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Voir aussi : A. Venara, V. De Franco, S. Mucci, E. Frampas, E. Lermite, N. Regenet, A. Hamy. Pancréatectomie centrale: anastomose pancréaticogastrique ou pancréaticojéjunale? Journal de Chirurgie Viscérale, Volume 149, Issue 2, April 2012, pp. 166-171. doi:10.1016/j.jchirv.2011.12.006; International audience; INTRODUCTION: The mild pancreatic tumors are more and more treated by central pancreatectomy (CP) in alternative with the widened pancreatectomies. Indeed, their morbidity is lesser but they are however burdened by a rate of important postoperative fistulas. The purpose of our study is to compare pancreatico-jejunal anastomosis and pancreatico-gastric anastomosis.METHODS: This work was realized in a bicentric retrospective way. Twenty-five CP were included and classified according to two groups according to the pancreatic anastomosis (group 1 for pancreatico-jejunal anastomosis and group 2 for the pancreatico-gastric anastomosis). CP was realized according to a protocol standardized in both centers and the complications were classified according to the classification of Clavien and Dindo and the fistulas according to the classification of Bassi.RESULTS: Both groups were comparable. The duration operating and the blood losses were equivalent in both groups. There was a significant difference (P=0,014) as regards the rate of fistula. The pancreatico-gastric anastomosis complicated more often of a low-grade fistula. However, in both groups, the treatment was mainly medical. Our results were comparable with those found in the literature and confirmed the advantages of the CP with regard to the cephalic duodeno-pancreatectomy (DPC) or to the distal pancreatectomy (DP). However, in the literature, a meta-analysis did not report difference between both types of anastomosis but this one concerned only the DPC.CONCLUSIONS: This work showed a less important incidence of low-grade fistula after pancreatico-jejunal anastomosis in the fall of a PM. This result should be confirmed by a later study on a more important sample of PM.

BACKGROUND: The aim of this prospective study was to determine the short- and long-term results of the Frey procedure in the treatment of chronic pancreatitis. METHODS: From September 2000 to November 2009, 44 consecutive patients underwent the Frey procedure. Patients were included in the study before surgery and followed prospectively with assessment of pain relief, weight gain and exocrine/endocrine insufficiency. Twenty-one patients (47.7%) were followed for more than 5 years. RESULTS: This study included 40 men (91 %) and four women (9 %) (mean age: 49 years) with a mean follow-up of 51.5 months. The primary etiology of chronic pancreatitis was chronic alcohol abuse in 38 patients (86.4 %). The major indication for surgery was disabling pain (95.5 %). There was no postoperative mortality. Postoperative morbidity occurred in 15 patients (34.1 %), with specific surgical complications in 11 patients (25 %). The percentage of pain-free patients after surgery was 68.3 %. Eight patients (18.1 %) and seven patients (16 %) developed diabetes de novo and exocrine insufficiency, respectively. The Body Mass Index showed statistically significant improvement during follow-up. Similar beneficial results concerning pain relief and weight gain persisted after the initial 5-year follow-up. CONCLUSIONS: The Frey procedure is an appropriate, safe and effective technique for management of patients with chronic pancreatitis in the absence of neoplasia, based on long-term follow-up.

International audience; Cholecystectomy is one of the most common abdominal surgical procedures. No formal agreement has been reached about the routine practice of intraoperative cholangiography (IOC). The purpose of this survey was to describe the practices and the opinions of surgeons in western France. A survey was conducted among 300 visceral surgeons practicing in western France who were asked to respond to a questionnaire with objective and subjective items. One hundred forty-eight answers were interpretable. Among these 148 surgeons, 125 (83.4%) performed IOC routinely (IOCr group) and 23 (15.4%) selectively (IOCs group). Mean age of responding surgeons was 49.3 years. Groups IOCr and IOCs were not significantly different concerning surgical experience. Surgeons in both groups responded that IOC effectively screens for intraoperative bile duct injury. In our survey, routine practice of IOC was more common than reported by our English-speaking colleagues. The routine users responded that IOC can screen for intraoperative bile duct injury or choledocholithiasis. The selective users responded that IOC has its own morbidity. IOC is commonly performed in France during laparoscopic cholecystectomy. Although it may not be indispensable, it allows rapid screening for intraoperative bile duct injury. It also provides documented proof of good surgical practice in the event of a litigation claim after bile duct injury.

