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Nitric oxide (NO), an endogenous free radical, has been implicated in a wide range of biological functions. NO is generated enzymatically from the terminal guanidinonitrogen of L-arginine by nitric oxide synthase (NOS). Despite intensive investigations, the role of NO--either as the primary product of the L-arginine/NOS pathway or provided from the NO donor sodium nitroprusside (SNP)--in carcinogenesis and tumour cell growth remains unclear and controversial. The objective of this study was to examine the growth effects of NO on a ductal pancreatic adenocarcinoma in the rat and on a human pancreatic tumour cell line (HA-hpc2). In vivo, both SNP and endogenous induction of NO by endotoxins [lipopolysaccharide (LPS)] plus L-arginine significantly reduced the tumour growth. To investigate the mechanisms of NO anti-tumour growth action, the effects of either the SNP or L-arginine/NOS pathway were analysed on the HA-hpc2 cell line. Nitrite/nitrate production, NOS activity and iNOS expression [assessed by reverse transcription-polymerase chain reaction (RT-PCR)] were tested and related to growth (assessed by [3H]thymidine incorporation assay) and apoptosis (assessed by internucleosomal DNA cleavage). SNP exerted a dual effect on tumour cells: stimulation of the proliferation up to 1 mM and inhibition at higher concentrations. These effects were related to NO production. Both proliferative and cytostatic responses were inhibited by NO scavenger 2-phenyl-4,4,5,5-tetramethyl-hemidazoline-1-oxyl3-oxide (carboxy-PTIO). The marked apoptotic DNA fragmentation induced by SNP was also abolished by PTIO association. Unlike macrophages, the human pancreatic tumour cells did not seem to express intrinsically the L-arginine/NOS pathway. Macrophages were activated by HA-hpc2 cells as well as by LPS plus cytokines [interleukin (IL)-1beta plus tumour necrosis factor (TNF)-alpha and interferon (IFN)-gamma]. In HA-hpc2/macrophage co-cultures, NOS activity and inducible NOS (iNOS) transcription were stimulated, whereas an antiproliferative response was observed. These effects were related to both macrophage amount and NO production. Addition of LPS plus cytokines to co-cultures doubled iNOS activity, nitrite/nitrate production and tumoricidal effect. These data suggest the involvement of NO in pancreatic tumour growth and support the fact that generation of high levels of NO with potential production of endogenous reactive nitrogen intermediates may contribute to induction of apoptosis and tumour growth inhibition. Images Figure 2 Figure 5 Figure 6 Figure 7

The aim of this study is to demonstrate the efficacy of wireless capsule endoscopy for preoperative identification of bleeding sources and/or small bowel tumours in surgical patients and to evaluate the feasibility of single-port surgery in the treatment of such pathologies.Five patients presenting with obscure gastrointestinal bleeding or/and mild small bowel obstruction were investigated to diagnose and localize the bleeding source or tumour using capsule endoscopy imaging, and, if necessary, with other investigative modalities. All patients were operated on using single-port surgery for small bowel exploration, lesion confirmation, small bowel resection and anastomosis.Small bowel pathology was successfully detected by video capsule endoscopy in three of four patients, and was further substantiated by contrast CT, double-balloon endoscopy or enteroclysis. Complete small bowel exploration, intra-operative identification and oncological resection of the involved segment and anastomosis (intracorporeal and extracorporeal) was successfully performed in all five patients using single-port access without any complication, morbidity or mortality.This study demonstrates the feasibility and safety of single-port small bowel resection performed after a high-quality preoperative localization of the tumour.

Parastomal herniation of end colostomies can be chronically debilitating for patients and a difficult problem to treat. To prevent parastomal hernia (PSH) formation an extraperitoneal colostomy (EPC) approach has been developed in open colorectal surgery and some studies have suggested a potential advantage to this approach. Here we describe our technique of laparoscopic extraperitoneal stoma formation and present our experience to date.We performed a retrospective analysis of consecutive patients undergoing a laparoscopic abdominoperineal resection between March 1999 and March 2011. We performed the EPC technique as follows: under laparoscopic guidance, a smooth tip instrument was used to gently separate the peritoneum from the posterior aponeurotic plane to create an extraperitoneal tunnel running from the skin incision to the left flank of the abdominal cavity to join the previously dissected paracolic gutter. The colon was exteriorized and the position was checked to ensure the absence of torsion or kinking.Twenty-two patients underwent a standard laparoscopic abdominoperineal resection with total mesorectal excision. Colostomy was constructed extraperitoneally (EPC) or transperitoneally (TPC) in 12 and 10 patients respectively. There were five complications requiring operative intervention: two stomal necrosis and one surgical site infection in the TPC group and two small bowel occlusions in the EPC group. Four patients from the TPC group developed PSH at 24, 36, 48 and 72 months respectively while there were no cases of PSH in the EPC group.Extraperitoneal laparoscopic colostomy showed a potential reduction of PSH in our series of patients.

