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Aim: Early gastric cancer (EGC) may have a 5-year survival rate of over 90% following surgery. Early multifocal gastric cancer (EMGC) accounts for between 8.3 and 17% of all EGCs. A multicenter retrospective study is reported of prevalence, characteristics, prognosis and type of resection for EMGC patients. Method: 333 patients with EGC were operated on, between January 1979 and December 1988, and followed to June 1996. Results: 33 EGC patients had EMGC. There was no significant difference in clinico-pathological features between EGC and EMGC. 21 cases of EMGC underwent a subtotal gastrectomy and 12 underwent a total gastrectomy. Recurrences after subtotal gastrectomy were, respectively, 10 and 18% for EGC and EMGC patients ( p =0.2). The cumulative 5 years specific survival rate for 298 EGC and 34 EMGC were 94 and 90%, respectively ( p =0.9). Five-year survival rates after subtotal gastrectomy were 92 and 90% for EGC and EMGC patients, respectively ( p =0.8). Conclusion: EGC and EMGC had the same clinico-pathological features and prognosis. A careful follow up of the stomach remnant is essential.

Background. The results of medial pancreatectomy have been previously reported anecdotally. The purpose of the study was to provide short- and long-term results of ALP in a large multicenter collective series. Methods. From 1990 to 1998, 53 patients (mean age +/- SD = 49 15 years) underwent medial pancreatectomy for primary cystic neoplasms of pancreas (n = 19), endocrine neoplasms (n = 17), intraductal papillary mucinous neoplasms (IPMN) (n = 6), fibrotic stenosis of the Wirsungs duct (n = 4), or other benign (n = 4) or malignant (n = 3) diseases. The proximal (right) pancreatic remnant was sutured (n = 53), and the distal (left) remnant was either anastomosed to a jejunal loop (n = 26), to the stomach (n = 25), or oversewn (n = 2). Medial pancreatectomy was indicated in 3 patients (6%) because of failed enucleation, in 3 (6%) to prevent worsening of preexisting diabetes, or to prevent de novo diabetes in a patient with chronic pancreatitis, and deliberately in the 4 7 others. Results. The length of the resected pancreas was 5.0 +/- 2.2 cm (range, 2-15). One Patient (2%) died from a pancreatic fistula and portal thrombosis. Three patients were reoperated on because of complications related to the left pancreas, which was partially or totally resected. Pancreatic fistula developed in 16 patients (30%). Mean delay for the return of oralfeeding was related to the Presence of a pancreatic fistula. At follow-up (median = 26 months, range, 12-131), 1 pancreatic recurrence and 1 de novo diabetes occurred in patients without IPMN. In patients with IPMN, the rates of pancreatic recurrence and diabetes were 40% (215), respectively. Conclusions. Medial pancreatectomy effectively preserves long-term endocrine function and is associated with a low risk of local recurrence, except in patients with IPMN. However, there is a high risk (30%) of PF after medial pancreatectomy.

Summary Background Because cadaveric organ donors are in short supply, living donors are increasingly being used in transplantations. We have developed a safe and reproducible method for laparoscopic liver resection. Methods Left hepatic lobectomy (resection of segments 2and 3) was done by laparoscopy in one woman aged 27years and one man aged 31 years. The grafts were prepared under laparoscopy, without any vascular clamping, and were externalised through a suprapubic Pfannenstiel incision. Both grafts were transplanted conventionally to the patients' respective sons, who were both aged 1 year and had biliary atresia. Findings Donor operations lasted 7 h for the woman and 6 h for the man, and warm ischaemia times were 4 and 10 min, respectively. Blood loss was 150 and 450 mL, respectively, and no transfusions were required. Neither patient had complications during or after sugery; and hospital stay was 7 and 5 days, respectively. Both recipients are alive and have excellent graft function. Interpretation We have shown the feasibility of laparoscopic living donor hepatectomy from parent to child. If the safety and feasbility of this procedure can be shown in larger series, laparoscopic donor left lobectomy could become a new option for paediatric living donor liver transplantation.

About one third of patients with chronic radiation enteritis will need to be operated on during follow-up. Morbidity and life expectancy after resection and conservative surgical management for chronic radiation enteritis have not been well documented.From 1984 to 1994, 109 patients were operated on with a mean follow-up of 40 months (range 1 to 293). Postoperative mortality, early and late morbidity, long-term survival were studied in patients after resection (n = 65) and after conservative surgical management (n = 42), and in patients after planned or emergency procedure. Existence of possible risk factors for reoperation after a first surgical procedure was analyzed.Five (5%) patients died in the postoperative course. Operative mortality was significantly higher when the procedure was performed as an emergency (P0.05). Although not statistically significant, mortality was higher in the resection group (5% versus 0%). Thirty-three (30%) patients experienced postoperative complications including anastomotic leak in 11. Morbidity was not statistically related to the nature of the treatment (ie, conservative versus resection) or to the indication (emergency versus elective). During follow-up, reoperation was required in 40% of the patients, because of recurrence of digestive symptoms suggestive of chronic radiation enteritis; the reoperation rate was higher in the patients of the conservative group (50% versus 34%). Overall survival, after a mean follow-up of 40 months in patients without cancer recurrence was 85% at 1 year and 69% at 5 years after surgery, respectively. Overall survival was influenced by the nature of the treatment with 51% and 71% 5-year survival after conservative and resection treatment, respectively.Despite high initial mortality and morbidity rates, life expectancy in patients with chronic radiation enteritis without recurrence of their previous neoplastic disease was good. Resection seems to provide a smaller reoperation rate and a better 5-year survival, but a higher postoperative mortality.

Objective To assess the feasibility and safety of laparoscopic liver resections. Summary Background Data The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. Methods A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO 2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. Results From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. Conclusion Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.

Background Percutaneous computed tomography (CT)-guided aspiration of abdominal collections is performed in necrotizing pancreatitis to detect infection of necrosis, which is an adverse prognostic factor and requires surgical drainage. However, in the case of sterile aspirates, the outcome and the optimum management are subject to debate. This study examined the clinical and bacteriological outcome of patients with severe acute pancreatitis with initially sterile necrosis and assessed the efficiency of percutaneous drainage in this setting. Methods Seventeen patients hospitalized for necrotizing pancreatitis with a septic course underwent a preliminary sterile CT-guided aspiration. Eight patients underwent simultaneous percutaneous drainage of the punctured collection. Supportive therapy was continued unless severe clinical deterioration or proven secondary infection of necrosis indicated the need for necrosectomy and drainage. Results Secondary infection of necrosis was observed in two patients of nine who had only fine-needle aspiration cytology of the collection, and in seven of eight it was drained percutaneously (P=0·01). Only one patient drained percutaneously recovered without surgery. Surgical drainage was required in 12 patients. The hospital mortality rate was 29 per cent and was not significantly affected by the bacteriological status of necrosis. Conclusion Percutaneous drainage of sterile collections predisposed to secondary infection of the necrosis and did not cure the patients. A first sterile percutaneous aspiration did not predict a favourable course and surgery frequently remains necessary.