International audience; L’Echinococcus granulosus, parasite appartenant à la famille des Cestodes est responsable, à travers sa forme larvaire, d’une maladie: l’hydatidose. Celle-ci se manifeste typiquement au niveau hépatique ou pulmonaire; cependant une fois sur dix, l’embryon va se loger dans n’importe quel tissu ou organe du corps humain.Les auteurs rapportent quatre cas de localisation inhabituelle de l’hydatidose: rénale, musculaire, pancréatique et thyroïdienne.

Voir aussi : X. Briennon, E. Lermite, K. Meunier, E. Desbois, A. Hamy, J.-P. Arnaud. Cure chirurgicale des larges éventrations par implantation intrapéritonéale d’une plaque composite (Parietex®) associée à une plastie aponévrotique (280cas). Journal de Chirurgie Viscérale, Volume 148, Issue 1, February 2011, Pages 56-61. doi:10.1016/j.jchirv.2010.12.009; International audience; AIMS OF THE STUDY: To evaluate post-operative complications and the recurrence rate after repair of large ventral incisional hernia with an open technique using intraperitoneal composite mesh and an associated aponeurotic overlay.PATIENTS AND METHODS: This prospective study included a total of 280patients who underwent repair of large incisional hernia using Parietex(®) composite mesh.RESULTS: The post-operative mortality rate was 0.35%. Six patients (2%) developed subcutaneous surgical site infection without infection of the prosthesis. Six other patients (2%) developed a deep-seated infection; in three cases, the mesh had to be removed. Nine patients (3.2%) developed recurrent incisional hernia.CONCLUSION: Large ventral incisional hernias can be effectively treated by the intraperitoneal placement of Parietex(®) composite mesh overlaid by an aponeurotic graft; the incidence of complications in this prospective study was very low.

International audience; PURPOSE: There is a need to identify a subgroup of high-risk patients with node-negative colorectal cancer who have a poor long-term prognosis and may benefit from adjuvant therapies. The aim of this study was to evaluate the prognostic impact of clinical and pathological parameters in a retrospective study from a prospective, continuous database of homogenously treated patients.METHODS: This study included 362 patients operated in a single institution for Dukes A and B (node-negative) colorectal cancer. The median follow-up was 140 months. The prognostic value of 13 clinical and pathological parameters was investigated.RESULTS: Multivariate analysis identified six independent prognostic factors: age at time of diagnosis (hazard ratio (HR) = 1.076), number of lymph nodes removed (HR = 0.948), perineural invasion (HR = 2.173), venous invasion (HR = 1.959), lymphatic vessel invasion (HR = 2.126), and T4 stage (HR = 5.876).CONCLUSION: These parameters could be useful in identifying patients with high-risk node-negative colorectal cancer who should be presented to adjuvant therapy.

International audience; The aim of this review is to define the relevance of surgical resection for liver metastasis of breast cancer. We report the rationale for hepatic surgery of liver metastasis, the survival prognosis factors for these patients, and the influence of liver resection on overall survival. The aim of this surgery is not only the local control, but also general control of the disease by preventing the selection of resistant tumor cell clones. Adjuvant therapies remain necessary for general control of the disease. While preoperative detection of small intra hepatic lesions remains difficult, MRI and preoperative ultrasound may help.

