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Resume Introduction La fistule anastomotique est la complication redoutee apres chirurgie colorectale. De nombreux travaux ont montre l’interet du dosage de la CRP en postoperatoire comme marqueur diagnostic precoce. Le seuil critique des marqueurs biologiques de l’inflammation doit-il rester le meme que la resection soit colique ou rectale ? Patients et methode Il s’agit d’une etude basee sur une cohorte constituee entre 2011 et 2014, incluant 497 patients avec une resection colorectale programmee. La proteine C-reactive et la pro-calcitonine ont ete mesurees tous les jours entre la veille et le 4e jour. Toutes les complications postoperatoires intra-abdominales ont ete considerees comme une fistule anastomotique. Les seuils de detection ont ete calcules a partir de l’aire sous la courbe ROC. Resultats Une complication septique intra-abdominale est survenue chez 16,9 % des operes d’une resection rectale contre 9,9 % apres colectomie (p = 0,03). Il n’existe pas de difference significative en termes de reponse inflammatoire postoperatoire entre les deux groupes en l’absence de complications, tant sur la CRP que la PCT. Apres resection rectale, la meilleure aire sous la courbe (AUC = 0,87) correspond a la CRP de j4 pour un seuil de 100 mg/L : sensibilite 83,3 %, une VPN 95,3 %. Pour les colons avec la meme CRP a 100 mg/L (AUC = 0,71), la sensibilite est de 63,6 % et la VPN de 93,9 %. Conclusion Malgre une chirurgie plus a risque, le seuil de detection de la fistule anastomotique apres chirurgie rectale reste le meme : CRP > 100 mg/L a j4.

Summary Introduction Anastomotic fistula is the most fearsome complication following colorectal surgery. Numerous studies have demonstrated the interest of postoperative CRP assay as an early diagnostic marker. Must the critical threshold for biological inflammatory markers remain the same, whether resection be colic or rectal? Patients and method This is a study based on a cohort constituted between 2011 and 2014, including 497 patients with planned colorectal resection. C-reactive protein and pro-calcitonin were measured daily from day before surgery to D4. All postoperative intra-abdominal complications were considered as an anastomotic fistula. Detection thresholds were calculated from the area under the ROC curve. Results An intra-abdominal septic complication occurred in 16.9% of the patients having undergone rectal resection vs. 9.9% of those having had colectomy (P = 0.03). In the absence of complications there was no significant difference between the two groups in terms of postoperative inflammatory response as determined by either CRP or PCT assay. Following rectal resection, optimal area under the curve (AUC = 0.87) corresponds to CRP on D4 for a threshold of 100 mg/L: sensitivity 83.3%, NPV 95.3%. For colons with the same CRP at 100 mg/L (AUC = 0.71): sensitivity 63.6%, NPV 93.9%. Conclusion Notwithstanding riskier surgery, the detection threshold for an anastomotic fistula following rectal surgery remains the same: CRP > 100 mg/L at D4.

Background The incidence of gastric poorly cohesive carcinoma (PCC) is increasing. The prognosis for patients with peritoneal metastases remains poor and the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is controversial. The aim was to clarify the impact of gastric PCC with peritoneal metastases treated by CRS with or without HIPEC. Methods All patients with peritoneal metastases from gastric cancer treated with CRS with or without HIPEC, in 19 French centres, between 1989 and 2014, were identified from institutional databases. Clinicopathological characteristics and outcomes were compared between PCC and non-PCC subtypes, and the possible benefit of HIPEC was assessed. Results In total, 277 patients were included (188 PCC, 89 non-PCC). HIPEC was performed in 180 of 277 patients (65 per cent), including 124 of 188 with PCC (66 per cent). Median overall survival (OS) was 14.7 (95 per cent c.i. 12.7 to 17.3) months in the PCC group versus 21.2 (14.7 to 36.4) months in the non-PCC group (P Conclusion In selected patients, CRS-HIPEC offers acceptable outcomes among those with gastric PCC and long survival for patients without PCC.

Resume Contexte Nous savons que l’inflammation est liee au pronostic du cancer colorectal et a l’apparition d’infections postoperatoires. Objectif Cette etude visait a comprendre la relation entre l’inflammation preoperatoire et le pronostic du cancer colorectal et a elucider si l’impact de l’inflammation sur le pronostic du cancer etait lie a un risque accru d’infection chirurgicale ou etait independant de celui-ci. Methodes Les patients ayant subi une chirurgie elective du cancer colorectal, entre novembre 2011 et avril 2014, ont ete inclus dans une base de donnees prospective (IMACORS). La proteine C-reactive (CRP) preoperatoire a ete collectee pour chaque patient. Les patients ont ete suivis selon les directives nationales francaises. Un seuil de CRP preoperatoire de 5 mg/L a ete choisi. Les caracteristiques cliniques ont ete comparees selon la CRP en utilisant le Chi2 test et le test de Mann–Whitney. La survie globale (SG) et la survie sans maladie (SSR) ont ete comparees par les courbes de Kaplan–Meier. Un modele de regression des risques proportionnels de Cox a ete applique pour effectuer une analyse multivariee des predicteurs de l'SG et du SSR. Resultats Un total de 254 patients a ete inclus. L’âge median etait de 68 ans. Le suivi median etait de 41,8 mois. La CRP mediane preoperatoire globale etait de 5 mg/L. La CRP preoperatoire etait significativement associee au statut N. Elle est significativement plus elevee chez les patients atteints de cancer du colon et chez les patients qui n’ont pas recu de traitement neoadjuvant. Une analyse multivariee a revele que la CRP preoperatoire est un facteur pronostique independant de la SG et de la SSR, respectivement (HR = 2,34 (1,26–4,31), p = 0,006 et HR = 1,83 (1,15–2,90), p = 0,01). Conclusion L’inflammation preoperatoire mesuree par la CRP est independamment liee a la survie globale et sans maladie du cancer colorectal.

