centres impacts not only hospital doctors, but also and more generally, university hospital (UH) staff. The goal of this survey was to analyse workplace quality of life among French UH digestive surgeons. Methods An online questionnaire was addressed to all members of sub-section 52-02 (digestive and visceral surgery) of the national university council (CNU). It contained isolated questions, as well as the specific Copenhagen Burnout Inventory (CBI) questionnaire, which assesses three fields: personal burnout (PBO), work-related burnout (WBO) and client-related burnout (CBO). Results While 132 (85%) out of the 156 surgeons responded, only 110 (70%) filled out the CBI questionnaire. Their perceptions of quality of life were poor or very poor (57%), and progressively poorer; this was mainly due to a lack of human, logistical and financial means, and also to conflictual relations with administration. The CBI questionnaire showed high scores for PBO (37%) and WBO (30%), with lower scores for CBO (8%). Depressive syndrome appeared among 26% of respondents. There were no significant differences according to region, gender or age. Conclusion This study objectifies a perceived deterioration of the working conditions of UH digestive surgeons, with elevated rates of BOS and a depressive risk superior to that of the overall population.

Resume Introduction Le syndrome d’epuisement professionnel (EP) touche toutes les categories professionnelles mais particulierement le secteur medical. La degradation ressentie des conditions de travail dans les centres hospitalo-universitaires touche les medecins hospitaliers mais aussi les hospitalo-universitaires (HU). Le but de cette enquete etait d’analyser la qualite de vie professionnelle des chirurgiens digestifs HU francais. Methodes Un questionnaire en ligne a ete propose a tous les membres de la sous-section 52-02 (Chirurgie Digestive et Viscerale) du Conseil national des universites. Il contenait des questions isolees ainsi que le questionnaire specifique Copenhagen Burnout Inventory (CBI) qui analyse trois domaines : l’epuisement personnel (EPer), l’epuisement professionnel (EPro) et l’epuisement relationnel (ERel). Resultats 132 (85 %) des 156 chirurgiens ont repondu, et seulement 110 (70 %) ont rempli le questionnaire CBI. Le ressenti de la qualite de vie professionnelle etait mauvais ou tres mauvais (57 %), allant en s’aggravant, principalement en raison de manque de moyens humains, logistiques, financiers, et des rapports conflictuels avec l’administration. Le questionnaire CBI montrait des scores eleves d’EPer (37 %), d’EPro (30 %) et a un moindre degre d’ERel (8 %). On notait la survenue declaree d’un syndrome depressif chez 26 % des repondants. Il n’y avait pas de differences significatives selon la region, le genre et l’âge. Conclusion Cette etude objective une degradation ressentie des conditions de travail des chirurgiens digestifs HU avec des taux eleves d’EP et un risque depressif superieur a celui de la population generale.

Surgical management of Hinchey III and IV diverticulitis involves Hartmann's procedure (HP) or primary resection anastomosis (PRA) with or without fecal diversion. These procedures were evaluated in four randomized controlled trials. Early results from these trials demonstrated similar rates of complications but higher rates of colonic restoration after PRA than HP. Long-term follow-up has not been reported to date. The aim of this study was to analyze long-term outcomes and quality of life (QoL) in patients previously enrolled in a prospective randomized trial comparing HP and PRA for generalized peritonitis due to perforated diverticulitis (DIVERTI trial).Follow-up data were available for 78 of 102 patients. Demographic data, incisional hernia rate, need for additional surgery related to the primary procedure, and QoL were recorded.The overall survival rate was 76% and did not differ between the two groups. Incisional hernia was reported in 21 (52%) patients in the HP arm and in 11 (29%) patients in the PRA arm (p = 0.035). The HP arm demonstrated significantly lower SF-36 physical and mental component scores. The mean general QoL (EQ-VAS) and mean EQ-5D index scores were better after PRA than after HP, but this difference was not statistically significant. The results of GIQLI, which measures intestine-specific QOL, did not differ between the two groups.This follow-up study with a median follow-up time of 9 years among living patients indicates that PRA for perforated diverticulitis is associated with fewer long-term complications and better QoL than HP. PRA significantly reduced the incisional hernia rate and the need for reoperation. Long-term survival was not jeopardized by the PRA approach. Future studies are needed to address the utility of protective stoma.

Résumé La pandémie de COVID-19 impose une réorganisation majeure de l’ensemble de notre système de soins. En France, des règles générales ont été diffusées au niveau national et sont déclinées par chaque établissement, public comme privé, sur l’ensemble du territoire. Ces recommandations, rédigées par un groupe d’experts sous l’égide de l’Association francophone de chirurgie endocrinienne (AFCE), ont pour objectif de proposer des principes spécifiques de prise en charge chirurgicale au cours et au décours de l’épidémie de COVID- 19, pour les pathologies chirurgicales de la thyroïde, des parathyroïdes, du pancréas endocrine, et des surrénales.

Background The benefits of single‐use ultrasonic scissors in thyroid surgery are still debated. Although this device has been shown to reduce operating time compared with conventional haemostasis, its cost‐effectiveness has never been demonstrated. The aim of this study was to evaluate the efficacy, cost‐effectiveness and safety of ultrasonic scissors for total thyroidectomy. Methods This was a prospective, randomized, multicentre trial conducted at 13 hospital sites. The primary endpoint was the percentage of patients with hypocalcaemia (serum calcium level below 2 mmol/l) on day 2. Secondary endpoints included postoperative complications and costs, with calculation of incremental cost differences and cost‐effectiveness ratios. Results In total, 1329 patients who underwent total thyroidectomy were included in the analysis: 670 were randomized to treatment with ultrasonic scissors and 659 to conventional haemostasis. There was no difference between groups in the rate of complications, including hypocalcaemia on day 2 (19.7 per cent in ultrasonic scissors group versus 20.3 per cent in conventional haemostasis group; P = 0·743). Median operating times were significantly shorter with ultrasonic scissors (90 versus 100 min with conventional haemostasis; P