International audience; Few cases of malignant rhabdoid tumour (MRT) of the liver are reported in literature and always in paediatric patients. We report the first two cases of young adults submitted to hepatic resection for MRT of the liver. A major liver resection was performed in both cases. The histology showed round or fusiform, loosely cohesive cells. The cytoplasm contained abundant eosinophilic inclusions, which caused the nuclei to be located in eccentric locations, giving the characteristic rhabdoid appearance. The immunohistochemical study was performed, and characteristic lack of nuclear INI1 protein expression was found. In a case surgery was associated to chemoradiotherapy. One patient died at 48 months followup for tumour recurrence. The other is still alive at 25 months followup. MRTs are rare tumours of pediatric age with poor prognosis. Hypothetical less malignant behaviour in the young adults could be supposed. Therefore an aggressive surgical and oncological treatment seems justified.

Different studies have suggested that the prevalence of gallstones is increased in patients with cirrhosis [1, 2, 3]. In the past, open cholecystectomy (OC) in cirrhotic patients was commonly accompanied by significant morbidity and mortality [4, 5]. Laparoscopic cholecystectomy (LC) has become the procedure of choice to treat symptomatic cholelithiasis in the general population. However, cirrhosis has been considered as a contraindication for LC due to the risk of bleeding and liver failure [6]. Currently, with the advances in laparoscopic technology, a range of increasingly complex procedures are performed, making traditional contraindications at best relative. Several studies have reported good results and suggested liberal use of LC in patients with early-stage cirrhosis and symptomatic cholelithiasis.

Gallstones remain asymptomatic in nearly 80% of cases [1]. The clinical features of gallbladder stone disease include biliary colic and acute cholecystitis. Biliary colic is caused by impaction of the stone in the cystic duct with distension of the gallbladder and activation of visceral sensory neurons [2]. The pain typically arises in the right upper quadrant of the abdomen or epigastrium, rapidly increases in intensity and then plateaus, lasts for 30 min to 6 h, and occasionally radiates to the right subscapular area. Associated symptoms including nausea and vomiting are common.

The treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of this retrospective study is to review the results of three surgical procedures used in our department of Visceral Surgery (subtotal colectomy, segmental resection following intraoperative irrigation, and Hartman's procedure) and to determine if there were advantages of one technique over the other.Ninety-three patients with acute left colonic obstruction were treated by subtotal/total colectomy (n=38), segmental resection following intraoperative irrigation (n=39), and Hartman's procedure (n=16). We assessed immediate postoperative results (mortality and morbidity rates, reoperation rate and hospital stay.The overall mortality and morbidity rates were respectively 13% (n=12) and 30.1% (n=28). The mortality rate was 13% (n=5) in the subtotal colectomy group, 7.7% (n=3) in the intraoperative colonic irrigation and 25% (n=4) in the Hartman's procedure group. The morbidity rates were similar after subtotal or segmental resection (7.9% vs. 10.2%), bowel movements were more frequent after subtotal colectomy (range 1-5 day) than segmental colectomy (range: 1-2 per day).Segmental resection following intraoperative irrigation is the preferred treatment for left sided malignant colonic obstruction. Subtotal colectomy is recommended for patients with ischemic lesions and serosal tears on the cecum, and when there is a synchronous neoplasm in the proximal colon.

The basic principle of radiofrequency ablation is that the deposit of electromagnetic energy in a tumor causes heat ("cooks the tumor") and thereby destroys it. In the liver, this ablation may be performed percutaneously (by needles) or surgically (laparotomy, laparoscopy). Guidance by an imaging technique is necessary: ultrasound, CT or magnetic resonance imaging. The principal hepatic indications are hepatocellular carcinoma and hepatic metastases smaller than5 cm. There is no associated mortality and only slight morbidity, due principally to hemorrhage, infection or stenosis of the bile ducts. Results show a 5-year survival rate of 40% for hepatocellular carcinoma and 22% for metastases.