Resume Introduction Les eventrations sont des complications frequentes des laparotomies. Pour leur reparation, il est recommande d’utiliser une prothese synthetique qui permet de renforcer la paroi et de prevenir les recidives. Cependant, l’utilisation de la prothese en milieu contamine comporte un risque d’infection de l’implant. Dans ce contexte sont apparues les protheses biologiques, puis les biosynthetiques, resistant en milieu contamine, voire infecte, mais au prix d’une resorption qui peut laisser le doute sur la survenue d’une recidive a ce moment. Les protheses biosynthetique en P4HB sont des treillis resorbables en 12–18 mois. Le but de cette etude etait d’evaluer le taux de recidive a 1 an de la reparation avec une prothese en P4HB. Methodes Tous les patients operes entre 2016 et 2018 au CHU de Dijon pour une eventration avec utilisation d’une prothese Phasix® ont ete inclus. Le suivi a ete complet jusqu’a un an avec realisation d’un scanner abdominopelvien systematique. Les complications postoperatoires ont ete recueillies. Resultats Un total de 29 patients a ete inclus dans l’etude (55,2 % de femmes), avec un IMC moyen de 30,25 kg/m2. Dix-neuf protheses ont ete posees en retromusculaire et 10 en intraperitoneal. Les complications a un mois etaient principalement classees Clavien-Dindo I et II (61,1 %). Aucune explantation ni infection chronique n’a ete detectee. La duree moyenne de sejour etait de 11,5 jours. Le taux de recidive a 1 an etait de 10,3 %. Conclusion A 1 an d’une reparation d’eventration complexe avec champ operatoire contamine, les protheses lentement resorbables en P4HB presentent un taux de recidive de 10,3 %. Aucune complication grave du site operatoire n’est apparue. Un suivi plus long sur une plus grande cohorte est necessaire afin de confirmer la place de cette prothese dans cette indication.

SCOPUS: ar.j, info:eu-repo/semantics/published

Summary Chyloperitoneum is a potential complication of omega-loop gastric bypass caused by internal herniation. Chronic compression of the mesentery leads to chylous extravasation that can mimic peritonitis.

Resume Contexte L’utilisation de drains chirurgicaux fait debat mais ils restent frequemment utilises, que ce soit de facon preventive ou curative. Leur migration par rapport a la position souhaitee lors de l’intervention chirurgicale est un phenomene peu etudie. Le but de cette etude a ete d’etudier l’incidence du deplacement des drains chirurgicaux parmi les patients operes d’une chirurgie digestive abdominale. Patients et methodes Nous avons inclus dans cette etude tous les patients ayant eu un scanner postoperatoire precoce (avant mobilisation des drains) apres chirurgie digestive abdominale, entre janvier 2013 et avril 2016 au CHU de Dijon. Les donnees pre-, per- (nombre, type et position des drains) et postoperatoires (imagerie et evolution) ont ete revues retrospectivement et colligees dans une base de donnees. Resultats Parmi les 125 patients inclus, 35 (28 %) d’entre eux presentaient une migration d’au moins un drain par rapport a son emplacement lors de l’intervention. Parmi les 207 drains, 41 (19,8 %) s’etaient deplaces. La morbidite postoperatoire n’etait pas plus elevee chez les patients chez lesquels le drain avait bouge ( p = 0,51). Aucun des facteurs pre- et peroperatoires etudies ne s’est revele etre un facteur de risque significatif de migration. Conclusion La migration des drains est tres frequente apres chirurgie abdominale. Cette migration ne semble pas avoir eu de consequence clinique dans notre experience. Lorsqu’un benefice est attendu de l’utilisation de drains chirurgicaux, une fixation intraperitoneale semble necessaire.

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.

Resume La presence d’une hernie interne lors d’un bypass en omega peut etre responsable d’un chyloperitoine du fait d’une compression chronique du mesentere entrainant une extravasation de chyle pouvant mimer une peritonite.

Introduction Des protocoles de rehabilitation precoce sont de plus en plus utilises en chirurgie digestive pour reduire la morbidite et ameliorer la recuperation des patients. Apres œsophagectomie, la gravite et la crainte de la fistule anastomotique peuvent etre un frein a leur generalisation. La proteine C reactive (CRP) pourrait etre un outil fiable pour identifier les patients a faible risque de fistule digestive apres œsophagectomie. Methodes Tous les patients ayant beneficie d’une œsophagectomie pour cancer avec une anastomose intra-thoracique par voie trans-thoracique droite entre janvier 2009 et septembre 2017 ont ete inclus. Les valeurs de la CRP ont ete recueillies aux 3e (J3), 4e (J4), et 5e (J5) jours postoperatoires, ainsi que toutes les complications postoperatoires, notamment la survenue d’une fistule digestive. Resultats Au total, 620 patients ont ete inclus. Parmi eux, 265 (42,7 %) ont presente une complication infectieuse, dont 79 (12,7 %) une fistule digestive. Le jour ou la CRP etait la plus discriminante pour le diagnostic de fistule digestive etait J5 (AUC 0,74 ; 95 % CI : 0,67–0,81). Un taux sanguin de CRP de 140 mg/l a J5 permettait d’obtenir une sensibilite de 85 %, une specificite de 55 % et une valeur predictive negative de 96 % pour la detection de la fistule digestive. Conclusion La proteine C reactive permet d’identifier les patients a tres faible risque de fistule digestive apres œsophagectomie. Les patients ayant des valeurs de proteine C reactive inferieures a 140 mg/l au 5e jour postoperatoire n’ont pas besoin d’imagerie de controle et peuvent integrer un protocole de rehabilitation amelioree incluant une realimentation orale qui devrait permettre leur sortie precoce de l’hopital.

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.

Contexte L’etude des donnees anthropometriques comme facteur pronostic postoperatoire est prometteur mais contradictoires. Le but de cette etude etait d’evaluer la repartition musculo-graisseuse abdominale preoperatoire comme facteur predictif d’inflammation et de morbi-mortalite postoperatoire. Methodes Au total, 254 patients beneficiant d’une chirurgie colorectale carcinologique entre 2011 et 2014 ont ete tires d’une cohorte prospective multicentrique (IMACORS). La musculature, l’adiposite viscerale et sous-cutanee ont ete mesurees au niveau lombaire a partir de coupes scanographiques. La correlation CRP/repartition musculo-graisseuse a ete calculee. Une analyse multivariee des donnees anthropometriques sur la morbi-mortalite a ete realisee selon le modele de Cox. Resultats Il existait une relation significative entre obesite viscerale et CRP > 125 mg/L a J4 (r = 0,8, p = 0,005). Obesite viscerale (HR = 1,7 IC 95 % = 1,3–3,5 ; p = 0,02) et sarcopenie (HR = 2,3 IC 95 % = 1,3–2,5 ; p Conclusion L’obesite viscerale et la sarcopenie preoperatoire ont un effet pronostique pejoratif sur la survie et le risque de fistule anastomotique. L’obesite viscerale etait correlee une CRP postoperatoire elevee.

