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Background: Incisional hernias can be associated with pain or discomfort. Surgical repair especially mesh reinforcement, may likewise induce pain. The primary objective was to assess the incidence of pain after hernia repair in patients with and without pre-operative pain or discomfort. The secondary objectives were to determine the preferred mesh type, mesh location and surgical technique in minimizing postoperative pain or discomfort. Materials and methods: A registry-based prospective cohort study was performed, including patients undergoing incisional hernia repair between September 2011 and May 2019. Patients with a minimum follow-up of 3–6 months were included. The incidence of hernia related pain and discomfort was recorded perioperatively. Results: A total of 1312 patients were included. Pre-operatively, 1091 (83%) patients reported pain or discomfort. After hernia repair, 961 (73%) patients did not report pain or discomfort (mean follow-up = 11.1 months). Of the pre-operative asymptomatic patients (n = 221), 44 (20%, moderate or severe pain: n = 14, 32%) reported pain or discomfort after mean follow-up of 10.5 months. Of those patients initially reporting pain or discomfort (n = 1091), 307 (28%, moderate or severe pain: n = 80, 26%) still reported pain or discomfort after a mean follow-up of 11.3 months postoperatively. Conclusion: In symptomatic incisional hernia patients, hernia related complaints may be resolved in the majority of cases undergoing surgical repair. In asymptomatic incisional hernia patients, pain or discomfort may be induced in a considerable number of patients due to surgical repair and one should be aware if this postoperative complication.

We report on a case of migration inside the liver of the distal end of a ventriculoperitoneal shunt catheter in an adult patient. A simple laparotomy permitted the surgical removal with no haemorrhagic complication. We discuss the other cases reported in the literature and we outline the need to perform an abdominal CT scan in patients carrying a VP shunt with digestive symptoms.

Pinaverium bromide is a specific calcium channel blocker used in the treatment of irritable bowel syndrome (IBS) for its spasmolytic activity. The aim of the present study was to evaluate the effect of orally administered pinaverium bromide on jejunal motility and total and segmental colonic transit time in control subjects. Gastrointestinal studies were performed in 10 healthy volunteers (30 +/- 3 years), before and after a treatment phase of 14 days (150 mg/d). Jejunal motility was measured by prolonged manometry (14 h) and colonic transit time by a multiple ingestion, single marker technique. No significant modification of phase III of the migrating motor complexes was demonstrated. On the contrary, a significant (p < 0.01) but weak decrease of the frequency of contraction was found. Unlike previous studies, no decrease of total or segmental colonic transit time was demonstrated.

The surgical treatment of severe attacks of sigmoid diverticulitis and the indications for prophylactic surgery are currently matters of debate. We have analysed our experience in a university hospital, bringing new information into the discussion.All patients admitted to our department between 1995 and 2002 for an attack of sigmoid diverticulitis were reviewed. There were 222 who had had a first attack and these formed the basis of the study. Analysis of short- and long-term outcomes was made.Of the 222 patients, 66 underwent an operation during the first admission (mainly Hartmann's operation) with no death. Twenty-five patients were operated during a subsequent admission, either for a deterioration of their symptoms or prophylaxis. One hundred and twenty-eight patients were managed conservatively, and were followed up for 5-12 years. Recurrence was observed in 43% of the patients with a trend to a higher incidence in patients under 50 years. Recurrent exacerbating diverticulitis were severe in 13% of cases.Complicated diverticulitis can be managed with a low mortality. Hartmann's operation was proven safe in our experience. The risk of recurrence was higher than observed in many recent studies but few recurrences were severe.

The authors have retrospectively analysed the drainage fluid of 39 patients undergoing Whipple's operation over a 18-year period. The aim of the study was to assess whether the volume and amylase concentration of the drainage fluid were good criteria of healing of the pancreatico-jejunal anastomosis. The patients have been divided into two groups: Group I (30 patients) with no complications at the pancreatico-jejunostomy--Group II (9 patients) with a pancreatic leak. The analysis of the volume, amylase concentration and amylase index (Log of the amylase concentration x volume) showed that the groups had clearly different profiles: in group I all three criteria were rapidly decreasing, while they remained abnormally high in group II. Those criteria may help the clinician in the monitoring of individual patients; they also may prove useful in prospective studies evaluating new means of prevention of this anastomosis.