Objectives: The purpose of this study was to analyze the diagnostic and therapeutic features of hemosuccus pancreaticus. Methods: We reviewed our experience with management of 17 patients admitted to surgery or gastroenterology units for hemosuccus pancreaticus between 1981 and 2005. We studied symptoms, contribution of established morphological examinations (upper digestive endoscopy, computed tomography, and selective digestive angiography), and treatment. Results: Fifteen men and two women with a mean age of 57 years presented hemosuccus pancreaticus. All the men had a history of chronic alcoholic pancreatitis. Thirteen patients (76.5%) presented overt digestive bleeding (5 melena, 2 hematochezia, 2 melena with hematochezia, and 4 hematemesis). The inaugural sign was anemia in 2 patients and epigastric pain another 2 patient. An upper digestive endoscopy was performed in 15 patients and visualized hemosuccus pancreaticus directly in 9 patients. Arteriography was performed in 16 patients (94.1%) and made the diagnosis in 14 (87.5%). Surgery was performed in 9 patients, after embolization in 2 patients. Embolization was performed in 9 patients and effective in 7 patients. Therapeutic abstention proved successful in 1 patient. There were no death and no recurrent bleeding. Conclusions: Hemosuccus pancreaticus is a rare cause of digestive bleeding. Upper digestive endoscopy and angiography during active bleeding can provide the diagnosis. Most cases can be managed by angioembolization. However, in patients with recurrent bleeding or failed embolization, emergency surgery is required.

Introduction En cas d’appendicectomie, la voie d’abord ne fait toujours pas consensus. Connaitre la satisfaction des patients apres chirurgie pourrait aider le praticien dans le choix de la voie d’abord. Le but de ce travail etait de comparer la satisfaction et la qualite de vie des patients a 12 mois entre les deux voies d’abord, ainsi que la morbi-mortalite a court terme. Methode Cette etude multicentrique observationnelle a inclus 139 patients ayant eu une appendicite aigue operee en 2013. Un suivi sur 12 mois de la qualite de vie et satisfaction des patients etait mene (patient scar assessement scale). Resultats Soixante-huit patients etaient des hommes (48,6%). L’appendicite etait compliquee chez 24 (17,2%). Sur la serie, et chez les patients ayant un indice de masse corporelle inferieur a 25 kg/m2, le temps operatoire etait superieur en cœlioscopie. Le nombre d’abces sous-cutanes etait plus important en cas d’appendicectomie par Mc Burney chez les patients en surpoids (21,4% vs 0%). Il n’y avait pas de difference dans la satisfaction de la cicatrice, sauf chez les patients en surpoids qui etaient plus satisfaits de la cœlioscopie. Conclusion Uniquement chez les patients en surpoids, la satisfaction de la cicatrice etait meilleure en laparoscopie et le taux d’abces superficiel etait moins important. La voie de Mc Burney ne devrait donc pas etre abandonnee. Elle fournit de bons resultats esthetiques avec une satisfaction des patients egale a la cœlioscopie. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.

International audience; BackgroundThe utility of preoperative endoscopic biliary drainage (PEBD) in jaundiced patients before pancreatoduodenectomy (PD) is still debated. This is in part due to the heterogeneity of the studied population, including different tumor location, drainage techniques, and surgical procedures. The aim of the current study was to report the influence of PEBD on postoperative infectious morbidity of PD. Materials and Methods Between January 1996 and December 2004, 124 patients underwent a PD and 28. Twenty-eight (22.6%) of these patients underwent a PEBD. This group of patients was matched to 28 control patients who underwent PD without PEBD during the same period. The 2 groups were matched for age, sex, indication of surgery, and serum bilirubin levels. Results The specific morbidity of PEBD before surgery was 10.7% (n = 3). The postoperative overall morbidity, medical morbidity, and surgical morbidity rates were not different between the 2 groups. At the time of surgery, 89.3% (n = 25) of the patients in the PEBD group had positive bile culture in comparison to 19.4% (n = 4) in the control group (P < .001). The number of patients with 1 or more infectious complications was higher in the PEBD group (50%; n = 14) than in the control group (21.4%; n = 6) (P = .05). Conclusions Before PD, PEBD should be routinely avoided whenever possible in patients with potentially resectable pancreatic and peripancreatic lesions. In patients with cholangitis, requiring extensive preoperative assessment (such as liver biopsy) or neoadjuvant treatment, PEBD might still be indicated.

