Emmanuel Benizri

HIF‐1α and CA IX staining in invasive breast carcinomas: Prognosis and treatment outcome

Hypoxia stabilizes HIF‐1α (Hypoxia Inducible Factor‐1α), which then triggers the expression of several genes involved in many aspects of cancer progression, including metabolic adaptation, cell survival and angiogenesis. The aim of our study was to evaluate the impact of HIF‐1α and CA IX (carbonic anhydrase IX) (one of its target genes) expression on prognosis and treatment outcome of patients with breast cancer. Because of the extreme O2‐dependent instability of the protein, we first validated HIF‐1α staining using xenograft tumours that were subjected to experimental conditions mimicking surgical clamping or sitting at room temperature under normoxic conditions after surgical excision but before fixation. Afterwards, the immunohistochemical staining of HIF‐1α and CA IX was evaluated in 132 invasive breast carcinomas with a 10‐year follow‐up, and correlated to classical clinicopathological parameters and response to adjuvant therapy. No significant correlation was found between tumour size or nodal status and the expression of HIF‐1α or CA IX. Statistically significant association was found between HIF‐1α or CA IX staining and the grade, hormonal receptors loss and the presence of carcinoma in situ. Overexpression of HIF‐1α and CA IX correlates with a poor prognosis in breast cancer. We show that HIF‐1α is an independent prognostic factor for distant metastasis‐free survival and disease‐free survival in multivariate analysis. Furthermore, overexpression of HIF‐1α or CA IX correlates with a poor outcome after conventional adjuvant therapy. CA IX is, however, a weaker prognostic and predictive factor than HIF‐1α, and its association with HIF‐1α does not modify the survival curve neither response to therapy, compared to HIF‐1α alone.

Multifilament polypropylene mesh for urinary incontinence: 10 cases of infections requiring removal of the sling

One hundred and forty-nine women received a suburethral woven polypropylene mesh insertion for urodynamic stress incontinence. Eleven patients (7.5%) presented between 4 and 17 months after surgery (mean 10 months) with symptoms of retropubic infection. Ten patients required surgical exploration, drainage of the collection and removal of the tape either unilaterally (six) or bilaterally (four). Bacterial cultures were negative in nine women. Following removal of the tape, eight patients reported residual incontinence, either stress leakage (five) or de novo urge incontinence (three). Multifilament polypropylene meshes appear to be more at risk of infection, usually requiring sling removal, which may be related to pore size of the mesh. Our data reinforce the importance of proper evaluation of new surgical procedures by rigorously designed randomised trials with adequate follow up to identify rare but potentially serious complications.Sir, Proposed mechanism for polypropylene tape erosions Repair of damaged connective tissue with implanted mesh is a well-established technique in almost any form of surgery. Any implanted foreign body may cause a foreign body–tissue reaction. Indeed, all ‘tension-free’ vaginal tape operations are based on this principle. An implanted plastic tape irritates the tissues to create a longitudinal deposition of collagen to reinforce the posterior pubourethral ligament,1 the anchoring point for the three-directional muscle forces that facilitate the urethral and bladder neck closure mechanisms.2 Bafghi et al.’s clinical observations of sinus formation were reported in the original animal studies on which all ‘tensionfree tape’ operations are based.1 Woven Mersilene multifilament tapes were implanted as an inverted ‘U’, with both ends lying free in the vagina. Ten of 13 canines developed a suprapubic sinus. Like Bafghi’s patients, all remained afebrile and well, and no significant growth was noted on bacteriological examination. Radioactive Gallium studies showed no evidence of infection. In all cases, the sinus disappeared within 48 hours of vaginal removal of the tapes, accomplished by pulling on the vaginal end. In that study, macrophages were noted in the interstices of the tape. In subsequent human and animal studies on multifilament polypropylene tapes, macrophages were noted surrounding individual microfibrils in spaces less than 5 m.3 These data do not support the ‘pore’ hypothesis, which states that macrophages cannot enter spaces less than 10 m. The experience of the two first authors over 4000 clinical cases confirms this experience: it is unusual to grow significant bacteria in cases of tape rejection, even in cases where a skin sinus is present. Neither Bafghi et al. nor de Boer grew significant bacteria, and there is no mention of bacteria being

Small bowel volvulus resulting from a congenital band treated laparoscopically

In recent years, laparoscopy has dramatically changed the approach to the patient with acute abdominal pain. We report the case of a patient with small bowel volvulus caused by a congenital band binding the greater omentum to the mesentery, which was promptly diagnosed and treated using laparoscopy. Early intervention averted irreversible ischemic lesions of the intestine and the need for bowel resection. With the routine use of laparoscopy in the setting of acute abdominal pain, rare affections can be easily diagnosed and effectively treated.

Small bowel involvement is a prognostic factor in colorectal carcinomatosis treated with complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy

BackgroundCytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising treatment for patients with peritoneal carcinomatosis (PC). Our objective was to identify new prognostic factors in patients with PC from colorectal cancer treated with this procedure.MethodsAll patients with PC from colorectal cancer treated by HIPEC from January 2000 to December 2007 were prospectively included. The tumor extension was assessed by the Peritoneal Cancer Index (PCI) and the residual disease was recorded using the completeness cytoreductive score (CCs). All clinical and treatment data were computed in univariate and multivariable analyses using survival as primary end point.ResultsWe carried out 51 complete procedures in 49 consecutive patients. The mean PCI was 10. The allocation of CCs was: CC-0 = 37, CC-1 = 14. The five-year overall and progression-free survival rate were 40% and 20%, respectively. Several prognostic factors for survival were identified by univariate analysis: PCI < 9 (P < 0.001), CC-0 vs. CC-1 (P < 0.01) and involvement of area 4 (P = 0.06), area 5 (P = 0.031), area 7 (P = 0.014), area 8 (P = 0.022), area 10 (P < 0.0001), and area 11 (P = 0.02). Only the involvement of the distal jejunum (area 10) was significant in the multivariable analysis (P = 0.027).ConclusionsWe demonstrated that the involvement of area 10 (distal jejunum of the PCI score) was an independent factor associated with poor prognosis.