Five patients with primary liver cancer presented with obstructive jaundice due to extension of tumour thrombus into the biliary ducts. Three patients had hepatocellular carcinoma, two of whom had alcoholic cirrhosis, and the other two had a peripheral cholangiocarcinoma. Preoperative diagnosis of biliary thrombus was best achieved by ultrasonography and computed tomography which showed peripheral hepatic tumour with dilated bile ducts containing dense material. All patients underwent liver resection associated with biliary exploration, clearance and T-tube drainage. Major hepatectomy was required in four cases. There were no postoperative deaths; one patient developed a subphrenic collection of bile which was drained percutaneously. All patients survived more than a year; median survival was 29 months. There are two long-term survivors without recurrence at 29 and 80 months. Patients with primary liver cancer and jaundice due to migrated tumour fragments in the common bile duct may benefit from surgical resection which can result in long-term resolution of symptoms and occasional cure.

From January 1989 to May 1992, 70 orthotopic liver transplantations (OLT) were performed in 69 patients, 53 of whom had cirrhosis (77%). Eleven patients (16%) had preoperative partial or total portal vein thrombosis (PVT). Ten of these patients had cirrhosis of various causes. PVT was total in three cases and partial in eight. Total PVT was detected preoperatively in all three cases. By contrast, partial PVT was diagnosed preoperatively in only three of the eight cases. In the five other cases of partial PVT, the obstruction was discovered intraoperatively during dissection of the portal vein. Surgical management of PVT consisted of phlebothrombectomy in ten cases followed by usual end-to-end portal anastomosis in nine cases and anastomosis of the graft's portal vein to the splenomesenteric confluence in one case. Atypical anastomosis of the graft's portal vein to a dilated choledocal vein was performed in one case of total PVT. There were no deaths or complications related to the presence of preoperative PVT or to its management. One patient died postoperatively of primary graft nonfunction at day 5. One patient had arterial thrombosis 3 months after OLT and was successfully retransplanted. Two patients died of recurrent carcinoma 3 and 7 months after OLT. Eight patients are alive 4 to 39 months after OLT. We conclude from this series that (1) the prevalence of preoperative PVT among patients transplanted for advanced cirrhosis may be high (19% of the cirrhotics in this series); (2) PVT is often partial and so difficult to diagnose preoperatively; (3) PVT, even when total, can be managed successfully during surgery and does not seem to affect survival.

A 28-year old man presented with a symptomatic giant haemangioma. On June 26, 1983, at laparotomy, no resection was attempted because the lesion involved the right lobe of the liver and a part of segments II and III. The patient underwent a right hepatic arterial embolisation with gelatine sponge particles. During follow-up, the patient remained asymptomatic. Five-year review by CT-scan showed a diminution of the size of the haemangioma and hypertrophy of the left lobe. On October 21, 1988, the patient was reoperated on for liver abscess and complete necrosis of the haemangioma. A right hepatectomy was performed. In conclusion, the long-term effect of hepatic arterial embolisation, as demonstrated in our case by regular CT-scans, is useful in cases of diffuse haemangioma as an alternative to hazardous major liver resection. To our knowledge, the long-term effect of hepatic arterial embolisation on symptoms and tumor size have never been reported for giant liver haemangioma.

International audience; BACKGROUND/AIMS: No agent has been consistently effective in preventing formation of peritoneal adhesions and postoperative bowel obstruction after abdominal surgery. The aim of this prospective multicenter study was to assess clinical safety and efficiency of a new adhesion-reduction barrier METHODOLOGY: Between September 2000 and April 2001, Prevadh was used in 78 patients. Operative procedures included 25 hepatic resections, 7 cholecystectomies, 32 colonic resections, 7 protectomies, 3 colostomy or recovery of continuity, 1 gynaecologic surgery and 3 others. Eleven patients were operated on by laparoscopy and 67 by laparotomy. RESULTS: The overall incidence of abscesses and wound complications was 2.4% and 9% respectively. After a mean follow-up of 36 months (range: 4-51 months), no patients experienced adverse events related to the adhesion barrier. Surgical reoperative procedures were performed in 10 patients for unrelated causes and no bowel obstruction occurred within the protected area. CONCLUSIONS: This study confirmed the safety of Prevadh adhesion barrier and suggested that this resorbable barrier might provide prevention from adhesion formation on peritoneal injured surfaces. However, a large randomized controlled trial remains necessary to prove the real effectiveness of adhesion barriers on clinical long-term outcome.

The more rapid and less complicated recovery after palliative stent insertion compared with surgery may theoretically facilitate the early administration of chemotherapy.A retrospective study.University tertiary care referral center.From January 1, 1996, to September 15, 2005, 58 patients with obstructing colon cancer and nonresectable synchronous metastases were treated with self-expanding colonic metallic stent (SEMS) (n = 31) or surgery (n = 27).Comparison of the use of SEMS and emergency surgery as palliative measures to treat obstructing colon cancer with special reference to time to chemotherapy administration and survival.Mortality and morbidity were comparable between the 2 groups. Median hospital stay was shorter after SEMS insertion than after surgery (median, 8.0 vs 13.5 days, respectively; P.01). Incidence of stoma creation was lower in patients treated with SEMS than in patients treated with surgery (6% vs 37%, respectively; P = .02). The median time to chemotherapy administration was shorter after SEMS insertion than after surgery (14.0 vs 28.5 days, respectively; P = .002). Three patients with SEMS and 0 patients in the surgical group underwent a curative colonic and hepatic resection after downstaging by chemotherapy (P = .27). Two patients (6%) with SEMS and undergoing chemotherapy had a tumor perforation requiring emergency surgery. There was no difference in survival between the 2 groups (median survival, 13.7 months for SEMS vs 11.4 months for surgery; P = .19).Insertion of SEMS should be the first step to treat obstructing colon cancer with nonresectable synchronous metastases because it allows chemotherapy to be administered earlier, may increase the resectability rate of metastases, and favorably impacts survival. The risk of tumor perforation while receiving chemotherapy requires attention.