Background Open studies have reported favourable results for sacral nerve stimulation in the treatment of refractory constipation. Here, its efficacy was assessed in a double-blind crossover RCT. Methods Patients with at least two of the following criteria were included: fewer than three bowel movements per week; straining to evacuate on more than 25 per cent of attempts; or sensation of incomplete evacuation on more than 25 per cent of occasions. Response to therapy was defined as at least three bowel movements per week and/or more than 50 per cent improvement in symptoms. Responders to an initial 3-week peripheral nerve evaluation were offered permanent implantation of a pulse generator and were assigned randomly in a crossover design to two 8-week intervals of active or sham stimulation. At the end of the two trial periods, the patients received active stimulation until the final evaluation at 1 year. Results Thirty-six patients (34 women; mean(s.d.) age 45(14) years) underwent peripheral nerve evaluation. Twenty responded and received a permanent stimulator. A positive response was observed in 12 of 20 and 11 of 20 patients after active and sham stimulation periods respectively (P = 0·746). Pain related to the device occurred in five patients and wound infection or haematoma in three, leading to definitive removal of the pulse generator in two patients. At 1 year, 11 of the 20 patients with an implanted device continued to respond. Stimulation had no significant effect on colonic transit time. Conclusion These results do not support the recommendation of permanent implantation of a pulse generator in patients with refractory constipation who initially responded to temporary nerve stimulation. Registration number: NCT01629303 (http://www.clinicaltrials.gov).

Introduction Majoritairement, l’hyperparathyroidie primaire (HPP) est liee a la presence d’un adenome unique. Le gold standard correspond a son exerese chirurgicale. Cela peut etre effectue sous anesthesie locale (AL) par abord local en ambulatoire (Benhami et al., 2018). Malgre les avantages de l’AL, les comorbidites et traits de personnalite des patients peuvent rendre difficile l’acte sous AL avec une position maintenue allongee (Mavros et al., 2011). De multiples interventions de type pleine conscience/hypnose, ont ete utilisees recemment et adaptees au monde de la sante afin de diminuer le stress, (Touze et al., 2018). L’objectif de notre etude a ete d’associer AL et hypnose afin d’ameliorer le controle de la douleur, de l’anxiete apres exerese d’adenome unique parathyroidien sous AL. Materiel et methodes Nous avons realise de novembre 2018 a avril 2019, une etude prospective, s’interessant a tous les sujets operes en ambulatoire d’HPP sous AL avec l’aide d’une infirmiere avec Diplome Universitaire (DU) de formation en hypnose therapeutique. Des questionnaires ont ete remis aux patients se focalisant sur le pre/per-operatoire, post-operatoire immediat et tardif. Les constantes per-operatoires ont ete relevees. Resultats Sur la periode pre-operatoire, la majorite des patients presentent un inconfort. En post-operatoire immediat, le confort s’ameliore (entre 8 et 10/10 pour 90 % des patients). Les reponses aux questionnaires a 15 jours laissent penser que ces resultats sont lies a l’adjonction de l’hypnose a l’AL. Discussion L’hypnose semble largement benefique pour le patient mais Il reste maintenant a valider cela avec une etude prospective comparative de plus grande ampleur.

Introduction Le lithium, utilise comme thymoregulateur au long cours, engendre une hyperparathyroidie chez 10 % des sujets (Balandraud et al., 2001) ; elle imposera un traitement chirurgical dans moins de 5 % des cas (Awad et al., 2003). L’objectif principal de notre etude a ete de suivre, le devenir osseux au long cours, des sujets operes d’hyperparathyroidie litho induite (HPLI). Materiel et methodes Nous avons realise de janvier 2002 a Decembre 2010, une etude descriptive observationnelle prospective, s’interessant a tous les sujets operes d’HPLI. 90 % ont garde leur lithotherapie en postoperatoire. L’influence sur le metabolisme osseux de la chirurgie parathyroidienne des sujets ayant une HPLI a ete evaluee en pre, per, postoperatoire immediat, a 3 mois, 12 mois et a la date de point (03/2012) sur des criteres cliniques (criteres NIH), biologiques et osteodensitometriques. Resultats Sur 10 patients, plus de 80 % etaient symptomatiques en preoperatoire, avec forte prevalence d’atteinte multiglandulaire. En postoperatoire, tous les criteres cliniques NIH etaient normalises, de meme que le bilan phosphocalcique. Cependant, la PTH et le calcium restaient eleves. A 3, 12 mois, et a la date de point, 1/10 patient gardait une PTH inadaptee a la calcemie. Le decouplage crosslaps-PAO etait assez important, marque par un moindre ralentissement de la resorption osseuse (crosslaps 47 %). Toute la cohorte presentait une osteoporose sur au mois un site. Discussion Meme apres normalisation du bilan phosphocalcique, le caractere litho-induit d’une HP impose une surveillance prolongee du metabolisme osseux en raison d’une resorption osseuse persistant un an apres le traitement chirurgical.

Objective This study is to determine the impact of complications after total thyroidectomy on health-related quality of life (HR-QoL) and to identify significant predictive factors of HR-QoL changes. HR-QoL is usually impaired in patients with thyroid diseases compared to the general population. Thyroidectomy is largely performed in the case of benign thyroid benign and can be associated with long-term complications (vocal cord palsy, hypoparathyroidism). Design The prospective ThyrQoL multicenter trial (NCT02167529) included 800 patients who underwent total thyroidectomy for benign or malignant non-extensive disease in seven French referral hospitals between 2014 and 2016. Methods HR-QoL was assessed using the MOS 36-item short form health survey (SF-36) self-questionnaire with a 6-month follow-up. Results We observed a significant improvement of HR-QoL 6 months after surgery (P Conclusion We observed a significant improvement of HR-QoL 6 months after total thyroid surgery for benign thyroid disease.