Since the first attempts at resection of Klatskin tumours, an increasingly aggressive surgical treatment has been proposed. Results obtained after examination of the specimen have shown that a significant proportion of resections were palliative. Curative resection appears to be difficult to perform selectively.This retrospective study evaluates the results of a surgically-oriented management of hilar bile duct cancers. Thirty-nine patients were operated on in the period 1982-1994. Eighteen resections were carried out, requiring liver resection in 13 cases. Pathology of the specimen showed that the resection had been curative in 14 cases. The remaining 21 patients had surgical palliation, i.e. bypass and/or stenting.In the resection group, there was no death but four patients suffered severe complications. The 1- and 5-year survival rates were 67 and 47 per cent respectively, with a median survival of 26 months. In the palliation group, the mortality rate was 14 per cent and median survival was 7 months.In the absence of evident contraindications, surgical exploration is worthwhile as it allows detection of the cases where curative resection is possible. Curative resection often requires a major hepatectomy, but mortality and morbidity may be kept low, and it offers a real hope of cure.

Evaluate the surgical approach of curative resection in patients treated for cancer of the hepatic hilus.We made a retrospective analysis of 50 cases collected between 1982 and 1994. Preoperative work-up was progressively centered on ultrasonography and Doppler examinations together with transhepatic cholangiography. Surgery was performed in 39 patients; surgery was not attempted in 11 patients in poor health status or with advanced stage disease.Curative resection was performed in 14 of the 39 operated patients. There were no hospital deaths and mean survival at 5 years was 60%. Median survival was 23 months. A palliative procedure was used in 25 patients with 3 deaths and a 7-month median survival. Transhepatic intubation of the bile ducts was performed in the 11 non-operated patients: there were 3 deaths and median survival was 3 months.A surgical approach, based on a simple preoperative work-up and extensive surgical exploration together with extemporaneous pathology can detect cases in which curative surgery is indicated. Care for operated patients given only palliative treatment is not compromised with this attitude and results are at least as good as those obtained with endoscopic or transhepatic intubation.

Internal fistulas in Crohn's disease join a diseased intestinal segment to a "victim organ" (VO) that is affected by proximity. While the diseased segment is resected, the other can be sutured in selected cases.Seventy-four patients with 100 internal fistulas were retrospectively reviewed to assess the results of this conservative operative approach.Closure of the fistulous defect of the VO was achieved by resection (n = 41) or suture (n = 59). The VO was histologically unaffected by Crohn's disease in 86 cases. One patient died postoperatively. Three patients had postoperative fistulas after suture of the VO. There was no long-term recurrence of an internal fistula.Surgical treatment of internal fistulas can be achieved safely by resection of the source of the fistula and suture repair of the VO when the latter is not affected by active Crohn's disease and when local conditions make it feasible.

Internal fistula is a complication of Crohn's disease. Among 589 patients operated upon at Hôpital Saint-Antoine between 1970 and 1992, 17 (2.9%) had entero-vesical fistula. Ileovesical fistulas were twice as frequent as sigmoidovesical fistulas. Typical symptoms were pneumaturia, fecaluria, and recurrent urinary tract infection. Cystoscopy was performed in 8 patients and determined the site of the fistula in each case. The indication for operation was the fistula itself (35%) or another complication of Crohn's disease (65%). Associated lesions were as follows: 6 entero-enteral, 2 ileogenital, 5 enterocutaneous fistulas and 6 intraabdominal abscesses. Resection of the bowel segment responsible for the fistula was performed in every case, with primary anastomosis in 9 cases and enterostomy in 8 cases. The vesical opening was excised and sutured in 10 cases and left open in 7 cases. An urethral catheter was left in place for at least 7 days. There was no postoperative death; one postoperative external vesical fistula healed without reoperation. Seven enterostomies have been closed, one is definitive. There were no late recurrences of vesical fistula.

