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BackgroundThe prognostic value of the primary neoplasm responsible for pseudomyxoma peritonei (PMP) remains poorly studied. The aim of this study was to determine the prognosis for patients with extra-appendicular PMP (EA-PMP) treated optimally with complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsAll patients treated for PMP with CCRS and HIPEC between 1994 and 2016 were selected retrospectively from a French multicentre database. Patients with EA-PMP had pathologically confirmed non-neoplastic appendices and were matched in a 1 : 4 ratio with patients treated for appendicular PMP (A-PMP), based on a propensity score.ResultsSome 726 patients were identified, of which 61 (EA-PMP group) were matched with 244 patients (A-PMP group). The origins of primary tumours in the EA-PMP group included the ovary (45 patients), colon (4), urachus (4), small bowel (1), pancreas (1) and unknown (6). The median peritoneal carcinomatosis index was comparable in EA-PMP and A-PMP groups (15·5 versus 18 respectively; P = 0·315). In-hospital mortality (3 versus 2·9 per cent; P = 1·000) and major morbidity 26 versus 25·0 per cent; P = 0·869) were also similar between the two groups. Median follow-up was 66·9 months. The 5-year overall survival rate was 87·8 (95 per cent c.i. 83·2 to 92·5) per cent in the A-PMP group and 87 (77 to 96) per cent in the EA-PMP group. The 5-year disease-free survival rate was 66·0 (58·7 to 73·4) per cent and 70 (53 to 83) per cent respectively.ConclusionOverall and disease-free survival following treatment with CCRS and HIPEC is similar in patients with pseudomyxoma peritonei of appendicular or extra-appendicular origin.

Background Epithelioid peritoneal malignant mesothelioma (EPMM) is the most common subtype of this aggressive tumor. We compared two antibodies against PD-L1, a recent theranostic biomarker, and evaluated the prognostic value of PD-L1 expression by mesothelial and immune cells in EPMM. Methods Immunohistochemistry was performed on 45 EPMM. Clinical and pathological data were extracted from the RENAPE database. Using E1L3N and SP142 clones, inter-observer agreement, PD-L1 expression by mesothelial and immune cells and inter-antibody agreement were evaluated. The prognostic relevance of PD-L1 expression was evaluated in 39 EPMM by univariate and multivariate analysis of overall survival (OS) and progression-free survival (PFS). Results Inter-observer agreement on E1L3N immunostaining was moderate for mesothelial and immune cells, and fair for mesothelial and poor for immune cells using SP142. Using E1L3N, 31.1% of mesothelial and 15.6% of immune cells expressed PD-L1, and 22.2% of mesothelial and 26.7% of immune cells using SP142. Inter-antibody agreement was moderate. In most positive cases, 1–5% of tumor cells were positive. Using E1L3N, PD-L1 expression by lymphocytes was associated with better OS and PFS by both univariate and multivariate analysis. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy predicted better prognosis than other treatments. Solid subtype was an independent prognostic factor for worse OS. Conclusion E1L3N appeared easier to use than SP142 to evaluate PD-L1 expression. A minority of EPMM expressed PD-L1, and only a few cells were positive. PD-L1 expression by immune cells evaluated with E1L3N was an independent prognostic factor in EPMM.

Few series are available on the results of repeat sleeve gastrectomy (re-SG) and Roux-en-Y gastric bypass (RYGB) performed to manage the failure of primary sleeve gastrectomy (SG). The objective of this study was to compare the short- and medium-term outcomes of re-SG and RYGB after SG. Between January 2010 and December 2017, patients undergoing re-SG (n = 61) and RYGB (n = 83) for failure of primary SG were included in this study. Revisional surgery was proposed for patients with insufficient excess weight loss (EWL ≤ 50%) or weight regain. The primary endpoint was the comparison of weight loss in the re-SG group and the RYGB group at the 1-year follow-up. The secondary endpoints were overall mortality and morbidity, specific morbidity, length of stay, weight loss, and correction of comorbidities. The mean interval between SG and re-SG was 41.5 vs. 43.2 months between SG and RYGB (p = 0.32). The mean operative time was 103 min (re-SG group) vs. 129.4 min (RYGB group). One death (1.7%; re-SG group) and 25 complications (17.4%; 9 in the re-SG group, 16 in the RYGB group) were observed. At the 1 year, mean body mass index was 31.6 in the re-SG group and 32.5 in the RYGB group (p = 0.61) and excess weight loss was 69.5 vs. 61.2, respectively (p = 0.05). Re-SG and RYGB as revisional surgery for SG are feasible with acceptable outcomes and similar results on weight loss on the first postoperative year.

