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Purpose: The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohn's disease who underwent laparoscopy compared with open surgery., Methods: Among 51 consecutive patients with inflammatory bowel disease (1996-2000), 46 with Crohn's disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures)., Results: There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes) vs. the open group (244.7 minutes) (P < 0.05), but this difference disappeared when data were adjusted for the extra time required to perform the laparoscopic hand-sewn anastomoses (288.2 minutes vs. 244.7 minutes). Bowel function returned more quickly in the laparoscopic group vs. the open group in terms of passage of flatus (3.7 vs. 4.7 days) (P < 0.05) and resumption of oral intake (4.2 vs. 6.3 day) (P < 0.01). There were significantly fewer postoperative complications in the laparoscopic group (9.5 percent) vs. the open group (18.5 percent) (P < 0.05); the length of stay was significantly shorter in the laparoscopic group (8.3 days) vs. the open group (13.2 days) (P < 0.01); and the cost of hospital admission was significantly lower in the laparoscopic group ($6106, United States dollars) vs. the open group ($9829, United States dollars) (P < 0.05)., Conclusion: There is a reduction in the postoperative ileus, length of stay, cost of hospital admission, and postoperative complication rate in the laparoscopic group. Laparoscopic surgery for Crohn's disease is safe, and it is potentially more cost-effective than traditional open surgery.

Acute abdominal pain is frequent and often distressing. This symptom must start a clinical investigation with mostly questioning and abdominal palpation for correct diagnosis and decision making. Half of the patients have either appendicitis or non-specific abdominal pain.

Purpose: With advances in laparoscopy, various hemostatic procedures have been advocated with variable results. Using currently available tools, some steps in laparoscopic colorectal surgery still represent technical challenges. Our aim was to investigate the feasibility and reliability of the Harmonic Scalpel in laparoscopic colorectal surgery., Methods: In this nonrandomized prospective study, 34 consecutive patients (15 males; mean age, 46 (range, 24-80) years) underwent laparoscopic colorectal surgery for benign disease (27 patients) and colorectal cancer (7 patients). Dissection, hemostasis, coagulation, and division of several types of vascular pedicles were performed exclusively with the Harmonic Scalpel. The 10-mm-blade Harmonic Scalpel device was used at full power mode for all purposes through a 10-mm port. Coagulation of vascular pedicles was always achieved with the blades in the flat position. The large pedicles (inferior mesenteric, right and left colic, and ileocolic) were coagulated for 20 seconds in several locations along the length (1 cm) before final division. Smaller vascular pedicles were coagulated for ten seconds before division. When the vein and the artery of major pedicles were divided at their origin, either for malignancy or for technical reasons, they were dissected and coagulated separately. For more limited resection of the mesentery, as in the case of benign disease, vascular pedicles were coagulated together as a single bundle. Operative time, minor or major intraoperative or postoperative hemorrhage, need for conversion to laparotomy, bowel injury, and trocar complications were recorded. All anastomoses were checked on Day 8 by a diatrizoate sodium enema., Results: There was no mortality. Mean operative time was 276 (range, 200-520) minutes. Neither minor nor uncontrollable hemorrhage occurred; no conversion to laparotomy and no vascular or bowel injury were recorded. There was one port-site hematoma. Neither hemoperitoneum, intraperitoneal hematoma, fistula, nor intra-abdominal abscess was observed., Conclusion: Coagulation and division of minor as well as major vascular pedicles in laparoscopic colorectal surgery with the Harmonic Scalpel" are technically easy, feasible, and reliable.

