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Portal pressure and portal-systemic collateral circulation after orthotopic liver transplantation have not been investigated. We studied systemic and splanchnic hemodynamics in 17 patients with cirrhosis before and 205 +/- 146 days after orthotopic liver transplantation. Among the 17 orthotopic liver transplantation patients, 12 had undergone hemodynamic study in the 6 mo before orthotopic liver transplantation. Controls were 50 patients with normal liver architecture. Cardiac index remained elevated in orthotopic liver transplantation patients compared with controls (3.6 +/- 0.9 vs 3.1 +/- 0.4 L/min.m2; p0.05). Azygos blood flow, which was elevated before orthotopic liver transplantation (585 +/- 402 ml/min), remained elevated after orthotopic liver transplantation (553 +/- 343 ml/min). In transplant patients, hepatic blood flow was higher than it was in controls (2.26 +/- 0.86 vs. 1.38 +/- 0.57 L/min; p0.05). Elevated hepatic blood flow correlated with cardiac index (r = 0.647, p0.025). In patients with normal graft function, hepatic venous pressure gradient was normal (2 +/- 1 mm Hg). In a patient with acute rejection, a sharp elevation in the hepatic venous pressure gradient was observed; it returned to normal 45 days after treatment. We conclude that despite normal portal pressure, portal-systemic collateral blood flow remains elevated after orthotopic liver transplantation. Possibly because of persistent collateral circulation, which may keep portal tributary blood flow elevated, hepatic blood flow is increased after orthotopic liver transplantation. Elevated splanchnic blood flow, in turn, contributes to the high cardiac index in liver recipients. Finally, a sharp elevation in portal pressure, which may be observed during acute rejection and subsides after treatment, merits further study.

Endoscopic ultrasonography (EUS) was compared to ultrasonography (US) and CT scan (CT) in order to evaluate its role in the diagnosis and the locoregional spread assessment of pancreatic cancer. Sixty-four patients suspected of pancreatic cancer were studied prospectively, and the results of imaging techniques were compared to histology and surgical exploration. There were 49 cases of pancreatic adenocarcinoma, 11 of pancreatitis, 2 of common bile duct carcinoma, 1 lymphoma and 1 hepatocellular carcinoma with peripancreatic metastatic lymph nodes. EUS was significantly more accurate (91%) than CT (66%) and US (64%) for diagnosis of pancreatic cancer. EUS was able to image all 7 cancers less than 25 mm in diameter, US and CT only one. There were 4 false positives with EUS which were all cases of pseudotumorous pancreatitis. For detecting lymph node involvement, EUS was significantly more sensitive (62%) and accurate (74%) than US (8% and 37%) and CT (19% and 42%), respectively. Invaded lymph nodes adjacent to large tumors and micrometastatic involvement were responsible for this lack of sensitivity. EUS was significantly more sensitive (100%) than CT (71%) and US (17%) for detecting venous involvement. The specificity of EUS was lower (67%) because of duodenal bulb stenosis and large tumors. In conclusion, this prospective and comparative study confirms that EUS is an accurate tool for diagnosis and locoregional spread assessment of pancreatic cancer when performed in a reference center. EUS is of particular interest for small tumours. However, EUS does not enable differentiation of pseudotumorous pancreatitis from adenocarcinoma.

Salvage oesophagoplasty using a free jejunal transplant is the ultimate reconstruction possible after repeated failures using the classic procedures of oesophagoplasty. The free jejunal transplant appears to be the best choice. Twenty-five free jejunal transplants were performed by the same surgeon for such reconstructions including 13 cases involving benign lesions and 12 cases of cancer. There were no post-operative death and none of the transplantations was a complete failure although three cases of stenosis and fistulization occurred. Several recommendations can be made: save the existing digestive tract, redissect the residual digestive plasty and pull it up. The residual digestive flap can be examined by opacification or endoscopically in order to evaluate its length. An arteriography of the pediculated plasty gives information on its vascularization. A free jejunal graft can safely cover 25 to 30 cm. When possible, residual plasties should be positioned subcutaneously. The reconstruction of the cervico-thoracic oesophagus usually requires a vascular bypass with a saphene graft. In difficult cases, it may be necessary to remove a part of the sternal manubrium and the head of the clavicular bone in order to avoid compressing the jejunal graft. When the length of the reconstruction is greater than 30 cm, a long jejunal transplant with two pedicules (1 pedicule revascularized from the cervical vessels and the other pedicule from the internal thoracic vessels) is needed. An alternative technique would be a free antebrachial flap (six cases operated with two post-operative deaths at 6 weeks and two fistulas).(ABSTRACT TRUNCATED AT 250 WORDS)