The sleeve gastrectomy (SG) can be performed with or without antral preservation (distance from the pylorus

Background Peritoneal metastasis from biliary carcinoma (PMC) is associated with poor prognosis when treated with chemotherapy. Objective To evaluate the impact on survival of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), and compare with conventional palliative chemotherapy for patients with PMC. Material and methods A prospective multicenter international database was retrospectively searched to identify all patients with PMC treated with a potentially curative CRS/HIPEC (CRS/HIPEC group). The overall survival (OS) was compared to patients with PMC treated with palliative chemotherapy (systemic chemotherapy group). Survival was analyzed using Kaplan-Meier method and compared with Log-Rank test. Results Between 1995 and 2015, 34 patients were included in the surgical group, and compared to 21 in the systemic chemotherapy group. In the surgical group, median peritoneal cancer index was 9 (range 3–26), macroscopically complete resection was obtained for 25 patients (73%). There was more gallbladder localization in the surgical group compared to the chemotherapy group (35% vs. 18%, p = 0.001). Median OS was 21.4 and 9.3 months for surgical and chemotherapy group, respectively (p=0.007). Three-year overall survival was 30% and 10% for surgical and chemotherapy group, respectively. Conclusion Treatment with CRS and HIPEC for biliary carcinoma with peritoneal metastasis is feasible and may provide survival benefit when compared to palliative chemotherapy.

Introduction Peritoneal metastasis (PM) of hepatocellular carcinoma (HCC) without distant spread are rare. The related prognosis is poor without standard treatment available. The role of cytoreduction surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is poorly documented. Methods An international multicentric cohort was constituted by retrospective analysis of 21 patients undergoing CRS/HIPEC for PM of HCC between 1992 and 2016 from 10 reference centers of PSOGI. Data on clinical features, treatment strategies, and survival outcomes were analyzed. Results The median time interval from the diagnosis of PM to the procedure was 4.5 months. The median peritoneal cancer index was 14. Sixteen patients had complete cytoreduction (CCR0-1). Ten patients had grades 3 to 4 complications. The median duration of follow-up was 52.2 months. The median OS was 46.7 months. The projected 3y-OS and 5y-OS were 88.9 and 49.4% respectively. The median OS for patients with CCR0-1 resection was not reached whereas it was 5.9 months for those with CCR2-3 resection after CRS (p = 0.0005). The median RFS was 26.3 months and projected RFS at 3 years of 36.5 months Three prognostic factors were associated with improved RFS in the univariate analysis: preoperative chemotherapy (p = 0.0156), PCI >15 (p = 0.009), Number of chemotherapy agents used for HIPEC (p = 0.005). Conclusion CRS/HIPEC is a safe and effective approach in selected patients with PM of HCC. CRS/HIPEC gives the patient a chance for a good relapse free and overall survival and should be considered as an option.

Background Desmoplastic Small Round Cell Tumor (DSRCT) is a rare disease affecting predominantly children and young adults and for which the benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) after complete cytoreductive surgery (CCRS) remains unknown. Methods To identify patients with DSRCT without extraperitoneal metastases (EPM) who underwent CCRS between 1991 and 2015, a retrospective nation-wide survey was conducted by crossing the prospective and retrospective databases of the French Network for Rare Peritoneal Malignancies, French Reference Network in Sarcoma Pathology, French Sarcoma Clinical Network and French Pediatric Cancer Society. Results Among the 107 patients with DSRCT, 48 had no EPM and underwent CCRS. The median peritoneal cancer index (PCI) was 9 (range: 2–27). Among these 48 patients, 38 (79%) had pre- and/or postoperative chemotherapy and 23 (48%) postoperative whole abdominopelvic radiotherapy (WAP-RT). Intraperitoneal chemotherapy was administered to 11 patients (23%): two received early postoperative intraperitoneal chemotherapy (EPIC) and nine HIPEC. After a median follow-up of 30 months, the median overall survival (OS) of the entire cohort was 42 months. The 2-y and 5-y OS were 72% and 19%. The 2-y and 5-y disease-free survival (DFS) were 30% and 12%. WAP-RT was the only variable associated with longer peritoneal recurrence-free survival and DFS after CCRS. The influence of HIPEC/EPIC on OS and DFS was not statistically conclusive. Conclusion The benefit of HIPEC is still unknown and should be evaluated in a prospective trial. The value of postoperative WAP-RT seems to be confirmed.

