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Objective: To report a severe complication after colorectal resection for rectovaginal endometriosis., Design: Case report., Setting: University hospital., Patient(s): A 37-year-old patient treated with colorectal resection 3 years ago for rectovaginal endometriosis was admitted with a rectal perforation at 37 weeks' gestation., Intervention(s): Caesarean section and simple interrupted stitch of the perforation by absorbable Vicryl., Main Outcome Measure(s): Determination of the cause of the perforation in healthy rectal tissue above the anastomosis., Result(s): The most likely mechanism was secondary colonic hyperpressure owing to stenosis of the colorectal anastomosis., Conclusion(s): Young patients planning to conceive but scheduled to undergo colorectal resection should be made aware of the significant complication rate associated with this procedure and the promising results of nodule excisions. We recommend close monitoring of patients suffering from chronic constipation after resection for rectosigmoid endometriosis., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Intrahepatic cholangiocarcinoma (ICC) is a rare tumor with a poor prognosis. The aim of this study was to evaluate current management and prognosis of ICC in nine French administrative areas, which are covered by population-based cancer registries., Methods: Between 1997 and 1998, 1100 cases of primary liver cancer were observed in nine French departments: 68 were ICC. Clinicopathological characteristics and applied treatments were recorded and a comparative analysis and a 5-year survival study were performed., Results: In most cases (85%), the presence of symptoms was the principal mode of discovery. Histological confirmation revealed ICC in two thirds of cases. The remaining liver was normal in 72% of cases (patients with cirrhosis: 12%). The mean size of tumours was 6 cm. Metastases were present in one out of four cases. Surgical management, chemotherapy and radiotherapy were performed in 40%, 20% and 11.5% of patients, respectively. Hepatic surgical resection was correlated with age and bilirubin level. One third of the patients were treated for symptoms. Five-year survival rate was 7.4% and median survival was 7 months. Patients with hepatic surgical resection had 5-year survival rate of 24.5%., Conclusion: At present, complete resection is the only therapy offering possible long-term survival in this entity. New adjuvant chemotherapy after surgery must be offered to these patients.

Laparoscopic splenectomy (LS) has become the standard approach to splenectomy for benign and malignant hematologic diseases despite a paucity of high-level evidence. The procedure requires expertise in laparoscopic surgical techniques and meticulous dissection of the spleen. Management should include a preoperative radiologic assessment to measure splenic volume and to detect the presence of accessory splenic tissue; the patient should undergo preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections. Prophylactic antibiotics are used in the perioperative period as well as prophylactic anticoagulation therapy which may be continued long-term in high-risk patients. LS is associated with a low morbidity and mortality; when compared to laparotomy, it reduces the length of hospital stay and improves the quality of life by decreasing postoperative ileus and pain. There are a variety of laparoscopic approaches; the hand-assisted technique and newer coagulating devices have facilitated the operative technique leading to increasing acceptance of laparoscopy as the preferred approach - even in patients with malignant hematologic disease and/or massive splenomegaly.

Objective: Since the first paper published by Matzel et al., in 1995, on the efficacy of sacral nerve stimulation (SNS) in patients with faecal incontinence, the indications, the contraindications, the stimulation technique and follow up of implanted patients have changed. The aim of this article was to provide a consensus opinion on the management of patients with faecal incontinence treated with SNS., Method: Recommendations were based on a critical review of the literature when available and on expert opinions in areas with insufficient evidence., Results: We have reviewed the indications and contraindications, proposed an algorithm for patient management showing the place of SNS. The temporary test technique, the implantation technique, the patient follow up and the approach in case of treatment failure were discussed., Conclusion: We hope not only to provide a guide on patient management to clinical practitioners interested in SNS but also to harmonize our practices.