The combination of cancers of the esophagus and of the ENT region has been extensively studied. Strangely enough, only a few cases of associated cancers of the esophagus and of the lung are reported in the literature. The authors report about 38 cases, including 21 with synchronous tumors and 17 with metachronous tumors. The bronchial cancer has always been discovered on systematic search during pre- or postoperative checkups in patients with cancers of the esophagus. Conversely, this search does not seem to have been made in patients with lung cancer: the cancer of the esophagus was always revealed by dysphagia. Double exeresis was performed in 19 patients (50%). There was no postoperative death. The duration and quality of survival were markedly better than in non-operated patients.

Superficial squamous cell carcinomas of the oesophagus are defined as cancers confined to the mucosa or involving the submucosa but sparing the muscularis mucosae, with or without lymph node extension. Although lymph node involvement is rare (less than 5%) in tumours confined to the mucosa, it is frequent (30 to 45%) in tumours involving the submucosa, which have a prognosis similar to that of the usual obstructive tumours. Endoscopic ultrasonography is the most accurate examination (diagnostic accuracy greater than 95%) to distinguish between superficial and advanced cancers. The absence of visualization of the muscularis mucosae with the currently available transducers limits the decision-making value of such a distinction except in the case of flat tumours in which the absence of ultrasonographically detectable parietal thickening indicates the presence of a cancer confined to the mucosa, with an excellent prognosis.

An original technique of OLT with preservation of the entire IVC of the recipient and side to side caval anastomosis is described. The procedure has permitted the avoidance of retrocaval dissection and temporary vena caval occlusion. The caval outflow was respected during the anhepatic phase. The technique, requiring only one caval anastomosis, has reduced the duration of the anhepatic phase and the need for venous bypass.

An original technique of orthotopic liver transplantation with preservation of the recipient's entire inferior vena cava and side-to-side caval anastomosis is described. This procedure was used in 21 consecutive patients. It has permitted to avoid vena caval occlusion and the need for venous bypass. No consequences on caval flow were observed during the anhepatic phase. Our technique avoids retrocaval dissection and requires only one caval anastomosis, reducing the duration of the anhepatic phase.

Carcinoma is one of the most severe complications of oesophageal diverticula. Its incidence varies from almost zero to 4 percent. The authors report 4 cases of carcinoma arising in a pharyngo-oesophageal diverticulum and 2 cases involving a diverticulum of the oesophageal body. In this disease, the diagnosis is often delayed, which may be the reason for the low long-term survival rate. The risk of carcinoma is another justification for resection of the pharyngooesophageal diverticulum. The post-surgical morbidity of the oesophageal body diverticula is an obstacle to systematic resection of these lesions.

A prospective randomized study was conducted on 100 patients operated upon for oesophageal diseases to evaluate the usefulness of fibrin glue in reinforcing oesophageal anastomoses. The anastomoses were located in the neck, the chest or the lower mediastinum. The operative mortality rate, the number and severity of fistulae and the incidence of anastomotic stenosis were studied. This series was insufficient to demonstrate that fibrin glue was effective in this type of surgery.

The aim of this study was to evaluate the pain relief related to resection of the celiac plexus in pancreatic carcinoma. This technique was attempted in 26 consecutive patients and performed in 23 (feasibility: 88%), whose mean age was 64 years. Before surgery, patients were divided into two groups: patients not treated by narcotic analgesics (group 1, n = 10) and patients treated by narcotic analgesics (group II, n = 13). Surgery was indicated in 22 patients for pancreatic resection or by-pass, and in 1 patient for pain relief after an unsuccessful per-cutaneous celiac plexus block. Resection of the celiac plexus was always performed via a trans-peritoneal approach, after mobilization of the head of the pancreas and the duodenum. Only the right half of the celiac plexus was resected in 4 patients (17%) due to technical difficulties. Pathologic examination was performed in 16 patients (8 patients from each group) and neoplastic involvement was observed only in 3 patients of group II. There was no operative death. Two complications related to this method occurred (9%). One patient developed a chylous ascites and was treated conservatively. In a second patient, an occlusion of the celiac trunk was complicated by infarction of the spleen and of the left lobe of the liver; this patient was reoperated and his subsequent post-operative course was uneventful. In group I, eight patients (80%) did not require narcotic analgesics after resection of the celiac plexus. Two failures occurred, one immediately after surgery and one delayed. In group II, seven patients (53%) did not require narcotic analgesics; 6 of these 7 patients died. Six failures occurred, 4 early after surgery and 2 delayed. Three of the 4 early failures occurred in patients who underwent resection of the right half of the celiac plexus. The authors concluded that resection of the celiac plexus seems to be an effective pain treatment in pancreatic carcinoma. However, resection must be bilateral to provide analgesia. Specific morbidity of this technique may lead to the use of non-surgical methods if surgery is not indicated for pancreatic resection or by-pass.