Background Pancreatic fistula (PF) and delayed gastric emptying (DGE) are, respectively, the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF and DGE after PD. Study Design Between January 1996 and December 2005, 131 consecutive patients underwent a PD with pancreaticogastrostomy. A total of 22 items, entered prospectively, were examined with univariate and multivariate analysis. PF was defined as amylase-rich fluid collected by needle aspiration from an intraabdominal collection or from the drainage placed intraoperatively from day 3. DGE was defined as the need for nasogastric decompression beyond the 10 th postoperative day. Results PF occurred in 14 patients (10.7%), with a mean length of hospital stay of 40.1±16.6 days. DGE occurred in 41 patients (31.3%), with a mean length of hospital stay of 35.5±13.6 days. PF and DGE increased postoperative length of stay. Multivariate analysis identified two independent factors for PF: heart disease as a risk factor and arterial hypertension as a protective factor. According to these two predictive factors, the observed rates of PF ranged from 4.1% to 66.6%. Age and early enteral feeding with nasojejunal tube were independent risk factors for DGE. DGE was statistically more frequent when surgical complications occurred or when an intraabdominal collection was present. Conclusions Heart disease was a risk factor and arterial hypertension was a protective factor of PF. Age and early enteral feeding were independent risk factors for DGE. DGE is linked to the occurrence of other postoperative intraabdominal complications.

The aim of this prospective study was to evaluate the feasibility of radiofrequency ablation of hepatic tumors. We studied the rates of mortality, morbidity, and recurrence and recorded overall and disease-free survival.All patients aged over 18 years with histologically proven malignant liver disease inaccessible to surgical treatment (one to four tumor localizations) were eligible for inclusion in the study. Child-Pugh scoreB9, platelets countor=50.103/mm3, prothrombin indexor=50% and pregnancy were exclusion factors.Between July 2001 and June 2004, 51 patients (13 women, 38 men, mean age 66 +/- 9 years) were included and underwent 61 radiofrequency thermal ablation procedures for 82 hepatic lesions: hepatocarcinoma (N=44), cholangiocarcinoma (N=1), metastasic tumors (N=37). Hospital morbidity and mortality were 11.5% and 2% respectively. Recurrence rate at 3 years was 20.6%. In multivariate analysis, only tumor size3 cm was correlated significantly with recurrence (P=0.03). Actuarial 1-, 2- and 3-year survival rates in the hepatocarcinoma group (N=31) were 84.7%, 57.7% and 34.6% respectively. Actuarial 1-, 2- and 3-year survival rates in the metastasis from colorectal adenocarcinoma group (N=14) were 90%, 54% and 54% respectively (P=0.72).Radiofrequency thermal ablation is an effective treatment for hepatic tumors measuring less than 3 cm. There is a low risk of complications and open surgery can be associated. However in the absence of randomized studies comparing radiofrequency and surgery, respective indications cannot be defined in detail.

