S. Noullet

Surgical management of sporadic medullary thyroid cancer

Inherited and sporadic medullary thyroid cancer (MTC) is a rare carcinoma. Sporadic MTCs represent 70% of cases. Diagnosis is currently made with the routine use of serum calcitonin (CT) measurements to screen patients with nodular thyroid disease. Surgery is the only curative treatment of MTC and since cervical lymph nodes metastases are frequent and can occur at an early stage, a standardized lymph node dissection should be associated to total thyroidectomy. However, the extent of lymphadenectomy remains debated. Prognosis of MTC is related to both the stage of the disease and the extent of initial surgery. When tumor remnants persist after surgery, there are very few therapeutic alternatives, and these are generally of limited curative value.

Ischaemic colitis: Indications, extent, and results of standardized emergency surgery

BACKGROUND Acute ischaemic colitis can occur postoperatively, mainly after aortic surgery, or spontaneously. Surgical treatment is debated. Study aim was to describe factors related to ischaemic colitis severity, determine if postoperative and spontaneous ischaemic colitis share similar outcomes, and evaluate results of standardized management. METHODS 191 consecutive cases of ischaemic colitis observed from 1997 to 2012 were retrospectively analyzed: 119 (62%) after surgery and 72 (38%) spontaneous. Colon resection was performed for endoscopic type 2 colitis with multiple organ failure, and for every type 3. Types 1 and 2 without multiple organ failure were managed nonoperatively. RESULTS Seventeen patients (9%) were managed nonoperatively, without mortality. Mortality rate after resection was 48% (84/174), within 9 days (range, 0-152). Multivariate analysis found 2 independent factors associated with postoperative death: age≥75 years and multiple organ failure. The context in which ischaemic colitis occurred was not a risk factor for mortality. Mortality rates were 51% for final type 3 (66% with multiple organ failure, 17% without), 53% for final type 2 with multiple organ failure, and 0% for type 1 or type 2 without multiple organ failure. CONCLUSION An aggressive surgical approach in patients with ischaemic colitis seems justified in patients with multiple organ failure and findings of severe form of ischaemia at endoscopy.

Can we consider immediate complications after thyroidectomy as a quality metric of operation

Background. Permanent recurrent laryngeal nerve palsy and hypoparathyroidism are 2 major complications after thyroid operation. Assuming that the rate of immediate complications can predict the permanent complication rate, some authors consider these complications as a valid metric for assessing the performance of individual surgeons. This study aimed to determine the correlation between rates of immediate and permanent complications after thyroidectomy at the surgeon level. Methods. We conducted a prospective, cross‐sectional study in 5 academic hospitals between April 2008 and December 2009. The correlation between the rates of immediate and permanent complications for each of the 22 participating surgeons was calculated using the Pearson correlation test (r). Results. The study period included 3,605 patients. There was a fairly good correlation between rates of immediate and permanent recurrent laryngeal nerve palsy (r = 0.70, P = .004), but no correlation was found for immediate and permanent hypoparathyroidism (r = 0.18, P = .427). Conclusion. The immediate hypoparathyroidism rate does not reflect the permanent hypoparathyroidism rate. Consequently, immediate hypoparathyroidism should not be used to assess the quality of thyroidectomy or to monitor the performance of surgeons.

Prognosis of papillary thyroid carcinoma in elderly patients after thyroid resection: A retrospective cohort analysis

AbstractThe size of the elderly population and the incidence of papillary thyroid carcinoma (PTC) in this group appear to be rapidly increasing, although published information based on more detailed older age groupings are lacking.This study aimed to determine the clinical features and outcomes of elderly patients in PTC.All consecutive patients who received surgery for PTC in our Department from 1978 to 2014 were included. We compared 3 patient groups: young (<65 years), older (65–75 years), and very old patients (>75 years). Total thyroidectomy was performed with lymph node (LN) dissection in most cases, and radioiodine therapy was administered as needed.A total of 3835 patients (3257 young patients, 450 older patients, and 128 very old patients) were identified. Very old patients were more likely to have advanced (III/IV) tumor, nodes, metastases (TNM) stage, greater tumor size, number of tumors, and extracapsular invasion compared with young and older patients. For the 2289 patients with LN dissection (60%), metastatic LNs were more frequent in the very old group (44%) than in the other groups (34% young and 33% older patients) (P = 0.01). Very old patients had more frequent distant metastases (5%) than the older (2%) and young groups (1%) (P < 0.001). The overall postoperative morbidity was not significantly different between the 3 age groups. Recurrence was documented in 202 (6.2%) young, 29 (6.4%) older, and 15 (11.7%) very old PTC patients (P = 0.04). The 5-year disease-free survival was 81.3% for very old, 92.9% for older, and 94.7% for young group (P < 0.001).Very old patients should be considered high-risk PTC patients and their therapeutic strategy may benefit from aggressive treatment.

