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Resume Introduction. – La hernie diaphragmatique est une complication rare apres œsophagectomie pour cancer. Le but de ce travail a ete de rapporter une serie de sept patients et de preciser les caracteristiques de cette entite. Patients et methodes. – Sept patients (six hommes et une femme) âges de 61 a 68 ans ont ete operes d’une hernie diaphragmatique a distance d’une chirurgie pour cancer œsophagien (adenocarcinome n = 4, carcinome epidermoide n = 3). Tous ces patients avaient eu une œsophagectomie par voie abdominale trans-hiatale quatre fois et par voie trans-thoracique trois fois, avec dans tous les cas un agrandissement de l’orifice hiatal. Resultats. – Trois patients, tous symptomatiques, ont ete reoperes en urgence dans les deux annees suivant l’œsophagectomie. Parmi les quatre patients operes entre deux et sept ans apres l’œsophagectomie, deux etaient asymptomatiques. Le caractere symptomatique ou non de la hernie diaphragmatique n’etait lie ni a la technique de l’œsophagectomie, ni au type de phrenotomie (anterieure ou section du pilier). La hernie etait toujours symptomatique quand elle contenait du grele. Tous les patients ont ete operes par voie abdominale. La hernie contenait du colon trois fois, du grele une fois, et etait mixte trois fois. Une phrenotomie d’agrandissement etait necessaire six fois pour reduire la hernie. Deux patients ont eu une colectomie pour traiter une ischemie colique transverse peroperatoire. L’orifice diaphragmatique etait calibre autour de la plastie gastrique par suture simple six fois ou par prothese resorbable une fois. Il n’y a eu aucun deces. Avec un recul de un a cinq ans il n’y a pas eu de recidive de la hernie. Conclusion. – La hernie diaphragmatique apres œsophagectomie est due a une phrenotomie trop importante. Les formes precoces sont mal tolerees et necessitent une intervention urgente. La prevention des hernies diaphragmatiques apres chirurgie du cancer œsophagien repose sur un calibrage de l’orifice hiatal adapte a la largeur de la gastroplastie.

We describe the technique of surgical ampullectomy, which consists of complete resection of the papilla of Vater, including the sphincter, the distal part of common bile duct and Wirsung duct, and the duodenal wall around the papilla. Limits of resection are assessed by frozen section, particularly on both biliary and pancreatic ducts which are sutured together and reinserted on the duodenal wall. Surgical ampullectomy, combined with frozen section, is associated with a low morbidity, and represents a valid alternative to pancreaticoduodenectomy and endoscopic ampullectomy for presumed-benign ampullomas.

Medial pancreatectomy is indicated for resection of benign or low-malignant tumors located in the middle part of the pancreas and not treatable by enucleation. This unfrequent procedure, the alternative of which is mainly left pancreatectomy, aims to preserve at the most pancreatic function.

Resume Nous decrivons ici une technique de pancreatectomie gauche debutee par une section de l’isthme precedant le controle de l’artere et de la veine splenique. La section prealable de l’isthme rend ce controle vasculaire plus facile et plus sur. Pour une splenopancreatectomie gauche, ce controle vasculaire splenique, associe a la ligature-section des vaisseaux gastro-epiploiques gauches et des vaisseaux courts, precede la mobilisation de la piece, diminue le saignement peroperatoire et apparait plus logique d’un point de vue carcinologique. De plus, cette technique peut constituer la premiere etape des pancreatectomies gauches avec conservation splenique.

Resume La pancreatite aigue est une complication rare de la chimio-embolisation par catheterisme arteriel non selectif des carcinomes hepatocellulaires avec une incidence allant de 1,7 % (pancreatite clinique) a 40 % (pancreatite biologique). Cette complication est due a l'embolisation de branches arterielles a destinee extrahepatique. Nous rapportons ici un cas de pancreatite aigue clinique survenue apres une deuxieme cure de chimio-embolisation par catheterisme selectif de l'artere hepatique propre. Ce patient ne presentait ni variation anatomique arterielle hepatique ni de facteurs de risque de pancreatite. Cette complication, a notre connaissance exceptionnelle apres catheterisme selectif, doit etre evoquee en cas de douleurs abdominales au decours d’une chimio-embolisation. Un dosage des enzymes pancreatiques seriques permet alors de ne pas confondre une pancreatite aigue avec un syndrome postembolisation.