Purpose Liver resection represents the best and potentially curative treatment for metastatic colorectal cancer (MCC) to the liver. After resection, however, most patients develop recurrent disease, often isolated to the liver. The aim of this study was to determine the value of repeat liver resection for recurrent MCC and to analyze the factors that can predict survival. Patients and Methods From January 1992 to October 2002, 42 patients from a group of 168 patients resected for MCC were submitted to 55 repeat hepatectomies (42 second, 11 third, and 2 fourth hepatectomies). Records were retrospectively reviewed. The primary tumor was carcinoma of the colon in 26 patients and carcinoma of the rectum in 16 patients. Liver metastases were synchronous in 24 patients (57.1%). Results There were 25 men and 17 women with the mean age of 63.5 years (range: 34–80). There was no intraoperative or postoperative mortality. The morbidity rates were 9.5%, 14.3%, and 18.2% (P = 0.6) respectively after a first, second, or third hepatectomies. No patients needed reoperation. Operative duration was longer after a second or third hepatectomie than after a first hepatectomie without difference for operative bleeding. Overall 5-year survivals were 33%, 21%, and 36% respectively after a first, second, or third hepatectomies. Factors of prognostic value on univariate analysis included serum carcinoembryonic antigen levels (P = 0.01) during the first hepatectomy, the presence of extrahepatic disease (P = 0.05) and tumor size larger than 5 cm (P = 0.04) during the second hepatectomie. Conclusions Repeat hepatectomies can provide long-term survival rates similar to those of first hepatectomies. J. Surg. Oncol. 2006;93:1–7. © 2005 Wiley-Liss, Inc.

There were no studies comparing whether the same principles as those in conventional surgery have been applied to the laparoscopic procedure. The aim of this study was to compare the quality of open sigmoid colectomy (OSC) with laparoscopic sigmoid colectomy (LSC) for diverticular disease. Specific measurements made were of the level of anastomosis from sacral promontory, distance from anal verge, specimen length and recurrence rates.Comparison was made between 72 consecutive patients who underwent an elective LSC to a control group of 22 patients who had previously undergone an OSC in the same institution. All patients had proctoscopy to measure the distance from the anal verge. A computed tomography without injection of contrast medium was performed in all cases to measure the distance from the sacral promontory to the top of the staple row. Length of fresh resected specimen and recurrence rates of diverticulitis were used for comparison.There was no statistical difference between the two groups in terms of distance of anastomosis from anal verge (p=0.78) and distance from sacral promontory (p=0.65) in LSC and OSC patients respectively. Specimen length was more extensive in the OSC group than in the LSC group (p=0.02). After a mean follow-up of 43.5 (+/- 14.8) months in the LSC group and 62.4 (+/- 7.4) months in the OSC group, there was no difference in recurrent attack's rates of diverticulitis.This study suggested that laparoscopic procedure applied the same principles as those used in conventional surgery.

Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity and mortality in critically ill or elderly patients.From October 1995 to March 2004, percutaneous cholecystostomy was performed in 65 patients with acute cholecystitis. The mean age was 78 years (range, 45-95). All patients were American Society of Anesthesiologists (ASA) class III (n = 51) or ASA IV (n = 14).Percutaneous cholecystostomy was technically successful in 63 patients (97%) with no attributable mortality or major complications. In two patients, bile drainage was inefficient, requiring emergency laparoscopic cholecystectomy. One patient developed necrotic cholecystitis and died. The 30-day mortality rate was 13.8% (n = 9); eight patients died of respiratory or cardiac complications related to comorbidities. Mean drainage time was 18 days (range, 9-60). Postoperative length of hospital stay was 15 days (range, 7-30). Early and delayed cholecystitis occurred in six and five patients, respectively. During follow-up (mean, 20.4 months), five patients died of their underlying medical condition at 5, 6, 8, 12, and 14 months, respectively. In this study, delayed elective cholecystectomy was performed in 10 patients (15.3%).Percutaneous cholecystostomy is a valuable and effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Resume Introduction Echinococcus granulosus, responsable de l’hydatidose, est principalement localise au niveau du foie et du poumon ; dans 10 % des cas cependant, il peut se loger dans n’importe quel tissu ou organe du corps humain. Observation Chez un homme âge de 28 ans, originaire du Portugal, une tumefaction cervicale gauche indolore est apparue brutalement. Apres isthmo-lobectomie thyroidienne gauche, l’examen anatomopathologique a permis de faire le diagnostic d’hydatidose. Commentaires La localisation thyroidienne du kyste hydatique est rare. Le diagnostic en est parfois difficile et la ponction cytologique est peu contributive. Le traitement est l’exerese chirurgicale. Un traitement complementaire par albendazole est recommande pour eviter une recidive.