Hypothesis The anti-infective actions of povidone-iodine (PVI) and sodium hypochlorite enemas are different. Design Prospective, randomized, single-blind study. Setting Multicenter. Patients Five hundred seventeen consecutive patients with colorectal carcinoma or sigmoid diverticular disease undergoing elective open colorectal resection, followed by primary anastomosis. Intervention All patients received senna (1-2 packages diluted in a glass of water) at 6PMthe evening before surgery. Patients were administered two 2-L aqueous enemas of 5% PVI (n = 277) or 0.3% sodium hypochlorite (n = 240) at 9PMthe evening before surgery and at 3 hours before operation. Intravenous ceftriaxone sodium (1 g) and metronidazole (1 g) were administered at anesthetic induction. Main Outcome Measure Rate of patients with 1 infective parietoabdominal complication or more. Results The percentages of patients with 1 infective parietoabdominal complication or more did not differ between the 2 groups (13.7% in the PVI-treated group vs 15.0% in the sodium hypochlorite–treated group). Tolerance was better in the PVI-treated group than in the sodium hypochlorite–treated group (79.4% vs 67.9%), with fewer patients experiencing abdominal pain (13.0% vs 24.6%) or discontinuing their preparation (3.0% vs 9.0%) ( P =.02 for all). There were more patients with malaise in the PVI-treated group than in the sodium hypochlorite–treated group (9.1% vs 4.9%, P Conclusion When antiseptic enemas are chosen for mechanical preparation before colorectal surgery, PVI should be preferred over sodium hypochlorite because of better tolerance and avoidance of necrotic ulcerative colitis.

Report the midterm results of laparoscopic resection for hepatocellular in chronic liver disease (CLD).Surgical resection for hepatocellular carcinoma (HCC) in chronic liver disease (CLD) remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity.From 1998 to 2003, patients with HCC and CLD were considered for laparoscopic liver resection. Inclusion criteria were chronic hepatitis or Child's A cirrhosis, solitary tumoror =5 cm in size, and location in peripheral segments of the liver. Mortality, morbidity, recurrence rates, and survival were analyzed.A total of 27 patients were included. Liver resections included anatomic resection in 17 cases and non anatomic resection in 10. Seven conversions to laparotomy (26%) occurred for moderate hemorrhage in 5 cases and technical difficulties in 2 cases. Mortality and morbidity rates were 0% and 33%, respectively. Postoperative ascites and encephalopathy occurred in 2 patients (7%) who both had undergone conversion to laparotomy. Mean surgical margin was 11 mm (range, 1-47 mm). After a mean follow-up of 2 years (range, 1.1-4.7), 8 patients (30%) developed intrahepatic tumor recurrence of which one died. Treatment of recurrence was possible in 4 patients (50%), including orthotopic liver transplantation, right hepatectomy, radiofrequency ablation, and chemoembolization in 1 case each. There were no adhesions in the 2 reoperated patients. Overall and disease-free 3-year survival rates were 93% and 64%, respectively.Our study shows that laparoscopic liver resection for HCC in selected patients is a safe procedure with very good midterm results. This approach could have an impact on the therapeutic strategy of HCC complicating CLD as a treatment with curative intent or as a bridge to liver transplantation.

Background Studies of risk factors after pancreatoduodenectomy are few: some concern restricted populations and others are based on administrative data. Methods Multicenter clinical data were collected for 300 patients undergoing pancreatoduodenectomy to determine (by univariate and multivariate analysis) preoperative and intraoperative risk factors for mortality and intra-abdominal complications (IACs), including pancreatic fistula. Fourteen factors including the center and volume effect were analyzed. Results In univariate analysis, mortality was increased with age 70 years or more, extended resection(s), and volume and center effects. IACs occurred more often with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, extended resection(s), and the center effect. Pancreatic fistula was more frequent with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, and the center effect. In multivariate analysis, independent risk factor(s) for mortality were age greater than 70 years (odds ratio [OR], 3; 95% confidence interval [CI], 1.3-8) and extended resection (OR, 5; 95% CI, 1.2-22), risk factors for IACs were extended resection (OR, 5; 95% CI, 1.2-22) and main pancreatic duct diameter of 3 mm or less (OR, 2; 95% CI, 1.1-3), and the risk factor for pancreatic fistula was main pancreatic duct diameter of 3 mm or less (OR, 2.5; 95% CI, 1.2-4.6). Conclusions Age more than 70 years, extended resections, and main pancreatic duct diameter less than 3 mm are independent risk factors that should be considered in indications for and techniques of pancreatoduodenectomy.

Prophylactic administration of octreotide acetate decreases the rate of postoperative intra-abdominal complications (IACs) after elective pancreatic resection.Single-blind, controlled, randomized trial.Multicenter (N = 20) trial in France.Of 230 randomized patients undergoing pancreatoduodenectomy and pancreatic enteric anastomosis or distal pancreatectomy for either malignant or benign tumor or chronic pancreatitis, 122 were allotted intraoperatively to receive octreotide; 108 served as controls.All 230 patients were analyzed. Both groups were comparable except that significantly more patients in the octreotide group had biological glue injected into the main pancreatic duct alone (P.001) or reinforcing the pancreatic enteric anastomosis (68% [83/122] vs 39% [42/108]; P =.002). Fewer patients (P =.08) in the octreotide group sustained 1 or more IACs (22% vs 32%). In subgroup analysis, octreotide significantly reduced the rate of patients sustaining 1 or more IACs when the main pancreatic duct diameter was less than 3 mm (P.02), when pancreatojejunostomy was performed (P.02), or both (P.02). No significant differences were found regarding IAC severity. Twenty-three patients (10%) died postoperatively, 16 (70% of deaths) of whom had 1 or more IACs. The only independent risk factor for IACs found on multivariate analysis was pancreatoduodenectomy compared with distal pancreatectomy (P.01) (odds ratio, 3.54 [95% confidence interval, 1.44-8.65]).Our results suggest that octreotide is not necessary for all patients undergoing pancreatic resection; it could be useful when the main pancreatic duct is less than 3 mm in diameter and when pancreatoduodenectomy is completed by pancreatojejunostomy.