Biliopancreatic bypass (BPB), a bariatric surgical procedure, leads to a malnutrition-induced general visceral atrophy except for the pancreas. This work investigates the implication of cholecystokinin (CCK) in the exocrine pancreatic adaptive process using a plasma CCK assay and the CCK receptor antagonist CR 1409. No significant reduction in weight and DNA content of the pancreas was noted 36 days after BPB, while a strong decrease in protein, enzymes and RNA contents indicating cellular hypotrophy became apparent. CR 1409 treatment strongly depressed pancreatic weight and its DNA content in BPB animals, suggesting an additional hypoplasia; however, the reduction in pancreatic enzyme content was not aggravated. BPB increased plasma CCK concentrations by 160%, unrelated to CR 1409 treatment. These results indicate that: (1) CCK is involved in the pancreatic adaptive response after BPB in rats, and (2) in the context of a protein malnutrition state, CCK dissociates its pancreatic growth and enzymatic effects, favouring the former.

Chylothorax after esophagectomy is a potentially life-threatening complication, with a reported incidence rate of 1-4%. Two cases of postoperative chylothorax successfully managed thoracoscopically are reported.In case 1, a 61-year-old man presenting with an adenocarcinoma of the lower esophagus underwent laparoscopic transhiatal esophagectomy after neoadjuvant chemotherapy. The thoracic duct was identified, and no obvious leaks were detected. The thoracic drain was removed on postoperative day (POD) 6, and chest X-rays were normal. The patient was discharged on POD 10. On POD 20, he was readmitted for acute cardiopulmonary distress. Computed tomography scan showed a massive right collection. After insertion of a chest tube, 8 l of chylous fluid were drained. Once hemodynamic stabilization had been established, the patient was scheduled for surgery. In case 2, a 54-year-old woman presenting with esophageal stenosis after caustic injury refractory to balloon dilation and stenting underwent esophagectomy. Mediastinal dissection was difficult due to fibrotic reaction. On POD 2, the patient presented with a massive chylothorax. In both cases, three trocars were inserted in the right pleural cavity. An incomplete lateral injury of the thoracic duct was found in case 1, and a complete transection proximal to the cervical anastomosis next to the left subclavian was found in case 2. Clips and sutures were used first to seal the duct. Fibrin glue was applied to reinforce the closure. A chest tube was left in place.The operative time was 60 min in case 1 and 55 min in case 2. The chylothorax did not recur, although the postoperative course was longer in case 2 due to associate comorbidities.The thoracic duct is exposed to injuries during esophagectomies, especially in cases of cancer and postcaustic injuries, leading to fibrotic reaction of the surrounding tissue. Early and delayed chylothorax can be managed efficiently by a thoracoscopic approach replicating the sealing techniques used in thoracotomy.

Laparoscopic reversal of Hartmann's procedure is technically demanding. We evaluated the technical aspects and outcome of a standardized approach in a single centre and examined the feasibility of including this into training curricula.The procedure entails a laparoscopy for adhesiolysis and identification and mobilization of the rectal stump. Mobilization of the splenic flexure is performed if necessary, and a colorectal anastomosis is fashioned after introduction of the stapler anvil via the colostomy with intra-abdominal positioning and delivery into the proximal colonic segment to be anastomosed. The stoma is excised as the last step in the operation.Forty-two patients underwent the procedure over an 8-year period with either an expert (n=21) or trainee under expert mentorship (n=21) as first operator. Intra-operative data and postoperative outcomes were evaluated by retrospective review of clinical charts and theatre records. There was a 9.5% conversion rate and 0% mortality. One patient suffered a ureteric injury, while postoperative surgical complications occurred in 7 patients (including one clinical anastomotic leakage). The mean operative time was 117 min. There was no significant difference in intra operative technical parameters or postoperative clinical consequences between procedures performed by a trained surgeon or by a trainee under mentorship.Adherence to a standardized operative protocol and expert mentorship allows this technically demanding operation to be associated with low conversion and complication rates. The absence of any difference between procedures performed by a trainee or trained surgeon suggests that the operation can be included in training programmes for laparoscopic surgery.

Virtually unknown at the beginning of the century, diverticulosis has become very prevalent in western countries. The natural history of the disease is notable for its acute, sometimes recurrent, attacks of diverticulitis and the significant risk of serious complications : abscess, fistula, peritonitis. CT scanning predominates in the diagnostic evaluation. It can provide both diagnostic and prognostic information. Most mild attacks of diverticulitis respond well to medical therapy while surgical treatment is indicated in the complicated forms of the disease. Surgical therapy has gradually evolved from a complicated three stage approach to two-staged, single-staged, or even minimally invasive procedures. The current trend is to intervene surgically well after the resolution of the acute attack. To achieve this, liberal use of percutaneous drainage of collections and medical treatment are advocated. The decision to perform prophylactic sigmoid resection must be based on a balance assessment of risk factors including age, severity of attacks and their recurrence.

