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Resume But La resection intra-gastrique laparoscopique (RIGL) de lesions benignes et malignes est une approche mini-invasive interessante notamment pour les lesions de la jonction oeso-gastrique ou antro-pyloriques. Le but etait d’en evaluer la faisabilite technique et les resultats a long terme. Methodes De 2000 a 2013, 25 RIGL etaient realisees pour lesions gastriques benignes ou malignes. Les indications chirurgicales, la technique operatoire, les complications postoperatoires, les resultats anatomopathologiques et le suivi a long terme etaient evalues retrospectivement. Resultats Dix-neuf lesions (76 %) etaient localisees sur la jonction oeso-gastrique, trois (12 %) sur la petite courbure gastrique, deux (8 %) sur la face posterieure de l’estomac et une (4 %) sur la region pre-pylorique. Une approche multi-trocarts a ete utilisee pour 15 patients (60 %) et mono-trocart pour 10 (40 %). La duree operatoire moyenne etait de 140 minutes (extremes 50–210). Aucune conversion en laparotomie n’etait necessaire. Une complication severe est survenue (4 %) mais la mortalite etait nulle. Aucun patient n’a presente de stenose ou de retrecissement. L’anatomopathologie montrait 11 adenocarcinomes (44 %), six tumeurs stromales gastro-intestinales (GIST) (24 %) et huit lesions benignes (32 %). La resection mono-bloc etait realisee chez 24 patients (96 %) et etait R0 pour 23 patients (92 %). Sur un suivi median de 89 mois (extremes 26–177) quatre patients (16 %) ont presente une recidive et un patient est decede de la maladie (4 %). Conclusion La RIGL est une technique sure avec une morbidite et des resultats a long terme acceptables. Elle constitue une alternative interessante chez des patients selectionnes permettant d’eviter des resections gastriques majeures lorsqu’une exerese endoscopique n’est pas accessible.

Background: The validity of laparoscopic distal pancreatectomy in left-sided pancreatic adenocarcinoma (PDAC) is still unclear. However, a meticulous surgical dissection through a “no-touch” technique might allow a radical oncological resection with minimal risk of tumor dissemination and seeding. This study aims to evaluate the oncological outcomes of the laparoscopic “no touch” technique versus the “touch” technique Methods: From 2001 to 2020, we analyzed retrospectively 45 patients undergoing LDP (laparoscopic distal pancreatectomy) for PDAC from two centers. Factors associated with overall (OS), disease-free (DFS) survival and Time to recurrence (TTR) were identified. Results. The OS rates in the ‘no-touch’ and ‘touch’ groups were 95% vs 78% (1-year OS); 50% vs 50% (3-year OS), respectively (p=0.60). The DFS rates in the ‘no-touch’ and ‘touch’ groups were 72 % vs 57 % (1-year DFS); 32% vs 28 % (3-year DFS), respectively (p=0.11). The TTR rates in the ‘no-touch’ and ‘touch’ groups were 77 % vs 61 % (1-year TTR); 54% vs 30 % (3-year TTR); 46% vs 11 % (5-year TTR); respectively (p=0.02) In multivariate analysis the only factors were Touch technique (OR= 2.62, p= 0.02) and lymphovascular emboli (OR= 4.8; p=0.002). Conclusion. We advise the ‘no-touch’ technique in patients with resectable PDAC in the pancreatic body and tail. Although this study does not provide definitive proof of superiority, no apparent downsides are present for the ‘no-touch’ technique in this setting although there could be oncological benefits.

Summary Background Technological and operative advancements have allowed laparoscopic intragastric surgery (LIGS) to be applied in the treatment of superficial gastric or submucosal lesions. The aim of this study was to evaluate short- and long-term outcomes following LIGS. Methods From 2000 to 2013, 25 LIGSs were performed for superficial gastric lesions. Clinical records were reviewed retrospectively for peri-operative course and long-term outcomes with particular attention to the oncological follow-up for patients with malignant lesions. Results Nineteen (76%) lesions were located close to the EGJ, three (12%) in the lesser curvature, two (8%) in the posterior wall and one (4%) in the prepyloric-antral region. A multiport technique was used in 15 (60%) patients and a single-access approach in 10 (40%) patients. The median operative time was 140 (50–210) minutes. No conversion to open or conventional laparoscopic surgery was needed. Mortality was nil, and severe morbidity occurred in one (4%) patient. The median length of stay was 6 (3–10) days. Indications of LIGS were adenocarcinoma in 11 (44%) patients, gastrointestinal stromal tumors (GISTs) in 6 (24%) patients and benign lesions in eight (32%) patients. En bloc resection was obtained in 24 (96%) patients with R0 margins in 23 (92%) patients. After a median follow-up of 76 (26–171) months, recurrence was detected in 4 (36%) patients with advanced malignant adenocarcinoma. Conclusion LIGS provides an interesting alternative to major gastric and EGJ resection when endoscopic resection is not suitable for highly selected patients with superficial gastric lesions.

Among the criteria used to diagnose metabolic syndrome (MS), obesity and diabetes mellitus (DM) are associated with poor postoperative outcomes following colectomy. MS is also associated with colorectal cancer (CRC) and diverticulosis, both of which may be treated with colectomy. However, the effect of MS on postoperative outcomes following laparoscopic colectomy has yet to be clarified. In an academic tertiary hospital, data from all consecutive patients undergoing laparoscopic colectomy from 2005 to 2014 were prospectively recorded and analysed. Patients presenting with MS [defined by the presence of three or more of the following criteria: elevated blood pressure, body mass index > 28 kg/m2, dyslipidemia (decreased serum HDL cholesterol, increased serum triglycerides) and increased fasting glucose/DM] were compared with patients without MS regarding peri-operative outcome [mainly anastomotic leaks, severe postoperative complications (Clavien–Dindo III and IV)] and mortality. Overall, 1236 patients were included: 508 (41.1%) right colectomies and 728 (58.9%) left colectomies. Seven hundred seventy-two (62.4%) of these procedures were performed for CRC. MS was diagnosed in 85 (6.9%) patients, who were significantly older than the others (70 vs. 64.2 years, p