Summary Introduction The use of surgical drains is the subject of much debate but they continue to be commonly used. The phenomenon of drain migration from their desired position following surgery has not been studied. The aim of this study was to evaluate the incidence of the displacement of surgical drains among patients undergoing abdominal gastrointestinal surgery. Patients and methods We performed a review of all patients who underwent an early CT-scan postoperatively after abdominal gastrointestinal surgery prior to drain mobilization, between January 2013 and April 2016 in the Dijon University Hospital Center. Pre-and intra-operative data (number, type and position of drains) and postoperative data (imaging and evolution) were collected retrospectively. Results This study included 125 patients. Thirty-five (28%) were found to have a displacement of at least one drain from its original position. Forty-one (19.8%) of the 207 studied drains had moved. Postoperative morbidity was not higher in patients with displaced drains (P = 0.51). None of all the studied preoperative and operative factors have been found to be a risk factor for drain displacement. Conclusion Surgical drains displacement is frequently encountered in patients undergoing digestive abdominal surgery. In our experience, this phenomenon does not seem to have any clinical implications. When a benefit is expected from the use of surgical drains, intraperitoneal fixation appears to be necessary.

IF 2.426; International audience; PURPOSE:C-reactive protein and procalcitonin are reliable early predictors of infection after colorectal surgery. However, the inflammatory response is lower after laparoscopy as compared to open surgery. This study analyzed whether a different cutoff value of inflammatory markers should be chosen according to the surgical approach.METHODS:A prospective, observational study included consecutive patients undergoing elective colorectal surgery in three academic centers. All infections until postoperative day (POD) 30 were recorded. The inflammatory markers were analyzed daily until POD 4. Areas under the ROC curve and diagnostic values were calculated in order to assess their accuracy as a predictor of intra-abdominal infection.RESULTS:Five-hundred-one patients were included. The incidence of intra-abdominal infection was 11.8%. The median levels of C-reactive protein (CRP) and procalcitonin (PCT) were lower in the laparoscopy group at each postoperative day (p < 0.0001). In patients without intra-abdominal infection, they were also lower in the laparoscopy group (p = 0.0036) but were not different in patients presenting with intra-abdominal infections (p = 0.3243). In the laparoscopy group, CRP at POD 4 was the most accurate predictor of overall and intra-abdominal infection (AUC = 0.775). With a cutoff of 100 mg/L, it yielded 95.7% negative predictive value, 75% sensitivity, and 70.3% specificity for the detection of intra-abdominal infection.CONCLUSION:The impact of infection on inflammatory markers is more important than that of the surgical approach. Defining a specific cutoff value for early discharge according to the surgical approach is not justified. A patient with CRP values lower than 100 mg/L on POD 4 can be safely discharged.

Background The peritoneal cancer index (PCI) is a comparative prognostic factor for colorectal peritoneal metastasis (CRPM). The ability of laparoscopy to determine the PCI in consideration of cytoreductive surgery remains undetermined, and this study was designed to compare it with laparotomy. Methods A prospective multicentre study was conducted for patients with no known CRPM, but at risk of peritoneal disease. Surgery began with laparoscopic exploration followed by open exploration to determine the PCI. Concordance between laparoscopic and open assessment was evaluated for the diagnosis of CRPM and for the PCI. Results Among 50 patients evaluated, CRPM recurrence was found in 29 (58 per cent) and 34 (68 per cent) at laparoscopic and open surgery respectively. Laparoscopy was feasible in 88 per cent (44 of 50) and deemed satisfactory by the surgeon in 52 per cent (26 of 50). Among the 25 evaluable patients with satisfactory laparoscopy, there was concordance of 96 per cent (24 of 25 patients) and 38 per cent (10 of 25) for laparoscopic and open assessment of CRPM and the PCI respectively. Where there were discrepancies, it was laparoscopy that underestimated the PCI. Conclusion Laparoscopy may underestimate the extent of CRPM.

The use of abdominal binders after laparotomy is a question of habit. Scientific evidence of their usefulness is limited. The aims of this work were to review the scientific literature and to depict the practices of French surgeons regarding the use of these devices.A systematic review of the literature about the use of abdominal binders after laparotomy was conducted. In order to depict surgeons' habits, an anonymous questionnaire was sent to all surgical departments affiliated to the FRENCH network (Federation of Surgical Research) and their surgical contacts. They were all asked about their use of binders, the type of binders they ordered, the expected benefit, the cost and the need for a randomized trial in this field.Only four trials have been published regarding the use of abdominal binders after laparotomy, all with a small number of patients. Some authors suggested that wearing binders procured a benefit in terms of postoperative comfort, but no significant difference was found. One study also suggested an improvement in respiratory volumes. No study focused on incisional hernia. Regarding the survey of practices, 50 questionnaires were retained for the final analysis (one questionnaire per department of surgery). The use of this device is really very frequent in France (94 % of surgeons order them), a habit usually acquired during the training in surgery. The main expected benefit is the prevention of abdominal wall dehiscence (83 %), but also an improvement in patients' postoperative comfort and pain (66 %). Although some surgeons order an abdominal binder for all their patients, most use them in selected patients (according to the operation and the patients' characteristics).Abdominal binders are frequently ordered by French surgeons after laparotomy. The expected benefit is the prevention of abdominal-wall complications, even though no data actually support this practice. Binders might have a benefit in terms of postoperative pain relief, but this needs to be analyzed. A prospective randomized trial is warranted.