Only 2 large (more than 100 patients) prospective trials comparing pancreatogastrostomy (PG) with pancreatojejunostomy (PJ) after pancreatoduodenectomy (PD) have been reported until now. One nonrandomized study showed that there were less pancreatic and digestive tract fistula with PG, whereas the other, a randomized trial from a single high-volume center, found no significant differences between the two techniques.Single blind, controlled randomized, multicenter trial. The main endpoint was intra-abdominal complications (IACs).Of 149 randomized patients, 81 underwent PG and 68 PJ. No significant difference was found between the two groups concerning pre- or intraoperative patient characteristics. The rate of patients with one or more IACs was 34% in each group. Twenty-seven patients sustained a pancreatoenteric fistula (18%), 13 in PG (16%; 95% confidence interval [CI] 8-24%) and 14 in PJ (20%; 95% CI 10.5-29.5%). No statistically significant difference was found between the 2 groups concerning the mortality rate (11% overall), the rate of reoperations and/or postoperative interventional radiology drainages (23%), or the length of hospital stay (median 20.5 days). Univariate analysis found the following risk factors: (1) ageor =70 years old, (2) extrapancreatic disease, (3) normal consistency of pancreas, (4) diameter of main pancreatic duct3 mm, (5) duration of operation6 hours, and (6) a center effect. Significantly more IAC, pancreatoenteric fistula, and deaths occurred in one center (that included the most patients) (P = .05), but there were significantly more high-risk patients in this center (normal pancreas consistency, extrapancreatic pathology, small pancreatic duct, higher transfusion requirements, and duration of operation6 hours) compared with the other centers. In multivariate analysis, the center effect disappeared. Independent risk factors included duration of operation6 hours for IAC and for pancreatoenteric fistula (P = .01), extrapancreatic disease for pancreatoenteric fistulas (P.04), and ageor =70 years for mortality (P.02).The type of pancreatoenteric anastomosis (PJ or PG) after PD does not significantly influence the rate of patients with one or more IAC and/or pancreatic fistula or the severity of complications.

Objective To assess the technical and oncologic results of anatomic hepatic bi- and trisegmentectomies. Summary background data Regardless of their size, some tumors require extensive hepatectomy only because they are located centrally or in the vicinity of major portal pedicles or hepatic veins. Anatomic bi- and trisegmentectomy might represent an alternative to extensive hepatectomies in such cases. Methods Of 435 liver resections, 32 cases (7%) included 2 or 3 adjacent segments (left lateral sectionectomies, ie, bisegmentectomies 2-3, excluded). There were 16 central hepatectomies (segments 4, 5, and 8), 7 right posterior sectionectomies (segments 6 and 7) and 2 central anterior (segments 4b and 5), 1 central posterior (segments 4a and 8), 2 right superior (segments 7 and 8), 3 right inferior (segments 5 and 6), and 1 left anterior (segments 3 and 4b) bisegmentectomies. Indications were malignant disease in 29 patients, including 15 with cirrhosis and 2 with benign tumors. External landmarks, selective devascularization, and intraoperative ultrasound were used to achieve anatomic resection. Results Mortality, transfusion, and morbidity rates were 0%, 26%, and 19%, respectively. Mean section margin was 9 mm (range, 1-40 mm). Isolated intrahepatic recurrence occurred in 7 patients (24%) and 3 (43%) underwent repeat hepatectomy. Conclusion Anatomic bi- or trisegmentectomy is a safe alternative to extensive liver resection in selected patients, avoiding unnecessary sacrifice of functional parenchyma and enhancing the opportunity to perform repeat resections in cases of recurrence.

The aim of this retrospective multicenter study was to evaluate the feasibility and the results of laparoscopic resection of benign submucosal gastric tumors.We reviewed the cases of 65 patients (20 centers) who have been operated on laparoscopically for benign submucosal gastric tumors. The tumor was symptomatic in 56 cases, located on the posterior wall in 23 cases. The mean size of the tumor was 3.8 cm (1.5-10).A laparoscopic wedge resection was performed in 53 cases. In 1 case a laparoscopic-assisted gastrectomy was done. A conversion to laparotomy was mandatory in 11 cases because of difficulties in localization of the tumor (n=5), in excision (n=5) or for safety reasons (n=1). There was no mortality. Two patients required reoperation because of bleeding. During follow-up, one patient developed recurrence requiring a second laparoscopic excision.Most submucosal benign gastric tumors can be removed by laparoscopy. The location of the tumor (posterior wall or closed to the lesser curvature) or the size of the tumor (large or very small) can make the laparoscopic approach difficult.

After technical advances in hepatic surgery and laparoscopic surgery, some teams evaluated the possibilities of laparoscopic liver resections. The aim of our study was to assess the results of laparoscopic left lateral lobectomy (bisegmentectomy 2-3) and to perform a case-control comparison with the same operation performed by open surgery.From 1996 to 2002, 60 laparoscopic resections were performed in selected patients, including 18 left lateral lobectomies. The resected lesions were benign tumors, hepatocellular carcinomas with compensated cirrhosis, and metastases. Surgical procedures were performed with a harmonic scalpel, an ultrasonic dissector, linear staplers, and portal pedicule clamping when necessary. Results were compared with those of patients who underwent open left lateral lobectomies selected from our liver resection database in a case-control analysis. Both groups were similar for age, type and size of the tumor, and presence of underlying liver disease.Compared with laparotomy, laparoscopic left lateral lobectomies were associated with a longer surgical time (202 versus 145 minutes, p0.01), a longer portal triad clamping (39 versus 23 minutes, p0.05), and a decreased blood loss (236 versus 429 mL, p0.05). There were no deaths in either group, and the morbidity rates were 11% in the laparoscopic group and 15% in the open group. There were no specific complications of hepatic resection after laparoscopy (no hemorrhage, subphrenic collection, or biliary leak), but some were observed in the open group.This study demonstrates the safety of laparoscopic left lateral lobectomy. Despite longer operation and clamping time, without any clinical consequences, the laparoscopic approach was associated with decreased blood loss and absence of specific complications of the hepatic resection.

Background The aim of the study was to evaluate the efficacy of adjuvant chemotherapy on survival after resection for gastric cancer. Methods Patients were enrolled if they underwent resection of gastric cancer but had lymph node or serosal involvement or both. Surgical resection was either total or partial gastrectomy according to the site of the tumor, and surgeons were allowed to perform either D1 or D2 gastrectomy. The subjects were random assigned in two treatment groups as follows: surgery alone as the control group, or surgery and adjuvant chemotherapy. Nine cycles of 5 days protocol every 4 weeks was proposed to the patients of the chemotherapy group. The protocol included a daily administration of 200 mg/m 2 of folinic acid, 5-fluorouracil (375 mg/m 2 during the first session increasing 25 mg by session until reaching 500 mg/m 2 ) and CDDP 15 mg/m 2 . Two hundred patients were required. Kaplan-Meier survival curves were compared according to the log-rank and the Mantel-Haenszel methods. Results In all, 205 patients were enrolled in the study; 104 had surgery alone and 101 had surgery and adjuvant chemotherapy. The patients' characteristics were similar except for the mean age, which was 4 years less in the control group. Because of toxicity, 54% of the patients stopped the protocol before the end of the nine courses, and 46% of the patients received the nine courses including 32% with a decreased dose and 14% with a full dose. The 5-year survival rate was 39% in the control group and 39% in the chemotherapy group. Conclusions This protocol of adjuvant chemotherapy failed to improve the 5-year survival after resection for gastric cancer.