A novel technique for diaphragm biopsies in human patients

BACKGROUND The diaphragm is difficult to biopsy because of its anatomic location. We describe a new laparoscopic diaphragm biopsy technique. MATERIAL AND METHODS Fifty one patients with amyotrophic lateral sclerosis gave their consent to diaphragm biopsy in the context of an implanted phrenic nerve stimulation protocol (NCT01583088). The biopsy was taken from the costal diaphragm, after opening the parietal peritoneum with scissors, and by grasping the diaphragmatic muscle over the rib with toothed laparoscopy forceps. RESULTS The first four electrocoagulation biopsies were unsuitable for morphologic examination. The following 47 biopsies were therefore performed without electrocoagulation. The mean size of the biopsy fragments obtained after preparation was 3 ± 1 × 2 ± 1 × 1 ± 1 mm (maximum: 4 × 3 × 2 mm). A diaphragmatic injury occurred during the section in three cases requiring immediate suture without causing pneumothorax. A small pleural effusion was observed on the postoperative chest x-ray in one patient with a spontaneously favorable outcome. Numerous stains were able to be performed on the fragments obtained. CONCLUSIONS Diaphragm biopsy can be safely performed by laparoscopy and yields tissue suitable for our future histologic evaluation.

How to Avoid Nontherapeutic Laparotomy in Patients With Multiple Organ Failure of Unknown Origin. The Role of CT Scan Revisited

Diagnosis of intra-abdominal diseases in critically ill patients remains a clinical challenge. Physical examination is unreliable whereas exploratory laparotomy may aggravate patients condition and delay further evaluation. Only a few studies have investigated the place of computed tomography (CT) on this hazardous situation. We aimed to evaluate the ability of CT to prevent unnecessary laparotomy during the management of critically ill patients. Charts of all consecutive patients who had undergone an emergency nontherapeutic laparotomy from 1996 to 2013 were retrospectively studied and patients demographic, clinical characteristics, and surgical findings were collected. During this period 59 patients had an unnecessary laparotomy. Fifty-one patients had at least one preoperative imaging and 36 had a CT scan. CT scans were interpreted to be normal (n = 12), with minor anomalies (n = 10), or major anomalies (pneumoperitoneum, portal venous gas/pneumatosis intestinalis, thickened gallbladder wall, and small bowel obstruction signs). Surgical exploration was performed through laparotomy (n = 55) or laparoscopy. Overall mortality was 37% with a median survival after surgery of 7 days. In univariate analysis, hospitalization in ICU before surgical exploration was the only factor related to death. In our series CT scans, objectively interpreted, helped avoid unnecessary surgical exploration in 61% of our patients.

Sigmoidectomy via an elective approach for sigmoid volvulus (with video)

Please cite this article in press as: Najah H, et al. Sigmoidectomy via an elective approach for sigmoid volvulus (with video). Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2016.11.003

Laparoscopic resection of interaortocaval paraganglioma in left lateral decubitus (with video)

Please cite this article in press as: Najah H, et al. Laparoscopic resection of interaortocaval paraganglioma in left lateral decubitus (with video). Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.012 de l’Hôpital, 75013 Paris, France c Service d’endocrinologie et métabolisme, Institut E3M, Hôpital de la Pitié-Salpêtrière, Paris VI, Pierre-et-Marie-Curie-Sorbonne universités, 47—83, boulevard de l’Hôpital, 75013 Paris, France

Management of traumatic small bowel injury by mechanical anastomosis "without resection" during damage control laparotomy.

Penetrating or blunt abdominal injury can produce small bowel injuries that are sometimes complex and difficult to repair. Management of these injuries requires a safe, quick and reproducible technique. Surgery should take into consideration not only the injury itself, but also patient status, the eventual presence of associated injuries, shock, hypothermia or metabolic acidosis [1]. For a stable, non-shocked patient, presenting with a simple small linear intestinal wound with clear and well-vascularized edges, simple suture closure, with either a continuous or interrupted sutures using slowly absorbable or non-absorbable material can be performed. Conversely for high-risk patients with complex gastro-intestinal wounds, or when the wound edges are torn, and damaged, we propose performance of a side-to-side stapled anastomosis ‘‘without mesenteric resection or ligation’’. This procedure is simple to perform, simple to learn and is easily reproducible. Morbidity is similar to that of manual repair and allows performance of the anastomosis on healthy tissues [2,3].

Le syndrome d’Amyand : une présentation rare de l’appendicite

Introduction La hernie d’Amyand (HA) correspond a un appendice contenu dans un sac herniaire inguinal, souvent droit. L’âge des patients peut varier entre 3 semaines et 92 ans. Son incidence dans la litterature est tres variable (0,2–1,7 %) et la presence d’une appendicite aigue associee est extremement rare (0,07–0,13 %). La mortalite varie de 5 a 30 % en rapport avec une peritonite grave secondaire a une perforation appendiculaire. Objectif Evaluer la prevalence et les caracteristiques cliniques des patients operes d’une HA en urgence ces 20 dernieres annees. Methodes Etude retrospective sur 1 866 patients operes d’une appendicite aigue entre 1994 et 2013. Resultats 5 patients ont ete operes d’une HA soit une prevalence de 0,2 % et 4,2 % parmi les patients âges de > 64 ans. L’âge moyen etait de 82 ans (75–89). La chirurgie a souvent ete retardee avec un delai moyen de 6 jours (3–15) apres le debut des symptomes. Dans cette serie le diagnostic a pu etre fait en preoperatoire par un scanner (4) ou une echographie. 3 patients (60 %) avaient une appendicite compliquee. La duree mediane de sejour etait de 7 jours (5–10 jours). Un patient a presente une complication postoperatoire (abces de paroi). Il n’y a eu aucun deces dans cette serie. Conclusion L’appendicite comme complication d’une hernie d’Amyand est une pathologie exceptionnelle. Dans notre serie les appendicites associees a une HA etaient frequemment compliquees et survenaient a un âge avance.