Objective: Few data are available from population-based statistics on hepatocellular carcinoma (HCC). The aim of this study was to report on their management and their prognosis in a French population., Methods: Between 1997 and 1998, 1,007 cases of HCC were registered in nine French departments: clinical presentation of patients with and without cirrhosis were compared as well as treatment. Prognosis was determined using crude and relative survival rates. A multivariate relative survival analysis was performed. HCC was associated with cirrhosis in 795 patients (79%) and to the absence of cirrhosis in 156 (15%)., Results: Whereas the presence of symptoms was the principal mode of discovery (63% of cirrhotic cases and 70% of non-cirrhotic cases), the follow-up of hepatic affections revealed the cancer in respectively 26% and 3% (P = 0.001). The diagnosis was histologically verified in 50% of cirrhotic patients and 80% of non-cirrhotic patients (P = 0.01). The size of tumours was significantly greater in non-cirrhotic than in cirrhotic cases (P = 0.004). Treatment for cure were implemented in respectively 15% and 30% (P = 0.001), resulting in 5-year survival rates of respectively 34% and 28%. Only 24 HCC cases received a liver transplant, with a 5-year survival rate of 60%. Surgical resection for cure was carried out in respectively 10% and 31% of HCC and HCNC cases (P = 0.001), with a 5-year survival rate of respectively 39% and 29%. The overall 5-year survival rates of HCC and HCNC were respectively 6% and 9%., Conclusion: HCC with and without cirrhosis has a poor prognosis with the majority of patients receiving palliative treatments, the efficiency of which is very limited. Considerable efforts are needed to develop primary and secondary prevention., ((c) 2008 Wiley-Liss, Inc.)

The amount of glomalin-related soil protein (GRSP), a glycoprotein produced by arbuscular mycorrhizal fungi (AMF), its contribution to the sequestering of Cu and Zn in the soil, and the microsite variation of other soil traits (pH, water-stable aggregates--[WSA], soil organic carbon--[SOC]) was studied in a semi-arid Mediterranean ecosystem near a copper smelter and affected by deposit of metal-rich particles since 1964. Rhizospheric (R) and non-rhizospheric (NR) soil of four representative plants (Argemone subfusiformis, Baccharis linearis, Oenothera affinis and Polypogon viridis) was analyzed. The results showed a strong variability in GRSP (6.6-36.8 mg g(-1)), Cu content (62-831 mg kg(-1) for the total Cu and 5.8-326 mg kg(-1) for the available Cu) and pH (4.2-5.5) in the different plant and rhizospheric zones analyzed. A strong relationship between the GRSP with the soil Cu and Zn contents was found (r=0.89 and 0.76 for Cu and Zn respectively, p<0.001). The GRSP-bound Cu ranged from 3.76 to 89.0 mg g(-1) soil and represents 1.44-27.5% of the total Cu content in soil. Moreover, the WSA reached 89% in P. viridis R. For this plant, the C contained in GRSP represented up to 89% of SOC, and this coincided with the most extreme conditions of soil degradation within the ecosystem (the highest content of heavy metals and low pH values). This study provides evidence on the role of the GRSP in Cu and Zn sequestration and suggests a highly efficient mechanism of AMF to mitigate stress leading to stabilization of soils highly polluted by mining activities.

Aim: To compare the management of colorectal cancer (CRC) before and after the French consensus conferences of rectal cancer (RC) in 1994 and colonic cancer (CC) in 1998., Methods: From 344 CCR incident cases in 1992 and 545 in 2000, patient characteristics, tumor data, and diagnostic and treatment modalities were collected to compare the management of CRC., Results: Post-operative mortality did not change significantly (4% in 1992 and 2.8% in 2000). No trends were observed in disease stage at diagnosis or rate of resection. For patients with CC (n=244 in 1992 and n=396 in 2000), the number of resection specimens with at least 12 lymph nodes increased from 11% in 1992 to 27% in 2000 (p<0.001). For CC with Dukes stage C and D, the use of chemotherapy increased significantly: for Dukes Stage C from 45% in 1992 to 55% in 2000; for Dukes Stage D from 37% in 1992 to 67% in 2000. For patients with RC (n=100 in 1992 and n=149 in 2000), no change in use of adjuvant radiotherapy was observed: 59% in 1992 versus 53.4% in 2000. Preoperative radiotherapy for RC was performed in 63% in 1992 and 75% in 2000 (p=0.7)., Conclusion: The consensus guidelines appear to have moderately influenced management practices. A better diffusion of guidelines to practitioners and a systematic evaluation of actual practices would be helpful to improve their impact.