The aim of this prospective study conducted by the AFCE was to analyze the indications, approach and results of all adrenalectomies performed during the year 1997 in 17 centers, active or specialized in endocrine surgery.During 1997, adrenalectomy was performed in 247 patients, 149 men and 98 women (mean age: 51 years). The lesion was located in the right side in 166 patients, in the left side in 99, in both sides in 28 patients and ectopic in four patients. Pheochromocytomas (n = 61), Conn adenomas (n = 50) and Cushing syndrome lesions (n = 48) were the most frequent in this series. Laparoscopic adrenalectomy was performed in 172 patients (70%) through a transperitoneal approach in all cases except one, and by 'open' surgery in 75 patients (30%).In patients operated on by the laparoscopic approach, the mean duration of surgery was 132 min, and there were peroperative complications in 15 patients (8.7%), mainly hemorrhages. Conversion rate into laparotomy was 7%. In the postoperative course, there were three reoperations and two deaths, an early one in a patient reoperated for bleeding and a very late one in relation with necrotising acute pancreatitis. Mean duration of hospitalization was 5.8 d. Mean tumoral size was 49 mm. In patients operated on by 'open' surgery, the mean duration of surgery was 148 min. There was a postoperative complication in eight patients (10.6%), mostly hemorrhages, and two intraoperative deaths in relation with uncontrollable bleeding. Mean duration of hospitalization was 11 d. Mean tumoral size was 72 mm.Laparoscopic adrenalectomy is now indicated for the majority of adrenal tumors. Several complications observed in this series were related to the learning curve in several centers. Laparoscopic adrenalectomy is the 'gold standard' in uni- or bilateral benign tumors no larger than 6 or 7 cm. 'Open' surgery is indicated in malignant tumors, especially in adreno-cortical carcinomas, and in all large tumors.

The authors describe the surgical technique for right and left adrenalectomy and the per- and postoperative course of the patients.Twenty-seven laparoscopic adrenalectomies were performed between November 1992 and February 1996: there were 18 women and 9 men ranging in age from 31 to 70 years (mean 50.8 years); the surgical procedure was a lateral decubitus transperitoneal flank approach in 26 patients, and a retroperitoneal approach in one.Twelve right and 15 left glands were removed. Adrenal diseases were primary aldosteronism in 20 patients, non-functional adenoma in 3 patients, 2 Cushing's syndrome, adrenal cyst in one and incidentaloma in one. Mean adrenal gland size was 2.6 cm (range 0.5 to 8 cm). Five patients (18.5%), were converted to laparotomy, for dissection problems in 4 and failure to locate the left adrenal gland in one. The mean anesthesia time was 205.7 min and the mean surgical time 141.2 min. Surgical morbidity was one adrenal vein injury sectioned close to the vena cava: the hemorrhage was controlled by laparoscopic suturing without conversion. No mortality occurred and postoperative morbidity was one minor chest infection. The mean postoperative stay in hospital was 3.7 days (range 2.8) for the non converted patients. Laparoscopic adrenal gland removal is safe and offers fast recovery and short hospital stay. Laparoscopic adrenalectomy combines the advantages of both the conventional anterior and posterior approach.Personal experience of laparoscopic adrenal gland removal is described: a safe adrenal vascular control and gland dissection were performed and the length of operation and postoperative course carefully presented.

Primary operations for hyperparathyroidism performed by experienced surgeons has a success rate of about 95% without any preoperative localization. After unsuccessful cervicotomy, localization studies must be performed in order to define the surgical approach. The objective of our retrospective studies was to determine the accuracy of non invasive and invasive localization studies in patients with persistent hyperparathyroidism.The present reoperative series involved 7 patients with persistent hyperparathyroidism. Six patients came from a series of 140 operated on at the department of Prof. J. Marescaux from 1991 to 1993 (success rate of 95.7% in cervical exploration). Patient n. 7 came from another department.After negative initial cervicotomy, non invasive localization procedure are undertaken, but with a high incidence of false-positive results (9% to 75%). Among available invasive techniques, it has been chosen to sample blood from large veins in the neck and mediastinum for Parathyroid Hormone (1-84 PTH) determination and to realise angiography for locating parathyroid adenomas as well as for vein mapping. Their combination permitted to localize all lesions.The specificity of serum concentration of 1-84 PTH determination by catheterization of cervical and mediastinal veins (100%) combined to the sensitivity of angiography (82%) allowed to obtain good result in parathyroid localization in persistent hyperparathyroidism.