L’exeresi chirurgica completa, R0, costituisce il solo trattamento dei cancri della colecisti che consenta delle sopravvivenze prolungate. La cattiva prognosi di questi cancri e legata alla precocita dell’invasione del parenchima epatico e dell’estensione linfonodale. L’estensione dell’exeresi prende in considerazione l’infiltrazione del parenchima epatico e dei visceri vicini e la disseminazione linfatica. Per i tumori di stadio pT1a, la colecistectomia semplice rappresenta un’exeresi oncologica. Per gli stadi superiori non metastatici, e indicata la resezione del parenchima epatico adiacente al letto coloecistico. Puo trattarsi di una resezione limitata al letto colecistico su uno spessore di 2 cm, di una bisegmentectomia 4b-5, che puo essere estesa al segmento 6, o di un’epatectomia destra allargata al 4 in caso di invasione dell’ilo epatico. La resezione della via biliare principale richiede, allora, un’anastomosi biliodigestiva. L’estensione al duodeno o al pancreas richiede una duodenopancreatectomia cefalica, che permette anche di realizzare una linfoadenectomia portale retropancreatica. Quest’ultima deve essere associata alla resezione epatica non appena lo stadio e superiore a T1a e i linfonodi del peduncolo epatico sono interessati. Essa asporta i linfonodi del peduncolo epatico e i linfonodi retropancreatici, ma richiede una duodenopancreatectomia cefalica o, al meglio, uno scollamento retroduodenopancreatico. Questi interventi estesi sono, tuttavia, gravati da un tasso di morbilita e di mortalita elevato, che li fanno riservare a rari pazienti di eta inferiore ai 70 anni, senza comorbilita, che hanno uno stato nutrizionale adeguato. Quando il cancro e stato scoperto solo secondariamente dopo una colecistectomia per litiasi, la necessita di ottenere una resezione R0 porta a reintervenire per eseguire l’exeresi adeguata, se lo stadio e superiore a T1a. La prognosi e legata all’estensione linfonodale e al carattere completo dell’exeresi. Quando l’exeresi non e praticabile, le terapie palliative fanno ricorso, in primo luogo, ai metodi endoscopici.

La exeresis quirurgica completa, de tipo R0, es el unico tratamiento de los canceres de la vesicula biliar que permite supervivencias prolongadas. El pronostico poco favorable de estos canceres guarda relacion con la invasion precoz del parenquima hepatico y la extension ganglionar. La extension de la exeresis depende de la infiltracion del parenquima hepatico, de los organos adyacentes y de la diseminacion linfatica. Para los tumores de estadio pT1a, la colecistectomia simple es una exeresis oncologica. Para los estadios superiores no metastasicos esta indicada la reseccion del parenquima hepatico adyacente al lecho vesicular. Puede tratarse de una reseccion limitada al lecho vesicular de 2 cm de grosor, de una bisegmentectomia 4b-5, con la posibilidad de extenderla al segmento 6, o de una hepatectomia derecha ampliada al segmento 4 en caso de invasion del hilio hepatico. La reseccion de la via biliar principal necesita entonces una anastomosis biliodigestiva. La extension al duodeno o al pancreas impone una duodenopancreatectomia cefalica, que tambien permite efectuar una linfadenectomia portal retropancreatica. Esta debe asociarse a la reseccion hepatica cuando el estadio es superior a T1a y estan afectados los ganglios del pediculo hepatico. Incluye los ganglios del pediculo hepatico y los ganglios retropancreaticos, pero necesita una duodenopancreatectomia cefalica o, mejor aun, un despegamiento retroduodenopancreatico. Sin embargo, estas intervenciones extensas tienen indices de morbilidad y de mortalidad elevados que obligan a reservarlas para los escasos pacientes menores de 70 anos, sin comorbilidad y con un estado nutricional adecuado. Cuando el cancer se ha descubierto de forma secundaria tras una colecistectomia por litiasis, la necesidad de obtener una reseccion R0 conduce a la reintervencion para efectuar la exeresis adecuada en caso de estadio superior a T1a. El pronostico correlaciona con la extension ganglionar y al caracter completo de la exeresis. Cuando la exeresis no es factible, los tratamientos paliativos se basan en primer lugar en los metodos endoscopicos.

Introduction Le syndrome de Tako Tsubo (STT) est une cardiomyopathie aigue se manifestant comme un syndrome coronarien aigu (SCA). Il resulte d’une hypersecretion de catecholamines qui peut etre provoque par un stress intense, soit par une pathologie sous-jacente comme le pheochromocytome. L’echographie montre une anomalie circonferentielle de la paroi du ventricule gauche avec un aspect de ballonnement apical du ventricule gauche dans sa forme typique et une coronarographie normale. Un STT peut aussi se presenter par une forme atypique de topographie non apicale et le cas des deux patientes que nous vous rapportons en sont des exemples. Observation Une patiente de 57 ans, suivi pour une neurofibromatose de type 1 et un incidentalome surrenalien gauche de decouverte recente est hospitalise pour plusieurs episodes de douleurs thoraciques lors d’evenements stressants de sa vie. La troponine et les NT-proBNP etaient normales. Un electrocardiogramme per-critique objectivait des ondes T negatives dans l’integralite des derivations evoquant un STT dans ce contexte d’incidentalome surrenalien. L’echographie cardiaque et L’IRM cardiaque etaient normales. Un scanner abdominal trouvait un rehaussement homogene de la surrenale gauche avec un wash-out apres injection d’iode avec une IRM normale des surrenales. Le dosage des derives methoxyles urinaire etait legerement augmente sur les metanephrines et les normetanephrines. La scintigraphie au MIBG montrait une hyperfixation moderee compatible avec un pheochromocytome surrenalien gauche. L’analyse histologique de la surrenalectomie gauche a montrait une proliferation tumorale positive au marquage par les anticorps anti-chromagranine A confirmant le diagnostic de pheochromocytome. Une femme de 68 ans a presente un episode de douleur thoracique au moment de l’anesthesie pour une pose de prothese de l’epaule droite. L’electrocardiogramme montrait sus decalage discret en avL et un sous decalage en inferolateral. L’echographie cardiaque retrouvait une hypokinesie anteroseptale et inferoseptale. La coronarographie etait subnormale. L’IRM cardiaque objectivait une FEVG a 47 % avec akinesie septomediane et anteromediane, et un hypersignal T2 diffus septal, anterieur et anterolateral avec un retard perfusionnel sous endocardique septomedian. Le diagnostic de SCA ST + avec IRM en faveur d’un STT de forme mediane a ete retenu. Un an plus tard, elle recidivait d’un autre SCA avec troponine a 871 ng/L complique d’un choc cardiogenique. L’ECG montrait un sus-decalage discret en AVL et un sous-decalage en infero-lateral. L’echographie cardiaque montrait une dysfonction systolique atypique avec hyperkinesie de la pointe du ventricule gauche et un aspect en as de pique en bi-plan. La coronarographie etait normale, il etait porte le diagnostic de STT basal-median donc de forme inverse. A l’interrogatoire elle rapportait des cephalees et des palpitations depuis 4 mois. Le scanner thoraco-abdomino-pelvien realise retrouvait un syndrome de masse surrenalien bilateral. Le dosage des derives methoxyles urinaires etait en faveur d’un pheochromocytome, avec des metanephrines a 10,89 μmol/24 heures (normale entre 0,20 et 1) et des normetanephrines etait a 3,65 μmol/24 heures (normale entre 0,40 et 2,10). La scintigraphie au MIBG montrait une hyperfixation en regard de la surrenale droite. L’analyse de la piece de surrenalectomie droite confirmait le diagnostic de pheochromocytome. Discussion Le pheochromocytome est une maladie qui peut se compliquer de cardiomyopathies multiples. Les STT representent 30 a 40 % de ces cardiomyopathies [1] , [2] . Les STT induit par un pheochromocytome sont de topographie inversee dans un tiers des cas contre 2,2 % des STT tout venant. La topographie globale (basal, apical et median) peut etre presente dans 20 % des STT lies au pheochromocytome contre 0 % dans les STT tout venant. [1] , [2] , [3] Dans ce contexte un taux de recidive est significativement plus eleve que dans les STT tout venant (17,7 % contre 3,26 %) et se compliquent plus souvent de choc cardiogenique (34,6 % contre 9,9 %) [1] , [3] . Conclusion Le syndrome de Tako Tsubo peut etre la manifestation initiale d’un pheochromocytome. Une topographie inversee, une forme compliquee d’un choc cardiogenique ou la recidive d’un STT doivent faire evoquer un pheochromocytome associe.