Resume Introduction La perfusion sur foie isole de la circulation est une methode de delivrance de la chimiotherapie permettant d’augmenter fortement les doses en diminuant la toxicite extrahepatique. Elle s’adresse a des patients porteurs de tumeurs hepatiques non resecables chirurgicalement. Principes Une exclusion vasculaire du foie est realisee apres verification de la bonne tolerance hemodynamique et de l’eventuel recours a un shunt cavo-cave et/ou porto-systemique. L’entree de perfusion peut etre arterielle et/ou portale, et la sortie portale ou cave. Le circuit de perfusion peut etre ouvert ou ferme, avec recours a une pompe de circulation avec ou sans oxygenation. Les differentes chimiotherapies utilisees sont le melphalan (avec ou sans TNF-alpha), l’oxaliplatine, le cisplatine et la mitomycine, a fortes doses, parfois associees a une hyperthermie moderee. La duree de perfusion oscille entre 30 et 90 minutes suivant les protocoles. Une technique percutanee avec exclusion incomplete est possible. Resultats Les series les plus importantes montrent un taux de reponse (partielle ou stabilisation) de 60 a 80 %, avec environ 5 % de reponses completes morphologiques. La morbidite et la mortalite sont autour de 40 % et 5 %, respectivement, incluant la morbidite liee a la procedure de perfusion et la morbidite specifique de la chimiotherapie. Conclusion La perfusion de chimiotherapie sur foie isole est une therapeutique recente, encore en voie de developpement, proposee aux patients atteints de tumeurs primitives ou secondaires du foie non resecables dans le cadre d’essais cliniques. Ses resultats semblent prometteurs, mais associes a une morbidite non negligeable.

Summary Introduction Isolated hepatic perfusion allows the delivery of high dose chemotherapy while decreasing extra-hepatic toxicity, and is used mainly for patients with surgically unresectable liver tumors. Principles Vascular exclusion of the liver is performed after obtaining satisfactory hemodynamic tolerance, occasionally after cavocaval shunt and/or porto-systemic shunt. Perfusion entry can be arterial and/or portal while the exit is portal or caval. The perfusion circuit can be open or closed, using a circulation pump with or without oxygenation. The chemotherapy regimens used are high dose melphalan (with or without TNF-alpha), oxaliplatin, cisplatin and mitomycin, sometimes associated with moderate hyperthermia. The duration of perfusion ranges between 30 and 90 minutes according to the different protocols used. A percutaneous technique with incomplete liver vascular exclusion is also possible. Results The larger series in the literature show a response rate (partial or complete stabilization) between 60 and 80%, with approximately 5% complete morphologic responses. Morbidity and mortality are 40 and 5%, respectively, including specific morbidity related to the perfusion procedure as well as to chemotherapy. Conclusion Chemotherapy delivered through isolated hepatic perfusion is a new therapeutic alternative, still under development, and can be proposed to patients with surgically unresectable primary or secondary liver tumors within clinical trials. These results seem to be promising, but are still associated with a non-negligible morbidity rate.

International audience; Based on the importance of assessing the true extent of peritoneal disease, PeRitOneal MalIgnancy Stage Evaluation (PROMISE) internet application (www.e-promise.org) has been developed to facilitate tabulation and automatically calculate surgically validated peritoneal cancer index (PCI), and other surgically validated scores as Gilly score, simplified peritoneal cancer index (SPCI), Fagotti and Fagotti-modified scores. This application offers computer-assistance to produce simple, quick but precise and standardized pre, intra and postoperative reports of the extent of peritoneal metastases and may help specialized and non-specialized institutions in their current practice but also facilitate research and multicentre studies on peritoneal surface malignancies.

Resume But de l’etude La fistule anastomotique est la complication la plus redoutee apres chirurgie colorectale. Ses consequences dependent de la precocite du diagnostic. La proteine C reactive (CRP) a deja montre son utilite dans la detection precoce, alors que la procalcitonine (PCT), plus utilisee en reanimation et plus onereuse, est peu evaluee dans ce contexte. Patients et methodes De mai 2010 a juin 2011, une etude prospective a inclus 100 patients beneficiant d’une chirurgie colorectale reglee. La CRP et la PCT ont ete recueillies en preoperatoire et jusqu’au quatrieme jour postoperatoire. Toutes les infections intra-abdominales ont ete considerees comme desunion anastomotique independamment de leur retentissement clinique et de leur prise en charge. La cinetique des marqueurs a ete analysee et leur aire sous la courbe a ete comparee. Resultats L’incidence de fistule anastomotique etait de 13 % et la mortalite globale de 2 %. La CRP et la PCT etaient significativement plus eleves chaque jour chez les patients ayant une fistule ; la meilleure capacite predictive etait obtenue pour la CRP a j4 (aire sous la courbe receiver-operating characteristics [ROC] : 0,69 vs 0,750, respectivement). Conclusion La PCT ne semble etre ni plus precoce ni plus discriminante que la CRP pour la detection des fistules anastomotiques apres chirurgie colorectale reglee.

Resume But de l’etude Savoir si le sentiment de securite du personnel du bloc operatoire s’est ameliore en passant de la chimiohyperthermie intraperitoneale (CHIP) « ouverte » a la technique fermee a ventre ouvert (ou « semi-ouverte »). Methode Enquete ecrite par questionnaire, anonyme et confidentiel, adresse au personnel du bloc operatoire, en dehors des chirurgiens impliques dans la CHIP. Des questions ont ete posees a propos des connaissances sur les risques de la CHIP, les symptomes percus apres la procedure, le sentiment de securite et l’evolution de ces parametres lors de la mise en place de la CHIP fermee a ventre ouvert. Resultats Le taux de reponse a ete de 86,8 %. Plus de la moitie du personnel rapportait des symptomes apres la CHIP ouverte, taux qui est descendu a 17,2 % apres la mise en place de la CHIP fermee a ventre ouvert ( p = 0,0055). Le sentiment de securite s’est ameliore avec la realisation de la nouvelle technique ( p = 0,0002) et 96,5 % des personnes se disaient rassurees par la presence du couvercle renfermant l’abdomen lors de la procedure. Conclusion La CHIP est associee a des craintes de la part du personnel soignant sur la securite et les potentiels effets indesirables. Ce sentiment s’est significativement ameliore avec la realisation de la CHIP fermee a ventre ouvert. Un effort de communication des risques reels est indispensable de la part de l’equipe chirurgicale.

A delayed colo-anal anastomosis has been proposed as a way to avoid diverting stoma after low anterior resection. Surgical and functional results were reviewed in 17 patients operated between 1999 and 2007 using this technique. Complications included one colonic necrosis, two pelvic abscesses and one colovaginal fistula. Results of continence and quality of life scores were satisfactory. Rates of parietal and septic complications are low after delayed colo-anal anastomosis and functional results are good. The use of this technique is particularly effective to avoid diverting ileostomy and for use in patients with a high risk of pouch fistula.