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

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

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

Objective: To evaluate the impact of randomised clinical trials (RCT) on decision-making and therapeutic policies among general and gastrointestinal surgeons in France., Design: Telephone questionnaire., Setting: Multicentre study, France., Subjects: A random sample of 152 surgeons, mean (SD) age 50 (8) years. INTERVENTIONS AND MAIN OUTCOME MEASURE: Surgeons were asked 12 questions about their knowledge of RCT and how trials were conducted; influence of RCT on their treatment policies; means of obtaining information about treatments; how they evaluated their own results; whether they were willing to take part in RCT; and personal details including age, speciality, and type of practice. Surgeons were stratified according to age and type of practice., Results: 148 questionnaires were suitable for analysis. 83 surgeons (56%) were under 50 years old, 38 (26%) were exclusively gastrointestinal surgeons, 82 (56%) worked in private practice, and 36 (24%) worked in teaching and university hospitals. The rest undertook mixed duties. When asked to say where they obtained their knowledge about antibiotics, 91 (61%) referred to RCT; these were mainly hospital-based, gastrointestinal, and younger surgeons. Asked to name a RCT-based policy, 81 (55%) gave medical rather than operative examples. 80 (54%) had already participated in a RCT; 79 (53%) said that they were willing to participate in a RCT that included random allocation of patients (there were no statistically significant differences in answers according to speciality or type of practice, although younger surgeons answered "yes" to both questions). Specialised journals were the main source of information for 115 (78%), and surgeons read a mean of 40 issues/year. 142 (96%) read journals in French and 66 (45%) in English, but this number fell to 10 (15%) of the 65 surgeons aged 50 or more. Personal experience was considered a more important source of therapeutic knowledge by older and specialist surgeons. 109 surgeons (74%) recalled patients during the first month postoperatively to evaluate their results., Conclusions: French surgeons, particularly those aged 50 or over, are not well informed about the nature, conduct, and value of RCT. Most of their information is acquired through reading and attending scientific meetings and congresses. Surgeons tended to attach more importance to the fame of the author than to the conduct of the study. The overall impact of RCT was weak among the surgeons questioned.

Objective: To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection., Summary Background Data: It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this., Methods: Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths., Results: Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups., Conclusion: OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Objective: To compare perineal healing with or without omentoplasty after abdominoperineal resection for carcinoma of the rectum., Design: Prospective multicentre study., Setting: 15 centres (three university, nine non-university teaching hospitals and three private clinics), France., Subjects: 186 consecutive patients (between January 1983 and August 1990): 21 were withdrawn because of protocol violation leaving 165 for analysis., Interventions: Abdominoperineal resection for adenocarcinoma of the distal third of the rectum followed by omentoplasty (n = 64) to the pelvic space or not (n = 101)., Main Outcome Measures: Number of healed perineums at one month, and the time interval to complete healing., Results: 7 patients (4%) died, 4 of whom had had omentoplasty and 3 who had not (one perineal abscess). The number who developed immediate postoperative complications (11/64, 17% and 18/101, 18%) and median duration of hospital stay (21 days, range 8-191, and 22 days, range 8-132) were similar. The median time to complete healing (20 and 21 days), the rate of healed perineums at one month (42/62 and 67/99, both 68%) and the number of persisting sinuses at 12 months were also similar. The number of dehiscences of the perineum was significantly higher (p = 0.04) in the no omentoplasty group (16 compared with 3). There were 3 late deaths in the omentoplasty group and 7 in the no omentoplasty group, 1 and 5 with local recurrence, respectively. There were more recurrences in the no omentoplasty group but not significantly so., Conclusions: Although this study was not randomised, the results suggest that omentoplasty to the pelvic space promotes perineal healing after abdominoperineal resection for carcinoma of the rectum by significantly reducing the need for secondary opening.

Background: Hernia repair is the second most frequently performed operation in France and in the United States, the prevalence being 36 for every 1000 males. Lowering the recurrence rate by 1% would mean 1000 fewer operations for hernia repair per year in France., Methods: Between 1983 and 1989, 1578 adult males with a total of 1706 nonrecurrent inguinal hernias were prospectively and randomly allotted to undergo either a Bassini's repair, Cooper's ligament, or Shouldice repair with polypropylene or a Shouldice repair with stainless steel for determination of which technique was associated with the lowest recurrence rate. Fifty-nine hernia repairs were withdrawn after inclusion. Of the 1647 remaining hernias, 52.2% were indirect, 25.6% were direct, and 23.2% were combined. Patients were seen every 6 months for 3 years and then every year. Median follow-up was 5 years 8 months (range, 3 months-8.5 years)., Results: At 8.5 years, 5.6% of hernias were lost to follow-up. Ninety-seven hernia repairs failed, 50% during the first 2 years. The actuarial recurrence rate was 7.94% at 8.5 years. The Shouldice repair (stainless steel or polypropylene) was associated with fewer recurrences (6.1%) than either the Bassini's (8.6%) or Cooper's ligament repair (11.2%) technique (p < 0.001). This difference remained significant even when the maximal bias test was used. Fewer recurrences (5.9%) were observed with the stainless steel wire Shouldice repair than with polypropylene version (6.5%), but the difference was not significant., Conclusions: Shouldice hernia repair provides the patient with the best chances of nonrecurrence regardless of the anatomical type of hernia. The Shouldice hernia repair should be the gold standard for inguinal hernia repair in men and serves as the basis for comparison with all other techniques, be they prosthetic or laparoscopic.