Background The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease. Methods Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics. Results Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017). Conclusion NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

Most pseudoaneurysms (PsA) of the peripancreatic arteries cause direct erosion of the arterial wall from pancreatic enzymes that are usually in contact with or in a pseudocyst (PC). Rupturing is a rare and serious complication (90% mortality if untreated). We report the case of a 56-year-old patient with chronic alcoholic pancreatitis who developed a cephaloisthmic PC, complicated with a PsA of the gastroduodenal artery revealed by pain and deglobulization associated with cholestasis. After a diagnostic scan, emergency selective arteriography with coil embolization was performed. Five days later, hemorrhage recurred and a cephalic duodenopancreatectomy was performed. PsA of the gastroduodenal artery occur in the first 10 years of chronic pancreatitis. They are revealed by abdominal pains and/or gastrointestinal hemorrhage or shock from rupture. A scan with arterial reconstruction provides diagnosis. Arteriography is the most sensitive technique to locate the aneurysm and its branches and to perform selective embolization with coils. The failure rate is between 0 and 23%. Surgical treatment (elective ligation of the artery or partial pancreatic excision) should be limited to when embolisation fails and/or recurrent hemorrhage.

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

The frequency of bariatric surgery has increased markedly in France in recent years, partly due to a better appreciation of the problem of morbid obesity but also due to the commercial introduction of adjustable gastric banding devices which can be placed by laparoscopic approach. Numerous complications of this surgery are known and require recognition to be appropriately treated. Studies of complications suffer from selection bias, methodologic flaws, and lack of follow-up. The incidence and type of complication are affected by the learning curve and surgical techniques. Postoperative mortality varies from 0.14% for laparoscopic gastric banding (LGB), to 0.31% for vertical banded gastroplasty (VBGP) and 0.35% for Roux-en-Y gastric bypass (GBP); pulmonary embolus accounts for 60-70% of deaths in all groups combined. Early post-operative complications vary with specific procedures. Abdominal wall complications, already frequent in an obese population, are decreased from 10% for open procedures to 6% for laparoscopic gastric banding. Both VBGP and GBP are now being done laparoscopically with increasing frequency. Complications specific to LGB include gastric perforation (0.3%), or port problems (5%). Complications with VBGP and GBP include fistula (1-3%), deep abscess, and pulmonary embolus (2%). Global early morbidity is 4.2% for LGB, and varies from 6.4%-22% for VBGP and 6.2%-11.3% for GBP depending on laparoscopic versus open approach. Late mechanical complications are also specific to type of surgery. Pouch dilatation is the most common late complication of LGB (6.3%) and seems related both to operative experience and to site of placement of the band; it has decreased with higher positioning of the band to leave a minimal gastric pouch and with dissection through the pars flaccida of the lesser omentum instead of directly along the muscular wall of the stomach. It usually requires reintervention. Erosion of the gastric band into the stomach (1.6%) is often asymptomatic and is suggested by late weight gain. With VBGP, disruption of a gastric staple line occurs in 12.1% and stenosis of the outlet with proximal dilatation in 6.5%; erosion of the calibrating band of Marlex or silastic occurs in 2.7%. With GBP, the disruption of a staple line across an intact stomach (23%) has become less of a problem with division of the gastric pouch from the distal stomach (2%). Stenosis of the gastrojejunostomy (3.7%) and marginal ulcer (3.5%) are not uncommon. The incidence of wound hernia, obstructive adhesions, and late cholecystectomy vary with the length and thoroughness of follow-up. Late functional complications such as vomiting, dysphagia, heartburn and esophagitis vary with the quality and length of follow-up study. GBP may cause diarrhea and dumping syndrome. Nutritional complications are more common with GPB than with purely restrictive procedures; iron, folate, and Vitamin B12 deficiency are the rule with GBP and require routine replacement therapy; iron deficiency has been noted even with LGB. ate death seems more related to co-morbidities than to the intervention itself. Thorough long-term follow-up study of complications is indispensable for assessment of outcomes and improvement of laparoscopic techniques. Even the less traumatic surgical approach of laparoscopic band placement should not be considered free of risk; strict adherence to pre-operative surgical indications should be maintained.