Adenocarcinoma of the oesophagogastric junction has an ominous prognosis. Until now, oesophageal adenocarcima care was close to the squamous cell cancer one whereas adenocarcinoma of the cardia was mixed with gastric cancers. Results from randomised studies mixed them without making distinctions. Nevertheless, context, natural history and clinical outcome differ. Five-year survival rate is around 40 %, all stages included. Results from several phase-III studies or meta-analysis allowed to define three therapeutic strategies applicable to adenocarcinoma of the oesophagus and the oesophagogastric junction. In Europe, in the case of a resectable tumour, preoperative chemotherapy became a standard treatment since results from the Magic trial. In the United States, post-operative radiochemotherapy according to the "Macdonald" scheme is used in case of a resected tumour with a R0 surgery. Actually, modern techniques of irradiation could reduce the rate of gastro-intestinal toxicities. The survival benefit from preoperative radiochemotherapy is still very controversial with high rates of postoperative morbidity and mortality. We have performed a review of the literature with a methodological analysis of data with a high level of evidence in order to advise perioperative treatment guidelines for patients with a resectable adenocarcinoma of the lower oesophagus or gastro-oesophageal junction. Results from pre- or postoperative strategies and the role of radiotherapy will need to be analysed in the future through a randomised study.

Resume But de l’etude etudier les lesions biliaires iatrogenes en cours de cholecystectomie : les facteurs de risque et les resultats de la reparation, pour en deduire une conduite a tenir. Patients et methode revision de la serie de patients adresses dans notre service dans une periode de 9 ans pour lesion de la voie biliaire au cours d’une cholecystectomie : type de lesion, circonstances, reparation et evolution. Resultats entre 1997 et 2005, 18 patients ont ete pris en charge pour lesion biliaire au cours de cholecystectomie (14 par cœlioscopie et 4 par laparotomie ; 9 femmes et 9 hommes). L’indication operatoire la plus frequente etait des coliques hepatiques (n = 8). Trois patients ont ete operes en urgence. Chez 9 patients il existait une paroi vesiculaire inflammatoire. Une cholangiographie peroperatoire a ete realisee chez 9 patients, ne permettant la decouverte de la lesion biliaire que dans un cas. La plaie laterale de la voie biliaire a ete le type de lesion le plus frequent. Dans 9 cas la lesion a ete decouverte en peroperatoire : un drainage biliaire a ete mis en place, associe a une reparation primaire chez 5 patients ; trois patients ont necessite ulterieurement une chirurgie biliaire. Chez 9 malades la decouverte de la lesion a ete tardive, et 6 ont necessite une derivation bilio-digestive. Deux patients sont decedes, 3 ont presente des episodes d’angiocholite pendant le suivi et 2 ont necessite une cure d’eventration. Conclusion l’inflammation est le principal facteur de risque de lesion de la voie biliaire. La realisation d’une cholangiographie peroperatoire ne met pas a l’abri d’une lesion meconnue de la voie biliaire. Le drainage biliaire pour les lesions detectees en cours d’intervention diminue la morbidite associee et serait un bon choix pour le chirurgien sans experience hepatobiliaire. La morbidite est plus elevee chez les patients avec decouverte tardive de la lesion biliaire.

The assessment of the microsatellite instability (MSI) status in colorectal cancers is presently warranted for three reasons: 1) as a screening tool for hereditary nonpolyposis colorectal cancer, 2) as a prognostic marker, and 3) as a potential predictive factor of chemotherapy response. The aim of this study was to evaluate, on a large scale with tissue samples coming from a number of different sources, the difficulties met with routine use of immunohistochemistry (IHC) and to determine if it really does offer an accurate alternative to PCR genotyping. Colorectal carcinomas from 462 consecutive patients resected in public or private hospitals were assessed for MSI status by two methods: MSI testing (with BAT-26 microsatellite) and IHC detection of hMLH1, hMSH2, and hMSH6 proteins. Of the 398 cancers tested, immunohistochemistry was noncontributory in 42 (10.5%), focal in 9 (2.3%), and discordant with the PCR results in 36 (9%). For these 87 cases, complementary analyses were performed to explain discrepancy. After additional IHC assay with modified processing protocols, 8 cases remained noncontributory, 2 focal, and 28 discordant: 18 microsatellite stability IHC/MSI PCR and 10 MSI IHC/microsatellite stability PCR. For these discordant cases, we performed a multiplex PCR assay on DNA extracted from the frozen sample and BAT-26 was amplified from DNA extracted from the paraffin blocks used for IHC. Four discordant cases were reclassified after PCR multiplex assay (3 as MSI and 1 as microsatellite stability). Five other cases displayed intratumoral heterogeneity and 19 remained discordant. The discrepancy could be partly explained by variable technical protocols of fixation in the different laboratories, leading to variations in staining quality and difficulties in IHC interpretation. This population-based study is the first one to show that IHC is not sensitive and specific enough to be used routinely. Immunohistochemistry analysis of MMR proteins must be performed in standardized conditions and interpreted by confirmed pathologists. It cannot replace PCR as long as protocols are not optimized and harmonized.

Resume But de l'etude. – Evaluer les traitements et le pronostic des perforations et ruptures de l'œsophage. Materiel et methodes. – Cette etude retrospective a porte sur 40 patients (26 hommes et 14 femmes, d'âge moyen 59 ± 17 ans) atteints d'une perforation ou rupture de l'œsophage. Sept perforations etaient cervicales : iatrogenes (n = 6) ou par ingestion de corps etranger (n = 1). Trente-trois perforations etaient thoraciques : iatrogenes (n = 15), par rupture spontanee (n = 14), par ingestion de corps etranger (n = 3) ou traumatique (n = 1). Tous les patients ayant une perforation cervicale ont ete operes (suture ou drainage). Un patient ayant une perforation thoracique est decede avant l'operation, 2 ont ete traites de facon non-operatoire et 30 ont ete operes. Vingt-huit gestes ont ete realises sur l'œsophage : suture (n = 13), œsophagectomie (n = 11) ou double exclusion (n = 4). Deux patients ont ete operes sans geste sur l'œsophage (une decortication pleurale et une ablation de corps etranger intrapleural). Resultats. – La mortalite globale a ete de 17 % (7/40). Elle a ete de 21 % (3/14) en cas de perforation spontanee et de 19 % (4/21) en cas de perforations iatrogenes (pas de deces lors des autres etiologies). La mortalite a ete de 14 % (1/7) au niveau cervical et de 18 % (6/33) au niveau thoracique. Elle a ete de 8 % (1/13) apres suture thoracique, de 18 % (2/11) apres œsophagectomie, de 50 % (2/4) apres double exclusion. Conclusion. – Les perforations iatrogenes et les ruptures spontanees ont le meme mauvais pronostic. Le traitement non-operatoire a eu une place limitee. L'œsophagectomie est une option valable en cas de lesion non suturable ou vue tardivement.