In the absence of randomized controlled data and even propensity-matched data, indications for, and outcomes of, laparoscopic repeat liver resection for hepatocellular carcinoma (HCC) remain uncertain. This study aimed to clarify the current indications for laparoscopic repeat liver resection for HCC, and to evaluate outcomes.Forty-two liver surgery centres around the world registered patients who underwent repeat liver resection for HCC. Patient characteristics, preoperative liver function, tumour characteristics, surgical method, and short- and long-term outcomes were recorded.Analyses showed that the laparoscopic procedure was generally used in patients with relatively poor performance status and liver function, but favourable tumour characteristics. Intraoperative blood loss (mean(s.d.) 254(551) versus 748(1128) ml; P 0·001), duration of operation (248(156) versus 285(167) min; P 0·001), morbidity (12·7 versus 18·1 per cent; P = 0·006) and duration of postoperative hospital stay (10·1(14·3) versus 11·8(11·8) days; P = 0·013) were significantly reduced for laparoscopic compared with open procedures, whereas survival time was comparable (median 10·04 versus 8·94 years; P = 0·297). Propensity score matching showed that laparoscopic repeat liver resection for HCC resulted in less intraoperative blood loss (268(730) versus 497(784) ml; P = 0·001) and a longer operation time (272(187) versus 232(129); P = 0·007) than the open approach, and similar survival time (12·55 versus 8·94 years; P = 0·086).Laparoscopic repeat liver resection is feasible in selected patients with recurrent HCC.Dado que no existen ensayos clínicos controlados ni estudios de datos emparejados por puntaje de propensión, todavía hay dudas sobre las indicaciones y los resultados de la resección iterativa laparocópica de un carcinoma hepatocelular (hepatocellular carcinoma, HCC). Este estudio tuvo como objetivo esclarecer las indicaciones actuales y los resultados de la resección hepática laparoscópica iterativa del HCC. MÉTODOS: Se incluyeron los pacientes de 42 centros de cirugía hepática a nivel mundial en los que se había realizado una resección hepática iterativa por HCC. Se analizaron las características del paciente, la función hepática preoperatoria, las características del tumor, el abordaje quirúrgico y los resultados a corto y largo plazo.El análisis demostró que la vía laparoscópica generalmente se utilizaba en pacientes con carácteristicas tumorales favorables, pero con estado funcional y función hepatica relativamente peores. La pérdida de sangre intraoperatoria (254,3 ± 551,2 versus 748,0 ± 1127,7 mL, P 0,001), la duración de la intervención (247,6 ± 155,8 versus 285,1 ± 167,0 minutos, P 0,001), la morbilidad (12,7 versus 18,1%, P = 0,005) y la estancia hospitalaria postoperatoria (10,07 ± 14,29 versus 11,80 ± 11,79 días, P = 0,010) fueron significativamente menores para los pacientes tratados por via laparoscópica en comparacion con la vía abierta, mientra que el tiempo de supervivencia fue comparable (mediana 10,04 versus 8,94 años, P = 0,297). El estudio de emparejamiento por puntaje de propensión mostró que la resección hepática iterativa por vía laparoscópica de un HCC (frente a la vía abierta) conllevaba una menor pérdida sanguínea intraoperatoria (268,0 ± 730,2 versus 496,5 ± 784,2 mL, P = 0,01), una mayor duración de la intervención (272,1 ± 187,2 versus 231,8 ± 129,1 minutos , P = 0,07) y un tiempo de supervivencia similar (mediana 12,55 versus 8,94 años, P = 0,0855). CONCLUSIÓN: La resección hepática iterativa por vía laparoscópica es factible en pacientes seleccionados con HCC recidivado.

The sequential FOLFOX7–FOLFIRI combination is not superior to FOLFOX4 in colorectal cancer patients with resectable metastases. Patients with synchronous metastases preferably received perioperative chemotherapy, while patients with metachronous metastases were given postoperative chemotherapy in preference. We observed the highest long-term survival rates ever reported in this setting. Background Perioperative FOLFOX4 (oxaliplatin plus 5-fluorouracil/leucovorin) chemotherapy is the current standard in patients with resectable metastases from colorectal cancer (CRC). We aimed to determine whether a sequential chemotherapy with dose-dense oxaliplatin (FOLFOX7) and irinotecan (FOLFIRI; irinotecan plus 5-fluorouracil/leucovorin) is superior to FOLFOX4. The chemotherapy timing was not imposed, and was perioperative or postoperative. Patients and methods In this open-label, phase III trial, patients with resectable or resected metastases were randomly assigned either to 12 cycles of FOLFOX4 (oxaliplatin 85 mg/m2) or 6 cycles of FOLFOX7 (oxaliplatin 130 mg/m2) followed by 6 cycles of FOLFIRI (irinotecan 180 mg/m2). Randomization was done centrally, with stratification by chemotherapy timing, type of local treatment (surgery versus radiofrequency ablation with/without surgery), and Fong's prognostic score. The primary end point was 2-year disease-free survival (DFS). Results A total of 284 patients were randomized, 142 in each treatment group. Chemotherapy was perioperative in 168 (59.2%) patients and postoperative in 116 (40.8%) patients. Perioperative chemotherapy was preferentially proposed for synchronous metastases, whereas postoperative chemotherapy was more frequently used for metachronous metastases. Two-year DFS was 48.5% in the FOLFOX4 group and 50.0% in the FOLFOX7–FOLFIRI group. In the multivariable analysis, more than one metastasis [hazard ratio (HR) = 2.15] and synchronous metastases (HR = 1.63) were independent prognostic factors for shorter DFS. Five-year overall survival (OS) rate was 69.5% with FOLFOX4 versus 66.6% with FOLFOX7–FOLFIRI. Conclusions FOLFOX7–FOLFIRI is not superior to FOLFOX4 in patients with resectable metastatic CRC. Five-year OS rates observed in both groups are the highest ever reported in this setting, possibly reflecting the pragmatic approach to chemotherapy timing. Clinical trials number NCT00268398.