Using a data base of 7,000 acute abdominal pains, we have described the assessed clinical features of acute diverticulitis of the sigmoid colon. Percentages of sensitivities have been replaced by adverbs or adjectives, applying a scale of equivalence. The modifications of the positive predictive values have been also replaced by verbs or typical expressions. In this article, abscesses, fistulas, generalized peritonitis and hemorrhage arising from an acute diverticulitis of the sigmoid colon were not studied.

Perforated diverticulitis is an uncommon but severe complication of diverticular disease. Whatever the type of the contamination, whether bacterial or fecal, the peritonitis is responsible for septic shock, which necessitates emergent and aggressive medical and surgical treatment. Intensive intravenous perfusion under monitoring, adapted antibiotherapy should come before surgical decision. The aim of surgery is twofold: to suppress the infectious source and to clean the peritoneum. After all, the peritonitis has a tendency to recur and therefore postoperative abscesses have to be searched systematically and if the case arises, these abscesses have to be reoperated or drained. Best results were obtained with immediate sigmoidectomy and colo-rectal anastomosis associated with loop colostomy; that procedure should be preferred to Hartmann technique. If the morbidity remains high, the mortality should decrease under 10% with intensive therapy.

Background: Disagreement continues among several studies as to the relative advantages and disadvantages of stapled versus sutured colorectal anastomoses., Methods: One hundred and thirteen consecutive patients (48 men and 65 women, mean age: 67 +/- 12 years) were randomized to either hand-sewn (n = 59) or stapled (n = 54) infraperitoneal colorectal anastomosis. Both groups had similar patient demographics except that fewer patients (4 versus 15) had chronic disease (p < 0.02) and were undergoing side-to-end (11 versus 39) and more patients were undergoing end-to-end (37 versus 20) anastomosis in the stapled group (p < 0.001)., Results: Overall mortality was 6% (7 of 113 patients), with no difference found between the two types of anastomosis. Fewer anastomotic leaks occurred in the stapled group (11 versus 7), with an a posteriori gamma error of 11%, whereas the other early postoperative complications occurred with similar frequency in the two groups. Nine mishaps occurred in the stapled group. Stapled anastomoses took less time (median, 42 versus 30 minutes) to perform (p < 0.02). At 8 months, two strictures occurred in the hand-sewn group (n = 52) compared with eight strictures in the stapled group (n = 50) (p < 0.001)., Conclusions: It was not possible to prove that lower anastomosis can be achieved with the stapling device. Routine or regular use of stapling instruments for infraperitoneal colorectal anastomosis cannot be advocated because of higher incidence of mishaps and strictures, even though the operation takes less time to perform and anastomotic leakage occurs less often.

Purpose: This study was developed to compare median and actuarial survival after left hemicolectomy vs. left segmental colectomy., Methods: Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64 +/- 12 (range, 18-91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmental colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested., Results: After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survival curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.

The records of 181 patients with carcinoid tumor of the appendix, seen during a ten year period (1977 to 1987), were analyzed retrospectively to determine the indications for right colectomy and the signification of intermediate histopathologic forms. Appendectomy was the only treatment in 146 patients; while right hemicolectomy was performed upon 35 patients--in seven patients with one postoperative death initially and in 28 patients without any death or morbidity, secondarily. Colectomy was indicated initially in seven patients for bulky tumors of the base of the appendix invading the cecum or for associated carcinoma of the right colon. The 28 secondary colectomies were indicated for tumors that were statistically larger and more invasive than those treated by simple appendectomy or for intermediate forms, or both, in five instances. There were five instances of residual tumor on secondary hemicolectomy specimens. In 11 of the 181 carcinoid tumors (6 percent), the intermediate type tumor was associated with mucinous production--seven adenocarcinoids and four carcinoids with mucocele. Of the seven instances of adenocarcinoid, there was one death at two years and one patient is alive with metastases. Other than size greater than 2 centimeters and base localization, the results of the current study suggest that the presence of mucinous production cells is a further indication for secondary right hemicolectomy.