The purpose of this study is to evaluate the sequential endoscopic-laparoscopic approach for clearance of common bile duct (CBD) and removal of gallbladder in patients with simultaneous cholecystolithiasis and choledocholithiasis. A data base of 990 patients undergoing Laparoscopic Cholecystectomy (LC) was compiled during an 5 years period. 88 patients were suspected of having CBD stones based upon clinical, biological and ultrasound evidence. The CBD cannulation rate was 93% (82/88). CBD stones were found in 43 patients (49%). The stones were removed preoperatively by Endoscopic Sphincterotomy (ES) in 37 patients of these 43 cases (86%). LC was performed in all patients after endoscopic retrograde cholangiopancreatography (ERCP). This treatment had showed no mortality and a morbidity of 14%. Efficacy of this sequential method of treatment of LVBP was 86%. With inclusion of laparoscopic extractions, the efficacy rate was 91%. The rate of residual stones was 1% (1/88). Experience with ERCP and ES before LC has been growing. ERCP-SE in the treatment of choice to clear the CBD before LC in high risk elderly patients (26) as well as in complicated stones. However, in this era of laparoscopic surgery, CBD stone can be removed laparoscopically in specialized centres with the advantage of a non-invasive single procedure for the patient. Laparoscopic CBD desobstruction and ES are not opposite but complementary. Preoperative ERCP and ES should be reserved for patients with serious illness. All other patients should be managed laparoscopically; in this case the future of sequential treatment resides in a one step-approach: preoperative ERCP if cholangiography is positive.

To investigate the ability of human collagen biomaterials to secure colonic anastomoses in dogs and to evaluate the biocompatibility of anastomotic protection patches (APP).Experimental open study.Experimental research centre, France.21 mongrel dogs randomised into three groups of 7 each.Standard transverse colonic end-to-end anastomoses were secured with two-layer oxidised collagen I + III sponge covered with thin crosslinked collagen IV film (APP 1) glued around the suture (n = 7); two-layer oxidised collagen I + III sponge covered with thin non-crosslinked collagen I + III film patch (APP 2) (n = 7); or sealed by fibrin sealant (n = 7), which acted as a controls.Gross examination, radiological control (barium enemas), and microscopic examination on day 35 postoperatively.Gross clinical and radiological examinations on day 35 showed normal wound healing in all but one dog in which the anastomoses had occluded by day 16. There was significantly less stricturing with the APP 2 patch (p0.05 compared with the controls). Microscopic examination showed complete absorption of the APP 2 patches as well as quicker mucosal and extracellular matrix repair than controls. The APP 1 patch gave the best healing of the muscular layer but did not reduce anastomosis stricturing, and was not totally absorbed.Collagen supporting devices do not alter healing of the large bowel. Encircling patches do not increase the number of adhesions or the rate of anastomotic stricturing and a thin fibrillar collagen I + III dense layer may even improve it. The speed of absorption of the patch depends on the type of dense collagen film. These results argue for a prospective clinical evaluation in humans.

Bleeding related to diverticular disease occurs in 10 to 30% of patients suffering from diverticular disease. Haemorrhage varies from occult to massive bleeding. Bleeding is related to mechanical aggression of the artery in the wall of a diverticulum. Bleeding prevalence is not exactly known. In 1 to 7% of cases, massive bleeding is observed; diverticular disease is thus the most common cause of major lower gastrointestinal tract haemorrhage, followed by angiodysplasias. Although 95% of diverticular involve the sigmoid colon, more than 50% of bleeding diverticular occur in the right colon. Classically, presentation of bleeding is sudden without any inflammatory diverticulitis. Bleeding from diverticula stops spontaneously in 80% of cases. For definite diagnosis, selective abdominal angiography during bleeding phase is the procedure of choice. Other explorations are not contributive. Most haemorrhages have a benign outcome. Massive, persistent or recurrent haemorrhage should benefit from surgical procedure. In case of active bleeding in which diverticular origin has been validated by angiography, intra-arterial perfusion of vasopressor agents may be attempted, as a temporary treatment before delayed colonic resection. Segmental colectomy usually prevents recurrent haemorrhage when site of diverticular bleeding has not been identified with precision by angiography. Subtotal colectomy should only be used in the last resort. Extent of surgery will be based on likely origin of bleeding.

Leiomyosarcomas are exceptional in peripheral veins. Clinical signs are not specific, secondary to effects of the tumoural mass. Computed tomography and MRI give a precise topographic diagnosis. Pathology examination on biopsy or surgical specimens establishes the histological diagnosis. Therapeutic management must take into account local tumour recurrence and metastasis. Surgical exeresis should be wider than the tumour's pseudocapsule to include micrometastases neighbouring the primary tumour. Post-operative radiotherapy (55 to 70 Gy) and chemotherapy should follow. With this management scheme, local disease is controlled in 85% of the cases with a 5-year follow-up. Local or metastatic extension usually occurs within the first 3 years. Management of venous sarcomas thus requires a multidisciplinary cooperation between the surgeon, the radiotherapists and the chemotherapist.