La morbidite des fistules apres chirurgie colorectale est elevee et leur traitement est difficile. Leur obturation par injection de colle de fibrine a ete ponctuellement publiee. Ce travail presente les resultats d’une etude prospective chez 14 patients. De juin 2004 a janvier 2008, les patients ayant une fistule postoperatoire ont ete inclus, a l’exclusion des fistules impliquant le vagin, celles de grand diametre (> 1 cm) ou communiquant avec une cavite non drainee. Quatorze patients (10 H), d’âge moyen 63,5 ans, ont ete traites; soit 11 cancers du rectum, 2 diverticulites et une tumeur stromale de la cloison recto-vaginale; trois sur 13 avaient recu une radiotherapie preoperatoire. Il s’agissait d’anastomoses colorectales (ACR), basses (n = 6) ou hautes (n = 4), dont neuf latero-terminales, de trois anastomoses colo-anales (CA) et d’une suture rectale sans anastomose. Dix etaient des anastomoses mecaniques. Sept patients avaient d’emblee une stomie (CA + ACR basses). Le diagnostic de fistule etait porte 11 fois sur l’imagerie (TDM, IRM), deux fois en endoscopie et une fois a l’examen clinique; neuf fois, il etait porte precocement ( 57 jours). Six fois, une stomie secondaire a ete necessaire, toujours pour des fistules precoces. L’encollage a ete effectue 1,5 fois en moyenne avec 1 a 3 ml de colle (Beriplast®); l’efficacite etait jugee sur un scanner ou une IRM. Douze fois sur l’imagerie, la fistule a ete consideree comme obturee et la stomie a pu etre retiree dans un delai moyen de 389 jours apres sa mise en place, en moyenne 44 jours apres le premier essai d’encollage pour les formes tardives et 168 pour les formes precoces. Dans deux cas, malgre une fermeture de la fistule, une infiltration presacree persistait au scanner sans recidive tumorale. Le retard a la fermeture des stomies pouvait etre lie a la necessite d’une chimiotherapie postoperatoire. Cette serie, la plus grande rapportee d’encollage de fistules post-chirurgie colorectale coelioscopique, montre l’efficacite d’une prise en charge endoscopique. L’atout essentiel de cette technique est son absence de morbidite et une reelle efficacite, surtout en regard de l’alternative chirurgicale, notamment dans les fistules chroniques. Elle a permis une fermeture de la fistule dans 12 cas sur 14.

The practice of laparoscopic liver surgery has developed gradually, and most liver resections seem currently feasible and safe for selected patients in centers where surgeons are experienced both in liver surgery and in laparoscopic surgery. However, further studies would be required, especially for long-term oncological results and for major hepatectomy follow-up, before laparoscopic hepatectomy becomes a common alternative to open liver surgeries. Laparoscopic major hepatectomy is a recent technique, due to its significant complexity. In this review, we showed that patients undergoing laparoscopic hepatectomy for liver metastases experienced decreased rates of overall and major postoperative complications without any compromise on long-term outcomes compared to patients treated by open resection.

Despite staging laparoscopy (SL) with peritoneal lavage is recommended in US Guidelines in patients with potentially resectable gastroesophageal adenocarcinoma, this procedure is not systematically proposed in French Guidelines. Therefore, we decided to analyze the results of systematic SL in patients considered for preoperative chemotherapy. From 2005 to 2011, 116 consecutive patients with distal esophagus, esogastric junction, and gastric adenocarcinoma ≥T3 or N+ without detectable metastatic dissemination by computed tomography (CT) scan imaging underwent SL before neoadjuvant chemotherapy. Positive and negative SLs were compared according to tumor characteristics. SL was positive in 15 cases (12.9%) including 14 with peritoneal seeding (localized in five, diffuse in nine). SL was positive in 7 (24.1%) of 29 patients with poorly differentiated tumor, in 9 (32.1%) of 28 patients with signet ring cells, in 7 (50%) of 14 patients with gastric linitis tumor, and in 15 (16.3%) of 92 patients with T3 or T4 tumor. All the lesions of distal esophagus extending to the cardia had a negative SL. Among the 14 patients with peritoneal carcinomatosis at SL, nine (65%) had signs of peritoneal seeding on initial CT scan. One (0.8%) patient had a small bowel perforation closed laparoscopically. If systematic SL before preoperative chemotherapy does not seem justified because of its low accuracy, it should be performed in patients with poorly differentiated tumor, signet ring cell, and gastric linitis plastica components on biopsy and when CT scan is suggestive of T4 tumor, ascites, or peritoneal nodule.

Resume Nous rapportons un cas d’anevrisme sacculaire sur une fenestration de l’artere basilaire, survenu chez une femme de 47 ans hospitalisee pour hemorragie meningee peri-mesencephalique. Les anomalies de la media de la tunique arterielle au niveau des bifurcations expliquent l’association entre les anevrismes vertebro-basilaires et les fenestrations de l’artere basilaire. L’arteriographie cerebrale a mis en evidence un anevrisme en situation termino-vertebrale a orientation ventrale. Le traitement a consiste en une embolisation. Ce cas clinique nous permet de revoir la morphogenese de l’artere basilaire, les anomalies parietales interessant les fenestrations, et de discuter les deux prises en charges therapeutiques envisageables.

Resume Dans les cancers du haut rectum, l'exerese du mesorectum se fait de facon extrafasciale, toujours en dehors du fascia recti, et la section se fait 5 cm sous le pole inferieur de la tumeur. Pour les cancers du bas rectum, la resection comporte une exerese extrafasciale de tout le mesorectum et une section du rectum 2 cm sous le bord inferieur de la tumeur, distance mesuree en salle d'operation sur la piece operatoire fraiche. Les cancers dont le pole inferieur est trop proche du canal anal (cancers de la jonction anorectale) et a plus forte raison ceux qui envahissent l'appareil sphincterien imposent une amputation abdominoperineale. Quelques cas selectionnes de lesions de la jonction anorectale, pris en charge par des centres specialises, peuvent relever d'un traitement conservateur avec resection intersphincterienne et anastomose coloanale. Schematiquement, et selon le siege de la tumeur, on decrit quatre techniques differentes de proctectomie avec conservation du sphincter anal : la proctectomie partielle avec exerese partielle du mesorectum suivie d'une anastomose colorectale haute manuelle ou mecanique ; la proctectomie partielle avec exerese totale du mesorectum suivie si le moignon rectal mesure plus de 2 cm d'une anastomose colorectale basse et si le moignon rectal mesure moins de 2 cm d'une anastomose mecanique colo-sus-anale avec reservoir colique ; la proctectomie totale avec exerese totale du mesorectum suivie d'une anastomose coloanale manuelle et ses variantes, sur reservoir, faite par voie perineale ; une nouvelle technique, adaptee de celle de Babcock, qui associe la proctectomie totale et la descente du colon a travers l'anus suivie, 5 jours plus tard, d'une resection du colon abaisse et d'une veritable anastomose manuelle coloanale directe par voie perineale. L'amputation abdominoperineale du rectum ajoute l'exerese du canal anal et de l'appareil sphincterien suivie d'une colostomie definitive. Certains points lui sont particuliers : elle ne necessite pas de decrochement de l'angle gauche ; on peut preserver, chez les sujets âges notamment, le pedicule sigmoidien ou sa premiere branche ; il est classique de lui associer une epiplooplastie pediculee sur les vaisseaux gastroepiploiques gauches. La cœlioscopie peut s'appliquer a toutes ces techniques. Elles peuvent aussi etre commencees par cœlioscopie puis converties par laparotomie, soit de principe, notamment si l'operation se prolonge, soit de necessite devant une difficulte technique, un defaut d'exposition ou un doute sur la qualite des marges laterales. L'amputation abdominoperineale une tres bonne indication d'approche cœlioscopique car la seule incision est celle de la stomie, l'exteriorisation de la piece pouvant se faire par le perinee.