Pilonidal sinus, acute or chronic suppuration of the sacrococcygeal region, is a common benign disease. Its treatment, usually surgical, remains controversial, between wide excision and limited excision and between primary closure and secondary closure. On the basis of our experience and a review of the literature, we propose limited excision with immediate closure for non-infected operations and exposure with immediate resection for pilonidal abscesses. Regardless of the technique used, the morbidity is high, associated with a recurrence rate of between 5 and 40%.

Entero-enteral fistulas join a segment affected by Crohn's disease to another which becomes a drainage route and a "victim" of the process. Surgical treatment can be radical (extensive resection of both segments) or conservative (resection of involved bowel and conservation of the "victim"). Fifty-nine patients operated on for Crohn's disease and having 80 entero-enteral fistulas were retrospectively studied.Main surgical indications were symptomatic intestinal stenosis (56%) or abdominal mass (20%) unresponsive to medical treatment. Fistula was discovered during operation in 33 patients (56%). Conservative treatment was performed in 39 fistulas (49%). In 41 fistulas (51%), proximity of fistulous ends, or Crohn's disease's extension, led to radical treatment. In 66 fistulas (82.5%), histologic examination revealed that Crohn's disease affected only one bowel segment, the other demonstrating only non specific features; in the 14 remaining fistulas (17.5%), Crohn's disease affected both segments.The clinical presentation of entero-enteral fistulas (non-specific symptoms, frequent peroperative diagnosis), their pathological features (victim segment often free of Crohn's disease) plead for a conservative surgical approach, i.e. adapted to real bowel involvement by Crohn's disease.

The aim of this study was to assess the results of ileal "J" pouch-anal anastomosis in ulcerative colitis. One hundred and fifty six patients operated on between 1983 and 1991 for ulcerative colitis were followed-up prospectively since the surgical procedure with a mean of 29 +/- 16 months (range: 6 to 92 months). There was no postoperative death. Forty-four patients (28%) presented 48 post-operative complications and 14 (9%) were reoperated. Twenty-five patients (16%) were reoperated because of a late complication. Three pouches had to be removed for untreatable fistulas which appeared to be related to a Crohn's disease in 2 cases; the reestablishment of a diverting loop ileostomy was mandatory in 2 further patients for anoperineal sepsis. The mean stool frequency at 1 year was 4.5 +/- 1.9; 40% of patients did not have nocturnal stooling. Daytime and nighttime continence were normal in 90.7% and 77.5% of cases respectively, 87% of patients considered their social life improved by the surgical cure of the disease. The results observed 5 years after the surgical procedure in 37 patients were similar to those observed at 1 year. Twenty-five patients (16%) presented one or several episodes of pouchitis, including 5 cases of chronic pouchitis. It is concluded that the treatment of ulcrerative colitis, ileal "J" pouch-anal anastomosis, is a safe and effective procedure which provides good functional results.

Between 1960 and 1988, 83 patients (38 men, 43 women) underwent colectomy and ileorectal anastomosis (IRA) for severe colonic or rectal Crohn's disease. The mean age at IRA was 28.5 years. The mean interval from diagnosis was 4 years. There were two post-operative deaths. Among the 81 survivors 5 patients who had a covering ileostomy have never had their stomas closed and 24 patients required exclusion or excision of their IRA and rectum. (= 10 defunctioning IRA, 14 proctectomies with definitive ileostomy). The mean interval between IRA and the creation of a permanent ileostomy was 4.1 years. The mean interval between the onset of problems following IRA and permanent ileostomy was 2 years. 25 patients had perianal lesions prior to IRA. 5 of these patients had unhealed perianal disease at IRA and 7 required defunctioning ileostomy (28%). The need for rectal excision or exclusion following IRA was not related to the presence of perianal disease prior to IRA but functional results were worse. 33 patients developed perianal lesions following their IRA, among whom 19 required exclusion or excision of the rectum. Failure of IRA was then significantly higher amongst those who developed lesions following IRA. Rectal preservation after IRA may be proposed with success to patients with a healthy rectum or with minimal or moderate proctitis, even if there is perianal disease that could be safely treated before IRA. In this last setting the patient has to be informed of the risk of rectal preservation and the possible risk of requiring ulterior protectomy.