Resume Les deux complications les plus frequentes de la chirurgie thyroidienne en postoperatoire immediat sont l’hypocalcemie et les paralysies recurrentielles dont l’incidence est respectivement de 20 a 30 % et de 5 a 11 % environ. Bien que leur taux soit inferieur a 0,1 %, la survenue d’une paralysie recurrentielle bilaterale en adduction ou d’un hematome compressif peut mettre en jeu le pronostic vital et imposer une prise en charge en urgence. La prevention des complications passe par une technique de resection soigneuse et pour certaines equipes par l’utilisation de technique specifique telle le neuromonitoring (NIM) recurrentiel. La compensation d’une hypocalcemie repose sur l’administration de calcium eventuellement couple a la vitamine D pendant au moins dix jours. Une paralysie recurrentielle recupere dans la majorite des cas, et aucune therapie invasive ne doit etre effectuee avant six mois en dehors des cas d’urgence. Les techniques de chirurgie laryngee permettent une amelioration notable si, apres six mois, les sequelles phonatoires ou respiratoires sont majeures, mais leur resultat est inconstant. La detection d’une complication apres thyroidectomie doit etre systematique et leur prise en charge pluridisciplinaire.

Background Radical surgery provides the best chance of cure for adrenocortical carcinoma (ACC), but perioperative surgical care for these patients is yet to be standardized. Methods A working group appointed jointly by ENSAT and ESES used Delphi methodology to produce evidence-based recommendations for the perioperative surgical care of patients with ACC. Papers were retrieved from electronic databases. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, and were discussed until consensus was reached within the group. Results Twenty-five recommendations for the perioperative surgical care of patients with ACC were formulated. The quality of evidence is low owing to the rarity of the disease and the lack of prospective surgical trials. Multi-institutional prospective cohort studies and prospective RCTs are urgently needed and should be strongly encouraged. Conclusion The present evidence-based recommendations provide comprehensive advice on the optimal perioperative care for patients undergoing surgery for ACC.

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

Resume Les complications liees a la creation du pneumoperitoine et a la mise en place du premier trocart restent a l’origine d’une morbidite et d’une mortalite qui, pour etre faibles, restent mesurables et n’apparaissent pas etre diminuees par la seule experience de l’operateur dans l’utilisation d’une technique donnee. Differentes methodes ayant chacune des partisans convaincus et des detracteurs acharnes existent. De nombreux articles consacres a l’une ou l’autre font etat de points techniques ou de l’utilisation de materiels specifiques censes limiter ce risque. Dans le but de degager une attitude consensuelle permettant d’etablir des recommandations pour la realisation de ce premier temps operatoire de toute laparoscopie, une comparaison entre les methodes « aveugles » et les methodes controlees visuellement est apparue necessaire. Ce travail presente les differentes techniques disponibles, les types de trocarts presents sur le marche et analyse la litterature sur les incidents relatifs aux unes et aux autres.