Resume Le rectum est le segment terminal du tube digestif. Il comporte deux parties : le rectum pelvien, encore appele ampoule rectale, qui mesure 12 a 15 cm, derive de l'intestin primitif ayant donc un meso dorsal (le mesorectum) et le rectum perineal ou canal anal, qui mesure 3-4 cm et correspondant aux sphincters parfaitement reperables par le toucher rectal, derive de l'ectoderme et n'ayant donc pas de meso. Le peritoine recouvre la face anterieure et les faces laterales de la moitie superieure du rectum qui est donc dite, a tort, intraperitoneale par opposition a la moitie inferieure situee sous le cul-de-sac de Douglas entierement sous-peritoneale. Le rectum pelvien est donc entoure soit par le peritoine soit par le feuillet visceral du fascia pelvien ou fascia propria encore appele fascia recti. Le feuillet parietal est parfois appele fascia presacre bien qu'il recouvre la totalite des parois de la cavite pelvienne et pas seulement le sacrum. C'est le fascia de Waldeyer des Anglo-Saxons. La vascularisation, sanguine et lymphatique, du rectum pelvien se fait dans le mesorectum, l'espace cellulograisseux compris entre le fascia recti et le rectum pelvien ; il disparait sur les 2 derniers centimetres de l'ampoule rectale. Les techniques actuelles de proctectomie comprennent une resection « totale » du mesorectum ; il s'agit d'une expression ambigue melangeant l'exerese extrafasciale, en dehors du fascia recti et toujours justifiee, et l'ablation de tout le mesorectum jusqu'au plan des releveurs qui n'est justifiee que pour les tumeurs de la moitie inferieure du rectum. Les deux feuillets, visceral et parietal, du fascia pelvien se rejoignent et fusionnent en avant et en arriere. Pour faire une exerese totale du mesorectum, il est donc necessaire au moins deux fois, de changer de plan en emportant l'aponevrose de Denonvilliers en avant et le ligament rectosacre en arriere. Les nerfs pelviens, sympathiques et parasympathiques, sont toujours recouverts par le fascia parietal, en arriere puis en dehors puis en avant et en dehors du rectum. Ils sont donc preserves par l'exerese extrafasciale, mais ils sont tres proches de la zone de liberation sur les faces anterolaterales basses ou des branches nerveuses penetrent le fascia recti pour innerver le rectum terminal. Le rectum perineal n'a pas de fascias propres, une vascularisation peu systematisee vers la peau et les fosses ischiorectales en partie a travers les muscles elevateurs de l'anus. D'un point de vue chirurgical, le repere de la marge anale est peu utile pour les tumeurs de l'ampoule rectale car trop variable selon la position du malade, son adiposite et la longueur du canal lui-meme ; le bord superieur des releveurs est beaucoup plus facile a reperer et l'on verra que c'est par rapport a lui que l'on decide de tel ou tel type de resection. Les distances « par rapport a la marge anale » sont encore faussees selon que l'on mesure la face anterieure tres courte avec un cul-de-sac de Douglas a 5,5 cm de la marge - mais parfois a 4 cm chez la femme - ou le bord posterieur tres long ce qui se traduit en coloscopie par une charniere colorectale parfois mesuree a 18, voire 19 cm de la marge anale. La localisation des tumeurs les plus basses par rapport a la marge anale est importante mais elle doit etre confirmee par rectoscopie ou anuscopie. Cliniquement, on peut diviser le rectum en trois parties : le haut rectum, moitie superieure de l'ampoule rectale, grossierement situe au-dessus du cul-de-sac de Douglas, s'etend de 6-8 cm a 15-19 cm de la marge anale selon les conditions de mesure ; le bas rectum, moitie inferieure de l'ampoule rectale qui se termine au bord superieur des releveurs et correspond au rectum sous-peritoneal ; il est explorable par le doigt ; le canal anal de 0 a 3-4 cm de la marge anale – egalement le siege des carcinomes epidermoides d'origine tegumentaire exclus de ce chapitre.

Resumen En los canceres de la porcion alta del recto, la exeresis del mesorrecto se hace de forma extrafascial, siempre por fuera de la fascia rectal, y la seccion se realiza 5 cm por debajo del polo inferior del tumor. En los canceres de la porcion baja del recto, la reseccion conlleva la exeresis extrafascial de todo el mesorrecto y una seccion del recto 2 cm por debajo del borde inferior del tumor, distancia que se mide en el quirofano en la pieza quirurgica fresca. Los canceres cuyo polo inferior esta demasiado cerca del conducto anal (canceres de la union anorrectal), y con mayor razon los que invaden el aparato esfinteriano, exigen una amputacion abdominoperineal. En algunos casos seleccionados de lesiones de la union anorrectal, tratados por centros especializados, se puede aplicar un tratamiento conservador con reseccion interesfinteriana y anastomosis coloanal. Esquematicamente, y segun el lugar donde se encuentre el tumor, se han descrito cuatro tecnicas diferentes de proctectomia con conservacion del esfinter anal: proctectomia parcial con exeresis parcial del mesorrecto y a continuacion anastomosis colorrectal alta manual o mecanica; proctectomia parcial con exeresis total del mesorrecto y posteriormente, si el munon rectal mide menos de 2 cm, anastomosis mecanica colo-supra-anal con reservorio colico; proctectomia total con exeresis total del mesorrecto seguida por una anastomosis coloanal manual y sus variantes, con reservorio, realizada por via perineal; una nueva tecnica, adaptada de la de Babcock, en la que se asocia la proctectomia total y el descenso del colon a traves del ano y a continuacion, cinco dias mas tarde, una reseccion del colon descendido y una autentica anastomosis manual coloanal directa por via perineal. En la amputacion abdominoperineal del recto se anade la exeresis del conducto anal y del aparato esfinteriano, seguida por una colostomia definitiva. Tiene algunas caracteristicas particulares: no es necesaria la desinsercion del angulo izquierdo; se puede preservar, sobre todo en los pacientes ancianos, el pediculo sigmoideo o su primera rama; es clasico asociar una epiploplastia pediculada sobre los vasos gastroepiploicos izquierdos. La laparoscopia puede aplicarse en todas estas tecnicas. Tambien es posible iniciarlas con una laparoscopia y convertirlas por laparotomia, ya sea por principio, sobre todo si la operacion se prolonga, ya sea en caso de necesidad ante una dificultad tecnica, una exposicion defectuosa o cualquier duda sobre la calidad de los margenes laterales. La amputacion abdominoperineal es una excelente indicacion de acceso laparoscopico, ya que la unica incision es la del estoma, siendo posible exteriorizar la pieza por el perine.