In order to precise the indications and results of this procedure, we assessed 11 cases of transformation of ileorectal anastomosis (IRA) to ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). These 5 men and 6 women had undergone IRA at a mean age of 31 years, 33 months after the diagnosis of UC (range 3-120). Four of these IRA, excluded by an ileostomy, had never been in function: the cause was severe persistent proctitis in 2 cases and anastomotic leakage and peritonitis in 2 cases. The other 7 IRA had been in function during a mean period of 25 months (range 6-45) and were reoperated because of anal sepsis (1 case), low rectal stenosis (1 case), disabling proctitis (4 cases) and rectal dysplasia (1 case). No patient had specific pathologic signs of Crohn's disease. The 11 IPAA were complicated by pelvic sepsis in 3 cases; surgical drainage succeeded in 1 case, but the 2 others needed pouch excision and terminal ileostomy. The diagnosis of Crohn's disease was eventually made in these 2 patients. The 9 patients with functioning IPAA, at a mean follow-up of 40 months (range 12-60), had 5.2 stools per 24 h (range 2-12), 5 patients had no nocturnal stooling, and 6 had a perfect continence. One patient had disabling chronic pouchitis. In conclusion, proctectomy with IPAA is always feasible when a previous IRA for UC had failed or offers poor results, but should be rejected in case of anal involvement, as that may suggest Crohn's disease. This procedure is followed by similar functional results than after primary IPAA.

Eighty-three consecutive patients (38 men, 45 women) underwent colectomy and ileorectal anastomosis (IRA) for Crohn's colitis between 1960 and 1988. The mean age at the time of IRA was 28.5 years after a mean interval of four years from diagnosis. At the time of IRA, 31 patients had proctitis, while 25 had perianal disease. Two patients died postoperatively. Postoperative complications appeared in 21 cases (25.3%) including 7 anastomotic leaks (13.2%). Leakage did not imply IRA compromise and the diverting ileostomy did not decrease the risk of preservation of the ileorectal anastomosis. With a mean follow-up of 8 years after IRA, among the 81 surviving patients, it was necessary to retain the stomy in five, 24 required exclusion or excision of their IRA (10 defunctioning ileostomies, 14 proctectomies) and 52 still had a functioning IRA at follow-up (64.2%). Among the 43 recurrences (53%), 21 underwent reoperation. The mean interval between IRA and recurrence was 2.2 years. The cumulative rate of recurrence reached 47% at 5 years and 57% at 10 years. Fifty percent of the patients still had a functioning IRA and were satisfied. Preoperative ileal lesions affected the functional results of the IRA and the recurrence rate. Development of ileal, rectal or anal disease after IRA significantly increased the risk of exclusion of the rectum but did not require suppression of anal function. Patients under 30 years of age or patients suffering for more than 5 years had poorer functional results and more frequent reoperations at 5 years. Rectal preservation after IRA may be proposed with success to patients with a healthy rectum or with minimal or moderate proctitis, even if there is perianal disease that could be safely treated before IRA. In this last setting, the patient has to be informed of the risk of rectal preservation and the possible risk of requiring ulterior proctectomy.