Fifty patients were reoperated for failed antireflux procedures or post-fundoplication symptoms. Cases of severe esophagitis, that is stenosis or Barrett's esophagus, were excluded. The usual cause of failure was a technical error. All of the operations, a new fundoplication in 35 cases and a total duodenal diversion in 15 cases, were performed via an abdominal incision. Operative mortality was nil. After a 42 months follow-up, according to the patient, the clinical results were good or excellent in 93% of the cases. The objective results-fibroscopy, pHmanometry, X-Ray were normal in 86%.

An analysis of the causes of failure of Heller's operation is necessary in order to arrive at appropriate treatment. We retrospectively studied 100 reoperations for failed esophagomyotomy. Usually, a repeat myotomy was performed via an abdominal approach if the initial Heller's operation proved a failure, or via a thoracic approach if extensive motor disorders were discovered at manometry. Until 1978, esophagogastric resections were performed for severe esophageal injuries due to reflux after Heller's operation, but since then, duodenal diversion has obviated the need for resection. Antrectomy with Roux-en-Y gastrojejunostomy and vagotomy might be performed via an abdominal approach because the latter, always mandatory, is feasible through a transdiaphragmatic approach. Esophageal resection was reserved for major esophageal asystole, some cases of sclerosis, and carcinomas occurring or discovered after Heller's operation.

Total duodenal diversion (TDD) was performed in 19 patients with severe post-gastric surgery symptoms. Previous operations were truncal vagotomy associated with pyloroplasty or antrectomy (n = 6), proximal esophagogastrectomy (n = 8) or total gastrectomy (n = 5). Technical adjustments to the standard procedure (truncal vagotomy, antrectomy and gastrojejunal anastomosis using a 70 cm Roux-en-Y loop) were required. There were no postoperative deaths, no anastomotic leakage or anastomotic ulceration. The main symptoms were eliminated, and endoscopic gastritis and esophagitis healed in all patients. Heartburn and bilious vomiting ceased in all patients, but in five out of 14 patients with a residual stomach some symptoms persisted. TDD proved a safe and effective treatment of disabling symptoms following gastric surgery.

Between 1976 and 1988, we treated 13 perforations of the thoracic esophagus, excluding ruptured carcinoma and intraoperative wounds, by mechanical sutures without exclusion. The delay between perforation and treatment ranged from eight to 168 hours, more than 24 hours in 11. The length of perforation was 0.5 to 15.0 centimeters. Suture was covered with a flap in ten instances; an antireflux procedure was associated with five instances. No digestive ostomies were performed. There was one death; a patient who was comatose upon arrival. The results of this small series suggest that myotomy exposing the mucosa and a flap are two essential elements of the technique; perforations of less than 6 centimeters, even when seen late, may be treated by primary surgical closure.

Between January 1988 and February 1991, 27 patients underwent pancreaticogastrostomy after pancreaticoduodenectomy. The mean age of the patient was 57 years and 18 of them were male. Pancreatic disease was malignant in 21 patients (78%) and benign in 6 patients. The pancreatic remnant was normal in 15 patients (56%) and fibrotic in 12 patients. There was one operative death (3.7%) unrelated to the pancreaticogastrostomy. Only two complications (7.5%) were related to pancreaticogastrostomy: one patient had intra-gastric bleeding and was reoperated, one patient developed a pancreatic leak (3.7%) which healed without reoperation. The authors conclude that pancreaticogastrostomy in the preferred method of management of the pancreatic remnant after pancreaticoduodenectomy.