From 1983 to 1991, 42 patients were operated on for hepatocellular carcinoma (HCC) complicating cirrhosis. Five presented with spontaneous rupture of the tumour: three had posthepatitis B and two non-A non-B cirrhosis. By contrast, 65 per cent of patients with non-ruptured HCC had alcoholic cirrhosis (P < 0.01). Laparotomy was carried out on an emergency basis (four patients) or after a 12-h delay (one) because of haemodynamic instability. Liver resection was performed in four cases (two wedge resections, one segmentectomy III, one extended right hepatectomy) and in the fifth patient hepatic artery ligation was performed. Bleeding was controlled after all four resections with one postoperative death, while the patient treated by ligation died during operation. Of the three surviving patients after liver resection, two died, 6 and 12 months after surgery. One patient is alive with recurrent tumour 43 months after extended right hepatectomy. The present data, combined with analysis of 250 cases of ruptured HCC from the literature, indicate that emergency resection is the treatment of choice in patients with limited tumour and preserved liver function. Transcatheter hepatic artery embolization, if available, is the next choice for high-risk patients or before surgical resection of the tumour. More conservative surgical approaches are the last choice because of poor reported results.

To compare the incidence of biliary complications after liver transplantation in patients undergoing choledochocholedochostomy reconstruction with or without T tube in a multicenter, prospective, randomized trial.Several reports have suggested that biliary anastomosis without a T tube is a safe method of biliary reconstruction that could avoid complications related to the use of T tubes. No large prospective randomized trial has so far been published to compare the two techniques.One hundred eighty recipients of orthotopic liver transplantation were randomly assigned to choledochocholedochostomy with (n = 90) or without (n = 90) a T tube in six French liver transplantation centers. All types of biliary complications were taken into account.The overall biliary complication rate was increased in the T-tube group, even though these complications did not lead to an increase in surgical or radiologic therapeutic procedures. The major significant complication was cholangitis in the T-tube group; this did not occur in the other group. The incidence of biliary fistula was 10% in the T-tube group and 2.2% in the group without a T tube. Other biliary complications were similar. The complication rate of cholangiography performed with the T tube was greater than with other types of biliary exploration. The graft and patient survival rates were similar in the two groups.This study is the first large prospective, randomized trial of biliary complications with or without a T tube. The authors found an increase in the biliary complication rate in the T-tube group, which was linked to minor complications. The T tube did not provide a safer access to the biliary tree compared with the others types of biliary explorations. The authors recommend the performance of choledochocholedochostomy without a T tube in liver transplantation.

Background The prognosis of early gastric cancer (EGC) is considered better than that of invasive gastric carcinoma, with a 5-year survival rate of more than 90% after surgery. The prevalence of lymph node metastasis in EGC ranges from 8% to 20% and is associated with a poor prognosis. Hypothesis The main prognostic factor of EGC in patients in France is lymphatic involvement. Design, Setting, and Patients From January 1979 to December 1988, 332 patients with EGC were operated on in 23 centers of 2 of the French Associations for Surgical Research. Clinical, pathological, and therapeutic data were reviewed, and the reckoning point was in June 1996. Main Outcome Measures The cumulative 5- and 7-year specific survival rates of EGC with or without lymphatic involvement. Results The cumulative 5- and 7-year specific survival rates of 332 patients with EGC (mean follow-up time, 80 months), excluding both operative and unrelated mortality, were 92% and 87.5%, respectively. Thirty-four patients (10.2%) had metastatic lymphatic spread: 13 exclusively in the lymphatic vessels close to the tumor, 17 in at least 1 lymph node, and 4 in both the lymphatic vessels and nodes. The rate of lymph node involvement (regardless of lymphatic vessel involvement) correlated significantly with submucosal invasion ( P = .05) and histologic undifferentiation ( P = .03). Lymphatic vessel involvement correlated positively with lymph node involvement ( P = .003). Since 5- and 7-year survival rates of the 13 patients with EGC who had lymphatic vessel involvement without lymph node involvement did not differ significantly from those of patients who had EGC with lymph node involvement (85% and 84% vs 72% and 63%, respectively [ P = .42]), all patients with lymph node and/or lymphatic vessel involvement were considered unique. Prognosis was poorest in these patients according to both univariate analysis (94% for 298 without node or vessel involvement vs 78% for 34 with node and/or vessel involvement; P = .006) and multivariate analysis ( P = .01). Submucosal invasion was a prognostic factor independent of lymphatic involvement ( P = .05). Five- and 7-year survival rates did not differ when the group of 211 patients for whom less than 15 lymph nodes were retrieved were compared with those (n = 51) for whom 15 or more lymph nodes were retrieved (95.5% vs 92% and 95.5% vs 88%, respectively), whether according to univariate ( P = .21) or multivariate ( P = .31) analysis. Conclusions Our results suggest that both lymph node and lymphatic vessel involvement are important prognostic factors in patients with EGC. Lymphadenectomy in EGC is important to identify the high-risk population for whom prognosis is worse. The extent of lymphadenectomy (at least 15 nodes) in these patients, however, does not alter prognosis.

Background. The aim of this study was to describe the features of posttransplantation tumors observed in a series of liver transplant recipients with special reference to patients receiving a transplant for alcoholic cirrhosis. Methods. Among 171 consecutive liver transplant recipients, 90 patients who had received a first liver allograft for cirrhosis were studied. After liver transplantation, detection of de novo malignancies was prospectively undertaken and the characteristics of the patients in whom tumors occurred were compared with those in whom tumors did not develop. Results. With a follow-up of 45.2±21.2 months, 11 tumors were observed in 90 patients (overall incidence of 12.2%). The incidence of tumors was higher in patients receiving a transplant for alcoholic cirrhosis than in patients receiving a transplant for nonalcoholic cirrhosis (26.7% vs. 5.0%, P

Background: Although hepatic vascular clampings are widely used during major hepatic resections, they may not always be necessary. Selective vascular clamping, which only controls the afferent blood flow of the resected liver, could be a valuable alternative, provided that blood loss is not increased because the opposite liver remains perfused. Study Design: The aim of the study was to assess the safety of selective vascular clamping in 43 patients who underwent 36 right hepatectomies and 7 left hepatectomies for lesions located peripherally within the liver. Blood transfusions, hepatic tests, morbidity, mortality, and hospital stay were evaluated. Results: Selective vascular clamping was efficient in 34 of the 43 attempts (79%), but bleeding from the contralateral liver required conversion to portal triad clamping in 9 patients (21%). Median blood transfusions were 0 units (range 0 to 4 U), and 28 patients (65%) did not require transfusions. Postoperative laboratory tests showed that larger changes occurred at day 1 and tended to return to preoperative values at the end of the first postoperative week. Median time of hospitalization was 10 days (range 7 to 28 days). Postoperative course was uneventful in 35 patients (81%). Nonlethal complications occurred in 7 patients (16.3%). One patient (2%) with massive hepatic steatosis died of liver failure after right hepatectomy. Conclusions: Selective vascular clamping is a safe alternative to total inflow occlusion for major hepatectomies applicable in 80% of selected patients with peripheral liver tumors.

