Vascular study of decellularized porcine long bones: Characterization of a tissue engineering model

INTRODUCTION

Massive bone allografts enable the reconstruction of critical bone defects in numerous conditions (e.g. tumoral, infection or trauma). Unfortunately, their biological integration remains insufficient and the reconstruction may suffer from several postoperative complications. Perfusion-decellularization emerges as a tissue engineering potential solution to enhance osseointegration. Therefore, an intrinsic vascular study of this novel tissue engineering tool becomes essential to understand its efficacy and applicability.

MATERIAL AND METHODS

32 porcine long bones (humeri and femurs) were used to assess the quality of their vascular network prior and after undergoing a perfusion-decellularization protocol. 12 paired bones were used to assess the vascular matrix prior (N = 6) and after our protocol (N = 6) by immunohistochemistry. Collagen IV, Von Willebrand factor and CD31 were targeted then quantified. The medullary macroscopic vascular network was evaluated with 12 bones: 6 were decellularized and the other 6 were, as control, not treated. All 12 underwent a contrast-agent injection through the nutrient artery prior an angio CT-scan acquisition. The images were processed and the length of medullary vessels filled with contrast agent were measured on angiographic cT images obtained in control and decellularized bones by 4 independent observers to evaluate the vascular network preservation. The microscopic cortical vascular network was evaluated on 8 bones: 4 control and 4 decellularized. After injection of gelatinous fluorochrome mixture (calcein green), non-decalcified fluoroscopic microscopy was performed in order to assess the perfusion quality of cortical vascular lacunae.

RESULTS

The continuity of the microscopic vascular network was assessed with Collagen IV immunohistochemistry (p-value = 0.805) while the decellularization quality was observed through CD31 and Von Willebrand factor immunohistochemistry (p-values <0.001). The macroscopic vascular network was severely impaired after perfusion-decellularization; nutrient arteries were still patent but the amount of medullary vascular channels measured was significantly higher in the control group compared to the decellularized group (p-value <0.001). On average, the observers show good agreement on these results, except in the decellularized group where more inter-observer discrepancies were observed. The microscopic vascular network was observed with green fluoroscopic signal in almost every canals and lacunae of the bone cortices, in three different bone locations (proximal metaphysis, diaphysis and distal metaphysis).

CONCLUSION

Despite the aggressiveness of the decellularization protocol on medullary vessels, total porcine long bones decellularized by perfusion retain an acellular cortical microvascular network. By injection through the intact nutrient arteries, this latter vascular network can still be used as a total bone infusion access for bone tissue engineering in order to enhance massive bone allografts prior implantation.

Treatment of mandibular osteoradionecrosis by periosteal free flaps

Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

Abstract P5-22-23: Electrochemotherapy : A new local therapy for cutaneous metastases of breast cancer

Background : Electrochemotherapy (ECT) is a new local therapy combining the administration of an intravenous chemotherapy (bleomycin) followed by the direct application of electric pulses by an electrode to the treated areas. Electric pulses transiently permeabilize the membrane of the tumor cell ( electroporation), improving intracellular diffusion of a poorly permeant chemotherapeutic agent, ithereby ncreasing its cytotoxicity and decreasing systemic toxicity.

ECT can be offered to patients with cutaneous or subutaneous metastases of breast cancer who are no longer suitable for extensive surgery or radiotherapy ( e.g. due to past irradiation of the breast or chest wall).

ECT 's applications are palliative. It is -, delivered with the aim of local control of the tumor, relief of symptoms associated with cutaneous recurrence -(ulceration, bleeding, pain),i and mproving patients'quality of life.

The aim of this study is to demonstrate that ECT has a high efficacity and a low toxicity profile making it an interesting alternative to conventional therapies.

Material and methods : our study is a retrospective study (approved by our local ethics committee) which included 8 patients between June 2013 and June 2016. The patients had histologically proven cutaneous and or subcutaneous metastases of their breast cancer, without any sign of lymphangitis. All the tumors expressed ER and /or PgR and 2 of them were HER2 positive tumors. The patients received a single or multiple courses of ECT ; the outcomes were clinical response, toxicity, local and distant recurrence. The two patients whose tumors expressed HER2, also had synchronous controlateral axillary nodal metastases. They underwent axillary dissection performed during ECT course. Among the six other patients, no other metastases than cutaneous lesions were observed.