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)

Endoscopic transrectal ultrasonography (EUS) is performed with an ultrasonic transducer (7.5 mHz or 12 mHz) situated in the tip of a side viewing endoscope. Its accuracy to assess the depth of rectal cancer invasion was studied prospectively in 31 patients. The ultrasonic examination was complete in 26 cases; in 5, the stricturing tumour could not be passed by the probe. The depth of invasion was correctly evaluated in 27 of the 31 patients (accuracy: 90 per cent). The 7 superficial lesions were all correctly detected with EUS. EUS appears to be a very promising method for the pretherapeutic staging of rectal cancer.

Endoscopic transrectal ultrasonography is performed with an ultrasonic transducer (7.5 MHz or 12 MHz) in the tip of a side viewing endoscope. Its accuracy to assess the depth of rectal cancer invasion was prospectively studied in 27 patients. The ultrasonic examination was correct in 23 cases; in 4 cases, the stricturing tumour could not be passed by the probe. The depth of invasion was correctly appreciated in 24 of the 27 cases (accuracy of 89%). The 6 superficial lesions were all correctly detected with endoscopic transrectal ultrasonography. Therefore, endoscopic transrectal ultrasonography appears to be a very promising method in the pretherapeutic staging of rectal cancer.

The value of endoscopic ultrasonography in the diagnosis of subepithelial tumors and extrinsic compression of the esophagus and the stomach was evaluated in 34 patients with 21 subepithelial tumors and 13 extrinsic compressions. Endoscopic ultrasonography was always performed after axial-vision fiberscopy anal routine biopsy specimens were obtained. Computed tomography was also done in all cases of extrinsic compression. Distinction between subepithelial tumor and extrinsic compression was made in all patients by endoscopic ultrasonography and in 5 cases by fiberscopic examination with biopsy specimens. Localization and intramural spread of subepithelial tumors were correctly determined in 12 of 13 cases by endoscopic ultrasonography (diagnostic accuracy: 92 percent). The echoendoscopic semiology of 21 subepithelial tumors was retrospectively established. The histologic nature of some of these tumors can be suggested by these signs. Endoscopic ultrasonography is superior to computed tomography in the evaluation of esogastric extrinsic compressions, particularly in the diagnosis of posterior mediastinal carcinomatosis and of tumoral invasion of the deep parietal layers. We conclude that endoscopic ultrasonography is currently the best procedure in the assessment of subepithelial tumors and extrinsic compressions of the esophagus and the stomach.

To investigate whether endoscopic ultrasonography could improve the preoperative staging of esophageal carcinoma we prospectively studied 56 tumors in 51 patients between March 1987 an March 1988. The results for assessing local and regional extension and preoperative staging were compared with those of computed tomography, surgery, and pathological findings. When the procedure was complete (n = 25) the accuracy of parietal spread assessment was 85.7 percent; sensitivity for nodal involvement was 83.3 percent versus 50 percent for computed tomography with an accuracy of 97.6 percent versus 96.4 percent; the discrimination between superficial and advanced cancer was 100 percent; the accuracy for preoperative staging using the Japanese classification was 84 percent. When the procedure was not complete (stenosis), endoscopic ultrasonography was complementary to computed tomography: local invasion of anatomical structures (n = 16) was better assessed by combined endoscopic ultrasonography and computed tomography (n = 11) than by endoscopic ultrasonography (n = 8) or computed tomography (n = 6) alone. We conclude that endoscopic ultrasonography is the best procedure for staging esophageal carcinoma without stenosis; further miniaturization of the transducer is necessary to improve results in the case of narrow stenosis.

14515 Background: In vitro spheroid model using cancer cell lines is widely admitted to mimic in vivo micro tumors, including micrometastases. Floating spheroid cell cluster culture has been recently used for normal and cancer stem cell expansion. Spontaneously spheroids generated in vivo have been only studied in ovarian cancer ascites while organoid aggregates have been sometimes observed in the establishment of human colon cancer cell lines. In this study, we investigated whether spontaneous spheroid aggregates from colon cancer could be isolated and characterized. Methods: 127 colorectal primary tumor specimens have been collected and mechanically dissociated into small fragments, which were then shortly cultured on cell plastic flask. Production of spheroid- like structures, referred to as colospheres, was examined at Day 1 and colospheres were gathered for phenotypic characterization. Results: Colospheres were successfully generated from 67 surgical specimens (53%). The capacity to form colospheres was strictly restricted to tumor tissue: dissociated normal colon mucosa never generated colospheres and colospheres were formed exclusively by cancer cells. The ability to generate colospheres was demonstrated to be significantly related to tumor aggressiveness, according to nodal status and AJCC’s stages (Chi-2 test, p No significant financial relationships to disclose.