Resumen El recto es el segmento terminal del tubo digestivo. Se compone de dos partes: el recto pelvico, tambien denominado ampolla rectal, que mide 12-15 cm, derivado del intestino primitivo, por lo que posee un meso dorsal (el mesorrecto) y el recto perineal o conducto anal, que mide 3-4 cm y corresponde a los esfinteres perfectamente palpables en un tacto rectal, derivado del ectodermo, de ahi que no tenga meso. El peritoneo recubre las caras anterior y lateral de la mitad superior del recto. Esta porcion se denomina de forma incorrecta intraperitoneal, en contraposicion a la mitad inferior, localizada bajo el fondo de saco de Douglas, completamente infraperitoneal. Asi pues, el recto pelvico esta recubierto sea por el peritoneo, sea por la hoja visceral de la fascia pelvica o fascia propia, tambien llamada fascia rectal. La hoja parietal se denomina a veces fascia presacra, aunque en realidad recubre todas las paredes de la cavidad pelvica, y no solo el sacro. Los anglosajones la denominan fascia de Waldeyer. La vascularizacion sanguinea y linfatica del recto pelvico discurre dentro del mesorrecto, en el espacio celulograso comprendido entre la fascia recti y el recto pelvico, y desaparece en los 2 ultimos centimetros de la ampolla rectal. Las tecnicas actuales de proctectomia consisten en una reseccion «total» del mesorrecto, expresion ambigua, ya que incluye la exeresis extrafascial, siempre justificada, por fuera de la fascia recti y la ablacion de todo el mesorrecto, solo justificada en los tumores de la mitad inferior del recto. Las dos hojas, visceral y parietal, de la fascia pelvica se unen y fusionan por delante y por detras. Por tanto, para efectuar una exeresis total del mesorrecto, hay que cambiar de plano al menos dos veces, y llevar la aponeurosis de Denonvilliers hacia delante y el ligamento recto sacro hacia atras. Los nervios pelvicos simpaticos y parasimpaticos estan siempre recubiertos por la fascia parietal, hacia atras, hacia fuera, por delante y por fuera del recto. Por tanto, se encuentran conservados en la exeresis extrafascial, si bien se situan muy proximos a la zona de liberacion, sobre las caras anterolaterales bajas, donde las ramas nerviosas penetran en la fascia recti para inervar el recto terminal. El recto perineal no posee fascia propia, y la vascularizacion esta poco sistematizada a traves del musculo elevador del ano hacia la piel y las fosas isquiorrectales. Desde un punto de vista quirurgico, resulta poco util localizar el margen anal en los tumores de la ampolla rectal, pues este varia mucho en funcion de la posicion del enfermo, su adiposidad y la longitud del conducto anal. El borde superior del elevador del ano es mucho mas facil de localizar y, como se vera, en funcion de la distancia al mismo se elegira el tipo de reseccion. Las distancias definidas “respecto al margen anal” seran falseadas en funcion de que se mida la cara anterior, muy corta con el fondo de saco de Douglas situado a 5,5 cm del margen (a veces a 4 cm en la mujer), o la cara posterior, muy larga, por colonoscopia. La distancia hasta la union colorrectal mide 18 cm, a veces incluso 19 desde el margen anal. La localizacion de los tumores mas bajos con respecto al margen anal es importante, pero debe confirmarse por rectoscopia o anoscopia. Desde el punto de vista clinico, el recto puede dividirse en tres partes: el recto superior, que corresponde a la mitad superior de la ampolla rectal, se situa por encima del fondo de saco de Douglas, y mide de 6-8 cm a 15-19 cm, dependiendo de las condiciones en las que se haya medido; el recto inferior, mitad inferior de la ampolla rectal, que se termina en el borde superior de los elevadores y corresponde al recto infraperitoneal y se puede explorar con el dedo; el conducto anal, de 0 a 3-4 cm desde el margen anal, donde suelen localizarse carcinomas epidermoides de origen cutaneo, no incluidos en este articulo.

We report a case of a mucinous cystadenoma of the pancreas communicating with the main pancreatic duct. To our knowledge, this is the first case in which a communication between the mucinous cystadenoma and the main pancreatic duct could be demonstrated by MRI.

Resume Objectif de l'etude Cette etude retrospective a pour objectif de rapporter cinq observations de lesions spleniques traitees sous cœlioscopie par splenorraphie avec la prothese perisplenique resorbable qui etait utilisee en chirurgie ouverte. Patients et methode De juillet 1996 a fevrier 1998, trois hommes et deux femmes (âge moyen: 52 ans) ont ete inclus dans l'etude. La lesion splenique etait liee a une chute ( n = 3), un accident de la circulation ( n = 1) et a une ponction pleurale pour mediastinite apres pose d'une valve cardiaque. La lesion splenique a ete reconnue par l'echographie. Tous les patients avaient un etat hemodynamique stable. Deux interventions ont ete realisees d'urgence et les trois autres dans les 24 heures. La rate a ete completement liberee. La prothese placee en arriere de la rate, recouvrant bien les poles superieur et inferieur de la rate, a ete deroulee d'arriere en avant et les trois bourses successivement serrees. Resultats II n'y a eu aucune conversion, ni mortalite, ni morbidite. Chez les quatre traumatises, la duree moyenne de l'intervention a ete de 120 minutes (extremes: 70–180 minutes), il n'y a eu aucune transfusion sanguine et les patients sont sortis a j4 ou j5. Le cinquieme patient apres pose d'une valve a ete opere sous traitement anticoagulant. La duree de l'operation a ete de 270 minutes. Il a recu quatre culots globulaires et est sorti a j26. Conclusion Cette technique associe les avantages de la prothese perisplenique qui est efficace et sure et les avantages de la cœlioscopie qui simplifie les suites operatoires. Elle ne peut etre envisagee qu'en cas de lesion splenique isolee chez des patients ayant un etat hemodynamique stable.