Unlabelled: Impact of the French consensus guidlines on the management of colonic and rectal cancer: A population-based study F. Borie, M. El Nasser, A. Herrero, C. Gras-Aygon, CRISAP-LR, J.-P. Daures, B. Tretarre Aim: To compare the management of colorectal cancer (CRC) before and after the French consensus conferences of rectal cancer (RC) in 1994 and colonic cancer (CC) in 1998., Methods: From 344 CCR incident cases in 1992 and 545 in 2000, patient characteristics, tumor data, and diagnostic and treatment modalities were collected to compare the management of CRC. Résults: Post-operative mortality did not change significantly (4% in 1992 and 2.8% in 2000). No trends were observed in disease stage at diagnosis or rate of resection. For patients with CC (n=244 in 1992 and n=396 in 2000), the number of resection specimens with at least 12 lymph nodes increased from 11% in 1992 to 27% in 2000 (p<0.001). For CC with Dukes stage C and D, the use of chemotherapy increased significantly: for Dukes Stage C from 45% in 1992 to 55% in 2000; for Dukes Stage D from 37% in 1992 to 67% in 2000. For patients with RC (n=100 in 1992 and n=149 in 2000), no change in use of adjuvant radiotherapy was observed: 59% in 1992 versus 53.4% in 2000. Preoperative radiotherapy for RC was performed in 63% in 1992 and 75% in 2000 (p=0.7)., Conclusion: The consensus guidelines appear to have moderately influenced management practices. A better diffusion of guidelines to practitioners and a systematic evaluation of actual practices would be helpful to improve their impact., (Copyright © 2008 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Biliary injuries after laparoscopic cholecystectomy are rare but serious. Their mortality rate can reach 9%., Aim of the Study: Describe the management of biliary injuries after laparoscopic cholecystectomy in our center., Patients: Between January 1995 and June 2005, 27 patients (13 women, 14 men) were treated. The mean age was 53 years old (range, 18-92 years). The biliary injuries were common bile duct sections (n=16, 60%), common bile duct stenoses (n=5, 18.5%), biliary fistulas from the cystic duct (n=4, 15%), and biliary fistulas from an aberrant biliary duct (n=2, 7.5%)., Results: Acute cholecystis was present in 40% of cases (n=11). An intraoperative cholangiography was done in 12 patients (44%). The mortality rate was 0%. Of the common bile duct sections, 43% were diagnosed during the cholecystectomy (n=7) or after the cholecystectomy within a mean of 11.2 days (n=9). Common bile duct injuries were treated in 16 cases with hepatojejunostomy and in five cases with an external biliary drain. Fistulas from the cystic duct were diagnosed within a mean 14.8 days. A fistula from an aberrant biliary duct was diagnosed during the cholecystectomy (n=1) or in the second postoperative day (n=1). Fistulas were treated with a clip on the cystic duct (n=2), an external biliary drain (n=1), a biliary endoprosthesis (n=1), and the biliary aberrant duct suture (n=2)., Conclusion: Common bile duct injuries are a serious complication because their treatment is a hepaticojejunostomy in 75% of cases.

Background: Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned., Methods: A retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival., Results: Eighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36-79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1-3), and 1 for high-grade dysplasia in Barrett's. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180-450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10-39). The median number of nodes harvested was 10 (range = 2-26). At a median follow-up of 13 months (range = 4-42), 13 patients were alive., Conclusions: Minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.