The prevalence of signs and symptoms of acute intestinal obstruction in the adult was studied in a prospective study of 600 cases extracted from a data base on acute abdomen in 7,000 patients. This study of prevalence allows a precise definition of intestinal obstruction syndrome and to differentiate two types of presentations according to the site of obstruction on the small bowel or the colon. However, it is more difficult to differentiate simple bowel obturation from vascular strangulation. Surgical treatment depends mainly on the cause of obstruction.

Incarcerated hernia or wound dehiscence are responsible for more than 10% of small bowel obstructions. The complication is easily recognized when hernia or wound dehiscence was previously diagnosed. Difficulties occur when mass is deeply located in a thick abdominal wall or inside the inguinal canal. Femoral hernias and direct inguinal hernias are those which strangulate the most. Strangulation in wound dehiscence is the most severe. Strangulated hernia should be routinely excluded in patient with intestinal obstruction, to avoid inappropriate surgical approach.

Using a data base of 7,000 acute abdominal pains, we here described the assessed clinical manifestations of the main diseases responsible for right lower quadrant pain. However, percentages of sensibilities have been replaced by adverbs or adjectives, applying a scale of equivalence. The possible modifications of the positive predictive values have been also replaced by verbs or typical expressions. We first described the acute appendicitis syndrome (which covered congestive endoappendicitis and suppurated appendicitis) with the clinical shades or the gathered and gangrenous forms or even of the diffuse peritonitis. Features of the acute appendicitis contrast with those of the so called "non specified abdominal pains" (a new entity), and those of the subacute or chronic appendicitis. We found a good correlation between clinical and pathological findings. One of the difficulties has been to determine if a subgroup of subacute appendicitis should be or not included into the acute appendicitis.

Each year in France, 75,000 appendectomies are carried out for normal or fibrous appendix and another 75,000 for a mere inflammation of the mucosa of submucosa. To decrease the incidence--four times higher than in other countries--it is suggested to keep under observation the patient with RIQ tenderness if they have neither rebound nor guarding, a temperature below or equal to 38 degrees C and a white blood cell count lower than 10,000/mm3. By following these guidelines, there is no risk to miss perforated or suppurated appendicitis.

A computer aid diagnosis of acute abdominal pain has been constructed on a 7,000 cases data base, using a Bayesian model. The system is used as a paraclinic test, increasing the reliability of the physician's clinical diagnosis or questioning that diagnosis in case of discrepancy.

The effectiveness of cefazolin or cefotaxime as antibiotic therapy was compared with that of ceftriaxone in a multicentre prospective randomized trial involving 1,254 consecutive patients operated upon for abdominal diseases. Patients about to undergo surgery of the colon or who had localized or generalized peritonitis at the time of operation were excluded from the study. The patients entered were divided into 4 strata according to the degree of operative contamination and to risk factors. In each stratum, the patients were allocated at random to one or the other of 2 treatment groups. Group 1 patients received cefazolin or cefotaxime in 3 doses of 1 g administered 8-hourly, the first dose being injected during induction of general anaesthesia. Group 2 patients received one single 1 g dose of ceftriaxone injected during induction of anaesthesia. There was no significant difference between the two groups in the wound infection rate and in the frequency of post-operative intra-abdominal abscesses. Although the percentage of post-operative pulmonary and urinary tract infections was lower in the ceftriaxone group than in the cefazolin/cefotaxime group, no significant difference was observed between the two groups in the number of patients who required curative antibiotic therapy. This study shows that one single dose of ceftriaxone is as effective as three doses of cefazolin or cefotaxime in preventing would infections and post-operative intra-abdominal abscesses, and that it is more effective in preventing extra-abdominal infections complicating surgery.

A prospective multicenter study concerning 30 vocabulary terms was undertaken to determine if: 1) these terms could be equated with specific percentages; 2) observer assessment varied with time; 3) teachers and students used the same words with the same meaning; 4) certain words were more discriminant than others, and 5) terms corresponding to numbers were the same in French as in English. Three hundred and thirty medical professionals, coming from general and digestive units of 45 University, regional, or private institutions, were asked to answer three types of questionnaires pertaining to the same 30 words, but in a different order. One to 3 months later, 170 of them were asked to fill out the same questionnaire with the same words but in a different order. Sixteen percent were University professors, 15 percent were hospital or private surgeons, 19 percent were senior residents, 29 percent were interns or junior residents and 21 percent were medical students.(ABSTRACT TRUNCATED AT 250 WORDS)

