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Laparoscopic colectomies have been recently shown to be feasible and safe, with the use of stapling devices to fashion the anastomosis. The aim of this study was to evaluate the feasibility and safety of laparoscopic intra-abdominal hand-sewn anastomosis.Seven patients (four males and three females, mean age 48 years) were included. There were two ileocolic resections for recurrence of Crohn's disease, two right colectomies (one for Crohn's disease and one for carcinoid tumor of the appendix), two left colectomies for diverticulitis and one segmental colectomy for sigmoid volvulus. There were: four side-to-side anastomoses, two side-to-end anastomoses and one end-to-end anastomosis. Anastomoses were fashioned with interrupted single layer sutures in four cases (two ileo-colic and two colorectal anastomoses) and with single layer running sutures in three cases (two ileo-colic and one colo-colic anastomoses). The specimens were retrieved by means of a plastic bag through a 3 to 5 cm long minilaparotomy in five cases and through the rectum in two cases.Mean additional time to perform hand-sewn intra-corporeal anastomosis was 90 +/- 15 min. There was no operative mortality and no intraoperative complications. Postoperative course was uneventful in six patients. Patients were started on an oral fluid diet on day 2 and discharged on day 5, except for one patient with Crohn's disease who had a severe anastomotic bleeding on postoperative day 2 and who required laparotomy for hemostasis through a service colotomy with a single suture. He was discharged on day 8.Intra-abdominal hand-sewn anastomoses are feasible and seem reliable. This represents a new step making laparoscopic procedures even closer to conventional techniques. This technique must be evaluated in larger series.

We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula).Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 +/- 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality.After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups.Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Senna is more efficient than polyethylene glycol as mechanical preparation before elective colorectal surgery.Prospective, randomized, single-blind study.Multicenter study (18 centers).Five hundred twenty-three consecutive patients with colonic or rectal carcinoma or sigmoid diverticular disease, undergoing elective colonic or rectal resection followed by immediate anastomosis.Two hundred sixty-two patients were randomly allotted to receive senna (1 package diluted in a glass of water) and 261 to receive polyethylene glycol (2 packages diluted in 2-3 L of water), administered the evening before surgery. All patients received 5% povidone iodine antiseptic enemas (2 L) the evening and the morning before surgery. Ceftriaxone sodium and metronidazole were given intravenously at anesthetic induction.Degree of colonic and rectal cleanliness.Colonic cleanliness was better (P=.006), fecal matter in the colonic lumen was less fluid (P=.001), and the risk for moderate or large intraoperative fecal soiling was lower (P=.11) with senna. Overall, clinical tolerance did not differ significantly between groups, but 20 patients receiving polyethylene glycol (vs 16 with senna) had to interrupt their preparation, and 15 patients (vs 8 with senna) complained of abdominal distension. Senna, however, was better tolerated (P = .03) in the presence of stenosis. There was no statistically significant difference found in the number of patients with postoperative infective complications (14.7% vs 17.7%) or anastomotic leakage (5.3% vs 5.7%) with senna and polyethylene glycol, respectively.Mechanical preparation before colonic or rectal resection with senna is better and easier than with polyethylene glycol and should be proposed in patients undergoing colonic or rectal resection, especially patients with stenosis.

OBJECTIVE: To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection. SUMMARY BACKGROUND DATA: It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this. METHODS: Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths. RESULTS: Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups. CONCLUSION: OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates.One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8 +/- 12.1 years) were randomized to undergo hand-sewn (n = 74) or circular stapled (n = 85) supraperitoneal colorectal anastomosis after left colectomy.Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n = 10) and hemorrhage (n = 5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p0.001), but this time gain did not significantly influence the overall duration of operation (identical median times). The median duration of hospitalization was 13 and 14 days, respectively (NS). At 8 months there were 2 of 74 strictures in the hand-sewn group and 4 of 85 strictures in the stapled group (NS).According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.