We report herein a modification of the standard wirsungojejunostomy in patients with chronic pancreatitis, which includes concomitant duodenum-preserving resection of the head of the pancreas as described by Frey. This technique is safe and seems to provide more effective long-term pain relief than standard wirsungo-jejunal anastomosis.

Resume But de l’etude : Rapporter une nouvelle serie de pancreatectomie mediane (PM), en analysant les resultats postoperatoires immediats et a distance. Patients et methodes : De 1990 a 1999, 11 patients (âge moyen = 53 ans, extremes : 28–70) – dont dix non diabetiques – ont eu une PM pour une tumeur neuroendocrine ( n = 5), une tumeur intracanalaire papillaire et mucineuse (TIPMP) ( n = 3), un cystadenome mucineux, une metastase d’un cancer du rein, et un nodule de pancreatite. L’intervention associait a une resection mediane plus ou moins etendue, un examen histologique extemporane, et une suture de la tranche cephalique ; la tranche corporeocaudale etait anastomosee a la face posterieure de l’estomac ( n = 9), ou suturee en cas d’atrophie ou de petite taille du pancreas caudal ( n = 2). Resultats : La longueur moyenne des pieces de PM a ete de 7 cm (extremes : 4–15). Le diagnostic suspecte en preoperatoire a ete confirme dix fois. Une suspicion d’adenocarcinome correspondait en realite a un nodule de pancreatite. Aucun deces n’est survenu. Les suites ont ete compliquees chez sept patients : une gastroplegie et six fistules pancreatiques (54 %), dont trois etaient associees a une collection. Deux patients ont ete reoperes pour drainer une fistule. La duree mediane d’hospitalisation etait de 14 jours (extremes : 10–21) en cas de suites simples, et de 30 jours (extremes : 11–90) en cas de suites compliquees. Apres un suivi moyen de 43 mois (7–130), un seul patient initialement non diabetique a developpe un diabete et prend des extraits pancreatiques apres une resection de 15 cm pour TIPMP. Il n’y a eu aucune recidive tumorale intrapancreatique isolee. Conclusion : La PM preserve efficacement la fonction pancreatique et est associee a un faible risque de recidive tumorale pancreatique. En revanche, elle est associee a un risque eleve de fistule pancreatique.

Resume But de l’etude : Dans le traitement de l’adenocarcinome du cardia et du bas œsophage, le choix de la voie d’abord (avec ou sans thoracotomie) pour realiser une œsogastrectomie polaire superieure (OGPS) reste debattu. Le but de ce travail retrospectif a ete de comparer la mortalite, la morbidite et la survie a long terme dans une serie de malades operes avec ou sans thoracotomie. Patients et methode : De janvier 1991 a juin 1997, 59 malades (âge moyen = 65 ± 10 ans, extremes : 30-83) ont eu une OGPS avec (n = 31) ou sans thoracotomie (n = 28). Tous les malades ont eu un curage cœliaque et gastrique gauche, une gastroplastie tubulisee et une anastomose œsogastrique. Un curage mediastinal sous-aortique n’a ete realise que chez les malades operes avec thoracotomie. Les deux groupes etaient comparables concernant l’âge, la taille et le poids, le staging tumoral sur les donnees de l’imagerie et de l’histologie. Dans le groupe sans thoracotomie, il existait un nombre plus important de malades a haut risque (insuffisance respiratoire, score ASA = 3) (NS). Resultats : La resection etait palliative chez quatre malades du groupe avec thoracotomie et deux malades du groupe sans thoracotomie. La mortalite operatoire a ete de 9 % avec thoracotomie et nulle sans thoracotomie (NS). Les complications pulmonaires etaient aussi frequentes avec et sans thoracotomie (35 % contre 32 %). La survie actuarielle globale (resections curatives et palliatives) des malades a trois ans etait identique dans les deux groupes (avec thoracotomie : 39 % contre sans thoracotomie : 46 %, NS), de meme que la survie apres resection curative (respectivement : 44 % contre 49 %, NS). Le type de l’intervention n’influencait pas la survie des malades N+ (respectivement 22 % contre 17 %, NS) et celle des malades N- (respectivement 86 % contre 77 %, NS). Conclusion : Ces resultats suggerent que, dans l’adenocarcinome du cardia et du bas œsophage, le benefice carcinologique theorique du curage mediastinal peut etre mis en balance avec un risque operatoire plus important lie a la thoracotomie.