Resume But de l’etude : L’objectif de cette etude a ete d’evaluer la cytotoxicite de la polyvidone iodee diluee in vitro sur des cellules cancereuses coliques et in vivo dans un modele de carcinose peritoneale chez le rat. Methodes : La cytotoxicite de la polyvidone iodee diluee a ete mesuree in vitro sur les cellules cancereuses coliques humaines HT29 et de rat DHD/K12/PROb. L’effet antitumoral des lavages abdominaux par la polyvidone iodee diluee a ete evalue chez le rat BDIX apres injection de 106 cellules en intraperitoneal. Les resultats ont ete compares a ceux obtenus apres lavage par du serum physiologique. Dans une experience, des scarifications peritoneales et une anastomose digestive ont ete realisees apres l’injection des cellules cancereuses. Resultats : La polyvidone iodee diluee sterilise les cellules HT29 et DHD/K12/PROb, in vitro, apres 10 min d’exposition. Utilisee en lavage peritoneal, elle evite le developpement des nodules de carcinose sur le peritoine parietal alors qu’un lavage mecanique par du serum sale seul est inefficace. Ce lavage n’empeche pas l’apparition de nodules dans l’epiploon, sur le peritoine parietal lese ou les anastomoses digestives. Conclusion : Malgre sa forte cytotoxicite in vitro, la polyvidone iodee a une efficacite insuffisante pour empecher le developpement tumoral sur les surfaces deperitonisees et sur l’epiploon. En revanche, le lavage abdominal a la polyvidone iodee diluee est un traitement prophylactique efficace de l’implantation et du developpement tumoral sur le peritoine sain.

Resume Objectifs – Les metastases pancreatiques des cancers du rein sont mal connues. L’objectif de cette etude a ete de rapporter les manifestations cliniques et radiologiques, le traitement effectue et la survie observee chez sept malades atteints de cette entite rare. Resultats – Tous les patients ont ete operes. Un malade avait une lesion inextirpable. Six patients ont eu une exerese a visee curative. Il y a eu un deces postoperatoire. Le recul apres pancreatectomie etait compris entre 6 mois et 6 ans. Deux patients ont developpe des metastases extra-pancreatiques un an et 3 ans apres la pancreatectomie. Conclusion – Les metastases pancreatiques des cancers du rein sont rares et surviennent le plus souvent plusieurs annees apres la nephrectomie. Toutefois leur resection est souvent possible et permet une bonne survie a distance. Patients et methodes – Sept patients (cinq hommes et deux femmes, âge moyen = 66 ans) ayant une metastase pancreatique de cancer du rein ont ete vus dans le meme centre de1988 a 2000. Un patient avait une metastase synchrone ; chez les six autres, les metastases ont ete decouvertes 4 a 16 ans apres la nephrectomie, en raison de douleurs ( n = 2), d’une hemorragie digestive ( n = 1), de malaises ( n = 1) ou dans le bilan de surveillance ( n = 2). Le diagnostic de metastase etait suspecte dans tous les cas par le scanner avec injection de produit de contraste.

Background Few data are available from population-based statistics on the risk of local recurrence after surgery for rectal cancer. The aims of this study were to determine factors influencing local control and to analyse treatment and prognosis of recurrences in a well defined population. Methods Data were obtained from the cancer registry of the Côte d'Or (France). From 1976 to 1995, 682 patients resected for cure for a rectal carcinoma were included. Recurrence rates and survival rates were calculated using actuarial methods. A relative survival analysis and Cox multivariate analysis were performed. Results During the study 135 local recurrences were registered. The 5-year cumulative local recurrence rate was 22·7 per cent. In multivariate analysis the two variables significantly associated with local recurrence risk were stage at diagnosis and the macroscopic type of growth. There was a non-significant decrease in local recurrence rate in patients treated by preoperative radiotherapy compared with that in patients treated by surgery alone. The proportion of patients re-resected for cure was 25·2 per cent, and increased from 13·0 per cent in 1976–1985 to 37·9 per cent in 1986–1995 (P = 0·001). The 5-year relative survival rate was 13·6 per cent overall and 40·6 per cent after resection for cure (P < 0·001). Conclusion Local recurrence of rectal cancer following resection remains a substantial problem. Improvement can be expected from better care and earlier diagnosis.

Resume But de l’etude : Le but de l’etude etait d’evaluer la mortalite et la morbidite de l’ulcere gastroduodenal hemorragique apres traitement chirurgical, compte tenu du vieillissement de la population et de l’amelioration des traitements medicaux et endoscopiques. Patients et methode : Cette etude retrospective a porte sur 49 patients, 15 femmes, 34 hommes, d’âge moyen 72 ± 14 ans (extremes : 21–92 ans) operes d’urgence dans le meme centre entre 1994 et 1999. Ces patients etaient classes ASA II ( n = 6), ASA III ( n = 20), ASA IV ( n = 21) et ASA V ( n = 2). L’indication operatoire a ete posee pour des hemorragies non controlables chez dix patients, recidivantes chez 28 patients, et persistantes chez 11. Il s’agissait d’un ulcere gastrique dans cinq cas, traite par resection–suture ( n = 2) et gastrectomie partielle ( n = 3) et d’un ulcere duodenal dans 44 cas traite par suture ( n = 30), gastrectomie partielle ( n = 10) et duodenomie exploratrice ( n = 4). Resultats : La mortalite globale a ete de 20,4 % (10/49). La mortalite a ete de 40 % (4/10) en cas d’hemorragie non controlable, de 7 % (2/28) en cas d’hemorragie recidivante, de 36 % (4/11) en cas d’hemorragie persistante. La mortalite n’a pas varie selon la technique operatoire. La morbidite a ete de 45 %, avec trois recidives hemorragiques en cas de suture et trois fistules duodenales en cas de gastrectomie partielle. Conclusion : Le traitement chirurgical d’urgence de l’ulcere gastroduodenal hemorragique garde une morbidite et une mortalite elevees. La recidive hemorragique n’apparait pas aggraver le pronostic alors que la persistance de l’hemorragie est un facteur de gravite.