Laparoscopic surgery is thought to promote early recovery and quicker return to bowel function. The objective was to evaluate the rate and predictive factors of success, the causes of failure, the morbidity, and mortality during and after hospitalization, as well as to determine whether laparoscopic treatment of acute small bowel obstruction offers the same benefits as for other laparoscopic procedures.The records of 308 patients with acute small bowel obstruction treated laparoscopically in 35 centres between 1 October 1988 and 30 September 1996 were retrospectively reviewed.Treatment was implemented completely by laparoscopy ('success' group) in 168 patients (54.6%). Conversion to laparotomy ('failure' group) was required in 140 patients (45.4%; during the same operation in 126 patients and after a median delay of 4 days (range: 1-12 days) in 14 patients). There were significantly more successes in patients with a history of one or two surgical interventions than in those with more than two (56% vs 37%; P0.05). There were significantly more successes in patients who had undergone appendectomy only (67/94; 71%) than in patients who (i) had no antecedent surgery (52%; P0.05), or (ii) underwent other surgery (33%; P0.001). The rate of success was significantly higher (P0.001) in patients operated on early (24 h) and in patients with bands (54%), than in those with adhesions (31%) or with other causes of obstruction (15%). The median duration of postoperative ileus was significantly shorter in the 'success' group than in the 'failure' group (2 days vs 4 days; P0.001). The median duration of postoperative hospital stay was shorter in the 'success' group than in the 'failure' group (4 days vs 10 days; P0.001). Fewer immediate wound complications were sustained in the 'success' group than in the 'failure' group (1.2% vs 10.7%; P0.001). The total number of immediate or delayed complications and particularly the number of recurrent obstructions after hospitalization as well as the number of deaths did not differ significantly between the two groups.Successful laparoscopic treatment of small bowel obstruction can be expected in patients who are seen early, and who have had one or two previous interventions (particularly appendectomy, especially if bands are found).

The case of a 59 year-old patient, who sustained a post-traumatic fracture of the silastic catheter of his totally implantable venous access device that migrated in the right pulmonary artery, is reported. The venous device was placed six months earlier for the treatment of metastatic spread of a primary unknown adenocarcinoma. The venous device was placed on the left side in consideration of a recent right supraclavicular node biopsy. The catheter was introduced through the left internal jugular vein and its peripheral end was positioned subcutaneously across the clavicle to be connected to the port chamber placed in the infraclavicular region. The accidental fracture of the catheter was attributed to a closed trauma occurred during the transport of a refrigerator on the homolateral shoulder. Treatment involved extraction of the migrated fragment through a percutaneous transfemoral angioradiological procedure. A few days later the chamber was removed and a new totally implantable venous access device was placed on the other side.

The aim of this study was to determine long term prognostic factors of gastric cancer in a population-based series.Out of 1 462 gastric cancers diagnosed in the Côte-d'Or area (494 000 residents) over a 20-year period (1976-1995), 649 (44.4 %) were resected for cure. Prognostic factors were determined using the actuarial method and relative survival and a multidimensional relative survival model.The 10-year crude survival rate was 8.7 % and the corresponding relative survival rate was 14.9 %. Age, stage and period of diagnosis were independent prognostic factors. After surgery for cure, operative mortality decreased from 18.3 % (1976-1979) to 6.6 % (1988-1991) and 10-year relative survival increased from 30.8 % to 37.2 % (NS). After resection for cure (postoperative mortality excluded), the 10-year survival rate remained stable over time. Stage at diagnosis was the main prognostic factor: the relative risk of death was more than 10 times higher at stages IIIB and IV than at stage I. Age, site and macroscopic type of growth were prognostic factors independently of stage. Prognosis did not improve over time after resection for cure.Although improving, the overall prognosis of gastric cancer remains poor. Improvement in prognosis was mainly due to decrease in operative mortality. Earlier diagnosis and effective adjuvant treatment represent two ways to improve prognosis.