Results : The 8 included patients had already received chest wall irradiation for the treatment of their primary breast cancer. A total of 37 nodules were treated (mean : 4.5 per patient), whose mean size was 17mm (10-34mm). Six patients(75%) had a complete response after a single course of ECT. Two patients exhibited a partial response and underwent a second course of ECT at 6 months. The two patients with Her2 positive tumors received taxane-based chemotherapy and anti HER2 agents. All the patients were also given endocrine therapy. After a median follow up of 26 months (11-47 months), no patient had a local cutaneous recurrence. Overall survival rate was 75% : 2 patients died following progression of systemic disease (pulmonary and hepatic metastases).

No complications due to toxicity were observed.

Discussion and conclusion :In selected patients with ( cutaneous and subcutaneous metastases of breast cancer with no sign of lymphangitis), ECT offers a very good rate of clinical response and a durable control of metastases. This innovative technique has the advantage of being minimally –invasive and well –tolerated.

Citation Format: Berliere M, Raguzzi E, Bernard M, Gerday A, Coyette M, Piette P, Duhoux F, Lengele B. Electrochemotherapy : A new local therapy for cutaneous metastases of breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-23.

Abstract P3-13-19: Isolated sternal metastases: The place of surgical resection

Background: Solitary sternal metastases from breast cancer are found in approximately 1.9 to 2.5 % of all advanced breast cancer cases. According to the latest AJCC classification, they are still considered as stage IV disease, but their prognosis is better in the absence of other foci of metastatic disease. Their treatment still remains controversial.

Material and methods: This is a monocentric retrospective study performed in our breast clinic and approved by our ethics committee. Twelve patients were included in this study between 2010 and 2015; 11 had a metachronous solitary sternal metastasis and 1 had a synchronous metastatic sternal lesion. Complete restaging was negative in all patients for other metastatic lesions. The extent of resection (different parts of the sternum and frequently also adjacent rib cartilages) necessary to obtain free margins was estimated preoperatively on MRI images focused with adequate sequences. All the patients underwent a large sternal resection and a chest wall reconstruction integrated in a multimodal approach.

Characteristics of the patients and of the tumors were studied.

The major outcomes studied were disease-free (DFS) and overall survival (OS).

Results: The mean interval between the initial diagnosis of breast cancer and the discovery of sternal metastasis was 115 months. After surgical resection, free margins were obtained in 10 patients. No post-operative complications were observed except for persistent thoracic pain in one patient with a medical history of chronic pain. Excellent cosmetic and functional outcomes were obtained without significant impairment of respiratory function. Ten patients received chemotherapy pre- or postoperatively. All the tumors expressed ER and /or PgR receptors, and endocrine therapy was administered in all patients.

Mean duration of follow-up was 25 months (9-51 months). Three patients presented distant recurrences: 2 liver lesions and 1 cervical nodal recurrence with pericardic effusion. Out of these 3 patients, 1 died after 51 months. Currently the DFS of this small study is 75 % and the OS is 91.6 %.

Conclusion: Treatment of isolated sternal metastases of breast cancer must be based on a multidisciplinary strategy.

Sternectomy and multilayered chest wall reconstruction (with different types of meshes and flaps) could be a curative approach in highly selected patients with no other metastatic lesions. In this group of patients, the good prognosis observed could be due to a different mechanism of dissemination, based on lymphatic rather than hematogenic diffusion.

Longer follow-up and prospective studies are needed to confirm these encouraging results.

Citation Format: Berliere M, Taburiaux L, Lacroix V, Gerday A, Coyette M, Lecouvet F, Piette P, Galant C, Duhoux F, Lengele B. Isolated sternal metastases: The place of surgical resection [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-19.