Ten patients underwent laparoscopic surgery for typical perforated peptic ulcer symptomatology. Two conversions to open surgery were due to technical problems related to delayed hospital admission. Nine patients underwent duodenal suture reinforced with fibrin glue, and one perforation was only glued. The postoperative course was uneventful without abdominal septic or abdominal wall complications in the eight patients treated by laparoscopy. Laparoscopic surgery may become the method of choice for the treatment of perforated peptic ulcer.

Recent improvements in miniaturization of implantable pumps and the ability of their control by teletransmission allow implantation of autonomous pumps which administer insulin into the peritoneal cavity. Fifty-six patients with diabetes mellitus underwent implantation of 66 pumps with a mean function life of 21.8 months per patient. No patient has died to date. Tolerance of implanted components was good. Morbidity was limited to local events, in this series 4 cutaneous erosions, two of them leading to final pump explantation. Mean global blood-sugar, pre- and post-prandial blood-sugar, and glycosylated hemoglobin assays were all lower versus pre-implantation assays. A statistically significant difference was demonstrated regarding mean global blood-sugar. The frequency of severe hypoglycemia incidents (2 in our series) and biochemical hypoglycemia (blood-sugar65 mg/100 ml) was decreased, representing a major benefit of the technique. The patients well-being and quality of life were notably improved. Implantable insulin-pump may be offered as alternative treatment to conventional insulin-therapy, especially in cases of diabetes which are difficult to control and particularly in cases with frequent hypoglycemic malaise.

Biliopancreatic bypass (BPB), the exclusion of a duodenojejunal loop from the digestive continuity, has been proposed as a bariatric procedure for treatment of morbid obesity. The present study in rats investigated the effect of this surgical procedure on the mucosae of the ileum directly anastomosed to the stomach, and of the jejunum irrigated only by biliopancreatic secretions. The proximal part of the ileum adapted by two-fold increases in its mucosal mass, total protein and RNA content; DNA content was four-fold higher than in sham-operated animals. There was a correlated increase of mucosal enzyme content, except for lactase. In the distal ileal mucosae, a slight, transient augmentation of mucosal mass, protein, DNA and RNA content was observed which tended to compensate for the shortening of the functional gut. No morphological changes were found in the excluded loop, probably because of an endoluminal stimulation by biliopancreatic secretions. Thus, in BPB, biliopancreatic secretions seem to exert trophic effects on the intestinal mucosa, but they are less potent than the endoluminal nutrition that restores the oral-aboral mucosal gradient.

The case of a series of grave complications after a laparoscopic cholecystectomy is reported: a common bile duct section diagnosed rather late, hemoperitoneum, inappropriate common bile duct reconstruction and late anastomic leakage, stenosis of an hepatico-jejunal anastomosis, haemorrhage through the external biliary drainage and iterating sepsis. The final outcome was good. The stenotic hepatico-jejunal anastomosis was dilated by a Gianturco self-expanding prosthesis percutaneously placed. As an evidence, this alternative treatment is only exceptional, the treatment of choice for postsurgical benign strictures being surgical repair.

Spontaneous rupture of esophagus is a rare affection resulting from barotrauma to lower esophagus during the effort of vomiting. The diagnosis is suggested by the presence of violent retrosternal pain after a bout of vomiting following the partaking of a copious meal by an alcoholic patient. Prognosis is dependent on the rapidity of treatment, always surgical and completed by long-term antibiotic therapy. Complementary examinations should be limited to a standard chest x ray and esophageal imaging with water-soluble contrast. Recovery is now the rule for patients treated within 24 hours. Mortality is high in patients diagnosed at a late stage, but this could be reduced by improved recognition of the syndrome.

Ten patients presenting with hiatus hernia and gastro-oesophageal reflux underwent laparoscopic Nissen-Rossetti fundoplication. All patients had either medical treatment failure or invalidating reflux. At present, complete fundoplication is the most effective surgical treatment of gastro-oesophageal reflux. The laparoscopic procedure was rigorously identical with the habitually used "open" procedure, the only difference being the abdominal access. No laparotomy was necessary in our patients, and no major complication was observed. The follow-up showed good clinical results. Laparoscopy has been reported to decrease postoperative pain and ventilatory disorders. Morover, this minimally invasive surgical technique enables rapid resumption of social and professional activities.

Six laparoscopic abdominal operations were performed in five patients with chronic renal failure with continuous ambulatory peritoneal dialysis. Coelioscopic exploration and operation disclosed several advantages including peritoneal dialysis catheter salvage, abdominal exploration in peritonitis or before catheter implantation, early dialysis after surgery, hence avoiding the need for transient hemodialysis. Furthermore, laparoscopy was reported to decrease postoperative pain and ventilatory disorders. This minimal invasive surgical technique allows rapid recovery of social and professional activities.