Volcanic soils in the south of Chile have an elevated quantity of total P, which is scarcely available due to its high P fixation capacity. One strategy for increasing the availability of P for the vegetables that grow there would be to use phosphate-solubilizing microorganisms. In one assay conducted in a greenhouse on a volcanic soil, the effect of inoculation with Penicillium albidum, a phosphate-solubilizing fungus, was studied on the growth of red clover (Trifolium pratense L). Some chemical and biological properties of the soil were also evaluated. There were three treatments: a) active inoculum [In(+)], b) inactive inoculum (autoclaved) [In(-)] and c) without inoculum [In(0)], each one done in three replicates. The In(+) significantly (P < 0.050) increased the growth of the plants, contributing particularly to root development. The P mobilized to the shoot with In(+) was higher than twofold related to In(0) and In(-) treatments; however, the In(+) plants had similar concentration of shoot P. In the soil, available-P was not statistically different (P < 0.050) among the treatments but phosphatase activity in In(+) was higher (P < 0.050) in comparison to In(0). The results suggest that Penicillium albidum contributed to growth and nutrition of the red clover through the induction of root development and enhancing phosphate mobilization from the soil and into the plant. It is concluded that Penicillium albidum, under greenhouse conditions, in soils deficient in available P can increase the inoculation potential for volcanic soils in Chile. Anyway further studies are required, especially in organic farming where the use of soluble P fertilizer is avoided.

Background: In spite of recent advances in our knowledge of tumor biology and therapy, the management and prognosis of patients with colon cancer (CC) revealed by intestinal obstruction or peritonitis (IOP) are not well defined. This study was undertaken to identify other factors which may influence morbidity and prognosis of CC revealed by IOP., Material/methods: We studied medical documentation from 247 incidental cases of CC registered in the Herault district in 1992 and followed up until 1997. The difference in postoperative mortality and the 5-year survival rate between CC with (n=41) and without IOP (n=206) were evaluated separately in relation to clinico-pathological characteristics, surgeon volume, and healthcare institutions by non-conditional logistic regression and multivariate survival analysis., Results: Higher rates of Dukes' stages B-C-D were observed in the emergency group than in the elective. Older age was associated with the presence of IOP (p=0.02). Factors predictive for postoperative mortality were IOP (p=0.02), surgical treatment in non-specialized hospitals (p=0.04) and residence in rural areas (p=0.01). The primary independent negative prognostic factor in multivariate analysis was the presence of nodal or distant metastases (Dukes' stage D, p=0.0001), followed by lack of chemotherapy (p=0.008), initial treatment in non-specialized hospitals (p=0.01), onset with IOP (p=0.02), low-volume surgeons (p=0.02)., Conclusions: As the presence of IOP influenced independently postoperative mortality and specific five-year survival, we suggest that the management of CC revealed by IOP should be concentrated in the hands of those surgeons and healthcare institutions that show the best outcomes.

The limitations associated with the traditional randomized controlled design as applied to clinical surgical research must be recognized. The aim of randomization is to ensure initial comparability between groups of eligible patients for whom treatments are compared, thus eliminating their individual influence on outcome. Randomized controlled trials in the surgical literature are sparse; patient preferences might be a major obstacle to their performance. External validity of results of clinical trials depends on the representativity of patients who participate in trials: Compliance to participate through informed consent may act as a selection bias. In surgical randomized trials where it is not often possible for patients to remain blinded to the treatment to which they have been allocated, patient preferences can influence the effectiveness of treatments. In this setting, we need to look at alternatives and the potential advantages of adopting more flexible and clinically relevant approaches to the design of surgical trials. We have to accept the weight of the patient's individual decision in everyday practice. Hence, to negate the importance of these individual choices when evaluating surgical outcomes is unrealistic. An original design reported herein might become a new paradigm for surgical evaluation.

The objectives of teaching evidence-based surgery (EBS) are to inform and convince that EBS is a method of interrogation, reasoning, appraisal, and application of information to guide physicians in their decisions to best treat their patients. Asking the right, answerable questions, translating them into effective searches for the best evidence, critically appraising evidence for its validity and importance, and then integrating EBS with their patients' values and preferences are daily chores for all surgeons. Teaching and learning EBS should be patient-centered, learner-centered, and active and interactive. The teacher should be a model for students to become an expert clinician who is able to match and take advantage of the clinical setting and circumstances to ask and to answer appropriate questions. The process is multistaged. Teaching EBS in small groups is ideal. However, it is time-consuming for the faculty and must be clearly and formally structured. As well, evidence-based medicine (EBM) courses must cater to local institutional needs, must receive broad support from the instructors and the providers of information (librarians and computer science faculty), use proven methodologies, and avoid scheduling conflicts. In agreement with others, we believe that the ideal moment to introduce the concepts of EBM into the curriculum of the medical student is early, during the first years of medical school. Afterward, it should be continued every year. When this is not the case, as in many countries, it becomes the province of the surgeon in teaching hospitals, whether they are at the university, are university-affiliated, or not, to fulfill this role.