Five currently used procedures of gastric esophagoplasty were done in 5 groups of 14 embalmed human cadavers. These procedures were: whole gastric intrathoracic transposition (Kirschner's procedure) isoperistaltic gastric cone (Akiyama's procedure) isoperistaltic gastric tube (Rutkowski's or Lortat-Jacob's procedure); isoperistaltic gastric tube with resection of the lesser curvature; anisoperistaltic gastric tube with intrahilar splenectomy (Gavriliu's, Heimlich's procedure). Gastric morphometry and ascinding vascularization ability and quality of the vascular network were assessed. Injection of plastic dye was used to evaluate the vascularization of the grafts. In 13 out of 14 grafts, whole gastric transposition extended above the sternal notch, for a mean distance of 7.7 +/- 4.9 cm. This basic performance was significantly correlated to the dimensions of the greater and lesser curvatures and to the cardioxiphoid, sternal and hyosternal distances. Absent or poor injection of the distal arterial network, over a mean distance of 3.6 +/- 0.8 cm, was seen in all 14 grafts. Study of the isoperistaltic gastric cone demonstrated that the graft extended above the sternal notch in all 14 cases. The mean distance of the graft segment above the sternal notch was 5.0 +/- 3.0 cm. This basic performance showed a significant correlation only with the dimensions of the greater and lesser curvatures. Absent or poor injection of the distal arterial network of the gastric cones was seen in 9/14 cases, the mean length of the devascularized segment being 1.3 +/- 1.3 cm. Subsequent to resection of the distal zone showing poor vascularization, 13 out of the 14 isoperistaltic cones still extended above the sternal notch. The mean length of the segment above the sternal notch was 3.7 +/- 2.6 cm. All 14 isoperistaltic gastric tubes (without resection of the lesser curvature) extended above the sternal notch. The mean length of the segment above the notch was 15.1 +/- 7.1 cm. This basic performance showed a statistically significant correlation only with the minimum pylorodiaphragmatic distance subsequent to extensive Kocher's manoeuver. Of these 14 gastric tubes, 9 showed poor or no vascularization of their distal arterial network. The mean length of the poorly injected segment was 8.0 +/- 1.8 cm. Subsequent to resection of the poorly vascularized territory, 12/14 grafts were still found to extend above the sternal notch. The mean length of the segment above the sternal notch was 7.1 +/- 6.9 cm.(ABSTRACT TRUNCATED AT 400 WORDS)

Physiopathological mechanism of respiratory distress syndrome associated with acute pancreatitis remains unclear. We observed a case of drowning-like hypoxemia due to a pancreaticobronchial fistula; this patient, with a necrotizing isthmic pancreatitis, had only two Ranson’s criteria, and showed a clearly isolated mechanical reason for respiratory failure. Then, the retrospective study of 40 patients having an objective surgical recognition of necrotizing pancreatitis (NP) was performed. Twelve patients received ventilatory support. The prevalence of isolated sepsis-related respiratory failure was 9 out of 12 cases (75%). Two patients had a secondary infection of necrosis also associated with a pancreaticobronchial fistula, and in 1 case this isolated mechanism of respiratory distress was obvious. Such a prevalence of 25% of fistula-related respiratory failure has never been observed before. The onset of severe hypoxemia in the course of NP appears to be a sensitive and pathognomonic sign of evolving complication of pancreatitis, leading to endoscopic retrograde pancreatography, and to prompt surgery. In the opposite way than that suggested by the enzymatic hypothesis, we were not able to show any reason for applying mechanical ventilation to patients suffering from pancreatitis, in the absence of intraabdominal sepsis, and/or pancreaticobronchial fistula.

This study concerns a series of 355 carcinomas of the thoracic esophagus treated over a six-year period. 5 points of the pre operative work up are discussed: total endoscopy, respiratory and hepatic function as most of the patients were heavy smokers and alcoholics, nutritional status and C.T. scan in order to precise the preoperative nutrition value and the true correlation between surgical and CT scan findings. As far as curative resection is concerned, the indications of cervical and intra-thoracic anastomoses and of phi en bloc- posterior mediastinectomy versus blunt dissection are discussed. The mortality rate in this series of 135 curative resections was 8 p. cent due to pulmonary infection and to fistulas. The late results are studied according to the Japanese classification. The overall five-year actuarial survival is 19 p. cent, and 30 p. cent for the group of curative resection in stage 0, 1 and II.