Diaphragmatic hernia is a rare complication of oesophagectomy for cancer. We report a series of seven patients to determine characteristics of this entity.Seven patients (six male and one female, 61 to 68 years old) were operated on for diaphragmatic hernia following oesophagectomy for carcinoma (adenocarcinoma N =4, squamous-cell carcinoma N =3). Oesophagectomy had been performed through abdominal transhiatal approach in four patients and transthoracically in three, with hiatal enlargement in all cases.Three patients, all symptomatic, underwent emergency surgery within two years following oesophagectomy. Of the four patients operated between two and seven years after oesophagectomy, two were symptomatic. Presence of symptoms were neither related with technique of oesophagectomy, nor to type of hiatal enlargement (anterior, or by crura division). All patients with hernia containing small bowel were symptomatic. All patients were operated through abdominal approach. Hernia contained colon three times, small bowel once, and both three times. Hernia reduction needed additional phrenotomy in six patients. Two patients underwent colectomy to treat peroperative colonic ischemia. Diaphragmatic hiatus was calibrated around the gastric tube by direct suture in six patients or with absorbable mesh in one. There was no death. No recurrences occurred with a follow up ranging from one to five years.The diaphragmatic hernia after oesophagectomy is due to excessive hiatal enlargement. Hernias occurring early after oesophagectomy are badly tolerated and need urgent reoperation. To prevent this complication of oesophagectomy, we advocate calibration of diaphragmatic hiatus fit to width of gastroplasty.

We describe the technique of surgical ampullectomy, which consists of complete resection of the papilla of Vater, including the sphincter, the distal part of common bile duct and Wirsung duct, and the duodenal wall around the papilla. Limits of resection are assessed by frozen section, particularly on both biliary and pancreatic ducts which are sutured together and reinserted on the duodenal wall. Surgical ampullectomy, combined with frozen section, is associated with a low morbidity, and represents a valid alternative to pancreaticoduodenectomy and endoscopic ampullectomy for presumed-benign ampullomas.

Medial pancreatectomy is indicated for resection of benign or low-malignant tumors located in the middle part of the pancreas and not treatable by enucleation. This unfrequent procedure, the alternative of which is mainly left pancreatectomy, aims to preserve at the most pancreatic function.

Haemobilia is a rare but serious complication of hepatic blunt trauma. Its diagnosis can be difficult because the delay between initial trauma and haemobilia ranges from few days to several months. Once the diagnosis is considered, a diagnostic and therapeutic arteriography must be performed as soon as possible. We reported the case of a patient who developed hemobilia 2 months after hepatic blunt trauma, due to pseudoaneurism of the anterior branch of the right hepatic artery; haemostasis was successfully obtained by arteriographic embolisation.

We describe a technique of distal pancreatectomy beginning with division of pancreatic neck before control of splenic vessels. Early neck division allows safer vascular control. For distal pancreatectomy, primary section of the neck and splenic vessels ligation, combined with division of left gastro-epiploic and short gastric vessels, precedes mobilization of a devascularized specimen, decreases operative bleeding and seems more logical from a carcinologic point of view. Furthermore, this technique could be the first step of left pancreatectomy with splenic preservation.