Perforated diverticulitis is an uncommon but severe complication of diverticular disease. Whatever the type of the contamination, whether bacterial or fecal, the peritonitis is responsible for septic shock, which necessitates emergent and aggressive medical and surgical treatment. Intensive intravenous perfusion under monitoring, adapted antibiotherapy should come before surgical decision. The aim of surgery is twofold: to suppress the infectious source and to clean the peritoneum. After all, the peritonitis has a tendency to recur and therefore postoperative abscesses have to be searched systematically and if the case arises, these abscesses have to be reoperated or drained. Best results were obtained with immediate sigmoidectomy and colo-rectal anastomosis associated with loop colostomy; that procedure should be preferred to Hartmann technique. If the morbidity remains high, the mortality should decrease under 10% with intensive therapy.

This study was developed to compare median and actuarial survival after left hemicolectomy vs. left segmental colectomy.Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64 +/- 12 (range, 18-91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmental colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested.After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survival curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.

The prevalence of signs and symptoms of acute intestinal obstruction in the adult was studied in a prospective study of 600 cases extracted from a data base on acute abdomen in 7,000 patients. This study of prevalence allows a precise definition of intestinal obstruction syndrome and to differentiate two types of presentations according to the site of obstruction on the small bowel or the colon. However, it is more difficult to differentiate simple bowel obturation from vascular strangulation. Surgical treatment depends mainly on the cause of obstruction.

Using a data base of 7,000 acute abdominal pains, we here described the assessed clinical manifestations of the main diseases responsible for right lower quadrant pain. However, percentages of sensibilities have been replaced by adverbs or adjectives, applying a scale of equivalence. The possible modifications of the positive predictive values have been also replaced by verbs or typical expressions. We first described the acute appendicitis syndrome (which covered congestive endoappendicitis and suppurated appendicitis) with the clinical shades or the gathered and gangrenous forms or even of the diffuse peritonitis. Features of the acute appendicitis contrast with those of the so called "non specified abdominal pains" (a new entity), and those of the subacute or chronic appendicitis. We found a good correlation between clinical and pathological findings. One of the difficulties has been to determine if a subgroup of subacute appendicitis should be or not included into the acute appendicitis.

The effectiveness of cefazolin or cefotaxime as antibiotic therapy was compared with that of ceftriaxone in a multicentre prospective randomized trial involving 1,254 consecutive patients operated upon for abdominal diseases. Patients about to undergo surgery of the colon or who had localized or generalized peritonitis at the time of operation were excluded from the study. The patients entered were divided into 4 strata according to the degree of operative contamination and to risk factors. In each stratum, the patients were allocated at random to one or the other of 2 treatment groups. Group 1 patients received cefazolin or cefotaxime in 3 doses of 1 g administered 8-hourly, the first dose being injected during induction of general anaesthesia. Group 2 patients received one single 1 g dose of ceftriaxone injected during induction of anaesthesia. There was no significant difference between the two groups in the wound infection rate and in the frequency of post-operative intra-abdominal abscesses. Although the percentage of post-operative pulmonary and urinary tract infections was lower in the ceftriaxone group than in the cefazolin/cefotaxime group, no significant difference was observed between the two groups in the number of patients who required curative antibiotic therapy. This study shows that one single dose of ceftriaxone is as effective as three doses of cefazolin or cefotaxime in preventing would infections and post-operative intra-abdominal abscesses, and that it is more effective in preventing extra-abdominal infections complicating surgery.