Introduction La mediolyse arterielle segmentaire (MAS) est une pathologie rare, d’etiologie indeterminee atteignant les arteres de moyen calibre, particulierement celles du tronc cœliaque et l’artere mesenterique superieure. Le principal symptome est la douleur abdominale intense traduisant un infarctus d’organe ou une hemorragie intra-abdominale mettant en jeu le pronostic vital. Une prise en charge diagnostique et therapeutique rapide est necessaire, d’autant plus que le traitement endovasculaire s’avere etre efficace. Observation Une femme de 50 ans, tabagique, non hypertendue, aux antecedents de colique nephretique est admise aux urgences pour une douleur abdominale. Un traitement de colique nephretique etait entrepris et deux jours plus tard, devant la persistance des douleurs, un scanner (TDM) abdomino-pelvien (AP) injecte est realise et montrait un kyste ovarien non rompu pour lequel un traitement symptomatique etait prescrit. Cinq jours plus tard, la douleur s’intensifiant, elle etait a nouveau admise aux urgences ou il etait constate une degradation de la fonction renale (augmentation de la creatinine de 47 a 109 μmol/L) associee a un syndrome inflammatoire biologique. Un nouveau TDM AP montrait une hypodensite du rein droit qui motivait une antibiotherapie par Ceftriaxone et Levofloxacine, malgre l’absence d’identification microbiologique. Le bilan immunologique etait normal. Le TDM de controle realise 48 heures plus tard objectivait une thrombose partielle de l’artere renale droite avec un infarctus renal droit. Une heparinotherapie etait alors debutee. Le lendemain elle presentait un malaise hypotensif avec une defense abdominale generalisee. Un nouveau TDM mettait en evidence un hemoperitoine, un hematome sous capsulaire du foie avec saignement actif et une dissection des arteres renales, mesenteriques et du tronc cœliaque inaccessible a un traitement endovasculaire. L’aspect clinique rapidement progressif et la topographie des dissections arterielles faisaient evoquer le diagnostic de mediolyse arterielle segmentaire. Plusieurs interventions chirurgicales etaient necessaires du fait de saignement diffus en nappe avec une difficulte majeure pour suturer les arteres lesees. Elle avait recu plus de 150 produits labiles sanguins afin de maintenir une hemodynamique stable. L’evolution a ete favorable avec disparition des douleurs et de l’hemorragie intra-abdominale. Discussion La physiopathologie de la MAS comprend une destruction de la media avec vacuolisation et lyse des cellules musculaires lisses vasculaires et un remodelage vasculaire avec developpement d’une fibrose [1] . Il en resulte une fragilite de la paroi arterielle avec developpement d’anevrysmes et de stenoses pouvant entrainer des dissections arterielles touchant preferentiellement la vascularisation mesenterique, renale, du tronc cœliaque mais rarement cerebral. [2] . L’errance diagnostique est frequente responsable d’un retard therapeutique pouvant etre dramatique comme chez notre patiente. Les diagnostics differentiels ont ete discutes et ecartes notamment : les infections bacteriennes ou mycotiques ; les vascularites et enfin les pathologies non infectieuses et non inflammatoires telles que le syndrome d’Ehler-Danlos, la neurofibromatose ou le pseudoxanthome elastique. La confirmation diagnostique est histologique soit sur des prelevements peroperatoires, soit en post-mortem. [3] . Actuellement un traitement endovasculaire par embolisation arterielle est privilegie. L’indication chirurgicale est limitee a l’hemorragie associee aux thromboses arterielles avec des phenomenes ischemiques ou pour des lesions vasculaires impossibles a traiter par le traitement endovasculaire, ce qui etait le cas chez notre patiente. Le pronostic reste effroyable a court terme avec 50 % de deces. Il n’existe pas de consensus pour les formes a- ou pauci- symptomatiques. [3] Conclusion La mediolyse arterielle segmentaire est une pathologie rare, avec de nombreux differentiels rendant difficile une prise en charge diagnostique adaptee et une prise en charge therapeutique rapide. Le pronostic a court terme reste encore sombre. Le traitement endovasculaire est essentiel dans les formes symptomatiques.

Thanks to a superior resolution and contrast, MRI allows recognizing the post therapeutic modifications of female pelvis, often very subtle and nonvisible by the other imaging modalities. The main surgical or medical therapies in the female pelvis will be described as well as the normal post therapeutic anatomical aspects. The main complications and failures will be mentioned and informed. Finally the keys that will allow to understand these complications and failures will be boarded.

Carcinoid tumors account for less than 1% of all malignancies. The majority arise in the gastrointestinal system (GI carcinoids). The diagnosis of GI carcinoids is often made late, the protean symptoms are easy to overlook. Diagnosis, prognosis and treatment options are based on biochemical markers and imaging investigations. A high concentration of urinary 5-HIAA or an elevated serotonin level in plasma help to establish the diagnosis of GI carcinoid. Plasma chromogranin A has poor specificity (68%); its level depends on disease involvement and therapeutic response. Octreoscan is the best imaging technique to detect GI carcinoids, but CT scan and MRI are superior for the detection of metastasis. 18F-DOPA or 11C-5-HTP/PET, imaging fusion as of octreoscan or PET scan with CT or MRI, improve the results of metabolic imaging. Coronal contrast-enhanced CT or MRI angiogram can evaluate mesenteric vessel spread before surgery. Upper endoscopy or colonoscopy, can be performed to detect foregut carcinoid in MEN, or hindgut carcinoid. Echoendoscopy visualizes abdominal wall and local node involvement. Enteroscopy and capsule endoscopy localize 66% of midgut carcinoids. Although there have been considerable advances in diagnostic modalities, the diagnosis of carcinoid tumors is still, all too often, late.

Resume L'echographie est l'examen de reference pour l'analyse des nodules thyroidiens. Le compte-rendu doit preciser la technique utilisee, et decrire precisement l'echostructure du parenchyme thyroidien, les caracteres des nodules (nombre, taille, echostructure, echogenicite, contours), la presence d'adenopathies. Les criteres de malignite d'un nodule sont : (1) nodule solide hypoechogene, (2) microcalcifications intranodulaires (3) contours irreguliers ou rupture du halo clair peripherique. Les criteres de malignite des adenopathies sont : (1) adenopathie supracentimetrique, (2) hypoechogene ou inhomogene avec alternances de zones hypo- et hyperechogenes, (3) kystisee, (4) avec calcifications internes, (5) d'aspect globuleux avec majoration du diametre anteroposterieur, et (6) rapport diametre longitudinal/diametre transversal superieur ou egal a 0,7, (7) mauvaise visualisation du hile. La presence de tels criteres impose une confirmation histologique et peut modifier la prise en charge chirurgicale des patients.

Papillary and follicular thyroid carcinomas are the most common form of endocrine carcinomas. Lymph node involvement seems to be a low risk factor for death, but it increases the risk for loco-regional recurrences and distant metastasis. The limits and the key points of the cervical lymph node dissection are described. The sentinel lymph node is used to rarely, so it could limit the lymph dissection. Node-picking has to be avoided. Central lymph node resection is recommended for high-risk patients, as male, patients more than 45 or less than 21 years old, papillary carcinomas greater than 1 cm or follicular carcinoma more than 2 cm in diameter. Lateral lymph node resection is performed when the lymph nodes of the central compartment are involved, more than 3 cm in diameter, and bulked. Prophylactic lymphadenectomy is useless. When thyroid carcinoma is known postoperatively, re-operation depends of the cervical mass and of the results of the radioactive iodine treatment.