Acute pancreatitis can complicate non-selective transcatheter arterial embolization of hepatocellular carcinoma with an incidence ranging from 1,7% (acute clinical pancreatitis) to 40% (biological pancreatitis). This complication is thought to be related to embolization of extrahepatic arterial collaterals. We report herein a case of acute clinical pancreatitis developing within 24 hours after a second course of selective transcatheter arterial chemo-embolization into the proper hepatic artery. Neither anatomical arterial variation nor particular risk factor for acute pancreatitis could be identified. This complication is unusual after selective arterial embolization. Because it may clinically mimick a postembolization syndrome, dosage of serum pancreatic enzymes should be performed systematically in case of abdominal pain following chemoembolization.

We report herein a modification of the standard wirsungojejunostomy in patients with chronic pancreatitis, which includes concomitant duodenum-preserving resection of the head of the pancreas as described by Frey. This technique is safe and seems to provide more effective long-term pain relief than standard wirsungo-jejunal anastomosis.

Radiation-induced oesophageal carcinoma can occur several years after mediastinal irradiation. The aim of this study was to report 11 cases of this rare entity with analysis of its diagnostic, therapeutic and prognostic special features.From 1983 to 2001, 10 female and one male patients, aged 47 to 76 years, were treated for an oesophageal squamous cell carcinoma which was diagnosed 5 to 25 years after mediastinal irradiation. This irradiation (30 to 78 Gy) was administered in 8 women for breast carcinoma and in other patients for lymphoma. Only one patient had alcoholic consumption and 2 were smokers. An oesophagectomy was performed whenever possible.All (but one) oesophageal tumors were symptomatic. Ten patients underwent an oesophagectomy, including 2 without thoracotomy. Postoperative course was uneventful in 6 cases, 3 patients developed transient respiratory failure and one patient died postoperatively. At late follow-up, 6 patients developed distant metastases (mainly hepatic and pulmonary). These metastases were associated with mediastinal recurrences in 2 cases. No isolated mediastinal recurrence occurred. Median survival was 13 months.Clinical presentation and surgical treatment of radiation-induced oesophageal carcinoma are similar to those of other oesophageal squamous cell carcinomas. After oesophagectomy, isolated mediastinal recurrences seem to be rarer than with other cancers. These cancers, which are almost all symptomatic, have a poor prognosis.

Chylothorax is a rare but life-threatening complication of esophagectomy for cancer. Elective ligation of the thoracic duct above the diaphragm does not suppress completely the risk of chylothorax due to possible trauma of the thoracic duct wall at the level of ligation, or incomplete ligation in case of anatomic variation. This study describes a technique of preventive ligation "en block" with surrounding tissues in order to minimize the risk of chylothorax following oesophagectomy, whatever performed transthoracically or through transhiatal approach.

To report a new series of medial pancreatectomy (MP), with analysis of early and long-term results.From 1990 to 1999, 11 patients (mean age = 53 years, extremes: 28-70)--including 10 non-diabetic--underwent MP for neuroendocrine tumor (n = 5), intraductal papillary mucinous tumor (IPMT) (n = 3), serous cystadenoma, metastasis from renal cell carcinoma, and focal pancreatitis. The procedure included medial resection of variable extent, frozen section, and suture of the cephalic stump. The caudal stump was either anastomosed to the posterior gastric wall (n = 9), or closed when atrophic or very small (n = 2).The mean length of resection was 7 cm (extremes: 4-15). The diagnosis suspected preoperatively was confirmed in 10 cases. In one patient, a suspected adenocarcinoma was actually a focal pancreatitis. No postoperative death occurred. Seven patients experienced complications: one delayed gastric emptying and 6 pancreatic fistulas (54%), including 3 associated with intraabdominal collection. Two patients were reoperated to drain a pancreatic fistula. The mean hospital stay was 14 days (extremes: 10-21) without complications, and 30 days (extremes: 11-90) after complications. After a mean follow-up of 45 months (extremes: 7-130), only one patient initially non-diabetic experienced post-operative diabetes and needs enzyme therapy after a 15 cm-resection for IPMT. No patient developed isolated intrapancreatic recurrence.MP preserves efficiently pancreatic function and is associated with a low risk of intrapancreatic recurrence. Conversely, MP is associated with an high risk of pancreatic fistula.