Unlabelled: Glicentin and glucagon-like peptide-1 (7-36) amide (GLP-1) are gut hormones released during digestion. Glicentin and GLP-1 slow down gastric emptying and glicentin can switch off the duodenojejunal fed motor pattern. The effect of glicentin on the motor activity of colon has never been reported in humans. Our aim was to determine if circular smooth muscle cells (SMC) from the human colon are target cells for glicentin or GLP-1, and if their motility is dependent upon these digestive hormones., Methods: Twenty-two resections were performed on patients operated for colon adenocarcinoma. The SMC were isolated from colonic circular muscle layer and cell contraction was assessed., Results: Glicentin caused a dose-related contraction of SMC, when GLP-1 determined a contraction of weak amplitude. Exendin-(9-39), described as a GLP-1 receptor antagonist, inhibited contraction due to glicentin or GLP-1. In contrast, on antral SMC from rabbit, GLP-1 exerts neither relaxation nor contraction; however, exendin-(9-39) dose dependently reduced the contractile activity of glicentin [glicentin EC(50) = 5 pM, exendin-(9-39) pA(2) = -9.36]., Conclusions: The circular muscle from the human colon is a target tissue for glicentin and GLP-1. Whereas glicentin is a long-life digestive hormone which would contribute to segmental contraction, the biological activity of GLP-1 remains unknown on this tissue. On the digestive smooth muscle, exendin-(9-39) behaved as an antagonist for two members of the glucagon-receptor family, GLP-1 and glicentin.

Early gastric cancer (EGC) is defined as a lesion in which the depth of invasion is limited to the mucosa, submucosa, or both regardless of lymph node status; moreover, it has an excellent prognosis, with a 5-year survival rate of more than 90%. We aimed to determine the prognostic factors for EGC in a large Western series. Over a 10-year period from January 1979 to December 1988 a series of 332 patients (mean age 64 years) with EGC were operated on in 23 centers (two French Associations for Surgical Research). The clinicopathologic data retrospectively and screened it for prognostic effect. The mean follow-up for the 332 EGC patients was 80 months. Postoperative mortality was 4% among 243 partial and 89 total gastric resections. The overall 5- and 7-year survival rates were 82% and 72%, respectively. The cumulative 5- and 7-year survival rates (mean follow-up 80 months) were 92.0% and 87.5%, respectively, excluding both operative and unrelated mortality. There was no significant difference in survival between partial and total gastric resection for lesions located in the lower third of the stomach ( p > 0.6). When survival data (excluding postoperative deaths) were analyzed using univariate analysis and Cox's proportional hazards model, lymphatic involvement ( p = 0.01), the site of the tumor in the upper two-thirds of the stomach ( p = 0.02), and submucosal lesions ( p = 0.049) showed a significant effect on predicting a poor prognosis. These results suggest that because of its prognostic value lymphadenectomy should be performed in addition to gastric resection for adequate classification of EGCs. Follow-up might be required only for patients with at least one poor prognostic factor.