A retrospective study was undertaken of abdominal echography in mode B with manual scanning in assessing the spread of 102 carcinomas pf the oesophagus. This showed echography to be reliable in the diagnosis of hepatic metastases (accuracy of method = 93%), ineffective in detecting coeliac lymph node involvement and specific in the recognition of fatty infiltration and steatofibrosis of the liver. However, with regard to hepatic metastases, the existence of false positives and false negatives, even few in number, was such that echography could not influence final decisions as to treatment. The authors feel that histopathological proof in doubtful cases by cytological puncture using a fine needle would avoid false positives and thus give echography its full value.

Since the GEEMO (European Group for Study of Esophageal Diseases) questionnaire is a retrospective study, we have decided to set some simple limits. The aims of this paper are (a) to assess the high risk group patients, (b) to assess if some forms of treatment are likely to improve the immediate outcome, (c) to find out whether some techniques or treatments are futile or poorly suited.

Adult respiratory distress syndrome (ARDS) is a frequent feature in acute pancreatitis, but précise etiology of hypoxemia remains unclear. Determinations of lipase and amylase levels are made in samples of bronchial secretion, in three intubated patients receiving assisted ventilation for severe hypoxemia occurring in the course of pancreatitis. This determination appeared to be valuable to incriminate the responsibility of a pancratico-bronchial fistula. In the first case, emergency laparotomy was able to show the fistulous track. In the second described case, an endoscopic retrograde pancreatography was performed, showing a fistula from pancreatic body to left bronchial tree. In the third case, the presence of a bronchial fistula was proved by a fistulography trough the abdominal pancreatic necrosis. A decrease of arterial PO2 followed pancreatography and fistulography. The surgical treatment was splenopancreatectomy, necrosectomy associated with left pulmonary lobectomy, and necrosectomy with colonic diversion. In the third case, pancreatico-bronchial fistula was the final evolution of an infected intra-abdominal necrosis, despite multiple surgical drainages. In the first and second cases, surgical treatment obtained a prompt and uneventful recovery. Few published cases of pancreatico-bronchial fistulae are reported. A retrospective study of 12 ARDS was made among 40 patients underwenting laparotomy, with an objective recognition of necrotizing pancreatitis, from 1980 to 1987. A pancreatico-bronchial fistula could be incriminated in three cases of these 12 ARDS. Such a prevalence of 25% has to be reevaluated after serial determinations of lipase and amylase levels in bronchial samples of intubated patients suffering from ARDS in the course of pancreatic disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic ultrasonography of the digestive tract provides for a precise ultrasonic study of the accessible gastrointestinal walls (oesophagus, stomach, duodenum, rectum) and, through these walls, of the adjacent organs (lymph node clusters, posterior mediastinum, pancreas, extrahepatic biliary ducts and perirectal environment). This method is better than computerized tomography to evaluate the local and regional extension of oesophageal and cardial carcinomas producing little or no stenosis and of rectal carcinomas. It is the examination of choice to detect a perianastomotic recurrence of these cancers and to evaluate submucosal tumours of the digestive tract and thick fold stomach diseases. Its use in the aetiological diagnosis of obstacles in the biliary tract and in the pretherapeutic assessment of pancreatic and biliary tract cancers seems to be very promising.

Four-hundred esophageal anastomoses were performed with a stapler in the Department of Digestive Surgery, Hospital Beaujon in Paris, in a six year period. The experience of the 14 different surgeons in esophageal surgery was very uneven (zero to 25 years). Two-hundred and sixty-eight esophagogastrostomies (220 in the chest and 48 in the neck), 83 esophagojejunostomies and 49 esophagocolostomies were done. The overall mortality rate was 9.2%, three per cent owing to leaks. The average incidence of leakage was 7% falling to 5.5% if cervical anastomoses were excluded. The incidence of stenoses was 8%. Several points which might account for problems are discussed. Stapled anastomoses seem to reduce the mortality and the morbidity rates of esophageal anastomoses, especially for surgeons with no experience in esophageal surgery.