In the treatment of adenocarcinoma of the cardia and lower oesophagus, the choice of the approach (with or without thoracotomy) to perform a proximal oesogastrectomy (POG) is still debated. The aim of this retrospective study was to compare mortality, morbidity and long-term survival in a series of patients operated on with or without thoracotomy.From January 1991 to June 1997, 59 patients (mean ages: 65 +/- 10 years, range: 30-83) underwent POG through a transthoracic (n = 31) or a transhiatal approach (n = 28). All patients underwent both coeliac and left gastric lymphadenectomy. A mediastinal subaortic lymphadenectomy was only performed in patients who had a transthoracic approach. Both groups were comparable concerning age, weight and height, and tumoral staging according to preoperative imaging and pathologic examination. The transhiatal group included more high-risk patients (respiratory insufficiency, ASA score = 3) (NS).Resection was palliative in four patients in the transthoracic group and two patients in the transhiatal group. Operative mortality was 9% in the transthoracic group and 0% in the transhiatal group (NS). Pulmonary complications were as frequent with and without thoracotomy (35% versus 32% respectively). Global (curative and palliative resections) 3-year actuarial survival was similar in both groups (transthoracic: 39% versus transhiatal: 46%, NS), as well as survival after curative resection (44% versus 49% respectively, NS). The operative approach did not influence survival in patients N+ (22% versus 17% respectively, NS) and in patients N- (86% versus 77% respectively, NS).These results suggest that, for adenocarcinoma of the cardia and lower oesophagus, the theoretical carcinologic benefit of mediastinal lymphadenectomy can be balanced with an higher operative risk related to the transthoracic approach.

A pancreatic fistula occurs in about 10% of cases after Whipple's procedure. This complication is associated with a mortality rate ranging from 7% to 30%. The main predisposing factor of pancreatic fistula is a soft pancreatic parenchyma. Several procedures have been proposed to decrease the rate of this complication. Occlusion of the residual stump is infrequently used and does not clearly reduce the rate of this complication. Pancreaticojejunostomy is the technique most frequently used. No alternative technique is clearly superior to pancreaticojejunostomy. Pancreaticogastrostomy and pancreaticojejunostomy have equivalent early results. Superiority of transient intubation of the Wirsung duct and mucosa-to-mucosa anastomosis is not demonstrated. Among the 7 controlled randomized studies which tested somatostatin or its analogs, many have methodological insufficiencies which prevent definite conclusions. Meanwhile, most studies suggest that these drugs decrease the rate of pancreatic fistula after pancreaticoduodenectomy. Further evaluation in high-risk patients (soft pancreatic parenchyma) is advisable.

Intraductal papillary and mucinous tumors of the pancreas (IPMT) have been recently well defined histologically. Recent reports have described their diagnostic and therapeutic modalities. The malignant potential of these lesions warrants their surgical resection. The main difficulty of their management is the pre-operative assessment of ductal extension and grade of dysplasia. Despite the use of various imaging modalities (ultrasound, endoscopic ultrasonography, CT scan, retrograde pancreatography, pancreatic MRI), examination of the pancreatic margin on frozen section remains mandatory to ensure complete resection of epithelial lesions. This usually requires partial pancreatic resection. The long-term outcome is favourable for lesions with no invasive component. Recurrence in case of invasive malignant transformation appear to be more frequent than previously reported.