One hundred and ten distal splenorenal anastomoses (DSRA) were performed between 1976 and 1988 for gastrointestinal haemorrhages secondary to portal hypertension. Thirty five patients underwent DSRA (Warren's operation) followed by a mesenteric disconnection procedure. Eleven patients (10%) died (nine Child B and two Child A), including two after an emergency shunt. The mortality was influenced by age (p less than 0.01) and by the number of previous episodes of ictero-ascitic decompensation (p less than 0.02). A single anastomotic thrombosis was observed; the high flow rate of the anastomoses (mean: 1200 +/- 650 ml/min) explains the high patency rate (more than 90%). Eleven patients developed partial or total thrombosis of the portal trunk less than 6 weeks after the operation. The quality of hepatic perfusion was not significantly influenced by the mesenterico-splenic disconnection and this was omitted in 75 patients. The mesenterico-splenic collateral venous circulation was more developed in the absence of disconnection (p less than 0.05). The long-term actuarial survival was 83% at one year, 53% at five years, 47% at eight years and 28% at ten years. Survival was not influenced by the disconnection. Warren's operation is more difficult to perform than a porto-caval or mesenterico-caval shunt. DSRA appears to have three advantages: 1) a high flow rate as it is arterialised by the splenic artery, 2) hepatopetal portal perfusion maintained for several days, weeks or months, possibly reducing the risk of encephalopathy, 3) the absence of dissection of the hepatic pedicle preserves the possibilities of liver transplantation.

Seven patients were treated by gastrocolectomy for either ulcers or cancers. Two patients had ulcerating gastrojejunocolic fistulae, four had cancers of the stomach, and one had cancer fistulae, four had cancers of the stomach, and one had cancer of the transverse colon. Two patients treated by immediate colon anastomosis for cancer, died after the anastomosis broke down, while the three other cases, treated by delayed colon anastomosis, survived. Both patients with ulcerating lesions survived, one after immediate and the other after delayed colon anastomosis. This latter procedure appears, therefore, to be imperative in cancer cases and of value, when used prudently, in ulcer cases.

General recognition of the presence of a specific hepatotrophic factor in portal blood that is necessary for liver regeneration was delayed by two major problems. First, there was a long period of confusion regarding liver atrophy, liver hypertrophy, and cellular hyperplasia. Second, because only exposure to other liver tissue destroys the hepatotrophic activity, all of the studies that were based on bypassing the portal blood into the systemic circulation merely diluted the active substance, which still was available to the hepatocytes by recirculation through the hepatic artery. These problems have been resolved by the development of more sophisticated methods by which to assay liver regeneration and by the introduction of the double liver model to study regeneration. During the time when liver weight alone was used to assess regeneration, the regenerative capacity of the liver was reported to be much greater after portacaval transposition than after end-to-side portacaval shunt, a finding that is inconsistent with current knowledge of the hepatotrophic portal blood factor. To re-evaluate the effect on liver regeneration of providing a compensatory systemic venous inflow after complete portal diversion, 40 partially hepatectomized inbred rats which had previously undergone either a sham operation and end-to-side portacaval shunt or a portacaval transposition were compared on the basis of six separate criteria of regeneration. All of the livers actively regenerated and no significant advantage of providing a substitute systemic venous inflow to the liver could be detected by any of the criteria.

Thirteen patients with intestinal lesions consecutive to radiotherapy for carcinoma of the uterus were operated upon between 1973 and 1979. The small bowel was involved in 9 patients and the colon and rectum in 4 patients. Urinary tract lesions were associated in 3 patients of each group. Intestinal necrosis, progression of the lesions and extensive pelvic fibrosis were the only criteria of poor prognosis. Twenty-two operations were performed: 4 for urinary tract lesions and 18 for intestinal lesions. Five patients died during the immediate post-operative period and five died within 2 to 30 months after surgery, including 4 whose carcinoma recurred. The operative technique should be selected according to the extent and severity of radiation-induced damage, as determined by pre-operative examination and thorough exploration of the abdominal cavity once opened. Limited lesions of the small bowel can be treated by resection, but intestinal bypass with latero-lateral anastomosis seems to be preferable in cases with extensive lesions. Patients with colorectal lesions should have defunctioning colostomy prior to any other procedure dictated by the state of affairs. Multiple anastomosis, extensive resections and excessive dissections should be avoided.