Resume L'hypertension (HTA) est tres frequente mais son origine n'est reellement connue que dans 1 a 5 % des cas. L'HTA est presente chez la moitie des patients porteurs d'un incidentalome surrenalien. Le bilan, comprenant interrogatoire, examen clinique, dosages biologiques, tomodensitometrie et scintigraphies surrenaliennes, a pour but d'isoler les lesions surrenaliennes secretantes. La surrenalectomie s'impose si la masse surrenalienne est suspecte, ou si le profil biologique est en faveur d'une hypersecretion. Si l'HTA semble independante de la pathologie surrenalienne, il convient d'eliminer un bloc enzymatique congenital afin d'eviter une surrenalectomie inutile, et de rechercher un adenome cortisolique infraclinique. Ce dernier est associe dans 91 % des cas a une HTA, et dans 50 % des cas a une obesite, un diabete de type 2, ou une dyslipidemie. L'exerese de l'incidentalome, ameliore l'HTA dans plus de la moitie des cas. Si l'incidentalome corticosurrenalien est non secretant, une surveillance prolongee s'impose. Le caractere essentiel de l'HTA ne pourra etre affirme qu'apres un nouveau bilan effectue trois ans plus tard.

Grenoble Test Source (GTS) is a room temperature electron cyclotron resonance ion source whose purpose is to deepen the knowledge of this type of device. GTS was designed according to magnetic scaling laws determined with the SERSE source [Hitz et al., Rev. Sci. Instrum. 73, 509 (2002); Gammino et al., ibid. 72, 4090 (2001)] while keeping enough flexibility in terms of magnetic confinement and rf heating to determine best conditions for the production of intense beams of any charge state. First results were presented 1 year ago [Hitz et al., 8th European Particle Accelerator Conference, 2002; 15th International Workshop on ECR Ion Sources, 2002]. Since then, some improvements have been performed mostly in the magnetic confinement, beam extraction and analysis. Updated ion beam intensities are presented: e.g., 0.5 mA of Ar11+ at 18 GHz, 20 μA of Ar16+ and 1.8 μA of Ar17+ when GTS is operated at 14.5 GHz. On the other hand, charge coupled device imagers have been installed to diagnose and monitor the ion be...

For the needs of future heavy ions accelerators, electron cyclotron resonance ion sources (ECRIS) should be able to deliver intense beams of multiply charged ions. The 1 emA level intensity has been reached by ECRIS for medium charge states (e.g. O6+, Ar8+). However, thanks to a better optimization of the ionic lifetimes inside the ion source, high charge states intensities are also been improved. After a presentation of some scaling laws governing the ECRIS behavior, different ion sources will be shown: new compact all permanent magnet source shown, upgrade of the CAPRICE type source and a fully superconducting source.

The Quadrumafios electron cyclotron resonance ion source (ECRIS) has been especially designed to permit physical studies of the plasma; this paper describes the source itself (which has been operated at 10 GHz in a first step), its preliminary performances, and the different diagnostics involved, which mainly concern the electron population [electron cyclotron emission (ECE), x rays, diamagnetism, microwave interferometer, and electron analyzer]. The results are presented and discussed: There is of course a close relationship between the parameters of the plasma and the performances of the source; this point will be discussed in the article.

Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15-30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI.Two hundred consecutive patients (six men; median age = 60; range 16-81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year.The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome.Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.

Primary hyperparathyroidism is an unusual cause of acute pancreatitis. The aim of this study was to analyse data from multiple centers concerning patients with primary hyperparathyroidism and associated acute pancreatitis and to analyze potential predictive factors.In this retrospective multicentric study, 19 patients were identified (Group A) with the associated diagnoses of acute pancreatitis and primary hyperparathyroidism. Their clinical data was compared to that of a control group of 65 patients (group B) with primary hyperparathyroidism without acute pancreatitis.Age, parathormone levels and pathology (uni/multiglandular disease) were similar between the two groups. The mean plasma calcium level was significantly higher in group A (12.64 mg/100ml) than in group B patients without pancreatitis (11.28 mg/100ml) (p0.0001).This study confirms the causal relationship between primary hyperparathyroidism and acute pancreatitis. The degree of hypercalcemia may play an important role in this association. Calcium levels should be measured in all patients with acute pancreatitis.

Thanks to a superior resolution and contrast, MRI allows recognizing the post therapeutic modifications of female pelvis, often very subtle and nonvisible by the other imaging modalities. The main surgical or medical therapies in the female pelvis will be described as well as the normal post therapeutic anatomical aspects. The main complications and failures will be mentioned and informed. Finally the keys that will allow to understand these complications and failures will be boarded.

Anterolateral hernias of the abdomen group together umbilical, epigastric, and spigelian hernias and diastasis of the abdominal rectus. In spigelian hernias, 90% are located in the subumbilical region at the Monro line. They are asymptomatic in 90% of cases. The risk of strangulation is 10%-25% and requires surgical treatment. A herniorrhaphy is sufficient if the ring is less than 2 cm in diameter. Beyond 2 cm, open or celioscopic mesh repair is necessary. The risk of recurrence is less than 2%. Umbilical hernias result from progressive enlargement of the umbilical ring. The risk of strangulation is higher than 10%. The morbidity and mortality rate reaches 15% in large strangulated hernias. All umbilical hernias should therefore be treated surgically. If their diameter is under 2 cm, a simple herniorrhaphy can be done; otherwise mesh repair is required. In the cirrhosis patient, hernia treatment is part of the ascites treatment. The indication for surgery depends on liver function. Epigastric hernias are most often symptomatic: 80% have a ring smaller than 25 mm and 20% are multifocal. The risk of strangulation is low. If the ring is less than 20 mm, these hernias can be treated by herniorrhaphy. Recurrence is frequent - more than 10% - and always difficult to treat. Diastasis of the recti does not lead to complication, and treatment is not necessary. Cosmetic surgery can be used to manage diastasis.