[Management of vascular anomalies in children]

Vascular anomalies, which are broadly identified as "angiomas", are rare entities and often unknown by the medical sphere. They are divided in two different categories which carry different prognosis and management: "vascular tumors" and "vascular malformations". Their precise identification is crucial and involves a good knowledge of the biological classification published by Mulliken and Glowacki and that has recently been updated by the International Society for the Study of Vascular Anomalies (ISSVA). Vascular tumors are benign, common, inborn or not and most of the time disappear with growth. Vascular malformations are always congenital and growth with the child. They can involve type of vessels solely or combined with others. A rheologic differentiation between slow and fast flow malformations is essential in order to characterize the seriousness of the lesion. Frequently, their diagnosis is clinically established and the anamnesis is conducted to answer three questions that are the time of revelation of the lesion ("When?"), its aspect ("What?") and its evolution ("How?"). Further investigations are usually not required but a non-invasive imaging technique such as Doppler ultrasound could be useful if a doubt exists. Surgery is not mandatory and must always be well thought because its consequences might be disastrous. It must be left to cosmetic sequelae of these lesions or to lesions that are totally resectable without causing any unacceptable deformation.

Abstract P2-12-04: Is there any benefit to perform extensive nodal dissection in primary or recurrent aggressive form of breast cancer?

Background: Breast oncologic surgery and especially nodal surgery has become ever more minimally invasive. However, some aggressive breast cancers exhibit at their primary or recurrent presentation extensive nodal invasion at the axillary, retropectoralis and sometimes supraclavicular and cervical levels. Surgical treatment of these tumors is not standardized.

Material and methods: Between January 2012 and April 2015, 7 primary breast cancer patients (group I) and 7 recurrent breast cancer patients (group II) were included in a prospective, non randomized study approved by our local ethics committee. All the patients had cytologically proven retropectoralis and infraclavicular lymph node invasion and 7 of them had cytologically proven cervical lymph node invasion (5 in the group of primary tumors and 2 in the group of recurrences). Four of the 7 primary tumors were triple negative and 3 were HER2 positive tumors, while 4 out of the 7 recurrent tumors were triple negative and 3were HER2 positive. All the patients underwent PET/CT and breast MRI at baseline. Visceral metastases were absent in all cases. In the group of primary tumors, all the patients were treated with neoadjuvant chemotherapy (plus trastuzumab for the 3 HER2 positive tumors); in the group of recurrent tumors, neoadjuvant chemotherapy associated with trastuzumab was administered in 3 patients, while the 4 other patients underwent complementary mastectomy plus extensive nodal surgery followed by chemotherapy. Radiotherapy was administered in all primary breast cancer patients and cervical radiotherapy was administered in 3 of the 7 recurrent diseases. The following parameters were assessed: disease-free survival, overall survival and adverse events of surgical treatment.

Results: All the patients are still alive after a relatively short mean duration of follow-up [24 months in group I (6 to 40 months) and 29 months in group II (3 to 39 months)]. Six of the 7 patients in group I have no signs of recurrence, one has metastatic evolution (bilateral cervical and mediastinal node evolution) and is currently receiving chemotherapy in combination with a PARP inhibitor. In group II, 6 of the 7 patients have no signs of recurrence and one has metastatic evolution (inguinal nodes and bone metastases), treated with chemotherapy and HER2-targeted therapy. The major adverse event is arm lymphedema, affecting 4 out of 14 patients (28%). No persistent pain nor motor troubles are noted.

Discussion: Patients with nodal metastases outside the axilla seem to benefit from extensive surgery integrated in a multidisciplinary therapeutic approach. Some studies have demonstrated survival benefits for patients undergoing surgical resection of these nodes.

Conclusion: In aggressive breast tumors (HER2 positive or triple negative tumors) presenting with extensive nodal invasion, surgical excision of these nodal metastases must be integrated in the multidisciplinary treatment and patients need to be followed prospectively for a long time to confirm survival benefits.

Citation Format: Berliere M, Duhoux F, Nardai P, Schmitz S, Taburiaux L, Galant C, Leconte I, Piette P, Lengele B. Is there any benefit to perform extensive nodal dissection in primary or recurrent aggressive form of breast cancer?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-04.