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

In the past two decades there has been an enormous increase in laparoscopic liver surgery. There is a trend from limited to laparoscopic major resections and more centres are adopting laparoscopic liver surgery as a standard of care. Although no randomized clinical trials are published, different reports on minor and major hepatectomies and meta-analyses suggest (at least) equal outcomes and cost-effectiveness compared to open procedures.

Intraabdominal cystic lymphangioma occurs rarely, and lymphangioma of the diaphragm has not been previously reported in the literature. The authors herein report the clinical features, radiographic findings, and treatment of one encountered case of lymphangioma of the diaphragm.

This study is concerned with a western series of 521 squamous cell carcinomas of the thoracic esophagus treated over a recent 9-year period. Six points of the preoperative work-up are discussed: (1) t

Advances in laparoscopic techniques, refinements of instruments and growth of practical experience in liver surgery during the last decade have prompted some surgeons to develop the laparoscopic approach for hepatic metastases of colorectal cancer (MCRC).Primary end points of this clinical study were safety and effectiveness of laparoscopic hepatectomy for MCRC, including early postoperative results and long-term outcomes (overall survival and disease-free survival).Retrospective analysis of data (clinicopathologic, operative, perioperative ad late results) collected in a prospective database.Between January 1997 and December 2004, 37 non-consecutive (selected) patients underwent curative laparoscopic hepatic resection (n = 42) for MCRC at Montsouris Institut of Paris. Resection was considered when all liver metastases can be totally removed with clear margins, and in absence of nonresectable extrahepatic diseases. Among them were 24 males and 13 females with average ages of 63.4 years (range, 42-78).Metastases were metachronous in 18, multiple in 21, bilateral in 12, and5 cm in diameter in 30. There were 21 major hepatectomies (n = 3 Couinaud's segments or more), 4 anatomical minor resections, and 12 wedge resections. Mean operative time was 324 +/- 105 mins. Conversion to laparotomy was necessary in 6 patients (16%), due to massive intractable bleeding in 3 patients, multiples adhesions in 1 patient, technical reasons (location of the lesion) in 1 patient, and for presence of localized carcinosis in 1 patient. Portal triad clamping was performed in 6 patients. Mean operative blood loss was 797 +/- 645 ml, and transfusions were required in 4 patients (11%). Clear resection margins (5 mm) were observed in 94%. Postoperative mortality was nil. The overall morbidity rate was 35%, with 2 early reoperations due to hemorrhage and postoperative ileus. Overall and disease free survival at 36 months were 87% and 55%, respectively. Five patients who had a recurrence of metastatic liver disease were referred to a second laparoscopic resection.This clinical study suggests that laparoscopic liver surgery for metastatic colorectal cancer can be accomplished safely, in selected patients and by experienced surgeons, with good early results and without detrimental consequences on survival.

To support software project managers for reliability evaluation, the company Mathix and the French telecommunications agency (France Telecom) have developed a CASE tool named M-elopee. The purpose of this tool is not only to provide some reliability growth model computations but, more generally, to propose an approach to do reliability studies, and therefore to offer all the features needed to undertake this approach. M-elopee typically promotes the transfer of software reliability technology to practice. Therefore it runs on PCs under Windows and benefits from the many facilities of this environment. This article describes the functionalites provided by M-elopee and its underlying methodology. Mainly, the following points are developed: the content and structure of the data processed by M-elopee; data processing; trend analysis; comparison of models; and the maximum number of failures to forecast.

The aims of the study were to evaluate the evolution of laparoscopic surgery during the past decade in terms of variations in the quality (complexity) of the procedures performed and of modifications in patient outcome.A retrospective analysis was performed of 3022 consecutive patients undergoing 99 different laparoscopic procedures at a center specialized in laparoscopic abdominal surgery. All the procedures were classified according to three classes of complexity. Results relating to the first 1511 patients were compared to those of the last 1511 patients.In the second group, medium- to high-class complexity procedures significantly increased, conversion rate was higher only for straightforward procedures, duration of low- to medium-class complexity procedures decreased, only the rate of slight complications increased, and mean postoperative hospital stay was longer. Frequency of conversion in medium- to high-class complexity procedures and severe complications was not different in the two periods.The quality of laparoscopic surgery has improved during the past decade, with no increase in the frequency of conversion or of major complications.

Preoperative nonresectability criteria for carcinoma of the pancreatic head remain controversial. We sought to assess prospectively the preoperative criteria used currently in clinical practice and to determine the different therapeutic strategies used between gastroenterologists (GEs) and digestive surgeons (Ss). The evaluation comprised all of the registered GEs (n = 3,466) and Ss (n = 687) who were sent a questionnaire surveying nonresectability criteria. The hypothesis in question concerned adenocarcinoma of the pancreatic head in a patient in the absence of general operative contraindication. Six hundred fifteen complete responses to the questionnaire were received (GEs, 426; Ss, 189). The mean estimated percentage of resected tumor was 22% (GEs, 19%; Ss, 31%; p0.0001). Preoperative nonresectability criteria differed between the two groups and included weight loss25% (percentage of GEs using this criterion, 57%; Ss, 48%; p0.04), duodenal wall invasion (GEs, 30%; Ss, 4%; p0.001), gastric extension (GEs, 55%; Ss, 23%; p0.001), invasion of gastroduodenal artery (GEs, 58%; Ss, 19%; p0.001), invasion of superior mesenteric artery (GEs, 85%; Ss, 92%; p0.02), invasion of portal vein (GEs, 78%; Ss, 52%; p0.001), tumor diameter6 cm (GEs, 52%; Ss, 38%; p0.001), peripancreatic lymph nodes (GEs, 33-69% depending on the node area; Ss, 5-52%; p0.02-0.001). Consensual criterion used by85% of GEs and Ss was celiac trunk invasion. Criteria rejected by85% both of GEs and Ss were back pain, weight loss25%, and tumor diameteror = 5 cm. Criteria without consensus (used or rejected by85% of GEs and Ss) were superior mesenteric vein and hepatic artery invasion. The preoperative nonresectability criteria used in determining operative resectability differs significantly between medical and surgical gastroenterologists. This study is the first to quantify this difference. These results underline the need for consensus agreement in the criteria of resectability.