In AIDS patients an acalculous cholecystitis may be responsible for abdominal pain subsiding after cholecystectomy. But the indications for cholecystectomy are not clear: cholecystitis is usually associated with diffuse cholangitis and this might cause the symptoms. Since 1985, 8 AIDS patients have undergone cholecystectomy for acute cholecystitis. Ultrasonography revealed a 5 to 12 mm thickening of the gallbladder wall in all of them and gallbladder stones in two; four patients had cholangitis. The decision to operate was based on persistent pain associated with fever, poor general condition and muscular rigidity at palpation. Four patients had septic shock at the time of surgery; one died in the immediate postoperative period. In all other patients pain and septic syndrome subsided. Two patients died of AIDS complications 20 days after surgery; the remaining five died of AIDS 6, 9, 10, 12 and 14 months respectively after surgery; in two of them cholestasis had reappeared due to cholangitis. To summarize, in the 8 AIDS patients studied cholecystectomy was performed for clinical deterioration. Gallbladder pathology was responsible for the abdominal pain and the febrile general condition which was relieved by cholecystectomy.

The aim of this study was to compare the functional results of ileo-rectal anastomosis and ileal pouch-anal anastomosis in a group of patients with familial adenomatous polyposis who had conversion of a ileorectostomy into a ileal pouch-anal anastomosis. In 2 cases (8.3 percent), the conversion was impossible because of abdominal desmoid tumors. For the remaining 21 patients, with more than 1 year follow-up, the number of bowel movements per 24 hours was 3.8 +/- 0.2 before and 4.6 +/- 0.3 after conversion. Daytime and nighttime continence and sensation of the need to defecate were unchanged. The number of patients having nocturnal bowel movements were higher after the pouch procedure (40 vs 10.5 percent). After ileorectostomy and after conversion, 89.5 and 80 percent of the patients had good functional results respectively. Ninety percent of the patients said that results were unchanged or improved after the conversion. In familial adenomatous polyposis the functional results of ileal pouch-anal anastomosis are similar to those of ileorectostomy but the first procedure eradicates the risk of rectal cancer. A conversion to ileal pouch-anal anastomosis should to be proposed to patients with ileorectostomy and at high risk for rectal cancer.

The relationship between pancreas divisum and chronic pancreatitis is controversial. We report the cases of two patients aged 40 and 53 years suffering from recurrent pancreatitis and known to have histologically proven idiopathic chronic pancreatitis. One patient had insulin dependent diabetes. Pancreatography demonstrated in these two cases a pancreas divisum with a dilated dorsal pancreatic duct. A pancreatico-jejunostomy was performed, associated in one case with splenopancreatectomy for pseudo-cyst. With a follow-up of 32 and 78 months, both patients were free of symptoms and the diabetic patient had normal blood glucose levels with diet alone. The clinical history of the patients suggests a relationship between pancreas divisum and chronic pancreatitis and that pancreatico-jejunostomy may improve pancreatic pain and pancreatic function.

The operative diagnosis of colonic ischaemia in association with acute necrotizing pancreatitis (ANP) may be difficult in the absence of unequivocal transmural necrosis or perforation. We introduced in May 1988 a new policy whereby, when colonic viability was dubious, resection was avoided and a diverting loop ileostopy (DLI) was performed. If necrosectomy led to extensive mobilization of the splenic flexure with a capillary drainage system placed in close contact, a DLI was again performed. Colectomy was only performed for unequivocal transmural necrosis. Among 30 patients operated on for ANP, 12 underwent DLI. This policy allowed us to spare potentially ischaemic colons. No secondary colonic complication occurred and there was no rise in the mortality rate. Among patients whose colon was kept in circuit there were bouts of bowel distension and unexplained bacteriemia ultimately leading to death from multiorgan failure. When colonic viability is dubious and when drainage is brought up in close contact with the bowel wall DLI might allow colonic resection to be avoided. In our experience DLI also seemed to prevent secondary colonic complications.

The hemostatic potential, tolerance and handiness of a new generation of hemostatic sheets (Hemostagene) were compared with those of reference collagen sheets in a randomized parallel-group multicenter study. Both types of hemostatic sheets, issued from calf derm, have been evaluated in digestive and neurosurgical pathologies. The comparability of both groups (52 patients in the Hemostagene group A, 54 in the reference group B) has been verified on morphological data, coagulation records and hemostasis conditions. The time required to achieve hemostasis was slightly, yet not significantly, shorter in group A (3 min 27 sec) than with the reference sheet (4 min 10 sec). This new sheet was judged significantly handier than the reference sheet. Adherence to the gloves and instruments was very significantly (p less than 0.0001) more frequent in the reference group B than in the group A. Both collagen sheets have quite similar clinical, biological and immunological tolerances which confirms the literature data. So, this new sheet, together with an hemostasis at least as good as the one obtained with the reference sheet, brings a highly improved handiness.