Brain death is a possible complication of orthotopic liver transplantation (OLT). In these cases, if the liver graft continues to function normally it could be resued for another recipient. To our knowledge this is the second reported case of liver graft reuse after brain death of the first recipient.

Preoperative distinction between focal nodular hyperplasia (FNH) that should be managed conservatively and hepatocellular adenoma (HA) that should be resected remains difficult. The result is controversial management of these patients. The aims of this study were to report the value of modern imaging procedures for noninvasive diagnosis of these lesions, to assess the value of intraoperative frozen section studies, and to propose a management strategy in those patients. Forty-one consecutive women with FNH (35 cases) or HA (6 cases) treated at our institution between 1985 and 1992 were studied. New imaging techniques, including enhanced magnetic resonance imaging (MRI) and color Doppler ultrasonography (US), were prospectively appraised in addition to usual techniques. Histological examination of surgical specimens was obtained in all cases. A sixfold increase in the number of patients with FNH was observed during this study, whereas the number of patients with HA did not change. FNHs were incidental US findings in 74% of the cases. The best imaging procedure in the diagnosis of FNH was enhanced MRI with a sensitivity of 70% and a specificity of 98%. Color Doppler US was a useful adjunct. Intraoperative frozen section studies were performed in 16 patients with 19 tumors with a sensitivity of 89% and a specificity of 100%.(ABSTRACT TRUNCATED AT 250 WORDS)

After liver transplantation for hepatitis C virus (HCV)-related cirrhosis, recurrent viral infection is almost constant, resulting in acute graft dysfunction in 30-75% of cases. Acute graft dysfunction in the post-transplant period may also be the result of various causes (such as rejection, CMV infection, sepsis, or technical problems). Therefore, the role of HCV reinfection is often difficult to document. The aim of this study was to assess the diagnostic value of serial HCV RNA quantitation in this setting. Fourteen patients transplanted with follow-up greater than 6 months were studied. HCV RNA was quantitated before and serially after transplantation, using branched DNA technology. In cases of acute graft dysfunction, usual investigations and additional HCV RNA quantitation were conducted. There were 15 episodes of acute graft dysfunction in 12 patients. Six episodes had a hepatitic biochemical pattern, and 5 of them were associated with a concomitant HCV RNA peak. Nine episodes had a mixed, hepatitic, and cholestatic biochemical pattern, and 5 of them were associated with a concomitant peak of HCV RNA. Overall, 10 of 15 (66%) episodes of acute graft dysfunction were associated with HCV RNA peak, which strongly suggests that HCV was the etiologic factor. In 9 of these 10 episodes, no other cause of dysfunction was found, and one had associated CMV disease. In 5 cases, no peak of HCV RNA was observed and the causes of dysfunction were CMV (in 2 cases) and rejection, granulomatosis, and unknown (in 1 case each). Serial quantitations of HCV RNA levels after liver transplantation for cirrhosis C provide a useful tool in the diagnosis of HCV reinfection of the graft.

Sixty-two OLTs in 61 patients were performed using a technical modification reported recently, including total hepatectomy with preservation of the inferior vena cava, partial clamping of the native vena cava, and side-to-side cavacaval anastomosis. We further modified the technique by adding the early construction of a temporary end-to-side portacaval shunt, and, more recently, by using an end-to-side caval reconstruction. With this technique, the caval and portal flows were maintained throughout the procedure. Hemodynamic parameters were analyzed prospectively during the operative period and remained stable at all stages of the procedure. Venous bypass was avoided in all cases without need for increased fluid infusion. Operative time and transfusion requirements were 6.8 +/- 1.6 hr and 9.8 +/- 4.3 U of packed RBC, respectively. There were no specific complications or deaths due to the technique used and hospital mortality was 10% (6/61). The technique used in this study is a safe adjunct to the technical armamentarium of clinical liver transplantation. Its main advantage seems to be hemodynamic stability throughout the procedure, obviating the need for venous bypass or fluid overload.

We report the cases of two patients who developed symptomatic common bile duct stricture 10 years after upper abdominal radiotherapy for malignant lymphoma. Both patients were in complete remission and presented with marked obstructive jaundice. Endosonography was useful in both cases and showed segmental thickening of the bile duct wall narrowing in the lumen. Both patients underwent surgical exploration, confirming biliary obstruction due to intrinsic wall thickening, and had successful biliary drainage by Roux-en-Y hepatico-jejunostomy. Histological examination of the resected bile duct, in one case, and of a bile duct biopsy, in the other, was consistent with late irradiation injury. We conclude that stricture may be a delayed consequence of radiotherapy applied to normal bile ducts.

Adequate hepatic arterial reconstruction is essential for successful liver transplantation. In the case of insufficient recipient hepatic arterial flow, most surgeons recommend the use of the aorta for arterialization of the graft. We report here on a technique in which the recipient splenic artery is used in such a setting. The splenic artery is dissected from its origin on a 3-to-4 cm segment and divided. The proximal segment is flipped to the right and anastomosed to the graft's celiac axis in an end-to-end fashion. This technique was used in 7 of 79 orthotopic liver transplantations (9%) because the native hepatic artery was deemed to be inadequate for anastomosis. There were no complications related to the use of this technique and no arterial thromboses. Arterialization of hepatic grafts using the recipient proximal splenic artery is a simple, safe, and efficient technique that can be recommended in the presence of an inadequate recipient hepatic arterial flow.