Recent improvements in miniaturization of implantable pumps and the ability of their control by tele transmission allowed implantation of autonomous pumps which administer insulin into the peritoneal cavity. Fifty-six patients with diabetes mellitus underwent implantation of 66 pumps with a mean function life of 21.8 months per patient. No patient died to this day. Tolerance of implanted components was good. Morbidity was limited to local events, in this series 4 cutaneous erosions, two of them dictating final pump explantation. Dosages of mean global blood-sugar, pre- and post-prandial blood-sugar, and glycosylated hemoglobin were all lower versus dosages before implantation. Statistically significant difference was demonstrated regarding mean global blood-sugar. Frequency of sever hypoglycemia incidents (4 in our series) and of biological hypoglycemia (blood-sugar65 mg/100 ml) was decreased, representing major benefit of the technique. The patients well-being and quality of life were notably amended. Implantable insulin-pump may be offered as a treatment alternative to conventional insulin-therapy, especially in cases of diabetes which are difficult to balance and particularly in cases with frequent hypoglycemic malaise.

The aim of this study was to prospectively study the complication rate of our 100 initial laparoscopic cholecystectomies. The ultimate goal was to obtain a morbidity rate comparable to open cholecystectomy. No major complications were noticed. The conversion rate to open cholecystectomy was 8%, slightly higher in comparison with the literature. Absence of major complications could be explained by: a) indications limited to symptomatic non complicated cholelithiasis; b) assistance at the beginning of our experience of gynecologists used to laparoscopic techniques; c) conversion to open cholecystectomy in case of technical difficulties. Application of these principles allows the digestive surgeon to start laparoscopic cholecystectomy without submitting the patient to additional risks.

In this study designed to investigate the nutritional state induced by biliopancreatic bypass in the rat, the pancreatico-biliary secretions were diverted via the duodenum and jejunum into the distal ileum, the remaining intestine being directly anastomosed to the stomach after antrectomy. Bypassed animals lost weight: it was only 56 percent of that of controls after 36 days and death by cachexia resulted within two months of the procedure. The reduced food intake (16 percent less than control) at the 36th postoperative day cannot by itself explain the weight loss, since pair-fed rat weights did not differ statistically from controls at 36 days. Protein-energy malabsorption occurred: drops in serum protein concentration (25 percent less than control), triglycerides (40 percent less) and total cholesterol (28 percent less) were recorded from the 12th postoperative day on. Biliopancreatic bypass may be an adequate procedure of treatment for morbid obesity simultaneously aggravated by metabolic disorders.

The effect of a 90% small bowel resection on the exocrine pancreas was investigated over a three month period in adult Wistar rats. Control animals underwent a sham-resection consisting of a transection and reanastomosis of the small intestine. After jejunoileal resection, the wet weight of a gland increased significantly (52%) from the 15th day. The parallel increase in total protein, DNA and RNA content without any modification in the ratios of pancreatic weight, protein, and RNA to DNA suggests that there is cellular hyperplasia but not hypertrophy. Small intestinal resection decreased significantly the amount of amylase when expressed per unit pancreatic weight; it reduced slightly but not significantly that of chymotrypsin, while it did not modify the amount of lipase. However, the total amount of these enzymes in the pancreas remained unaltered when compared with controls. It is concluded that a massive resection of the small bowel induces cellular hyperplasia in the rat exocrine pancreas; this could compensate that reduced level of enzymes in acinar cells.

1. 1. Auto- or homoimplantations of thyroid tissue were performed into the testicles of surgically thyroidectomized male guinea pigs. 2. 2. In this experiment, three groups of animals were studied: autografted, homografted (both without any thyroidal remnant) and regenerates in situ after surgical thyroidectomy without testicular graft; their hormonal release was compared with that of control animals. 3. 3. This activity was estimated by various techniques (plasma P.B. 131I, radiochromatography and chemical dosage of the P.B.I). 4. 4. The hormonal release of the auto- and homografts, as well as of the regenerates, appeared to be quantitatively and qualitatively normal. 5. 5. However, the iodine turnover differed in both grafted thyroids and regenerates with respect to normal thyroid in situ. The biological significance of these differences is discussed.

To control hemorrhage and eliminate the ulcerogenic mechanism, some surgeons have favored gastric resection and others have preferred the more conservative approach of a vagotomy. The analysis of our 50 cases has shown a high frequency of hemorrhage by arterial erosion. All the patients have been treated by transfixing the ulcer with a local suture, associated with a truncular vagotomy and a gastric drainage, the global mortality rate was 26%. The mortality rate in the group of patients with massive bleeding forcing emergency operation is 33%. No death was observed in the group of patients where bleeding was controlled firstly by non operative measures and operated on later. The patient's chances of survival are markedly improved in the group of younger patients. The analysis of literature have shown that the incidence of rebleeding is the same following vagotomy or partial gastrectomy. The post operative mortality rates after these two types of emergency operative procedures are also quite similar. In conclusion, direct ligation of the ulcer base in massive bleeding, coupled with vagotomy, seems to be the operation of choice.