Complete arterial revascularization in coronary artery bypass grafting in a patient with solitus inversus totalis

Dextrocardia with complete situs inversus is a rare condition that occurs approximately in 2/10,000 live births. Coronary revascularization management in this setting differs in the technical considerations imposed by the malposition of the heart itself. We report here a case of complete arterial revascularization using both internal thoracic arteries and the left (homologous vessel to the right) gastroepiploic artery in an adult patient with triple-vessel disease and situs inversus totalis. Strategies for the choice of conduits and anastomoses as well as technical details are discussed.

[Peroperative desaturation during gynaecological laparoscopy-hysteroscopy: an unknown aetiology, pleural extravasation]

A 41-year-old patient presented several episodes of desaturation during a gynaecological laparoscopy. The major complication of this procedure is the venous air embolism. Several other side-effects have been reported: heart rate disorders, subcutaneous emphysema or pneumothorax. Pleural effusions during gynaecologic laparoscopy are apparently rare and the volume of effusion must be important to induce clinical symptoms. This fact can probably explain the frequent difficulty of diagnosis. The role of the diaphragmatic lymphatic network and other physiologic aspects are discussed in this article.

Adult-to-adult living related liver transplantation: initial experience

The number of adult patients on the liver transplantation waiting lists is growing steadily. Adult living related liver transplantation (LRLT) represents the ultimate means to expand the donor pool. The success of this model of "small for size" grafting relies on strict donor and recipient selection. The choice of the graft (2 left and 4 right hepatectomies) was made on the minimal ratio between estimated graft and recipient body weights (0.8-1%), necessary to meet the recipient's metabolic demands. Our experience with six adults is reported. Donor morbidity was minimal (one wound infection); there was no mortality. Four (66%) recipients are doing well, two died of infectious complications. All recipients had a complicated post-transplant course. Due to its complexity, both in donor and recipient, LRLT should only be developed very carefully in experienced liver transplant centers.

Present status of laparoscopic splenectomy for hematologic diseases: certitudes and unresolved issues

Laparoscopic splenectomy is considered to be the "gold-standard" treatment of benign hematologic diseases, with normal or slightly enlarged spleens. Laparoscopic treatment of malignant diseases and splenomegalies remains more controversial. The procedure requires a great surgeon's laparoscopic expertise, appropriate positioning of the patient and trocar insertion, and gentle and meticulous dissection of the spleen. The technique is feasible in 91% of the patients with a 0.9% operative mortality and a postoperative complications rate of 12%. When compared with open splenectomy in retrospective case-controlled studies, the laparoscopic approach includes a longer operative time and higher operative room costs. However, advantages include reduced postoperative hospital stay and faster return to normal activities. Despite scarce reported data, long-term hematologic cure rate seems to be equivalent in patients with idiopathic thrombocytopenic purpura. The accuracy of laparoscopic exploration to detect all accessory spleens is however questioned, and residual postoperative accessory splenic tissues have been observed. Prospective randomized controlled trials comparing short- and long-term results of open and laparoscopic splenectomies are required to confirm definitely the role of laparoscopy in the management of hematologic disorders.

Radical debridement and omental transposition for post sternotomy mediastinitis

OBJECTIVE

Reported mortality for postoperative mediastinitis treated by debridement alone can reach 40%. The authors' experience with radical debridement and omental transposition is reviewed.

METHODS

Between May 1990 and August 1996, 14 patients with untractable mediastinitis had a transfer of the greater omentum: 11 after coronary artery bypass grafting (CABG) (6 bilateral internal thoracic arteries ITA grafts), one after a heart transplant, one after an aortic valve replacement and CABG, and one after a repair of the aortic isthmus related to a motor vehicle accident. The mean age was 63 +/- 8 years. Infection was proven in all patients by cultures of intraoperative specimens. Two patients had such a large sternal defect that no primary closure could be attempted. The remaining 12 patients had a mean of 1.4 +/- 0.7 previous debridement. Five patients had a total sternectomy. After radical debridement, the omentum was transferred over the entirety of the wound and covered with a meshed thin skin graft. All patients had a minimum of 4 weeks of i.v. antibiotic therapy.