Blood loss is the major cause of postoperative mortality and morbidity associated with hepatic resection. A prospective multicenter study was conducted to determine if ultrasonic dissectors (USD) were useful in hepatic resection and could reduce this hemorrhagic risk. Forty-seven hepatic resections were performed in 42 consecutive patients during a two month period in 11 public, surgical centers. Twenty-one patients had primary or secondary malignancies, six had benign tumors, two had biliary cysts, one had cholangiocarcinoma, one had Caroli’s disease, and 11 had hydatid cysts of the liver. Two different USD devices were evaluated (CUSA System-Lasersonics and NIIC-DX 101 T). The hepatic resections tested included a wide range of procedures. Each surgeon had the possibility of choosing between the USD and his own usual technique for each operative step and according to local conditions. The average volume of blood infused, irrespective of the underlying pathology or the procedure performed, was 1.0 L (range 0-4.8 L). Fourteen patients required no transfusions. No operative or immediate postoperative deaths were recorded. Five major complications, all unrelated to the use of the USD, developed in three patients. Access to intra and extraparenchymal arterial and venous tributaries and particularly the control of the hepatic veins were facilitated by USD. While transection of hepatic parenchyma was neither easier nor faster than with conventional techniques, it was found to be less hemorrhagic. Overall appraisal was expressed on an analog scale; the USD was found to be helpful or very helpful in 75 percent of all resections. With regard to the pathology being treated, total or partial excision of hydatid cysts was greatly enhanced by the use of the USD while this benefit was not found for wedge resections of other hepatic lesions. With regard to user friendliness and maintenance, the NIIC-DX 101 T device was preferred. We conclude that the USD facilitates formal hepatic resections. Converging opinions emerging from various surgical centers reinforce this conclusion.

Hypothesis Laparoscopic liver resection for subcapsular hepatocellular carcinoma in patients with chronic liver disease is associated with lower morbidity than open resections. Design A case-comparison study. Setting A tertiary referral center. Patients and intervention From December 1, 1998, to November 30, 2000, 13 patients with chronic liver disease who underwent laparoscopic resection of hepatocellular carcinoma formed the laparoscopic group (LG). Tumors were 5 cm or smaller, subcapsular, and located in anterolateral segments (segments II-VI). A control group was created by matching each laparoscopic case with patients identical for liver disease, tumor size, and location and type of hepatectomy who underwent open liver resection. Fourteen patients fulfilled the criteria and formed the open group (OG). Main outcome measures Postoperative mortality and morbidity. Results One segment or less was resected in 21 patients and 2 in 6 patients. Operative duration and cumulative portal triad clamping times were longer in the LG (267 +/- 79 minutes vs 182 +/- 57 minutes, P =.006; 68 +/- 24 minutes vs 25 +/- 19 minutes, P =.006, respectively). Mortality rates were 0% in the LG and 14% (2/14) in the OG (P =.2). Postoperative liver failure and ascites occurred in 8% (1/13) in the LG and 36% (5/14) in the OG (P =.15). Surgical margin was not different in the 2 groups. Three-year survival was significantly higher in the LG (89% vs 55%; P =.04), but 3-year recurrence rates were similar (46% vs 44%). Conclusion Our study suggests that, despite longer operative and clamping times without clinical consequences, the rate of decompensation of liver disease could be lower after laparoscopy.

Background: The role of preoperative biliary drainage (PBD) before liver resection in the presence of obstructive jaundice remains controversial. Our patients with proximal duct carcinoma undergo noninvasive assessment followed by rapid laparotomy without PBD if the lesion is deemed resectable. Hypothesis: Our aim was to report operative outcome of these patients and to analyze their specific features by comparison with patients without biliary obstruction who underwent major liver resection. Design: A case-comparison study. Setting: A tertiary care university hospital in a metropolitan area. Patients: Twenty consecutive jaundiced patients underwent major liver resection without PBD. The jaundiced patients were matched with 27 nonjaundiced patients with normal underlying liver selected from a computer bank of 261 patients undergoing liver resections and identical for age, tumor size, type of liver resection, and vascular occlusion. Main Outcome Measure: Postoperative course including mortality, morbidity, transfusion rates, and results of liver function tests. Results: Seventeen jaundiced patients (85%) and 13 nonjaundiced patients (48%) received blood transfusions (P = .03). Morbidity was 50% in jaundiced and 15% in nonjaundiced patients (P = .006), mainly resulting from subphrenic collections and bile leaks occurring only in jaundiced patients. In contrast, there were no significant differences for mortality (5% vs 0%) and liver failure (5% vs 0%). Postoperative changes in liver function test results were comparable between groups. Conclusions: Major liver resections without PBD are safe in most patients with obstructive jaundice. Recovery of hepatic synthetic function is identical to that of nonjaundiced patients. Transfusion requirements and incidence of postoperative complications, especially bile leaks and subphrenic collections, are higher in jaundiced patients. Whether PBD could improve these results remains to be determined. Arch Surg. 2000;135:302-308

To report the technique and results of an alternative method of vascular clamping during liver resections.Most liver resections require vascular clamping to avoid excessive blood loss. Portal triad clamping is often sufficient, but it does not suppress backflow bleeding, which can be prevented only by hepatic vascular exclusion. The latter method adds clamping of the inferior vena cava, which results in hypotension, requiring invasive anesthetic management. There is growing evidence that intermittent clamping is better tolerated than continuous clamping, especially in the presence of underlying liver disease.Hepatic vascular exclusion with preservation of the caval flow (HVEPC) involved conventional inflow clamping associated with outflow control by clamping the major hepatic veins, thus avoiding caval occlusion. HVEPC was used in 40 patients undergoing major or complex liver resection, including 16 with underlying liver disease. HVEPC was total (clamping of the porta hepatis and all major hepatic veins) in 20 cases and partial (clamping of the porta hepatis and the hepatic veins of the resected territory) in 20. Clamping was continuous in 22 cases and intermittent in 18. Resections included 12 hemihepatectomies, 12 extended hepatectomies, 3 central hepatectomies, and 13 uni- or bisegmentectomies.Hemodynamic tolerance of clamping was excellent in all cases, without the need for therapeutic adjustment. Median red cell transfusion requirements were 0 units, and 28 patients (70%) did not receive any transfusions during the hospital stay. There were no deaths, and the morbidity rate was 17.5%. Median hospital stay was 10 days.HVEPC is a safe and effective procedure applicable to liver tumors without invasion to the inferior vena cava. It offers the advantages of conventional hepatic vascular exclusion without its hemodynamic drawbacks, and it can be applied intermittently or partially.