International audience; Patients who have an interruption of the small bowel with a high enterostomy usually need parenteral supply or reinfusion of chyme to maintain nutritional and electrolytic balances before restoring intestinal continuity. Ten patients (aged 28-76 years) with a terminal jejunostomy located within the first meter of jejunum were treated by infusion of an elemental diet into the distal small bowel (IEDDSB). In addition, five of these patients had an extensive small bowel resection. IEDDSB was started 32 days after operation and lasted 4 to 8 weeks. Mean daily caloric infusion was 1,732 +/- 666 kcal diluted in 2,860 +/- 808 ml; mean associated oral intake was 1,187 +/- 480 kcal/24 hr, and jejunal fecal losses averaged 3 kg per day. IEDDSB was well tolerated in 4 patients; 5 experienced transient abdominal pain or diarrhea; 1 developed severe and protracted diarrhea. Biological cholestasis was seen before IEDDSB and persisted in most patients; 1 patient developed biliary sludge. Through IEDDSB, nutritional status improved or remained satisfactory in 9 patients, and worsened in 1 patient with sepsis and a short lower intestine. Mean body weight, triceps skin fold, muscle circumference, serum albumin, serum transferrin did not change significantly. Digestive nitrogen balance performed in 6 patients showed a net absorption between 5 and 15 g/24 hr. Fluid and electrolyte balance was maintained in 9 patients and 1 received iterative intravenous saline. Digestive sodium balance showed a net absorption rate greater than 60 mmol/24 hr. in all patients, except the one who required intravenous supply. Postoperative recovery was uneventful in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1978 to 1987, thirty patients were secondarily referred to Saint-Antoine Hospital for the treatment of their hepatic trauma. Seventeen were referred because of a postoperative complication (group I) and thirteen after peri-hepatic packing (group II). In group I, transfer was decided because of hemorrhage (8 patients), sepsis (6 patients) and haemobilia (3 patients). The lesions observed in this group (hemoperitoneum, hepatic sequestrum, intrahepatic hematoma, choleperitoneum and subphrenic abscess) were often related to an incomplete assessment of hepatic damage due to an inadequate exploration and the absence of operative cholangiography. In group II, peri-hepatic packing was effective in eleven patients. The overall mortality was 16.6% (17.6% in group I and 15.4% in group II). Postoperative complications occurred in 50% of the patients (64.6% in group I and 30.7% in group II). Good exposure of the liver, operative cholangiography and, in selected cases, a direct approach to the lacerated liver with suture ligation of severed blood vessels and bile ducts are mandatory for the complete exploration and the treatment of severe hepatic trauma. Peri-hepatic packing and the transfer of the patient to a specialized center is a reliable method when the injury cannot be treated locally.

The records of 56 patients operated upon for ampullary tumors were reviewed in order to determine the best way to diagnose and treat these tumors. Thirty six males and 20 females, 30 to 89 years old, were operated upon between October 1970 and October 1985. Eighty six p. 100 had jaundice and 21 p. 100, anemia. In recent years, ultrasonography, duodenoscopy and ERCP appeared to be the most useful tests for diagnosis. Mean size of the tumors was 2.3 cm (0.5 to 5 cm). Five tumors were benign (8.9 p. 100) and 51 were malignant. According to the classification of Martin, 5 were grade I: 10, grade II: 18, grade III: and 18, grade IV. The correct histologic diagnosis was obtained on biopsy specimens taken during endoscopy in 7 of 12 patients. Nine patients underwent palliative choledocoduodenostomies: only one is alive at 3 years; 47 underwent resection of the tumor: 3 local excisions associated with sphincterotomy for small benign tumors, 6 ampullectomies (followed in 3 by a Whipple procedure for recurrence) and 41 Whipple procedures. After pancreatic resection, 3 patients died during hospital stay and 12 had reversible complications; overall 5 year survival was 41 p. 100. It was 75 p. 100 in grade I, 50 p. 100 in grade II, 40 p. 100 in grade III and 10 p. 100 in grade IV. Patients who received an ampullectomy were alive with a follow up of 1, 2, and 3 years. All patients operated upon for a benign tumor were alive except one who died of cardiac failure.(ABSTRACT TRUNCATED AT 250 WORDS)