Ascites and malnutrition are predictive factors for incomplete cytoreductive surgery for peritoneal carcinomatosis from gastric cancer

BACKGROUND Prognosis in peritoneal carcinomatosis from gastric cancer has improved with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy. The aim of this study was to identify predictive factors for incomplete CS. METHODS Forty-five patients undergoing laparotomy for gastric cancer with peritoneal carcinomatosis were prospectively included from January 2000 to December 2010. In case of optimal CS, patients (n = 14) received hyperthermic intraperitoneal chemotherapy. Otherwise, the laparotomy was closed or a palliative procedure was performed if necessary. All preoperative data were compared between the 2 groups. RESULTS Ascites (hazard ratio, .09; 95% confidence interval, .010-.48; P = .0103) and nutritional status evaluated by the prognostic nutrition index (hazard ratio, .11; 95% confidence interval, .0019-.54; P = .027) were independent predictive factors for incomplete CS. CONCLUSIONS The selection of patients for CS plus hyperthermic intraperitoneal chemotherapy should include the assessment of nutritional status and the detection of an ascites.

Post-traumatic transdiaphragmatic intercostal hernia: report of two cases

Transdiaphragmatic intercostal hernias (TIH) are rare. Less than 40 cases of TIH have so far been reported, with only 8 cases involving herniation of the liver. This report presents the case of 2 patients with a right-sided abdominal lump following a fall. Thoracoabdominal CT-scan showed a TIH between the 9th and 10th ribs with liver and right colonic herniation in both patients. Both patients were successfully treated with mesh repair. The presentation, physiopathology and management of this rare occurrence are discussed.

Swallowing a safety pin: Report of a case

Ingestion of a foreign body is a frequent and well-known medical problem with several diagnostic and therapeutic approaches. Usually, ingested foreign bodies pass through the alimentary tract without incident. In some cases, they can be lodged in the appendix and may cause appendicitis. We report a case of a 29-year old woman, suffering from mental illness, with a safety pin lodged in the appendix. Initially, the patient consulted for abdominal pain. After a period of waiting, during which time the foreign body did not move, a colonoscopy was performed but failed to see the safety pin. Then, the patient underwent a laparoscopic appendectomy. Pathological examination showed an ulcerative appendicitis.

Customized femoral vein grafts for inferior vena cava reconstruction

After extended en-bloc resection of a retroperitoneal neoplasm, prosthetic grafts can efficiently replace the inferior vena cava. However, in cases of concomitant biliary or bowel surgery, there is a risk of infection, and autogenous materials typically used present with size match. We present a method of autogenous graft construction using the femoral vein for replacement of the inferior vena cava, with an alternate configuration for renal vein implantation.

Traitement chirurgical de la rectocèle antérieure de la femme.La voie transanale

Anterior rectocele is a herniation of the anterior rectal wall into the vagina, which may be either isolated or associated with other pelvic floor disorders. Rectocele could result in outlet obstruction with dyschezia, manual extraction of faeces and/or false incontinence. Rectocele is diagnosed clinically, and can be confirmed by defecography. Other tests may demonstrate associated causes of constipation. Symptomatic rectoceles can be treated via a transrectal route, with two or three layers of plication of the rectal wall and excision of the redundant mucosal flap. The results of transrectal repair are good: short hospital stay, no mortality, morbidity less than 5%, good short- and mid-term results in approximately 80% of cases. Selection criteria in favour of the transrectal approach have not been clearly identified.

Perforation recto-sigmoïdienne au cours d’un effort de défécation : définition, prise en charge et propositions physiopathologiques de cette nouvelle entité

Introduction Les perforations recto-sigmoidiennes au cours d’un effort de defecation representent un probleme diagnostique et therapeutique, avec un morbi-mortalite potentiellement elevee en raison de la peritonite stercorale qui en resulte. Materiel et methodes Nous avons pris en charge dans notre institution entre mai 2008 et janvier 2014, cinq patients pour apparition soudaine d’une douleur abdominale intense lors de la defecation. Ces 5 patients presentaient un syndrome peritoneal generalise a l’admission aux urgences avec un scanner evocateur d’une perforation d’organe creux. Resultats Une intervention a ete realisee pour chaque patient et a revele une perforation recto-sigmoidienne sur le bord anti-mesenterique du recto-sigmoide ; la perforation n’etait pas exteriorisable. Pour ces 5 patients, le colon etait macroscopiquement sain et ne presentait pas de diverticulose. Une coelioscopie premiere a ete realisee chez 3 patients. La localisation et la taille de la perforation ne permettaient pas techniquement une suture coelioscopique pour 4 patients. Discussion Differentes hypotheses semblent pouvoir expliquer la fragilite de la jonction recto-sigmoidienne : vascularisation precaire du bord anti-mesenterique, angulation de la charniere rectosigmoidienne realisant un « pseudo-sphincter », presence d’un ralentissement du transit iatrogene ou iodiopathique, etc. Toutefois, la physiopathologie exacte de cette maladie n’est pas encore etablie.