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

The prevalence and mechanisms of intestinal obstruction following laparoscopic abdominal surgery have not been studied extensively.Retrospective review of cases of intestinal obstruction after laparoscopic surgery.Sixteen surgical units performing laparoscopy in France.Twenty-four patients with intestinal obstruction.Prevalence values and descriptive data.The 3 most frequent primary procedures responsible for intestinal obstruction were cholecystectomy (10 cases), transperitoneal hernia repair (5 cases), and appendectomy (4 cases). Prevalences of early postoperative intestinal obstruction after these procedures were 0.11%, 2.5%, and 0.16%, respectively. Intestinal obstruction was due to adhesions or fibrotic bands in 12 cases and to intestinal incarceration in 11 cases. Obstruction was located at the trocar site in 13 cases (9 incarcerations and 4 adhesions), mainly at the umbilicus, and in the operative field in 10 cases (2 incarcerations in a wall defect after transperitoneal inguinal hernia repair, 4 adhesions, and 4 fibrotic bands). The small intestine was involved in 23 of 24 cases; the other was due to cecal volvulus following unrecognized intestinal malrotation. Intestinal obstruction was treated by laparoscopic adhesiolysis in 6 patients and by laparotomy in 18 patients, 6 of whom required small intestine resection. Three postoperative complications but no deaths occurred.Intestinal obstruction following laparoscopic abdominal surgery can occur irrespective of the type of operation; the prevalence is as high as (cholecystectomy and appendectomy) or even higher than (transperitoneal hernia repair) that seen in open procedures.

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

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

Omentoplasty (OP) is thought to fill residual cavity, to assist healing of raw surfaces, and to promote resorption of serosal fluid and macrophagic migration in septic foci. Results published to date, whether retrospective or prospective, are not controlled and are discordant.The authors investigated whether OP, either filling the residual cavity after unroofing, or covering the hepatic raw surface after pericystectomy, could reduce the rate or severity of deep abdominal complications (DAC) after surgical treatment of hydatid disease of the liver. Between January 1993 and December 1996, 115 consecutive patients (51 males and 64 females, mean age 42+/-16 years [range 10 to 80 years]) with previously unoperated uni- or multilocular hydatid disease of the liver, complicated or not, without other abdominal hydatid disease, were randomly allotted to OP (n = 58) or not (NO) (n = 57) after unroofing, total, or partial pericystectomy. Patients were divided into 2 strata according to the site of the cyst with respect to the diaphragm: a) posterosuperior segments II, VII, and VIII or b) anterior segments III, IV, V, and VI. Main outcomes measures included deep bleeding, hematoma, infection, or bile leakage. Subsidiary measures included wound complications, extraabdominal complications, duration of operation, and length of hospital stay.Both groups were comparable regarding patient demographics, cyst characteristics, intraoperative procedures, search for bile leaks, and intraoperative transfusion requirements. On the other hand, more patients (86%) in NO had associated drainage of the abdominal cavity than in OP (64%) and the duration of operation was 9 minutes longer in OP, but neither of these differences was statistically significant. Less DAC occurred in OP (10%) than in NO (23%) (a posteriori gamma risk0.05) and fewer deep abdominal abscesses (0 versus 11%) (p0.03). Median duration of hospital stay, however, was similar.OP decreases the rate of DAC and especially deep abdominal abscess after surgical treatment (unroofing or pericystectomy) for hydatid disease of the liver and should be recommended in this setting.