In 4 patients with Hodgkin's disease treated with chemotherapy persistent residual masses, remarkable by their initial volume in 3 cases, were surgically removed. Histological examination showed that the masses were histologically stable and non-evolutive. The incidence of residual masses is discussed with a review of the literature. These masses, which should not be confused with therapeutic failures, constitute a striking example of the special place occupied by surgery in certain forms of Hodgkin's disease.

Early or late postoperative complications in 52 patients undergoing colic esophagoplasty for benign (27 cases) or malignant (25 cases) lesions of esophagus are discussed in relation to radiologic findings. Immediate postoperative complications due to infection were mainly bronchopneumopathies (14 cases), their incidence being increased by recurrent nerve palsy, and mediastinitis (3 cases). The frequency of upper anastomotic fistulae (16 cases) emphasizes the need for routine radiologic follow up on the 7th postoperative day by upper digestive tract follow-through examination with water-soluble contrast. Stenosis of upper part of graft may be of ischemic or fibrous origin. Ischemic stenosis develops 2 weeks to 4 months after surgery as a long filiform narrowing. Fibrous stenosis occurs in upper anastomosis at a later stage, after the 3rd month, as a short regular narrowing. Other complications are rare.

Perforation of the esophagus is considered to be one of the most dangerous esophageal diseases with regard to morbidity and mortality. In the majority of the cases the perforation has an iatrogenic cause, and this explains why many different treatments are proposed in the medical literature to reduce the death rate.

Total duodenal diversion was performed in 60 patients with reflux oesophagitis complicated by stricture, brachyoesophagus, endobrachyoesophagus or previous oesophago-gastric surgery. The standard operation (truncal vagotomy, antrectomy, 70 cm Roux-en Y anastomosis) was carried out in 41 patients; technical adjustments were necessary in 19 patients previously operated. One patient died of post-operative pulmonary embolism. Lasting cure of the oesophagitis was obtained within less than 3 months in 56/59 patients (93 per cent). Three-hour post-prandial pH measurements showed control of the reflux in 48/52 patients (92 p. 100). Anastomotic ulcers developed in 3 patients who did not have vagotomy. One case of complete remission of endobrachyoesophagus was observed, and 4 cases are now in partial remission. Digestive tract sequelae were found in 9 patients who had undergone surgery, but they were disabling in only one of these. These results suggest that total duodenal diversion is a suitable treatment of complicated reflux oesophagitis.

Three cases of adenomatous lesions of the pancreatic ducts are reported. There was 1 case each of adenoma of the main pancreatic duct, adenomas of the uncinate process and diffuse adenomatosis of the cephalic pancreatic ducts with ampullary involvement. On ultrasound and computerized tomography, the main pancreatic duct was enlarged in all cases, associated in 2 cases with a mass in the head of the pancreas, and in 1 case, with pseudocystic dilation of the uncinate process ducts. At duodenoscopy, the papilla was tumoral in 1 case, enlarged with mucous flow in 1 case and normal in the third case in which cytologic examination of secretions disclosed glandular cells. Endoluminal lesions were diagnosed by endoscopic retrograde pancreatography in 2 cases and on gross pathologic examination in 1 case. Treatment was surgical: cephalic pancreatoduodenectomy in 2 cases and local resection in 1 case, which relapsed 3 years later. At pathology, lesions were benign in all 3 cases including 1 case of severe dysplasia. On the basis of these 3 cases and a review of the literature, distinctive features of pancreatic endoluminal adenomas and adenocarcinomas are specified. Pancreatic resection is mandatory because of the risk of pancreatic obstruction and malignant degeneration.

Between 1980 and 1987, 38 patients with liver metastases have been operated on. In 28 cases the primary tumor was a colo-rectal carcinoma. 11 lobectomies and 27 minor resections or segmentectomies have been performed. The post-operative mortality was 5%. The actuarial survival for the metastases of colo-rectal carcinomas was 54% at 2 years, 27% at 3 years and 18% at 5 years. The results of this series are compared to those of the literature, to discuss indications, technical modalities and prognostic factors of the surgical treatment of liver metastases.

Connection between the left hepatic veins and inferior diaphragmatic veins were studied after injection in 20 embalmed cadavers. An unusual (5%) variant is described in which the left diaphragmatic vein replaces the left posterior hepatic vein and drains sub-segmental branches. Simple methods to recognize this abnormality are described. In such cases, it is recommended, when dividing the left triangular ligament, to sever the left inferior diaphragmatic vein between two ligatures and to work behind it.