Resume But de l'etude Evaluer les effets de l'hyperthermie et de l'hypothermie intraperitoneale sur la penetration tissulaire et tumorale du cisplatine administre par voie intraperitoneale chez le rat. Materiel et methodes Une carcinose peritoneale macroscopique a ete obtenue 20 jours apres l'injection intraperitoneale de 1 × 10 6 cellules DHD/K12/PROb chez des rats BD IX. Trois groupes de 15 rats, porteurs de carcinose peritoneale, ont ete traites par du cisplatine intraperitoneal (25 μg/mL de dialysât) a ventre ouvert et en circuit ferme a une temperature intra-abdominale moyenne de 16,6 °C pour l'hypothermie, de 37,6 °C pour la normothermie et de 41,8 °C pour l'hyperthermie. Resultats Avec l'hyperthermie, les concentrations tumorales et diaphragmatiques de platine etaient significativement superieures a celles obtenues avec la normothermie alors que les concentrations renales etaient significativement inferieures (Anova, p p Conclusion L'hyperthermie augmente la penetration intratumorale du cisplatine lors de la chimiotherapie intraperitoneale alors que l'hypothermie a l'effet inverse. Ces donnees experimentales confirment l'avantage pharmacologique de la chimiotherapie hyperthermique intraperitoneale.

Background Pancreatic fistula (PF) is a major source of morbidity after pancreatectomy. The International Study Group on Pancreatic Fistula (ISGPF) defines postoperative fistula by an amylase concentration in the abdominal drain of more than three times the serum value on day 3 or more after surgery. However, this definition fails to identify some clinical fistulas. This study examined the association between lipase measured in abdominal drainage fluid and PF. Methods Amylase and lipase levels in the abdominal drain were measured 3 days after pancreatic resection. Grade B and C fistulas were classified as clinical fistulas, regardless of whether the measured amylase concentration was considered positive or negative. The PF group included patients with a clinical fistula and/or those with positive amylase according to the ISGPF definition. Results Sixty-five patients were included. The median level of lipase was higher in patients with positive amylase than in those with negative amylase: 12 176 versus 64 units/l (P < 0·001). The lipase level was 16 500 units/l in patients with a clinical fistula and 224 units/l in those without a clinical fistula (P = 0·001). Patients with a PF had a higher lipase concentration than those without: 7852 versus 64 units/l (P < 0·001). A lipase level higher than 500 units/l yielded a sensitivity of 88 per cent and a specificity of 75 per cent for PF. For clinical fistulas the sensitivity was 93 per cent and specificity 77 per cent when the threshold for lipase was 1000 units/l. Conclusion Lipase concentration in the abdominal drain correlated with PF. A threshold of 1000 units/l yielded a high sensitivity and specificity for the diagnosis of clinical PF.

The authors report a rare anomaly of portal vascularization which was detected by CT-scan and MRI and then confirmed surgically. There was no portal bifurcation at the hilum of the liver. After giving off its right dorsal branch, the portal vein entered the right liver and divided in the parenchyma into the right ventral and left branches. The arterio-biliary distribution was normal. Only a few similar cases have been reported. The left branch of the portal vein is reported to have few variations in contrast with the right one, which has many. The venous structure of the liver varies increasingly with the distance from the left umbilical vein. During a right hepatectomy, the possibility of such a vascularization makes it necessary to ensure that the left branch of the portal vein starts upstream before dividing a portal branch entering the right liver.

The authors report an original procedure of open-abdomen intraperitoneal chemo-hyperthermia. The skin edges are watertightly stapled with a soft "abdominal cavity expander", supported by a Thompson self-retaining retractor positioned over the abdomen. So, the level of the liquid can be widely raised above the level of the skin edges. The anterior wall peritoneum, the wall edges are constantly exposed to the liquid. Large amplitude movements become possible: introduction into the abdomen of two forearms, even two arms, does not induce loss of any liquid. The small bowel, the stomach can be partially exteriorized. It becomes very easy to expose all the peritoneal spaces, to maintain an homogeneous hyperthermia within the abdomen, while using only one inflow drain, and one outflow drain.

A cadaver liver is divisible into two transplants by section between right and left lobes, or section between left medial segment and left lateral segment medial to the umbilical cleft. To establish the ideal basis of partition of the portal elements, an anatomic study of 33 livers was performed. It is preferable to section the left portal vein, longer and more constant than the right, the right branch of the hepatic artery, larger and more constant than the left, and the left hepatic duct because of the vascularization of the common hepatic duct. To use the length of the left portal vein, it is necessary to section all its branches to segment I and then to resect this segment. After a section between the left medial segment and the left lateral segment medial to the umbilical cleft, the left medial segment always loses its total portal venous vascularization and should be resected. Before a split-liver, cholangiography and arteriography should be performed to detect anatomical variations without performing an extensive dissection which may endanger the vascularity of the bile ducts.

After a total proctocolectomy, ileoanal continuity is achieved by an ileal pouch–anal anastomosis. This anastomosis is not possible when the ileum cannot reach the anus. To avoid definitive ileostomy in this circumstance, we devised a gastric pouch, taken from the left half of the vertical portion of the stomach, vascularized by the right gastroepiploic pedicle, then interposed it between the ileum and the anus. The aim of this anatomical study on seven cadavers was to estimate the capacity of this gastric pouch to reach the anus. The distance between the caudal edge of the pubic symphysis and the apex of the pouch was measured. It is accepted that an ileal pouch always reaches the anus without tension if it comes down 6 cm below the caudal edge of the pubic symphysis. The apex of the gastric pouch reached a mean of 13.3 cm (range 10–18 cm) below the caudal edge of the pubic symphysis. This technique was then performed on four patients. The apex of the gastric pouch reached a mean of 12.5 cm (range 10–14 cm) below the caudal edge of the pubic symphysis and always reached the anus. These findings emphasize that a gastric pouch interposed between the ileum and the anus after a total proctocolectomy has an excellent capacity to reach the anus without tension.