The aim of this retrospective study, in 100 patients who had an esophagectomy from 1987 to 1992 for squamous cell carcinoma of the thoracic esophagus, was to determine the accuracy of endoscopic ultrasonography (EUS) and computed tomography (CT) in the preoperative staging of esophageal squamous cell carcinoma (SCC). The EUS report were compared to the pathological findings for the T stage. Both EUS and CT reports were compared with surgical and pathological findings for N stage (N0/N1) and mediastinal extension. In the 100 patients, EUS accuracy for T stage was 80%; EUS was more accurate for N stage than CT (71% vs 55% respectively; p0.02), and as accurate as CT for mediastinal extension (86% vs 85%). In the 26 SCC estimated superficial by EUS (all passed through), EUS accuracy was 92% for T stage and 77% for the distinction between mucosal and submucosal tumours; for N stage, EUS and CT accuracies were equivalent (77% vs 81%). In the 44 SCC passed and estimated advanced by EUS, EUS accuracy for T stage was 68%; EUS was more accurate than CT for N stage (77% vs 48%, p0.01) and as accurate as CT for mediastinal extension (86 vs 84%). In the 30 SCC not passed by EUS, accuracies of EUS and CT were equivalent for N stage (57% vs 47%) and for mediastinal extension (73% vs 73%). This study suggests that: a) for SCC estimated superficial by EUS, EUS does not differentiate reliably mucosal from submucosal tumors and CT is useless; b) routine EUS seems unnecessary for SCC not passed through by endoscopy; c) CT is still useful in patients with advanced SCC, mainly for detection of distant metastases.

The aim of this study was to evaluate the pain relief related to resection of the celiac plexus in pancreatic carcinoma. This technique was attempted in 26 consecutive patients and performed in 23 (feasibility: 88%), whose mean age was 64 years. Before surgery, patients were divided into two groups: patients not treated by narcotic analgesics (group 1, n = 10) and patients treated by narcotic analgesics (group II, n = 13). Surgery was indicated in 22 patients for pancreatic resection or by-pass, and in 1 patient for pain relief after an unsuccessful per-cutaneous celiac plexus block. Resection of the celiac plexus was always performed via a trans-peritoneal approach, after mobilization of the head of the pancreas and the duodenum. Only the right half of the celiac plexus was resected in 4 patients (17%) due to technical difficulties. Pathologic examination was performed in 16 patients (8 patients from each group) and neoplastic involvement was observed only in 3 patients of group II. There was no operative death. Two complications related to this method occurred (9%). One patient developed a chylous ascites and was treated conservatively. In a second patient, an occlusion of the celiac trunk was complicated by infarction of the spleen and of the left lobe of the liver; this patient was reoperated and his subsequent post-operative course was uneventful. In group I, eight patients (80%) did not require narcotic analgesics after resection of the celiac plexus. Two failures occurred, one immediately after surgery and one delayed. In group II, seven patients (53%) did not require narcotic analgesics; 6 of these 7 patients died. Six failures occurred, 4 early after surgery and 2 delayed. Three of the 4 early failures occurred in patients who underwent resection of the right half of the celiac plexus. The authors concluded that resection of the celiac plexus seems to be an effective pain treatment in pancreatic carcinoma. However, resection must be bilateral to provide analgesia. Specific morbidity of this technique may lead to the use of non-surgical methods if surgery is not indicated for pancreatic resection or by-pass.

Between January 1988 and February 1991, 27 patients underwent pancreaticogastrostomy after pancreaticoduodenectomy. The mean age of the patient was 57 years and 18 of them were male. Pancreatic disease was malignant in 21 patients (78%) and benign in 6 patients. The pancreatic remnant was normal in 15 patients (56%) and fibrotic in 12 patients. There was one operative death (3.7%) unrelated to the pancreaticogastrostomy. Only two complications (7.5%) were related to pancreaticogastrostomy: one patient had intra-gastric bleeding and was reoperated, one patient developed a pancreatic leak (3.7%) which healed without reoperation. The authors conclude that pancreaticogastrostomy in the preferred method of management of the pancreatic remnant after pancreaticoduodenectomy.