RESULTS

There was no operative death. Apart from one focal necrosis and one traumatic dehiscence of the omentum, there was no hospital complication. Sepsis was controlled in all patients. The median hospital stay was 31 days (range 20-154 days). At a median follow-up of 20 months (range: 6-44 months), there were two late deaths: one sudden and unexpected death and one after a re-do CABG. The remaining patients had resumed their previous activities. One patient had developed an incisional hernia and another underwent further surgery for cosmetic reasons.

CONCLUSION

Radical debridement and omental transposition may achieve a cure for postoperative mediastinitis with good mid-term results.

Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy. A shortcoming of the laparoscopic approach in hematologic diseases

BACKGROUND

The ultimate goal of surgery for hematological disorders is the complete removal of both the spleen and accessory spleens in order to avoid recurrence of the disease. Whereas splenectomy by open surgery provides excellent results, the validity of laparoscopic splenectomy in this regard remains unknown.

OBJECTIVE

The purpose of this study was to evaluate the detection of accessory spleens during laparoscopic splenectomy for hematologic diseases.

METHODS

We therefore evaluated the pre-, intra-, and postoperative detection of accessory spleens in a consecutive series of 18 patients treated by elective laparoscopic splenectomy for hematological diseases by using computed tomography (CT) and denatured red blood cell scintigraphy (DRBCS).

RESULTS

Preoperative CT, DRBCS, and laparoscopic exploration detected 25%, 25%, and 75% of accessory spleens, respectively. At time of laparoscopy, 16 accessory spleens were detected in seven of the 18 patients (41%). In two patients (11%), laparoscopic exploration failed to detect accessory spleens, whereas preoperative CT (one case) and DRBCS (one case) did reveal them. Postoperatively, during a mean follow-up of 28 months (median, 24; range, 12-44 months), nine patients (50%) showed persistence of splenic tissue by DRBCS, and three of them had signs of disease recurrence.

CONCLUSIONS

This prospective clinical study suggests that elective laparoscopic surgery for hematological diseases does not allow complete detection of accessory spleens. Moreover, after such a laparoscopic approach, residual splenic tissue is detectable in half of the patients during the follow-up.

Heller-Dor procedure for achalasia: from conventional to video-endoscopic surgery

A Heller-Dor procedure was performed by laparotomy (group A: n = 8) or by laparoscopy (group B: n = 12) after failure of one to 17 sessions of intraluminal dilatations (n = 13) or as a primary treatment of oesophageal achalasia (n = 7). The oesophagomyotomy was extended over the thoracic oesophagus by thoracoscopy in two patients having vigorous achalasia. Injury to the oesophageal mucosa occurred in two group A patients who had previously been dilated. At follow-up (range: 1 to 113 months), 6 patients of group A (75%) and 10 of group B(83.3%) had no residual dysphagia. The four patients (group A: n = 2; group B: n = 2) who complained of heartburn prior to the operation were asymptomatic, only one group A patient developed symptoms of reflux, and oesophageal pH-monitoring was normal in the 6 group B patients investigated at follow-up. The laparoscopic approach reduces the magnitude of the operation, and the magnified overview permits precise dissection of the intraparietal adhesions which may develop after numerous sessions of dilatation.

[Liposuction as a help for radiologists. Technical note]

Based on a series of eight cases of severe extravasations of contrast medium injected under pressure, the authors suggest the use of liposuction for the elimination of the toxic agent and of the infiltrated cellular tissue. If applied promptly, this simple and semi-conservative treatment salvages the skin and prevents the development of scar sequelae of the soft tissues.