On the forehead, the epicranial fascia or aponeurosis (galea) splits to enclose the musculus frontalis. The superficial fascia, thin and transparent, separates the muscle from the fatty layer (panniculus) of the overlying skin. The deep fascia, thick and fibrous, is separated from the periosteum by a loose areolar tissue which allows the whole skin to move over the skeleton. The two bellies of the m. frontalis are anchored jointly on the midline, where their superficial and deep fasciae are tightly joined together. The loose areolar tissue beneath the galea is a cleavage plane facilitating plastic surgery of the scalp. On the scalp and forehead of adult male patients, benign, well differentiated and encapsulated lipomas may develop in this deep plane. This localization seems to be particularly frequent but has seldom been described. According to the available literature, 1.9 to 14.5 per cent of cutaneous lipomas are situated on the head and neck. In a retrospective review of 246 skin lipomas from our own files, we found 20 lipomas of the forehead (8 per cent), and among these 12 were located beneath the galea, between the frontal muscle and the periosteum. While the M/F sex ratio is approximately 2:1 for the cervico-cephalic lipomas, subfascial lipomas of the forehead prevail in adults and old men (90 per cent). Clinically, the "subfacial forehead lipoma" presents as a round or oval, smooth, flat or dome-shaped tumour. The skin is raised above the lesion, glides over its surface, and the parallel pattern of its wrinkles remains unaltered. The lesions are usually symptom-free and are ascribed by some patients to a minor, woundless trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report 11 cases of hemorrhage due to vascular ulcerations arising early or late in the course of acute pancreatitis. The seriousness of these hemorrhages, the difficulties of their therapy are pointed out. In all cases, bleeding should be controlled by surgery. Therefore, attention is drawn to the need for prompt laparotomy in all the shocked patients who failed to respond to conservative measures, for in such cases, a fatal outcome may rapidly occur. The respective advantages and inconveniences of the 2 main surgical treatments, ligation of bleeding vessels or pancreatectomy removing the source of bleeding, are discussed, basing on the presently reported cases and the data of the literature.

Two cases of end-to-end and end-to-side jejuno-ileal bypass for the treatment of obesity are reported in which both patients underwent reoperation 17 and 23 months later respectively. Macroscopic examination and measurements of length of the various segments of the small intestine have been performed twice in each patient: at the time of the bypass and at the second surgical procedure. In one patient a histological study of both the excluded and functioning small intestine was carried out at the time of each surgical procedure. The functioning intestine had increased in size while the excluded segment had become narrowed. The height of the villi had increased slightly in the functioning ileum and more so in the functioning jejunum compared with the preoperative measurements. In contrast, the height of the villi was moderately reduced in both the bypassed jejunal and Heal segments. These findings confirm the results of experimental studies in animals.

The authors have reviewed a series of 5 348 cases of appendectomy. They have registered 25 post-operative deaths, of which 22 were due to medical complications and 3 to surgical complications. Surgical complications, which involved a second operation in the early post-operative period, were noted in 31 patients. In over 50 p. cent of the cases, complications have been observed after appendectomies for common appendicitis. Most of the time, they were revealed by an occlusion, a peritoneal syndrome or a setting of intraperitoneal abscesses. In about 50 p. cent of the cases, the post-operative occlusion points to the presence of an abscess, a peritonitis or an hematoma. The most frequent and severe complications are caused by infection. In the present series, an overall mortality of appendectomy of 0.47 p. cent has been observed. In the patients who have to be reoperated, the overall mortality of 6.6 p. cent corresponds to a risk which is 15 times higher.

International audience; The effect of a chronic administration of cholecystokinin (CCK) on the rat pancreas has been studied in rats subjected to a 90% jejunoileal bypass or an intestinal transection (controls). Jejunoileal bypass, when compared to transection, did not modify the size of the pancreas but decreased its enzyme content, especially for amylase, and reduced the number of zymogen granules. These structural and biochemical changes were maintained when bypassed animals were treated three times daily and for six days with cholecystokinin (20 Ivy Dog Units (IDU)/kg). In contrast, CCK treatment in transected animals induced growth of the pancreas due to cellular hypertrophy and hyperplasia; pancreatic enzyme content, especially for chymotrypsin, and the population of zymogen granules in acinar cells were also enhanced. It is concluded that jejunoileal bypass prevents the trophic action of chronic CCK on the pancreas.