The follow-up of patients with curative resection of colorectal cancer is still controversial. The means mobilized for postoperative monitoring come at a high cost. However, the modalities are neither formalized nor validated with regard to an improved 5-year survival rate. To compare the cost-effectiveness of both strategies for patient follow-up during the 7 years following curative resection of colorectal cancer, we performed a costeffectiveness analysis adjusted for quality of life. Using data from the literature and a population study, a simulation of follow-up on patients who had undergone curative resection of colorectal cancer was carried out over a 7-year period using a Markov model. Two Markov processes were modeled to compare the cost-effectiveness ratio adjusted for quality of life in patients with a follow-up in accordance with the recommendations of the 1998 French Consensus Conference (standard follow-up) with the carcinoembryonic antigen (CEA) assay and a simplified follow-up. The influence of standard follow-up on the quality-adjusted life expectancy of patients who had Duke's stage A and B colorectal cancer appears to be modest, with increases of 2.5 months and 1.3 months, respectively; it is more acceptable for patients who had had Duke's stage C, with an increase of 11 months. The high variability of cost-effectiveness ratios (> 7 years) of +/- 44,830 and 180,195 Euro per quality-adjusted life-years (QALY), respectively) did not favor the standard follow-up. The cost-effectiveness ratio (> 7 years) of patients having had Duke's stage C colorectal cancer was 1,058 (sd: 2746) Euro per QALY and could favor the standard follow-up. This study showed that standard follow-up with CEA assay tended to preferentially improve the survival of Duke's stage C patients. The type of examination needed and the frequency with which it has to be carried out should take account of the stage, treatment for the initial illness, and the patient's age.

Background: The extent of lymphadenectomy (limited vs. extended) and that of gastric resection (partial vs. total) remain controversial issues in the management of early gastric cancer (EGC). A multicentric study was performed to elucidate the appropriate gastric resection with lymph node dissection for early gastric cancer., Methods: From 1979 to 1988, 332 patients with EGC underwent surgery in 23 French centers. Clinicopathological data, the extent of resection, and the number of lymph nodes retrieved were reviewed retrospectively and screened for prognostic effect. The mean follow-up for the 332 EGC patients was 80 months., Results: Postoperative mortality was correlated to age (odds ratio [OR], 1.1) and extent of gastric resection (OR,10.3). Examination of survival data (excluding postoperative deaths) with univariate analysis and the Cox proportional hazards model showed that the independent factors for excellent prognosis included no lymphatic involvement (P =.005), 10 or more lymph nodes retrieved (P =.003), site of the tumor in the lower third of the stomach (P =.01), and mucosal lesions (P =.04). The extent of resection did not influence long-term survival., Conclusions: Our results suggest that because of the associated good prognosis, the appropriate surgical treatment for EGC is partial gastrectomy with lymphadenectomy retrieving 10 or more lymph nodes.

Whether for a diagnostic evaluation or for the treatment of common bile duct lithiasis, the laparoscopic approach is the most efficient method compared with the other alternatives. The authors describe in the present article the method to treat laparoscopically common bile duct lithiasis.

Current practices for diagnosis and treatment of common bile duct stones are not evidence-based. Acute biliary pancreatitis (ABP) is a specific situation in which endoscopic procedures are either overused or misused. Pancreatitis is a poor marker for choledocholithiasis. Prognostic systems are accurate to discern those patients with ABP who do not need aggressive procedures. Patients with a benign ABP do not need an endoscopic approach. Laparoscopic common bile duct exploration is an underrated treatment for patients with choledocholithiasis. Laparoscopic approach to infected necrotic collections and pseudocysts warrant further investigations.

Intraoperative cholangiography under fluoroscopic control is a fundamental step in laparoscopic cholecystectomy. Its two principal objectives are delineation of the anatomy of the biliary tree, and detection of stones within the main bile duct. Cannulation of the cystic duct is possible in 90% cases. The ability to detect common duct stones is excellent and offers the benefit of treatment of choledocholithiasis with a single operative procedure. We encourage the systematic performance of intraoperative cholangiography because it permits a diminution of both the incidence and severity of injuries to the biliary ductal system.