To propose guidelines for treatment based on the study of early and late outcome after various surgical procedures for sclerosing encapsulating peritonitis (SEP). PRIMARY BACKGROUND DATA: SEP is rare. The main complication is intestinal obstruction. Ideal treatment is resection of the membrane, whenever possible. Mortality and morbidity, however, have not been well analyzed.The case records and histopathological reports of 32 operated cases of SEP (18 centers during 16 years) were retrospectively studied. Patients underwent four types of procedures: group 1 (n = 5), membrane resection; group 2 (n = 12), enterolysis with partial excision of the membrane; group 3 (n = 7), intestinal resection, and group 4 (n = 8), exploratory laparotomy only. Five cases were considered as idiopathic. Medical and surgical antecedent history for the 27 other cases (6 patients had associations) included laparotomy for carcinoma (n = 14) or benign disorders (n = 5), beta-blocker treatment (n = 4), cirrhotic ascites (n = 4), generalized peritonitis (n = 3) and continuous ambulatory peritoneal dialysis (n = 3). Indications for operation included subacute (n = 22) or acute intestinal obstruction (n = 6), abdominal mass (n = 8), other clinical presentations (n = 4) and asymptomatic SEP discovered during surgery for portacaval shunt (n = 1). Seven patients had two associated clinical presentations. All cirrhotic patients with ascites and the asymptomatic patient were in group 4. None of the imaging techniques (plain radiograms, barium follow-through, sonograms and CT scans) were formally contributive to the preoperative diagnosis of SEP.In group 1, both complicated patients, one with an inadvertent intraoperative intestinal wound, the other with a postoperative intestinal leak, healed uneventfully. In group 2, 4 inadvertent intraoperative intestinal wounds led to 4 postoperative leaks with 3 consequent deaths. One further patient died of persistent intestinal obstruction. In group 3, 1 inadvertent intestinal intraoperative wound healed uneventfully and 2 deaths, one due to persistent intestinal obstruction associated with anastomotic leakage and the other due to ventricular fibrillation, were noted. In group 4, there were no intraoperative wounds, no postoperative morbidity or deaths. The median follow-up was 49.5 months (range 4-142 months). Seven patients (1 or 2 in each group) experienced transient episodes of subacute intestinal obstruction between 1 month and 6 years after discharge, none of which required a repeat operation. Eight patients (in all groups) died of their initial cancer between 4 and 75 months after discharge.Our results suggest that: (1) resection of the membrane should be attempted when feasible; (2) in case of inadvertent intestinal wound(s), the most proximal one should be brought out as a stoma, and partial resections should not be anastomosed primarily, but (3) no surgical treatment is required in ascites, asymptomatic SEP or subacute intestinal obstruction.

In patients with symptomatic cholelithiasis, preoperative diagnosis of common bile duct (CBD) stones can modify the therapeutic strategy. The aims of this prospective, controlled multicenter study were to assess the feasibility, concordance, discordance, and indexes such as sensitivity, specificity, positive and negative predictive values, and accuracy of preoperative endoscopic ultrasonography compared with those of intraoperative cholangiography (IOC) in the diagnosis of asymptomatic CBD stones (i.e., patients undergoing cholecystectomy with no clinical or biologic evidence of CBD stones).From October 1993 to October 1995, 240 consecutive patients with symptomatic cholelithiasis, scheduled for cholecystectomy in 14 surgical centers, were enrolled in this study. All patients were selected for this study according to a preoperative high-risk CBD stone predictive score. Each patient underwent both endoscopic ultrasonography and IOC, as well as surgical exploration of the CBD when stones were detected during one or both preoperative investigations. All patients were seen 1 months and 1 year after operation to check for residual stones.The feasibility of endoscopic ultrasonography was significantly higher overall than that of IOC (99% vs 90%; p0.001), except when IOC was through a laparotomy (97% vs 93%; p = 0.16). The number of patients available for study was 215. In 198 cases (92%), results of both investigations were in concordance (161 negative and 37 positive values). Seventeen cases (8%) were discordant. There was overall concordance between the two investigations (kappa coefficient 0.764; 95% confidence interval 0.66 to 0.87), but the percentage of discordance was in favor of IOC. Sensitivity and specificity of IOC were significantly higher than those of endoscopic ultrasonography (1.00 and 0.98 vs 0.85 and 0.93, respectively). With a prevalence of CBD stones of 19%, positive and negative predictive values of IOC were significantly higher than those of endoscopic ultrasonography (0.93 and 1.00 vs 0.75 and 0.96, respectively).Although endoscopic ultrasonography is feasible more often than IOC, IOC is associated with a slightly lower degree of discordance and better information indexes and remains an efficient method of investigation for CBD stones. Endoscopic ultrasonography can be suggested in preference to endoscopic retrograde cholangiography when postoperative residual stones are suspected but need not be performed routinely before cholecystectomy.