One hundred and twenty cases of post-operative jejuno-ileal fistula with evisceration are reported: 90% of the patients came from other departments. Depending on their mechanism, these fistulae fell into two categories: out-flowing fistulae (93 cases) consecutive to spontaneously opened peritonitis draining through the surgical incision, and in-flowing fistulae (24 cases) resulting from trauma of a superficial small bowel loop; 48% of open small bowel fistulae were due to a questionable operation. Unfavourable prognostic factors were: age over 50, supramesocolic initial lesion, fluid production equal or superior to 1000 ml/24 h, history of at least 2 previous median laparotomies and presence of one or several of 7 severity factors. The overall mortality rate was 46%, falling to 38.5% (inoperable cases excluded) after active treatment. The authors propose to concentrate on prolonged medical intensive care, salvage operations being reduced to a minimum. Over the last 4 years, this approach has brought down to 36% the overall mortality rate.

Preservation of the anal sphincter system is now often considered in the treatment of adenocarcinomas of the mid-rectum (inferior limit between 11 and 6 cm of the anal margin). Direct anastomosis of the rectum to the anus or the last two centimeters of the rectum after resection of the rectal pouch is a source of discomfort. The construction of a colon pouch, placed directly above the anus, has been devised in order to improve these results. In the last three years, a J-shaped colon pouch, measuring 8 centimeters X 2, was constructed in 76 patients and anastomosed in its portion to the anal canal, after complete rectal resection. The functional results of this procedure, with uneventful post-operative course, were evaluated in 66 patients with a mean follow-up of 17 months. Continence was satisfactory in 96% of patients, with an average number of stools of 1.4 in 24 hours. Thirty one per cent of the patients require a small enema or a suppository to induce defecation.

An experimental study was carried out in rats to evaluate the outcome of small bowel anastomoses in the presence of peritonitis with and without protection by a polyglactin 910 mesh. One hundred and thirty rats were operated. 1) Thirty small bowel anastomoses were performed in a sterile environment to evaluate the morbidity and mortality due to the surgical procedure itself. All these animals had an uneventful course. 2) Forty anastomoses were performed in a septic environment without protection. Twelve rats died immediately after the procedure. Six rats developed an anastomotic fistula and 22 had an uneventful course. 3) Sixty anastomoses were performed in a septic environment and protected by a polyglactin 910 mesh. Seventeen rats died immediately after the procedure. There were no anastomotic disruptions. Seventeen rats had an uneventful course, and 28 (65%) developed stenosis of the anastomosis. Protection of small bowel anastomoses by a polyglactin 910 mesh appears to effectively prevent disruptions (no anastomotic fistulae or locoregional infections were recorded). However, the mesh is responsible for an intense inflammatory reaction, that often results in intestinal obstruction.

The efficacy of Noxythiolin in solution for peritoneal toilet during operation on 48 patients with acute generalized peritonitis was evaluated. The trial was prospective, with random selection of patients who were divided into two groups with identical backgrounds, initial affections, and therapies applied. No significant differences were noted in prognosis, bacteriological findings or subsequent course in the survivors in the two groups. The only favorable effect noted in the group treated with Noxythiolin was the frequency with which further operations had to be performed, but the difference was nos significant. Though the use of peritoneal antiseptics isjustified when positive bacteriological test are reported, the determining element in peritoneal toilet appears to be the volume of liquid employed, independently of its composition.

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