The surgical results of inguinal hernia repair depend on the operative indications. When surgery is being discussed, four factors should be taken into account: patient age and sex, the type of hernia (location, age, side, recurrence), and the patient characteristics that favor hernia onset or increase the surgical risk. In females, hernias are for the most part femoral, and inguinal hernias are rarely isolated. Femoral hernias and hernias that have recently appeared are at a high risk for strangulation. The complications of recurring hernias are always serious. These hernias should be treated no matter how old the patient is, with the risk of strangulation increasing above the age of 65. A repair procedure can be done under local anesthesia with no increase in the postoperative complication rate, even in older patients and patients who are at high risk for surgery. On the other hand, interventions done in an emergency situation induce excessive morbidity and mortality, which persist during the year following the surgery. Hernial strangulation multiplies postoperative morbidity by 2.67 and mortality by 10. In cases of asymptomatic bilateral hernia with no risk of complication, the indication should be weighted by age and any associated comorbidities. Finally, with an old hernia, the surgical risk should be compared to the risk of strangulation.

Carcinoid tumors account for less than 1% of all malignancies. The majority arise in the gastrointestinal system (GI carcinoids). The diagnosis of GI carcinoids is often made late, the protean symptoms are easy to overlook. Diagnosis, prognosis and treatment options are based on biochemical markers and imaging investigations. A high concentration of urinary 5-HIAA or an elevated serotonin level in plasma help to establish the diagnosis of GI carcinoid. Plasma chromogranin A has poor specificity (68%); its level depends on disease involvement and therapeutic response. Octreoscan is the best imaging technique to detect GI carcinoids, but CT scan and MRI are superior for the detection of metastasis. 18F-DOPA or 11C-5-HTP/PET, imaging fusion as of octreoscan or PET scan with CT or MRI, improve the results of metabolic imaging. Coronal contrast-enhanced CT or MRI angiogram can evaluate mesenteric vessel spread before surgery. Upper endoscopy or colonoscopy, can be performed to detect foregut carcinoid in MEN, or hindgut carcinoid. Echoendoscopy visualizes abdominal wall and local node involvement. Enteroscopy and capsule endoscopy localize 66% of midgut carcinoids. Although there have been considerable advances in diagnostic modalities, the diagnosis of carcinoid tumors is still, all too often, late.

Nowadays, colonoscopy has become an invaluable tool in the diagnosis and treatment of diseases of the colon and rectum. Colonoscopy is still an invasive exam with several complications. The most common complications are perforation and bleeding, which occur in up to 1% after diagnostic colonoscopy and 3% of patients undergoing therapeutic colonoscopy. Less common complications include pneumothorax, pneumomediastinum, colonic volvulus, hernia incarceration, retroperitoneal abscess and mesenteric tear. Splenic rupture is a rare and potentially lethal colonoscopic complication with less than 45 cases reported in the world. The overall incidence is 0.004%. Mechanisms of injury and available treatment options remain discussed. We present a case of splenic rupture after colonoscopy with polypectomy in a 73-year-old woman managed first with nonoperative treatment and nine days later with surgical treatment. As the indications for colonoscopy expand, including the introduction of mass screening for colorectal cancer, endoscopists should be increasingly aware of that life-threatening complication after colonoscopy and know the emergency treatment.

A new high voltage platform has been installed at the ORNL Multicharged Ion Research Facility (MIRF) to extend the energy range of multicharged ions available for experiments studying their collisional interactions with electrons, atoms, molecules, and solid surfaces. For the production of the multiply charged ions, a new all‐permanent magnet ECRIS has been designed and fabricated at CEA/Grenoble. After a brief overview of the basic features of the new platform, and associated beam transporta detailed description of the new ion source design and performance is provided, together with some typical Ar, Xe, and O beam intensities obtained during source commissioning prior to shipment to ORNL.

Colon cancers arise only rarely in the course of a pregnancy. Yet colon obstruction, perforation and metastatic spread seem to occur more frequently in this setting than with the average colon cancer. Perhaps this is due to the immunotolerance which accompanies pregnancy. No case of epidermoid (squamous cell) cancer of the colon has been previously described in a pregnant woman. This conjunction has a catastrophic prognosis: the diagnosis of colon tumor is delayed since symptoms are masked by the pregnancy, and epidermoid colon cancer is a particularly aggressive lesion. A major sub-diaphragmatic surgical procedure can be performed with reasonable safety to mother and fetus. Radiotherapy is contraindicated. Neo-adjuvant chemotherapy can be administered although the risks to the fetus are not well known. During the first trimester, a therapeutic abortion can be proposed to optimise the treatment of the mother. During the second and third trimesters, treatment of the mother exposes the fetus to the risk of malformations or premature delivery; delay in maternal treatment in hopes of prolonging the pregnancy in order to obtain a viable neonate diminish the chances of maternal survival.

Spontaneous cholecystocutaneous fistula is a rare complication of gallbladder empyema without treatment. The incidence has further decreased with the advent of resuscitation and surgical treatment. These fistulas are like a cholecystostomy. The diagnostic is confirmed with a fistulogram which allows visualization of the fistula tract. Traditional treatment has consisted of broad-spectrum antibiotics administration, cholecystectomy and fistula drainage. One-stage treatment is the preferred option. Laparoscopic approach appears feasible even the conversion rate is high.

A reliable model, usable in vitro and in vivo, is necessary for analysis of processes engaged during cell death, regeneration and differentiation. The peripheral olfactory system is an attractive model for studying these processes through its dynamic neurogenesis that occurs continually throughout the lifetime.The aim of this study was the analysis of these processes on an animal model.We performed axotomy of the nerve olfactory on young animals and chicken embryos E17. Then we infused IGF-I (insulin-like growth factor-I) in the lesioned site. Death, regeneration and differentiation of cells were studied by immunocytology.After hatching, the section of the olfactory nerve induced a rapid neuronal apoptosis at the 24th hour followed by a wave of mitosis 24 hours later. In prenatal stages, the response to the axotomy was rather similar to a dedifferentiation. In postnatal stages, the IGF-I infusion at the lesioned site had a triple function: survival of mature neurons, maintenance of differentiation and stimulation of mitosis. The neoneurogenesis, which occurred from neuronal stem cells would depend on the maturation and environment of the olfactory neurons protected from apoptosis by IGF-I.The avian olfactory epithelium is a good model for analysis of cell death, regeneration and differentiation. The capacity of these neuronal stem cells to dedifferentiate makes then more primitive than the pluripotent cells, closer to totipotent embryonic stem cells.

