N. Pirro

Anatomical study of the infrapatellar branch of the saphenous nerve using ultrasonography

The purpose of this study was to determine whether ultrasonography allows precise assessment of the course and relations of the infrapatellar branch of the saphenous nerve.

Long-Term Outcome After Ampullectomy for Ampullary Lesions Associated With Familial Adenomatous Polyposis

PURPOSEUp to 90 percent of patients with familial adenomatous polyposis develop adenomas in the upper gastrointestinal tract. Besides pancreaticoduodenectomy, which remains indicated in duodenal and ampullary cancer, less aggressive surgical procedure (such as ampullectomy) must be evaluated in selected patients with familial adenomatous polyposis patients presenting low-risk benign duodenal adenomas.METHODSFrom 1995 to 2000, we performed a retrospective, observational study, which included eight patients (5 females) with familial adenomatous polyposis underwent ampullectomy (with frozen sections) for presumed benign polyposis lesions. Six patients had an ileal pouch-anal anastomosis performed 2 to 27 years before ampullectomy. The remaining two patients had ampullectomy during the same operation than ileal pouch-anal anastomosis.RESULTSNo patient died postoperatively. Mean hospital stay was 15 ± 6.5 (range, 10–21) days. There was one major complication (pancreatic fistula), which was treated conservatively. Final pathologic examination of the specimens revealed that three patients had a severe dysplasia. Mean follow-up of the patients was 58 ± 37 (range, 24–119) months. During endoscopic follow-up, although all the patients underwent endoscopic resection of duodenal polyps, none presented recurrence at the ampullectomy site.CONCLUSIONSAmpullectomy could be safely proposed in selected familial adenomatous polyposis patients. Our low morbidity and the absence of recurrence after almost five years of follow-up suggests that such conservative treatment could be proposed before pancreaticoduodenectomy in patients with high-risk ampullary adenomas without invasive carcinoma.

Female patient-specific finite element modeling of pelvic organ prolapse (POP)

Pelvic organ prolapse (POP) occurs only in women and becomes more common as women age. However, the surgical practices remain poorly evaluated. The realization of a simulator of the dynamic behavior of the pelvic organs is then identified as a need. It allows the surgeon to estimate the functional impact of his actions before his implementation. In this work, the simulation will be based on a patient-specific approach in which each geometrical model will be carried out starting from magnetic resonance image (MRI) acquisition of pelvic organs of one patient. To determine the strain and stress in the soft biological tissues, hyperelastic constitutive laws are used in the context of finite element analysis. The Yeoh model has been implemented into an in-house finite element code FER to model these organ tissues taking into account large deformations with multiple contacts. The 2D and 3D models are considered in this preliminary study and the results show that our method can help to improve the understanding of different forms of POP.

Rationale for Possible Targeting of Histone Deacetylase Signaling in Cancer Diseases with a Special Reference to Pancreatic Cancer

There is ongoing interest to identify signaling pathways and genes that play a key role in carcinogenesis and the development of resistance to antitumoral drugs. Given that histone deacetylases (HDACs) interact with various partners through complex molecular mechanims leading to the control of gene expression, they have captured the attention of a large number of researchers. As a family of transcriptional corepressors, they have emerged as important regulators of cell differentiation, cell cycle progression, and apoptosis. Several HDAC inhibitors (HDACis) have been shown to efficiently protect against the growth of tumor cells in vitro as well as in vivo. The pancreatic cancer which represents one of the most aggressive cancer still suffers from inefficient therapy. Recent data, although using in vitro tumor cell cultures and in vivo chimeric mouse model, have shown that some of the HDACi do express antipancreatic tumor activity. This provides hope that some of the HDACi could be potential efficient anti-pancreatic cancer drugs. The purpose of this review is to analyze some of the current data of HDACi as possible targets of drug development and to provide some insight into the current problems with pancreatic cancer and points of interest for further study of HDACi as potential molecules for pancreatic cancer adjuvant therapy.