Gastric cancer remains a common cancer with a poor prognosis. Improving trends seen in Japan have not yet been observed in Western countries.A population-based series of 1329 patients with gastric cancer diagnosed over an 18-year period in Côte d'Or, France, was used to establish time trends in diagnostic strategy, treatment and prognosis.The use of endoscopy alone increased from 2.7 per cent in 1976-1978 to 76.6 per cent in 1991-1993 (P0.0001). This trend was associated at first with a significant decrease in the use of radiography alone, then by a significant decrease in the use of both radiography and endoscopy. The proportion of resections for cure increased from 37.9 per cent in 1976-1978 to 50.0 per cent in 1991-1993 (mean 3-year variation + 5.8 per cent, P0.01). The proportion of cases confined to the gastric wall increased from 6.1 to 11.7 per cent (mean 3-year variation + 13.1 per cent, P0.01), while the proportion of other stages remained stable. The operative mortality rate decreased dramatically from 25.6 per cent in 1976-1978 to 13.6 per cent in 1991-1993 (P0.001) and the 5-year relative survival rate rose from 12.8 per cent in 1976-1978 to 26.4 per cent in 1988-1990 (P0.001).This study has demonstrated that improvements in the care of patients with gastric cancer have been achieved, but that further progress may be made.

The incidence of gastric carcinoma is variable through the world. This incidence has significantly decreased during recent decades, in France and in industrialized countries. The decline of gastric carcinoma is attributable to changes in the living habits and mostly to preservation of foodstuffs by refrigeration; it is explained by the decrease in number of intestinal or differentiated histologic type carcinomas according to the Lauren's classification; on the contrary, diffuse or poorly differentiated histologic type carcinomas became more common in France and in low-risk areas, but is it a relative or an absolute increase? There has been also an unexplained change in location of the tumor with a decreasing incidence in the cancers occurring in the prepyloric area and an increasing incidence in those occurring in the gastric cardia area. Early gastric carcinoma should be really a precursor of the invasive gastric carcinomas. Diagnosis of gastric carcinoma is now based on gastroscopy and biopsy of the lesion. Tumoral extension through the gastric wall and nodal involvement can be appreciated by endoscopic sonography. The procedure (subtotal versus total gastrectomy) depends on the site and extent of the lesion. Elective total gastrectomy is not advocated in patients with carcinoma of the antrum. The value of extended lymph node dissection commonly performed in Japan, is still controversial in Western countries. In patients with carcinoma of the gastric cardia, there is controversy concerning the approach and type of resection, in relation with the frequent esophageal and mediastinal extension of the tumor. In a global series including 408 operated patients, the 5-year survival rate was 51% after resection with curative intent and the overall 5-year survival was 28%.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinomas of the gastric stump are divided into two types. In the main group of patients (n = 18), carcinoma developed after resection for benign ulcer disease, and in the second group (n = 4) after resection for early gastric carcinoma. In the first group, the mean age of the patients was 63, and the male-to-female ratio of 17:1. The mean interval between the primary operation and the diagnosis of cancer was 27 years. Biopsies were positive in 16 out of 18 patients. The resectability rate was 72%, resection being performed with curative intent in 50%. Total gastrectomy was performed in 50% of the cases. There were no postoperative deaths. The 5-year survival rate was 33% for all patients and 50% after tumoral resection. Early detection was achieved by means of an endoscopic survey of the gastric stump. A comparison between gastric stump carcinomas and other gastric carcinomas in our series fails to reveal any major differences. Gastric stump carcinoma is not specific. In the second group, the mean age of the patients was 72.5 and the sex ratio 1:1. The mean interval between the two operations was 5 years. The resectability rate was 100%, and all the patients survived with follow-up ranging from 2 to 10 years. The second lesion could be considered a metachronous cancer, but it may have been present and overlooked at the time of the initial gastrectomy. Differentiating between synchronous and metachronous lesions is quite difficult.