Introduction Les eventrations volumineuses et complexes constituent toujours une prouesse technique surtout en raison de l’importance du defect aponevrotique. Pour prendre en charge ces malades difficiles, la mise en place d’un renfort en position intra-peritoneale (IP) semble etre la solution ideale. Le but de ce travail multicentrique etait de preciser l’efficacite (en termes de recidives) et la tolerance d’un renfort en polyester, protege par un film anti-adherentiel, employe pour le traitement de ces eventrations difficiles. Patients et Methodes De mars 2005 a juillet 2009, 54 patients, presentant une eventration large (diametre transversal > 10 cm) et/ou recidivee, etaient traites dans 5 centres universitaires en employant dans tous les cas un renfort Parietex® composite en polyester protege sur une face par un film hydrophile resorbable anti-adherentiel. Il s’agissait de 25 femmes et de 29 hommes avec un âge median de 59 ans. 54 % (29/54) avaient un score ASA 2 ; 28 % (15/54) un score ASA 3. Le BMI median etait de 30,9 kg/m2, le diametre transversal median etait de 12,6 cm. 28 % des patients avaient subi une ou plusieurs interventions pour eventration. Les parametres etaient recueillis a 1 mois (51 patients), 1 an (42 patients), 2 ans (32 patients) et 3-4 ans (24 patients). Resultats La duree moyenne de retour aux activites quotidiennes etait de 26,4 jours. A 1 mois, 51 % (26/51) des patients avaient des douleurs residuelles mineures (echelle visuelle analogique score moyen : 2/10). Les complications postoperatoires etaient mineures : 1 serome, 2 hematomes, 2 infections superficielles et 1 granulome. Les patients ont ete suivis sur une duree mediane de 2,7 (± 1) ans. Les complications, pendant cette periode, sont : 4 douleurs residuelles mineures (limitees a la cicatrice), 3 fistules entero-cutanees, 1 absence de cicatrisation cutanee, 1 abces superficiel, et 4 recidives. Conclusion Le traitement des eventrations abdominales complexes par le renfort Parietex® composite permet obtenir une reparation efficace a long terme. Son positionement intra-peritoneal est peu algique ; le taux de complications liees a ce renfort est faible compte tenu de la complexite des cas traites et aux nombreux facteurs de comorbidites.

The aim of this prospective non-randomized study was to compare Stoppa's technique to laparoscopic approach in totally extraperitoneal repair of bilateral inguinal hernia.From December 1996 to December 1998, 117 consecutive patients with 234 hernias underwent either Stoppa's technique (74 patients) or a totally extraperitoneal laparoscopic approach (43 patients). Patients were randomized in two groups according to the surgeon to whom they were referred. All patients were reviewed in December 1999.There was no mortality. Complications occurred in 3% of patients after Stoppa's technique (group S) and in 4% of patients in the laparoscopic group (group L). The conversion rate was 7% (3 cases). Postoperative analgesia use, hospital stay, and duration of disability were significantly shorter in group L, the cost was lower, but the operating time was significantly longer than in group S. Recurrence rates were similar in the two groups: 2% in group S, 1.1% in group L.The laparoscopic approach appears to be preferable to Stoppa's technique in the treatment of bilateral inguinal hernia.

Gallbladder carcinoma is a highly lethal disease. The advantages of radical surgery remain controversial. The authors' objective was to evaluate the effectiveness of an aggressive approach to gallbladder carcinoma on long-term survival.A questionnaire was sent to 73 institutions in France, Europe, and overseas. Data, from 724 patients treated between 1980 and 1989, were analyzed for patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports and survival. Seventy-eight percent of the patients were women, and 22% were men. Gallstones were present in 86% of the cases. Four percent of the patients had Tis lesions, 11% had T1 to T2 lesions, and 85% had T3 to T4 lesions.Twenty-three percent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (70 years) had a higher operative risk. The overall median survival was 3 months, and long-term survival correlated with cancer stage: Tis60 months, T1 to T222 months, and T3 to T4 2 to 8 months. Projected five-year survival for cancers limited to the gallbladder and treated by simple cholecystectomy was 93%, 18% and 10% for Tis, T1 and T2 respectively. For T3 to T4, no difference was observed among the different surgical procedures adopted--hepatic resection, trans-tumoral stenting or biliary-enteric anastomosis.In conclusion, a simple cholecystectomy is effective only for Tis cancer. An extended cholecystectomy for invasive cancer should be performed, but only if there is limited involvement of the immediately adjacent hepatic parenchyma. There is now a need to evaluate more effective adjuvant therapy in the form of radiotherapy or newer chemotherapeutic agents.

The aim of this retrospective study concerning the repair of postoperative incisional hernia using Dacron mesh was to compare results according to the extra- or intraperitoneal mesh position in order to assess the respective indications of each option.From January 1985 to December 1996, 172 patients (mean age: 61.3 years) were operated on using Dacron mesh extraperitoneally (n = 99) or intraperitoneally located (n = 73). For statistical analysis, both groups were compared using Chi square test or Fisher's test.There were no postoperative deaths in the group with extraperitoneal mesh and two postoperative deaths in the group with intraperitoneal mesh. There were no significant differences when results comparing parietal complications (sepsis: 2% vs 2.7%, pain: 9.1% vs 16.9%), secondary intestinal disorders (2% vs 4.2%) and recurrence rate (4% vs 5.6%) were assessed between extraperitoneal and intraperitoneal mesh. Recurrences were related to pareital infection treated by partial removal of the mesh (n = 2) or to the lateral detachment of the mesh (n = 6).In the group of patients receiving extraperitoneal mesh there were no postoperative deaths and morbidity was low (this technique is generally used in the treatment of large incisional hernia). In the group of patients receiving intraperitoneal mesh, similar parietal and general complications were observed. But the risk of serious complications and postoperative death is higher; this technique must be limited to the most serious incisional hernia and to high risk patients.