Portal pressure and portal-systemic collateral circulation after orthotopic liver transplantation have not been investigated. We studied systemic and splanchnic hemodynamics in 17 patients with cirrhosis before and 205 +/- 146 days after orthotopic liver transplantation. Among the 17 orthotopic liver transplantation patients, 12 had undergone hemodynamic study in the 6 mo before orthotopic liver transplantation. Controls were 50 patients with normal liver architecture. Cardiac index remained elevated in orthotopic liver transplantation patients compared with controls (3.6 +/- 0.9 vs 3.1 +/- 0.4 L/min.m2; p0.05). Azygos blood flow, which was elevated before orthotopic liver transplantation (585 +/- 402 ml/min), remained elevated after orthotopic liver transplantation (553 +/- 343 ml/min). In transplant patients, hepatic blood flow was higher than it was in controls (2.26 +/- 0.86 vs. 1.38 +/- 0.57 L/min; p0.05). Elevated hepatic blood flow correlated with cardiac index (r = 0.647, p0.025). In patients with normal graft function, hepatic venous pressure gradient was normal (2 +/- 1 mm Hg). In a patient with acute rejection, a sharp elevation in the hepatic venous pressure gradient was observed; it returned to normal 45 days after treatment. We conclude that despite normal portal pressure, portal-systemic collateral blood flow remains elevated after orthotopic liver transplantation. Possibly because of persistent collateral circulation, which may keep portal tributary blood flow elevated, hepatic blood flow is increased after orthotopic liver transplantation. Elevated splanchnic blood flow, in turn, contributes to the high cardiac index in liver recipients. Finally, a sharp elevation in portal pressure, which may be observed during acute rejection and subsides after treatment, merits further study.

Endoscopic ultrasonography (EUS) was compared to ultrasonography (US) and CT scan (CT) in order to evaluate its role in the diagnosis and the locoregional spread assessment of pancreatic cancer. Sixty-four patients suspected of pancreatic cancer were studied prospectively, and the results of imaging techniques were compared to histology and surgical exploration. There were 49 cases of pancreatic adenocarcinoma, 11 of pancreatitis, 2 of common bile duct carcinoma, 1 lymphoma and 1 hepatocellular carcinoma with peripancreatic metastatic lymph nodes. EUS was significantly more accurate (91%) than CT (66%) and US (64%) for diagnosis of pancreatic cancer. EUS was able to image all 7 cancers less than 25 mm in diameter, US and CT only one. There were 4 false positives with EUS which were all cases of pseudotumorous pancreatitis. For detecting lymph node involvement, EUS was significantly more sensitive (62%) and accurate (74%) than US (8% and 37%) and CT (19% and 42%), respectively. Invaded lymph nodes adjacent to large tumors and micrometastatic involvement were responsible for this lack of sensitivity. EUS was significantly more sensitive (100%) than CT (71%) and US (17%) for detecting venous involvement. The specificity of EUS was lower (67%) because of duodenal bulb stenosis and large tumors. In conclusion, this prospective and comparative study confirms that EUS is an accurate tool for diagnosis and locoregional spread assessment of pancreatic cancer when performed in a reference center. EUS is of particular interest for small tumours. However, EUS does not enable differentiation of pseudotumorous pancreatitis from adenocarcinoma.

An original technique of OLT with preservation of the entire IVC of the recipient and side to side caval anastomosis is described. The procedure has permitted the avoidance of retrocaval dissection and temporary vena caval occlusion. The caval outflow was respected during the anhepatic phase. The technique, requiring only one caval anastomosis, has reduced the duration of the anhepatic phase and the need for venous bypass.

An analysis of the causes of failure of Heller's operation is necessary in order to arrive at appropriate treatment. We retrospectively studied 100 reoperations for failed esophagomyotomy. Usually, a repeat myotomy was performed via an abdominal approach if the initial Heller's operation proved a failure, or via a thoracic approach if extensive motor disorders were discovered at manometry. Until 1978, esophagogastric resections were performed for severe esophageal injuries due to reflux after Heller's operation, but since then, duodenal diversion has obviated the need for resection. Antrectomy with Roux-en-Y gastrojejunostomy and vagotomy might be performed via an abdominal approach because the latter, always mandatory, is feasible through a transdiaphragmatic approach. Esophageal resection was reserved for major esophageal asystole, some cases of sclerosis, and carcinomas occurring or discovered after Heller's operation.

Total duodenal diversion (TDD) was performed in 19 patients with severe post-gastric surgery symptoms. Previous operations were truncal vagotomy associated with pyloroplasty or antrectomy (n = 6), proximal esophagogastrectomy (n = 8) or total gastrectomy (n = 5). Technical adjustments to the standard procedure (truncal vagotomy, antrectomy and gastrojejunal anastomosis using a 70 cm Roux-en-Y loop) were required. There were no postoperative deaths, no anastomotic leakage or anastomotic ulceration. The main symptoms were eliminated, and endoscopic gastritis and esophagitis healed in all patients. Heartburn and bilious vomiting ceased in all patients, but in five out of 14 patients with a residual stomach some symptoms persisted. TDD proved a safe and effective treatment of disabling symptoms following gastric surgery.

Between 1976 and 1988, we treated 13 perforations of the thoracic esophagus, excluding ruptured carcinoma and intraoperative wounds, by mechanical sutures without exclusion. The delay between perforation and treatment ranged from eight to 168 hours, more than 24 hours in 11. The length of perforation was 0.5 to 15.0 centimeters. Suture was covered with a flap in ten instances; an antireflux procedure was associated with five instances. No digestive ostomies were performed. There was one death; a patient who was comatose upon arrival. The results of this small series suggest that myotomy exposing the mucosa and a flap are two essential elements of the technique; perforations of less than 6 centimeters, even when seen late, may be treated by primary surgical closure.