Surgical anatomy of the extrapelvic part of the pudendal nerve and its applications for clinical practice

PurposeThis study aims to report the topography of the extrapelvic part of the pudendal nerve (EPPN) and its relationship with the sacrospinous ligament and the pudendal artery.MethodsThe pudendal nerve (PN) was dissected by a gluteal approach in 40 cases. The morphology of the EPPN, its topography and the relationship between the PN on the one hand, and the pudendal artery and the tip of the ischial spine on the other hand were reported.ResultsThe length and the diameter of the EPPN were identical on the right and on the left side. The PN was a single trunk in 3/4 of cases. The PN was medial to the pudendal artery in 32 cases and crossed the sacrospinous ligament in 32 cases and the ischial spine in 6 cases.ConclusionsThe topographic variations of the EPPN are large and complicate its surgical and radiological approach.

Therapeutic anticoagulant does not modify thromboses rate vein after venous reconstruction following pancreaticoduodenectomy.

Recommendations for anticoagulation following major venous reconstruction for pancreatic adenocarcinoma (PA) are not clearly established. The aim of our study was to find out the relation between postoperative anticoagulant treatment and thrombosis rate after portal venous resection. Materials and methods. Between 1986 and 2006, twenty seven portal vein resections were performed associated with pancreaticoduodenectomies (n = 27) (PD).We defined four types of venous resection: type I was performed 1 cm above the confluent of the superior mesenteric vein (SMV) (n = 12); type II lateral resection and venorrhaphy at the level of the confluent SMV (n = 12); type III (n = 1) resulted from a primary end-to-end anastomosis above confluent and PTFE graph was used for reconstruction for type IV (n = 2). Curative anticoagulant treatment was always indicated after type IV (n = 2) resection, and after resection of type II when the length of venous resection was longer than ≥2 cm. Results. Venous thrombosis rate reached: 0%, 41%, and 100% for type I, II, IV resections, respectively. Among them four patients received curative anticoagulant treatment. Conclusion. After a portal vein resection was achieved in the course of a PD, curative postoperative anticoagulation does not prevent efficiently the onset of thrombosis.

Quels sont les facteurs de risque de l’incontinence anale du post-partum ?

Resume L’incontinence fecale est une des complications fonctionnelles les plus redoutees de l’accouchement. Elle est due a des lesions sphincteriennes ou neurologiques, parfois les deux associees. L’incidence de l’incontinence fecale dans le post-partum varie de 13 a 54 % mais demeure mal connue a moyen et long terme. Le taux de plaie perineale avec rupture des sphincters de l’anus et de rupture sphincterienne occulte varie de 1 a 9 % et de 18 a 35 %. Pres d’une femme sur deux a des troubles de la continence a moyen et long terme, apres une reparation faite au decours de l’accouchement. Une neuropathie pudendale, d’etirement, secondaire aux efforts de poussees et a la descente de la tete foetale dans le pelvis peut survenir des le 1er accouchement. Les principaux facteurs de risque de rupture sphincterienne et de neuropathie pudendale sont les extractions instrumentales, la macrosomie et une duree d’expulsion prolongee. Le risque d’incontinence fecale doit etre evoque des la 1re grossesse. La realisation d’une episiotomie ne protege pas les femmes d’une incontinence anale et pourrait meme la favoriser. La neuropathie pudendale consecutive a l’accouchement favorise probablement l’apparition d’une incontinence fecale retardee sous l’effet conjoint de la carence hormonale et de la senescence tissulaire. Le benefice de l’episiotomie precoce chez les femmes ayant des facteurs de risque de rupture sphincterienne reste a demontrer.