Background: Several technical approaches for laparoscopic CBD exploration (LCBDE) exist. Laparoscopic choledochotomy is required in some situations and whenever a transcystic approach fails. Biliary drainage after choledochotomy has a 5% morbidity rate and avoidance of biliary drains might therefore further improve the results of LCBDE. The authors report a prospective multicentric evaluation of laparoscopic choledochotomy with completion choledochoscopy and primary duct closure without any biliary drainage., Methods: Between October 1991 and December 1997, 100 patients from four surgical centers underwent this approach for CBD stones. Choledocholithiasis had been demonstrated preoperatively in 35 patients (35%), suspected in 52 and was incidentally found during routine intraoperative cholangiography in 13 patients. External ultrasound was the only preoperative imaging investigation in 87 patients. LCBDE was attempted irrespective of age, ASA score, or the circumstances leading to the preoperative diagnosis or suspicion of CBD stones (acute cholecystitis in 33% of patients, cholangitis in 10%, or mild acute pancreatitis in 6% of all patients)., Results: The technique was equally feasible in all participating centers (University hospital, general hospital, or private practices). Vacuity of the CBD was achieved in all patients without mortality. Eleven patients had complications and 3 patients required a laparoscopic reintervention. Median postoperative hospital stay was 6 days (range: 1-26). No patient required additional CBD procedures during follow-up., Conclusions: In case of LCBDE, choledochotomy with primary closure without external drainage of the CBD is a safe and efficient alternative, even in patients with acute cholecystitis, cholangitis, or pancreatitis, provided that choledochoscopy visualizes a patent CBD. This technique is applicable in all types of medical institutions if required laparoscopic skills and equipment are available.

Objective: To assess the outcome of laparoscopic Heller myotomy for achalasia using a specific quality of life (QoL) instrument for gastrointestinal disorders., Summary Background Data: Current therapies for achalasia do not restore normal esophageal motility but aim at palliating dysphagia. However, many other symptoms may persist that cannot be assessed objectively by currently available symptom scores. Although generic QoL instruments have shown improvement in QoL after myotomy, disease-specific QoL instruments may be more responsive to change and therefore more reliable for comparing outcomes of therapeutic options for achalasia., Methods: The Gastrointestinal Quality of Life Index (GIQLI) was studied before and after laparoscopic Heller myotomy associated with posterior partial fundoplication., Results: Starting in January 1991, 73 consecutive patients were operated on laparoscopically for various clinical stages of achalasia. Since 1996, 40 patients completed a GIQLI questionnaire both preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 84 (range 34-129) out of a theoretical maximum score of 144. At a median follow-up of 31 months (range 12-54), the score had significantly improved to 119 (range 77-143), close to the range for the normal French population. Not only items assessing gastrointestinal symptoms but also the domains of physical, social, and emotional function were significantly improved. The most marked improvements were achieved in patients with the lowest preoperative scores., Conclusions: The GIQLI allows us to objectify the impact of achalasia symptoms on health-related QoL. At medium-term follow-up, laparoscopic Heller myotomy, performed either as primary treatment or after endoscopic dilation, significantly improves most health-related QoL aspects. Short of randomized comparisons between the different therapeutic options available for achalasia, reported series could be made more comparable if validated QoL instruments specific for gastrointestinal disorders were used routinely for outcome evaluation.

Background and Objectives: Colorectal cancer is one of the highest-ranking cancers in France, both sexes combined, with 33000 new cases per year. To report on the practice and the efficiency of the healthcare system, an evaluation of the therapeutic management of colorectal cancer was carried out in the department of the Herault, in the south of France., Methods: Cases of colorectal cancer in 1992 (344 colorectal cancer incidental cases) in the department of the Herault were reviewed. The diversity of the therapeutic choices and survival were evaluated for the different types of healthcare facilities (private hospitals, nonspecialized and specialized hospitals) and residential areas (rural, semi-urban, urban)., Results: Two hundred seventy-one patients with colorectal cancer (78.8%) and 234 patients with colorectal cancer (67.7%) were respectively diagnosed and treated in the private sector. Sixteen cases (23.5%) in the public sector (29.7% in the university hospital) and 24 cases (19%) in the private sector involved surgical emergencies (peritonitis, intestinal obstructions) (P = 0.003). Radiotherapy was performed in 59% of patients with rectal cancer. Preoperative radiotherapy was used primarily in specialized hospitals (80% of radiated rectal cancer; P = 0.002), as opposed to postoperative radiotherapy, which was used predominantly in private hospitals (P = 0.005). Forty-five percent of the patients with colorectal cancer who had lymph node involvement have been treated with chemotherapy. In multivariate analysis, lymph node metastasis and the presence of metastases (Dukes stage) were the most important independent pejorative prognostic factors, followed by the initial treatment in nonspecialized hospitals, complicated colorectal cancer (intestinal obstruction, peritonitis), lack of histological differentiation, and rural and urban residential areas., Conclusions: Apart from independent prognostic factors, such as parietal, ganglionic, or metastatic extensions, the lack of histological differentiation, and the complicated forms, heterogeneity and inequality persist in the distribution, treatment for, and the survival of patients with colorectal cancer based on the type of healthcare facility and the living area of this French population., (Copyright 2002 Wiley-Liss, Inc.)