The aim of this study was to analyze the evolution of surgical indications in alcoholic chronic pancreatitis (ACP) and to compare long term results after medical (n = 72) and surgical (n = 150) treatment with or without pancreatic resection. Since 1968, a retrospective study was carried out on 222 consecutive male patient. 68% of them, were operated on for unrelieved pain or complications at a mean of 5 years after the onset of the symptom. The mean follow-up was 10 years. The study of evolution of the indications and results of surgical treatment was made on two consecutive ten-year periods and showed that 68% of pancreaticoduodenectomies and 55% of distal pancreatectomies (DP) were performed during the first period. Indications for primary pancreaticoduodenectomy did not decrease since 1980, while those of distal pancreatectomy (DP) changed (no DP for acute pancreatic effusion with fistula before 1980, no DP for unrelieved pain after 1980). Ten patients underwent operative drainage of pseudocysts before 1980 versus 21 after 1980 (13% vs 29%) with no operative death. Twenty patients underwent biliary and/or intestinal and/or ductal drainage during the first period versus 22 during the second (25% vs 30%). The overall 12-year actuarial survival between operated and non operated patients was no significantly different (respectively 72% +/- 10% and 64% +/- 12%). The actuarial 10-year survival rate was significantly better after DP (73% versus 53% after drainage and 28% after pancreaticoduodenectomy). No patients underwent specific pancreatic reoperation after pancreaticoduodenectomy versus 25% after DP.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study was to evaluate the independent influence of clinical and pathological variables on survival of patients with gastric carcinoma using the Cox regression proportional hazard model. Of 156 patients operated on for gastric adenocarcinoma, 46 (29.5%) underwent palliative operation, 24 (15.5%) had a palliative resection, and 86 (55%) had a curative resection. The overall 5-year survival rate was 25 +/- 4%. After curative resection, the 5-year survival rate was 44 +/- 6%. Univariate analysis applied to these patients showed that poor survival was related (p less than 0.01) to: age (over 80 years), absence of epigastric pain, vomiting and dysphagia, total gastrectomy, tumor size (more than 4 cm), lymph node involvement (LNI), invasion through the muscularis propria, absence of intestinal metaplasia near the tumor, and linitis plastica. In multivariate analysis, lymph node involvement was found to be the only independent prognostic factor. The 5-year survival rate was 75.5 +/- 8% without LNI, 28 +/- 10% with proximal LNI and 7 +/- 6% with distal LNI. Our results suggest that classification into 3 LNI groups is the best staging system for curative resection in gastric carcinoma.

It may be better to use the term of "superficial carcinoma" than "early gastric carcinoma". Out of 194 patients operated on for gastric carcinoma, 37 had a superficial carcinoma (19%). Seventeen had previously been treated for duodenal (n = 10) or gastric (n = 7) ulcer. Out of 23 barium meal examinations, 3 were normal. The macroscopic appearance at endoscopic examination was normal in 4 patients. In these cases the carcinoma was identified in biopsies. At laparotomy the gastric wall was normal in 16 patients. Gastric resection was subtotal (n = 28), total (n = 6), or partial (n = 1). The tumor was multifocal in 8 cases, and associated with intestinal metaplasia in 24 cases. The five-year actuarial survival rate was 77%. It is important to do not miss superficial carcinoma even in patient treated for peptic ulcer, and to perform biopsies even if endoscopic examination is normal. A subtotal gastrectomy may be performed with excellent results.

The surgical treatment of patent ductus arteriosus (PDA) in adults as in children, usually comprises section and suture, but a certain number of technical precautions must be taken. The aortic wall is often fragile due to atheromatous lesions which are more common with increasing age. Associated hypertension may add to the fragility. Controlled medicated hypotension and reinforcement of sutures with a piece of pericardium may be useful in reducing the risk of haemorrhage. It is sometimes necessary to use partial femoro-femoral cardiopulmonary bypass circuit. The presence of an aneurysm at the aortic end of a calcified ductus necessitates the same precautions. When PDA is complicated by pulmonary hypertension, the surgical indication can only be considered when the left-to-right shunt remains voluminous and when pulmonary artery pressures fall significantly during catheter or peroperative trials of closure. The operative risk in these cases increases with age. Cardiopulmonary bypass may also be very useful in these cases. Secondary repermeabilisation of an operated ductus, and cases complicated by endocarditis require an endopulmonary approach under cardiopulmonary bypass because of the fragility of the ductus region and difficulty in controlling haemorrhage. This technique is also preferred when an associated intracardiac malformation is to be corrected. Between 1965 and 1981, 37 patients were operated in the department of thoracic and cardiac surgery at the Pitié Hospital. The ages ranged from 20 to 65 years with a mean of 34 years. Cardiopulmonary bypass was necessary in 5 cases, (partial in 4, and total in 1 case of endoaortic closure).(ABSTRACT TRUNCATED AT 250 WORDS)