Forty-three state-run medical schools admit 30000 students per year but only 3500 receive their diploma after 6 years of studies. After passing a special examination, 480 of 2000 residents choose surgery and train during twelve 6-month rotations. Surgical research is organized through government agencies, individual units, or volunteer groups. In 1992, of 8268114 procedures, appendectomy represented 4.15%; hernia, 4.09%; varicose veins, 3.61%; and cholecystectomy, 1.82%. Appendectomy has decreased from 306500 per year in 1980 (34% of all gastrointestinal surgical procedures) to 159900 (15%) in 1996, whereas cholecystectomy has increased from 64700 to 95300. Emergency gastrointestinal procedures represented 15% of all surgical procedures in 1996, doubling in the last 4 years (essentially for labor and endoscopic procedures). Ambulatory procedures have increased 12-fold since 1980, essentially (75%) in private practice. About 27% of 160000 appendectomies and 77% of 95300 cholecystectomies were performed laparoscopically in 1997. One person of 4 in France has or has had cancer, mainly due to tobacco abuse. In 1993, 32000 surgical procedures were performed for gastrointestinal cancer. Of 532000 deaths (1992), about 150000 were due to cancer, 10000 to alcohol-related disease, and 22000 to trauma. Transplantation in France increased from 3180 procedures in 1993 to 2807 in 1996, essentially lungs and heart and lungs. Between 60% and 100% of health expenditures are reimbursed by the government, the remaining being covered by private insurances. Approximately 60% of 4500 French surgeons are in private practice; 25% also have part-time hospital employment. Almost 40% of surgeons work full-time in hospitals.

Objective: To report the results of a deliberately aggressive surgical management in patients with intrahepatic cholangiocarcinoma. Design: A case series of patients with intrahepatic cholangiocarcinoma. Setting: A tertiary care university hospital in a metropolitan area. Patients: From 1989 to 1993, 19 patients with intrahepatic cholangiocarcinoma underwent laparotomy, with a 74% resectability rate (14 liver resections). In addition, two selected patients with a slow-growing tumor underwent orthotopic liver transplantation after limited recurrence following resection in one case and after exploratory laparotomy in the other. Interventions: The 14 liver resections included six right or left hepatectomies and eight extended right or left hepatectomies. Total vascular exclusion of the liver was used in nine cases (64%) and resection of the biliary confluence with reconstruction was used in six cases (43%). Results: There was one postoperative death (7%). There were four postoperative biliary fistulas (28%). Overall actuarial 1- and 2-year survival rates were 58% and 32%, respectively. The 1- and 2-year survival rates were 100% after curative resection (no lymph node invasion, clearance margin of ≤1 cm, and solitary tumor [five cases]) and 48% and 10% after palliative resection. Median survival was 14 months for the whole series and 27 and 9 months following curative and palliative resections, respectively. The two liver transplant recipients are alive and free of disease at 25 and 31 months. Conclusion: These results support aggressive surgical management in patients with intrahepatic cholangiocarcinoma, including complex liver resection procedures and selective use of orthotopic liver transplantation. (Arch Surg. 1995;130:1073-1078)

A new endoprosthesis designed for surgical intubation of neoplastic strictures of the proximal biliary tract has been developed. The technical aspects of intubation by this endoprosthesis are discussed, and the results in the first 25 patients are given. The results suggest that this device was well tolerated. Mortality and morbidity related to the endoprosthesis were low in comparison to the results given in the literature for intrahepatic cholangioenteric anastomosis. The authors conclude that this procedure could favorably replace intrahepatic cholangioenteric anastomosis as currently used for selected cases of malignant biliary stricture.

The role of computerized tomography in the diagnosis and treatment of late complications of acute pancreatitis was evaluated in 25 patients with acute pancreatitis. The clinical severity of the pancreatitis was assessed by Ranson's criteria. In each patient. the scan showed abnormalities of the pancreatic and at least one intraabdominal extrapancreatic extension of the disease. The scan precisely locates the intraabdominal extensions secondary to acute pancreatitis, and thus can guide surgical drainage, but it is less accurate in differentiating solid infiltration of fat planes from necrotic collections. However, in most of our patients, the association of general signs of sepsis with a collection shown on computerized tomographic scan indicated necrosis requiring surgical drainage.

• We report two cases of chronic pancreaticopleural fistulas occurring in chronic pancreatitis. In both cases the primary clinical manifestation was a recurrent left pleural effusion with a high content of pancreatic amylase. The pleural effusion was associated with subcutaneous fat necrotic lesions in one patient, and with expectoration of an amylase-rich fluid in the other. Endoscopic retrograde cholangiopancreatography is important because this examination allows a precise evaluation of the ductal morphology and is indispensable to the surgical procedure. We recommend surgical treatment when the fistula does not close spontaneously within two weeks. Both patients were successfully treated by surgery. (Arch Surg1984;119:1204-1206)

In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.

Twenty-four pyogenic liver abscesses have been treated during a six-year period percutaneously. Percutaneous management included percutaneous drainage and fine needle aspiration under ultrasound or CT scan guidance. Percutaneous management was successful in 92% of cases, and no further treatment was required in 91% of these.One patient died, giving a mortality rate of 4.1%. There were no complications related to this method. The authors conclude that percutaneous management of pyogenic liver abscesses should be attempted in all cases, since results compare favourably with surgical procedures.

A randomized prospective multicentric study was organized to compare results between techniques using continuous sutures and interrupted sutures in closing abdominal midline incisions. The suture material employed was polyglycolic acid. This study included 3,135 patients who were randomized between the two methods of closure and who were stratified according to the type of wound: clean, clean-contaminated, and contaminated. The overall dehiscence rate was 1.6% in the continuous sutures group vs 2% in the interrupted sutures group. The dehiscence rate in the interrupted sutures group was significantly higher than in the continuous sutures group only in the stratum of contaminated wounds. The death rate was significantly higher in the interrupted sutures group. The number of needle sets was significantly less important when the continuous sutures technique was used. Continuous closure is preferable because it is more economic and expedient and also because it has the same incidence of wound dehiscence as interrupted sutures closure.

From 1981 to 1987, 40 patients with severe acute pancreatitis were operated on using a direct retroperitoneal approach, 22 primarily and 18 after a first operation performed through another incision. The severity of the disease was assessed by Ranson's bioclinical and computed tomography scan scoring systems. The retroperitoneal approach consisted of a left lateral incision, just anterior to the 12th rib, allowing direct access to the pancreas and a complete manual exploration of the gland and peripancreatic spaces. All patients but one were operated on for infected necrosis. The overall mortality rate was 33 per cent but was lower in the patients operated on primarily through a direct retroperitoneal approach (18·2 per cent). Twenty patients (50 per cent) developed a local complication (haemorrhage, colon fistula and/or necrosis). The direct retroperitoneal approach permits the removal of necrosis and several reoperations without the risk of large wound dehiscence and does not preclude the extension of the incision to a subcostal incision when necessary.