Volvulus du cæcum : Bases anatomiques et physiopathologie

Resume Le but de ce travail etait de rapporter 7 cas de volvulus du caecum et d’evaluer les anomalies anatomiques qui favorisent cette pathologie. Materiel et methodes 7 malades consecutifs (4 femmes) operes pour un volvulus du caecum ont ete inclus. Les parametres cliniques et paracliniques, les modalites de prise en charge ont ete etudies par l’analyse des dossiers medicaux. Les anomalies favorisant le volvulus du caecum ont ete recherchees par une etude anatomique et par une analyse de la bibliographie. Resultats tous les malades ont ete hospitalises pour des douleurs abdominales associees ou non a un syndrome occlusif. Le diagnostic a ete evoque 3 fois en preoperatoire. Tous les malades ont ete operes (colectomie droite : n = 6, caecopexie : n = 1). Les taux de mortalite et de morbidite etaient 0 et 28%. Le caecum etait fixe pour 15 sujets de l’etude anatomique (75%). Sept d’entre eux avaient un recessus retrocaecal. Le caecum etait mobile dans 5 cas (25%) similaire a l’incidence d’un defaut d’accolement peritoneal du colon droit rapportee dans la litterature variant de 11 a 25%. La frequence des volvulus du caecum est beaucoup plus faible suggerant qu’un defaut d’accolement est indispensable mais non suffisant ; le principal facteur de risque etant le sexe feminin. Conclusion le volvulus du caecum doit etre evoque chez les malades qui ont une douleur abdominale aigue. L’examen clinique et les cliches standards de l’abdomen sont souvent peu specifiques. La tomodensitometrie est l’examen le plus performant. Une prise en charge rapide et adaptee est necessaire pour eviter un taux de morbidite et de mortalite eleves.

Faisabilité de la chirurgie colorectale sans préparation colique. Étude prospective

INTRODUCTION Mechanical bowel preparation (MBP), aimed at reducing the infectious complications of colorectal surgery, was considered as indispensable. This benefit is actually disputed. The aim of this study was to report an experience of colorectal surgery without MBP. MATERIALS AND METHODS Hundred ninety patients without MBP and without low residue diet, who underwent colorectal surgery with primary anastomosis not requiring a diverting stoma were included. The main outcome were the rate of mortality, anastomotic leak, wound infection and intra-abdominal abscess. Secondary outcomes were duration of intravenous perfusion, nasogastric aspiration, total hospitalisation stay and time to realimentation. RESULTS The procedure was performed by laparotomy (n=142) or laparoscopy (n=48). Forty-eight patients underwent emergency surgery. Ninety-two patients were operated for malignancy. The rate of mortality was 6.3% in correlation with the scale of AFC. The rate of anastomotic leak was 3.7%. The rate of specific morbidity was independent of scale of AFC on the contrary to the frequency of non-specific complications. The mean duration of intravenous perfusion and nasogastric suction were 6 days and 0.3 day. The patient had normal diet to the 4th day (4+/-3 days). The mean hospital stay was 13.4 days. CONCLUSION The colorectal surgery without MBP may be safely performed and could improve the quality of life of patients in the perioperatory period.

Anal Sphincter Reconstruction Using a Transposed Gracilis Muscle With a Pudendal Nerve Anastomosis: A Preliminary Anatomic Study

PURPOSEFew studies have demonstrated the feasibility of cross innervating a skeletal muscle neosphincter with the pudendal nerve in an animal model. This study was designed to evaluate in humans the technical feasibility of anastomosing the nerve of the gracilis muscle and the pudendal nerve when the gracilis muscle is transposed around the anus.METHODSAnatomic assessment was made in 30 cases. The gracilis muscle and its principal neurovascular pedicle were dissected and the nerve to the gracilis divided at its origin. The gracilis muscle, accompanied by its nerve, was then transposed around the anus. The pudendal nerve was dissected in its extrapelvic portion and divided at its termination. Gracilis reinnervation was considered feasible when the proximal end of the nerve to the gracilis muscle and the distal end of the pudendal nerve were able to be placed into tension-free contact.RESULTSThe mean lengths of the nerve to the gracilis and the pudendal nerve were 126.5 ± 20.6 mm and 57.5 ± 16.3 mm. Anastomosing the nerve of the gracilis muscle and the pudendal nerve was possible in 28 cases. There was a total mean surplus nerve length of 25.1 ± 20.9 mm. In 26 cases, the distal end of the pudendal nerve (mean, 3.3 ± 1.1 mm) was similar or larger than the end of the nerve to the gracilis (mean, 3 ± 0.8 mm).CONCLUSIONSAnal sphincter reconstruction using transposed gracilis muscle with pudendal nerve anastomosis is anatomically achievable in cadavers, and supports the potential applications of this technique for perineal reconstruction in clinical practice.