The influence of a 90% jejunoileal bypass on the rat exocrine pancreas was studied by morphometrical procedures. In sham-operated animals exocrine acinar cells accounted for 80.3% of the pancreas volume. These cells are composed of 9.9% nuclei, 8.4% mitochondria, 12.2% zymogen granules, 0.3% lipid droplets and 69.2% of a compartment (“ERGLS”) composed of endoplasmic reticulum, ribosomes, Golgi areas, lysosomes and the cytoplasmic ground substance. Intestinal bypass did not change the volume density of exocrine cells nor that of nuclei in the cells during the three postoperative months. The means nuclear diameter was approximately the same in both groups. However, the volume density of secretory granules diminished by 50%. This was accompanied by a decrease in mean granular diameter, but not in their numerical density. The volume density of lipid droplets increased 10 fold, that of mitochondria increased slightly from the 15th postoperative day but significantly from the 45th day. The remaining cellular compartment composed of “ERGLS” was not modified by intestinal bypass. These findings suggest that a 90% jejunoileal bypass induces major changes in the composition of pancreatic acinar cells but not in their size.

The rare instance of a gastrointestinal hemorrhage caused by a lithiasis of the duct of Wirsung is described. The world literature records only 13 other cases. Pancreatic calculi cause hemorrhage by either migrating through the pancreatic parenchyma to perforate the duodenum, ulcerating the vessels of the periductal parenchyma, or rupturing the pancreas. The usual sign of this complication of chronic calcifying pancreatitis, difficult to diagnose, is repeated gastrointestinal hemorrhages and sometimes pain, as in epigastric colitis. The immediate therapy is control of the hemorrhage. With transcatheter occlusive techniques, radical surgery can be postponed until it is more tolerable.

Three observations including one cyst and two pseudocysts of the adrenals are reported. Such lesions are uncommon and are only detected fortuitously or because of poorly specified pains. Diagnosis, formerly based upon intravenous urography and arteriography, has largely benefited from echotomography and computed tomography. Endothelial cysts and pseudocysts account for most of these lesions. The possibility of malignancies justifies the systematic surgical approach.

Biochemical, structural, and functional studies of the exocrine pancreas were performed in adult male Wistar rats over a 3-month period following a 90 per cent jejunoileal bypass or sham operation. The wet weight of the gland, its content in total protein and DNA, as well as its structural organization were similar in both groups. The enzyme content was globally reduced after bypass surgery. However, amylase was much more and earlier affected than lipase and chymotrypsinogen. In addition, zymogen granules diminished in size while lipid droplets deposited in acinar cells. Enzyme secretion stimulated or not by increasing concentrations of caerulein in vitro was generally reduced after intestinal bypass and approximately parallel to the depressed amount of enzymes in the pancreas. These findings suggest that jejunoileal bypass does not modify the size of the rat pancreas despite protein deficiency, but its enzymatic composition and secretory function is altered.

Morphologic and functional adaptations of the functioning intestine were evaluated in 41 patients before and after biliopancreatic bypass for morbid obesity. This surgical procedure diverts pancreatobiliary secretions via the duodenum and the jejunum into the colon, the remaining small intestine being anastomosed to the stomach after antrectomy. In the proximal ileum there was an 80% increase of the height of villi; the specific activities of maltase, sucrase, and aminopeptidase in brush border membranes remained unaffected, and that of lactase tended to decrease. In the distal ileum villi heights increased only by 58%, and disaccharidase activities (except for maltase) were slightly enhanced. In the colon the mucosa displayed, in some patients, focal appearance of true villi, and brush border enzyme activities increased concomitantly. We conclude that biliopancreatic bypass induces an adaptation of all intestinal segments of the functioning intestine; this adaptation tends to compensate for the shortening of the gut continuity.

Peritoneal mesothelioma ranks second in frequency after pleural mesothelioma. A well-established clinical entity since 1960, mesothelioma is increasingly frequent due to improvements in diagnostic methods and to the fairly wide industrial use of asbestos, a well-known carcinogenic substance for mesothelial cells. The diagnosis of malignant peritoneal mesothelioma rests on a corpus of convergent data. Treatment consists of surgery combined with radiotherapy and chemotherapy. The mean survival from the time of diagnosis is 8-10 months.

The authors report a series of 22 patients operated for primary hyperparathyroidism. The parathyroid adenoma was located preoperatively by MRI and ultrasonography. Measurement of the relaxation time was performed in vitro at 37 degrees C in a 0.47 Tesla field during the 30 minutes following resection. The relaxation times obtained at a precession frequency of 20 mHz were 0.844 +/- 0.16 sec for T1 and 0.082 +/- 0.025 sec for T2. MRI had a sensitivity of 73% and a specificity of 88% for the localization of the parathyroid adenoma, while ultrasonography had a sensitivity of 73% and a specificity of 98%.