We have previously shown that intraperitoneal (i.p.) epinephrine enhances tumour penetration and anti-cancer activity of i.p.-administered cisplatin in rats with peritoneal carcinomatosis. Here, we show a direct correlation between the i.p. epinephrine concentration and cisplatin accumulation in rat peritoneal tumour nodules up to a concentration of 5 mg/l. This concentration leads to a maximal 3.7-fold increase of tumour platinum content and a maximal vasoconstriction of the peritoneal and tumour superficial microcirculation when registered by a laser doppler probe. Further, epinephrine half-life was 20.8+/-3.6 min in the peritoneal cavity of two laparotomized pigs. In these animals, epinephrine plasma concentration, heart rate and systolic blood pressure were dependent on the intraperitoneal dose of epinephrine, and life-threatening signs were not observed in either animal. In conclusion, a 5 mg/l concentration of epinephrine could be safely maintained in peritoneal fluid by regular replacement. This concentration is sufficient to maintain a constant vasoconstriction of the peritoneal and tumoral microvascular bed, and enhance the slow diffusion of cisplatin into peritoneal tumour nodules in the course of per-operative intraperitoneal chemotherapy.

The authors report a tubular duplication of the thoracic esophagus in a 17-year-old male. This anomaly, rare in the adult, can be explained either by a failure of esotracheal compartmentalisation, or a notochordodysraphy or more probably by an error during vacuolisation of the esophagus. The anatomical characteristics of the duplication were clearly seen on MRI. This investigation showed the intramural duplication, with only a thin barrier without muscle, between the esophageal lumen and the duplication channel: two communications were present between the esophageal lumen and the duplication. The esophagus was accessed by right thoracotomy. The close contact between the duplication and the esophagus did not allow them to be separated. A subtotal esophagectomy was necessary, with digestive continuity being restored by coloplasty after a left cervicotomy and a laparotomy. The anatomy seen on the MRI should have predicted that an esophagectomy was necessary and that a thoracotomy could have been avoided by performing the procedure with a closed thorax.

Introduction Les complications septiques, en particulier les fistules anastomotiques, sont responsables d’une part importante de la morbidite en chirurgie colorectale. Une detection precoce de ces complications permettrait de diminuer la morbidite, la duree de sejour et le taux de readmission, en particulier a l’ere de la rehabilitation precoce. Le dosage de la proteine C reactive pourrait permettre cette detection precoce. Patients et Methode Entre novembre 2007 et octobre 2008, a ete menee une etude prospective portant sur les patients ayant une chirurgie colorectale reglee avec retablissement de continuite. Les donnees suivantes ont ete collectees regulierement en postoperatoire puis evaluees comme facteurs predictifs de complications septiques (en particulier les fistules anastomotiques) : temperature, pouls, reprise de transit, examen abdominal, numeration leucocytaire et mesure de la valeur de la proteine C reactive. Les facteurs predictifs potentiels ont ete analyses de maniere univariee puis multivariee ; une regression logistique a ete realisee et les precisions diagnostiques des facteurs ont ete comparees. Resultats Pendant la periode de l’etude, 133 patients ont ete inclus. Le taux de mortalite a ete de 4,5 % (6/133), le taux de complications septiques de 39,1 % (52/133) et le taux de fistules de 15,5 % (21/135 anastomoses) independamment de leur retentissement clinique. Parmi les facteurs predictifs potentiels, la valeur de proteine C reactive au quatrieme jour post operatoire a eu la meilleure precision diagnostique : 0,787 pour les complications septiques et 0,845 pour les fistules. Avec une valeur seuil de 125 mg/dl la proteine C reactive avait une sensibilite de 81,8 % et une valeur predictive negative de 95,8 % pour la detection de fistule. Conclusion Une valeur elevee de proteine C reactive est un fort indicateur de fistule anastomotique. Un dosage systematique de la proteine C reactive pourrait permettre d’ameliorer la prise charge des suites operatoires de chirurgie colorectale reglee. Les patients dont le dosage de proteine C reactive est superieur a 125 mg/dl au quatrieme jour post operatoire d’une chirurgie colorectale reglee devraient rester hospitalises.

From 1981 to 1988, 138 patients with hiatal hernia were treated surgically at our centre. Twenty-one (mean age 76.6 years, 17 women, four men) had an associated intrathoracic gastric volvulus. Eleven patients (mean age 73.2 years), of whom eight were asymptomatic, had an elective procedure. Ten patients (mean age 80.3 years) had emergency surgery, six for acute complications of the volvulus (five cases of strangulation and one of perforated ulcer) and four because of other, unrelated causes of acute abdomen. There were four deaths after operation, all in the emergency surgery group. Four other patients had significant morbidity, all in the emergency group. In the elective cases, all hernias were easily reduced. In one emergency case a gastrotomy was necessary for decompression, and in another gastrectomy was necessary because of gastric gangrene. Our results indicate the need for elective intervention when intrathoracic gastric volvulus is first diagnosed.

The impact of changes in diagnostic strategies for gastric cancer and attitudes towards surgery in elderly patients is not known. A population-based series of 842 gastric cancers diagnosed between 1976 and 1993 in patients aged 70 and older in Cote-d'Or, France, was used to establish trends in diagnostic strategy, treatment, and prognosis. The use of endoscopy alone increased from 3% (1976-78) to 81% (1991-93). This trend was initially associated with a decrease in the use of x-ray alone, then with a decrease in the use of both x-ray and endoscopy. The proportion of resection for cure increased from 26% during 1976-78 to 43% during 1991-93 (P < 0.001). The proportion of cancers not extending beyond the gastric wall increased from 12% to 24% (P < 0.05). Operative mortality decreased from 38.7% (1976-78) to 13.3% (1991-93) and the corresponding 3-year crude survival rate rose from 7% to 18%. Improvements in the care of gastric cancer in elderly patients have been achieved, but further progress is warranted.