En bloc and standard esophagectomies by thoracoscopy

Subtotal esophagectomy was attempted by right thoracoscopy on 13 patients, 10 having cancer and 3 long caustic stenosis. Thoracoscopy was converted into thoracotomy in 2 patients, owing to loss of selectivity in one-lung ventilation in 1 and injury to a right intercostal artery flush to the aorta in the other. One patient with cancer underwent an esophageal bypass operation only, owing to tumor invasion into the lung at exploratory thoracoscopy. The ten esophagectomies that could be performed in totality by thoracoscopy consisted of seven en bloc resections of the esophagus with extensive lymph node clearance in the posterior mediastinum, and three standard resections without any lymph node dissection. Postoperative complications included one death due to hepatic failure, two cases of acute pneumonitis, and one persistent chest wall discomfort at the trocar sites. Up to 51 lymph nodes were found in the resected specimens of the cancer patients. Six of the 7 cancer patients who were discharged from the hospital after esophagectomy completed by thoracoscopy were alive at 2 to 20 months of follow-up. Five of them were disease free. The study shows that esophageal resections as extensive as those carried out by thoracotomy can be performed by thoracoscopy. It suggests that prompt management of untoward injury to any mediastinal structure adjacent to the esophagus is less easy by thoracoscopy than by thoracotomy, and that classic complications of open thoracic surgery may occur after thoracoscopy as well.

A peri-implant capsule flap

Spherical expanders (30 ml) were implanted under the skin vascularised by the left inferior epigastric pedicle in rats. When expansion was complete, the expander was removed and the animals divided into three groups of 15. In the first group, the floor of the capsule was simply everted. In the second group, a capsule island flap was raised; in the third group, a capsule free flap was raised, transferred to the heterolateral vessels by microanastomosis; the inner side of the various capsule flaps was covered with autologous skin graft. In the three experimental groups, there was complete "take" of the skin grafts in 80% of the animals. Pedicle or free flaps of capsular tissue may be raised and transferred safely in rats.

Intestinal hemorrhage three years after incidental appendectomy by total inversion

A late hemorrhagic complication of incidental appendectomy by entire inversion is reported in a liver transplant child. The use of proper surgical technique for inversion appendectomy is emphasized, including total devascularization of the appendix before inverting it.

[Left caudal vena cava: report of a case]

The infrarenal part of the vena cava inferior running at the left side of the abdominal aorta has been observed in a 70 years old caucasian man without any other anomaly in the position of the abdominal viscera. This atypical vascular pattern was associated with the persistence of a rudimentary right inferior vena cava corresponding to the right supracardinal vein. The embryonic origin of this anatomical variation and its clinical importance are discussed.

Microradiographic and histological study of the styloid process of the temporal bone

In order to establish the mechanisms underlying the morphogenesis of the so-called 'elongated styloid process', a comparative microradiographic and histological study was performed on 19 long and short processes. Some morphological differences between short and long processes are noticed. Numerous partially calcified cartilaginous islets are observed within the trabecular bone of very long styloid processes or covering their tip. Calcified fibrous tissue or calcified fibrocartilage sometimes contributes to the thickening of enlarged styloid processes. But the growth of the process does not seem to be due either to calcification or to ossification of the stylohyoid ligament, as thought in the past. Mechanical stresses stretching the second branchial arch during the fetal development probably induce a variable involvement of the different parts of Reichert's cartilage in the morphogenesis of the styloid process. The so-called 'elongated styloid process' should thus be congenital. However, a further growth is still possible through the activity of the cartilaginous cap of the tip.

Hepatic ascaridiasis

Adult Ascaris, which are usually found in the intestine, can enter the ampulla of Vater if the sphincter of Oddi is not efficient. This situation seems common in children; in adults it occurs after endoscopic or surgical sphincterotomy. The worms can then migrate up into the intrahepatic bile ducts and provoke biliary stasis which may become infected and complicated by abscesses. It is inside such abscesses that we may find fragments of adult Ascaris. In the 4 cases reported in the literature during the last 20 years, we note in particular that the clinical signs vary considerably, according to the age of the patient. In children, the parasitic infestation is often massive and the clinical features are extremely serious, namely shock and acute abdominal pain, which lead to a laparotomy being done. In adults, the clinical feature is that of a biliary infection. Here we describe a fifth case of hepatic ascaridiasis which differs from the others in that the diagnosis was established by ERCP and CT scan and that treatment was medical.