One hundred and ten distal splenorenal anastomoses (DSRA) were performed between 1976 and 1988 for gastrointestinal haemorrhages secondary to portal hypertension. Thirty five patients underwent DSRA (Warren's operation) followed by a mesenteric disconnection procedure. Eleven patients (10%) died (nine Child B and two Child A), including two after an emergency shunt. The mortality was influenced by age (p less than 0.01) and by the number of previous episodes of ictero-ascitic decompensation (p less than 0.02). A single anastomotic thrombosis was observed; the high flow rate of the anastomoses (mean: 1200 +/- 650 ml/min) explains the high patency rate (more than 90%). Eleven patients developed partial or total thrombosis of the portal trunk less than 6 weeks after the operation. The quality of hepatic perfusion was not significantly influenced by the mesenterico-splenic disconnection and this was omitted in 75 patients. The mesenterico-splenic collateral venous circulation was more developed in the absence of disconnection (p less than 0.05). The long-term actuarial survival was 83% at one year, 53% at five years, 47% at eight years and 28% at ten years. Survival was not influenced by the disconnection. Warren's operation is more difficult to perform than a porto-caval or mesenterico-caval shunt. DSRA appears to have three advantages: 1) a high flow rate as it is arterialised by the splenic artery, 2) hepatopetal portal perfusion maintained for several days, weeks or months, possibly reducing the risk of encephalopathy, 3) the absence of dissection of the hepatic pedicle preserves the possibilities of liver transplantation.

Seven patients were treated by gastrocolectomy for either ulcers or cancers. Two patients had ulcerating gastrojejunocolic fistulae, four had cancers of the stomach, and one had cancer fistulae, four had cancers of the stomach, and one had cancer of the transverse colon. Two patients treated by immediate colon anastomosis for cancer, died after the anastomosis broke down, while the three other cases, treated by delayed colon anastomosis, survived. Both patients with ulcerating lesions survived, one after immediate and the other after delayed colon anastomosis. This latter procedure appears, therefore, to be imperative in cancer cases and of value, when used prudently, in ulcer cases.

With a bank of data collected locally and a probability program of diagnostic aid, the computer is capable of making the correct diagnosis in 79% of acute abdominal pain syndromes. Its performance in this respect is somewhat superior to that of clinicians (73.5%). Including a computer program in diagnostic procedures would reduce the number of errors by excess or omission. In abdominal emergencies computerization would help either by increasing the reliability of clinical diagnoses or by suggesting that other possibilities should be investigated.

Thirteen patients with intestinal lesions consecutive to radiotherapy for carcinoma of the uterus were operated upon between 1973 and 1979. The small bowel was involved in 9 patients and the colon and rectum in 4 patients. Urinary tract lesions were associated in 3 patients of each group. Intestinal necrosis, progression of the lesions and extensive pelvic fibrosis were the only criteria of poor prognosis. Twenty-two operations were performed: 4 for urinary tract lesions and 18 for intestinal lesions. Five patients died during the immediate post-operative period and five died within 2 to 30 months after surgery, including 4 whose carcinoma recurred. The operative technique should be selected according to the extent and severity of radiation-induced damage, as determined by pre-operative examination and thorough exploration of the abdominal cavity once opened. Limited lesions of the small bowel can be treated by resection, but intestinal bypass with latero-lateral anastomosis seems to be preferable in cases with extensive lesions. Patients with colorectal lesions should have defunctioning colostomy prior to any other procedure dictated by the state of affairs. Multiple anastomosis, extensive resections and excessive dissections should be avoided.

The authors report 3 cases of acute complicated duodenal ulcers occurring during the course of Listeria meningitis. These three adults (2 females and 1 male) suffered from localised neurological involvement and, in 2 cases neurovegatative disorders an altered level of consciousness. The ulcers were situated in the duodenal cap, and in each case there were at least 2 large excavated ulcers. These ulcers were the site of late complications on the 13th and 15th days after the onset of neurological disease. In two cases the major symptom was haemorrhage, whilst in the third it subsided leaving a syndrome of peritonitis due to perforation. Treatment in all three cases consisted of vagotomy with pyloroplasty (the ulcers being excised or sutured). All the patients recovered from their digestive complications without relapse despite the persistence 6 and 10 months later of the same neurological problems in two of them. All these facts would be in favour of a neurogenic aetiopathogenesis, via the vagal nerve. Thus acute late duodenal ulcers in patients with neurological disease from a separate enity within the context of stress lesions.