In a prospective multicentric trial we compared the post-operative mortality and the 5-year survival of elective total gastrectomy (TG) versus subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study: thirty two were excluded after pathological examination (linitis plastica, superficial cancer, lymphoma). One hundred and sixty nine patients remained for analysis with 93 TG and 76 SG. Elective TG did not increase post-operative mortality (1.3%) in comparison with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both operations TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.

The results of exploratory laparotomy in 48 patients with an acute abdomen are reviewed. Overall mortality was 29 p. cent (14 cases) and was influenced by three main factors: patients over 50 years of age, multiple visceral lesions, and when exploratory laparotomy was conducted for an acute painful febrile abdominal syndrome (10 deaths in 32 cases) or during the postoperative period (4 deaths in 11 cases). In contrast, exploratory laparotomy is a benign procedure in patients with abdominal contusions. It is essential, therefore, to try to establish the diagnosis before proposing laparotomy, which should only be performed when all other diagnostic investigations have proved negative.

The distal splenorenal shunt is less likely to provoke encephalopathy than conventional shunting procedures, and it may offer a survival advantage for certain cirrhotic individuals, presumably because of its selective nature. This study suggests that the distal splenorenal shunt, even with exceptional efforts to achieve portomesenteric-gastrosplenic (PM-GS) disconnection, is not nearly as selective as it originally was assumed to be. In 11 patients intraoperative pressure determinations showed a significant decrease in portal pressure after end-to-side distal splenorenal anastomosis and no restoration of portal pressure after PM-GS disconnection. Measurements of flow through the shunt were comparable to those reported for portacaval shunts, and shunt flow was not decreased significantly by PM-GS disconnection. Postoperative angiography showed some PM-GS collateral in 17 of 18 patients, and later angiographic studies showed a tendency for progressive collateral development and consequent loss of hepatopetal portal perfusion. The advantages of the distal splenorenal shunt must accrue from gradual, as opposed to abrupt, portal deprivation, rather than from lasting selectivity.

With a bank of data collected locally and a probability program of diagnostic aid, the computer is capable of making the correct diagnosis in 79% of acute abdominal pain syndromes. Its performance in this respect is somewhat superior to that of clinicians (73.5%). Including a computer program in diagnostic procedures would reduce the number of errors by excess or omission. In abdominal emergencies computerization would help either by increasing the reliability of clinical diagnoses or by suggesting that other possibilities should be investigated.

The authors report 3 cases of acute complicated duodenal ulcers occurring during the course of Listeria meningitis. These three adults (2 females and 1 male) suffered from localised neurological involvement and, in 2 cases neurovegatative disorders an altered level of consciousness. The ulcers were situated in the duodenal cap, and in each case there were at least 2 large excavated ulcers. These ulcers were the site of late complications on the 13th and 15th days after the onset of neurological disease. In two cases the major symptom was haemorrhage, whilst in the third it subsided leaving a syndrome of peritonitis due to perforation. Treatment in all three cases consisted of vagotomy with pyloroplasty (the ulcers being excised or sutured). All the patients recovered from their digestive complications without relapse despite the persistence 6 and 10 months later of the same neurological problems in two of them. All these facts would be in favour of a neurogenic aetiopathogenesis, via the vagal nerve. Thus acute late duodenal ulcers in patients with neurological disease from a separate enity within the context of stress lesions.

Over an 8-year period, 1246 consecutive patients undergoing abdominal surgery were followed up postoperatively for a maximum of 5 years to study retrospectively the incidence, date of occurrence location and risk factors of incisional hernia. Only 1081 cases were assessable. Overall 94 incisional hernias (9%) were evidenced. The actuarial rate of incisional hernia was shown to be 13% at 5 years, occurring during the first 24 months in 80% of cases. Risk factors were analyzed according to four parameters: patient's status, underlying disease, surgical technique, postoperative complications. Morbid obesity, underlying disease, emergency surgery, wound or deep abscesses or early reoperation were all statistically significant factors. From the overall analysis of results it is shown that at 5 years 13% of patients at risk present postoperative incisional hernia. The two main factors on which surgeons are able to act preventively are the choice of incision site and the onset of wound abscesses. Subcostal incision is the most suitable and prevention of abscesses can be obtained essentially by antibiotic prophylaxis.