14515 Background: In vitro spheroid model using cancer cell lines is widely admitted to mimic in vivo micro tumors, including micrometastases. Floating spheroid cell cluster culture has been recently used for normal and cancer stem cell expansion. Spontaneously spheroids generated in vivo have been only studied in ovarian cancer ascites while organoid aggregates have been sometimes observed in the establishment of human colon cancer cell lines. In this study, we investigated whether spontaneous spheroid aggregates from colon cancer could be isolated and characterized. Methods: 127 colorectal primary tumor specimens have been collected and mechanically dissociated into small fragments, which were then shortly cultured on cell plastic flask. Production of spheroid- like structures, referred to as colospheres, was examined at Day 1 and colospheres were gathered for phenotypic characterization. Results: Colospheres were successfully generated from 67 surgical specimens (53%). The capacity to form colospheres was strictly restricted to tumor tissue: dissociated normal colon mucosa never generated colospheres and colospheres were formed exclusively by cancer cells. The ability to generate colospheres was demonstrated to be significantly related to tumor aggressiveness, according to nodal status and AJCC’s stages (Chi-2 test, p No significant financial relationships to disclose.

Five currently used procedures of gastric esophagoplasty were done in 5 groups of 14 embalmed human cadavers. These procedures were: whole gastric intrathoracic transposition (Kirschner's procedure) isoperistaltic gastric cone (Akiyama's procedure) isoperistaltic gastric tube (Rutkowski's or Lortat-Jacob's procedure); isoperistaltic gastric tube with resection of the lesser curvature; anisoperistaltic gastric tube with intrahilar splenectomy (Gavriliu's, Heimlich's procedure). Gastric morphometry and ascinding vascularization ability and quality of the vascular network were assessed. Injection of plastic dye was used to evaluate the vascularization of the grafts. In 13 out of 14 grafts, whole gastric transposition extended above the sternal notch, for a mean distance of 7.7 +/- 4.9 cm. This basic performance was significantly correlated to the dimensions of the greater and lesser curvatures and to the cardioxiphoid, sternal and hyosternal distances. Absent or poor injection of the distal arterial network, over a mean distance of 3.6 +/- 0.8 cm, was seen in all 14 grafts. Study of the isoperistaltic gastric cone demonstrated that the graft extended above the sternal notch in all 14 cases. The mean distance of the graft segment above the sternal notch was 5.0 +/- 3.0 cm. This basic performance showed a significant correlation only with the dimensions of the greater and lesser curvatures. Absent or poor injection of the distal arterial network of the gastric cones was seen in 9/14 cases, the mean length of the devascularized segment being 1.3 +/- 1.3 cm. Subsequent to resection of the distal zone showing poor vascularization, 13 out of the 14 isoperistaltic cones still extended above the sternal notch. The mean length of the segment above the sternal notch was 3.7 +/- 2.6 cm. All 14 isoperistaltic gastric tubes (without resection of the lesser curvature) extended above the sternal notch. The mean length of the segment above the notch was 15.1 +/- 7.1 cm. This basic performance showed a statistically significant correlation only with the minimum pylorodiaphragmatic distance subsequent to extensive Kocher's manoeuver. Of these 14 gastric tubes, 9 showed poor or no vascularization of their distal arterial network. The mean length of the poorly injected segment was 8.0 +/- 1.8 cm. Subsequent to resection of the poorly vascularized territory, 12/14 grafts were still found to extend above the sternal notch. The mean length of the segment above the sternal notch was 7.1 +/- 6.9 cm.(ABSTRACT TRUNCATED AT 400 WORDS)

Physiopathological mechanism of respiratory distress syndrome associated with acute pancreatitis remains unclear. We observed a case of drowning-like hypoxemia due to a pancreaticobronchial fistula; this patient, with a necrotizing isthmic pancreatitis, had only two Ranson’s criteria, and showed a clearly isolated mechanical reason for respiratory failure. Then, the retrospective study of 40 patients having an objective surgical recognition of necrotizing pancreatitis (NP) was performed. Twelve patients received ventilatory support. The prevalence of isolated sepsis-related respiratory failure was 9 out of 12 cases (75%). Two patients had a secondary infection of necrosis also associated with a pancreaticobronchial fistula, and in 1 case this isolated mechanism of respiratory distress was obvious. Such a prevalence of 25% of fistula-related respiratory failure has never been observed before. The onset of severe hypoxemia in the course of NP appears to be a sensitive and pathognomonic sign of evolving complication of pancreatitis, leading to endoscopic retrograde pancreatography, and to prompt surgery. In the opposite way than that suggested by the enzymatic hypothesis, we were not able to show any reason for applying mechanical ventilation to patients suffering from pancreatitis, in the absence of intraabdominal sepsis, and/or pancreaticobronchial fistula.

This study concerns a series of 355 carcinomas of the thoracic esophagus treated over a six-year period. 5 points of the pre operative work up are discussed: total endoscopy, respiratory and hepatic function as most of the patients were heavy smokers and alcoholics, nutritional status and C.T. scan in order to precise the preoperative nutrition value and the true correlation between surgical and CT scan findings. As far as curative resection is concerned, the indications of cervical and intra-thoracic anastomoses and of phi en bloc- posterior mediastinectomy versus blunt dissection are discussed. The mortality rate in this series of 135 curative resections was 8 p. cent due to pulmonary infection and to fistulas. The late results are studied according to the Japanese classification. The overall five-year actuarial survival is 19 p. cent, and 30 p. cent for the group of curative resection in stage 0, 1 and II.

Since the GEEMO (European Group for Study of Esophageal Diseases) questionnaire is a retrospective study, we have decided to set some simple limits. The aims of this paper are (a) to assess the high risk group patients, (b) to assess if some forms of treatment are likely to improve the immediate outcome, (c) to find out whether some techniques or treatments are futile or poorly suited.

Four-hundred esophageal anastomoses were performed with a stapler in the Department of Digestive Surgery, Hospital Beaujon in Paris, in a six year period. The experience of the 14 different surgeons in esophageal surgery was very uneven (zero to 25 years). Two-hundred and sixty-eight esophagogastrostomies (220 in the chest and 48 in the neck), 83 esophagojejunostomies and 49 esophagocolostomies were done. The overall mortality rate was 9.2%, three per cent owing to leaks. The average incidence of leakage was 7% falling to 5.5% if cervical anastomoses were excluded. The incidence of stenoses was 8%. Several points which might account for problems are discussed. Stapled anastomoses seem to reduce the mortality and the morbidity rates of esophageal anastomoses, especially for surgeons with no experience in esophageal surgery.

Perforation of the esophagus is considered to be one of the most dangerous esophageal diseases with regard to morbidity and mortality. In the majority of the cases the perforation has an iatrogenic cause, and this explains why many different treatments are proposed in the medical literature to reduce the death rate.