Study Aim: Reversal of the Hartmann's procedure is associated with a high morbidity. The aim of this study was to evaluate the feasibility and results of laparoscopic reversal of the Hartmann's procedure., Patients and Method: Thirty eight consecutive patients, mean age 60 +/- 13.5 years were included in this retrospective study. The most common indication for the primary procedure was diverticular disease (70%). The mean time from the primary operation to the reconstruction was 136 +/- 124 days. The stoma was first dissected in 24 patients, allowing introduction of the first port. In the remaining 14 patients a standard umbilical port was inserted. The amount of adhesions was classified as low in 13 patients, mild in 15 patients and severe in 10 patients. All patients had a mechanical anastomosis., Results: The conversion rate was 15%, due to adhesion problems in 5 patients and for a positive leakage test in one. The morbidity rate was 23.5% including 8 surgical complications. One patient died after post operative peritonitis complicating an anastomic leakage. The average hospital stay was 10 +/- 4.4 days., Conclusion: Our results indicate that laparoscopic reversal after Hartmann's procedure is feasible. The morbidity is lower than after classical open reconstruction. The presence of diffuse peritonitis at the primary operation as well as a short delay before the reconstruction, are important factors of conversion.

To prevent direct secondary aortoenteric fistulas, a devastating complication of abdominal aortic surgery, we describe here a rapid, very easy to perform and no cost operating technique. A part about 4 cm long of the vascular prosthesis was cut to obtain a partial tailored ring which was passed through the prosthesis. After the anastomosis was realized, the tailored ring was hitched up to totally cover proximal anastomosis and prevent direct contact between aorto-prosthetic anastomosis and the bowel.

Unlabelled: Optimal modalities of surveillance of colorectal cancers (CRC) resected for cure have not been determined so far and the overall improvement of 5-year survival related to surveillance has not been demonstrated., Aim of the Study: To retrospectively evaluate modalities, results and costs of follow-up of patients during the 5 years following the resection for cure of CRC., Methods: We studied medical and economical data from records of 256 patients registered in the cancer registry of the Herault area who underwent a potentially curative resection of CRC in 1992. We analyzed comparatively modalities of follow-up in patients who were followed according to recommendations from the 1998 French consensus conference (standard follow-up) and in those who had a simplified follow-up. We evaluated cumulative costs of follow-up., Results: Nine patients died in the postoperative period. Recurrence rate was 27% (69 patients). Sixty-nine patients had a standard follow-up (30% of the 231 classified patients) and 162 patients (70%) had a simplified follow-up. The specific survival rate (taking into account only death related to CRC) 5 years after resection for cure was 75%. The 5-year specific survival rate after diagnosis of recurrence was 12% in the patients with recurrent disease within the 5 years after initial therapy. The 5-year survival rate after standard and simplified follow-up were 85% and 79%, respectively (P=0.25). Total cost of follow-up of the 256 patients was 1 085 507 French francs (FF). Mean follow-up cost per patient was 5 527 FF. Cost of the examinations not recommended by the consensus conference represented 30% of the expenses. Individual total cost of the follow-up of patients alive 5 years after the diagnosis of the recurrence was 120 356 FF., Conclusion: In Herault area, clinicians carried out in 70% of the patients a simplified follow-up and in 30% of the cases a reinforced follow-up in comparison with French recommendations. Survival rates were not significantly different between the 2 groups.

Background: Although carbon dioxide (CO2) pneumoperitoneum is proposed increasingly for treatment of secondary peritonitis, associated deleterious effects have been reported in experimental models, with the hypothesis that increased intraperitoneal pressure might facilitate bacterial translocation. The purpose of this study was to compare the outcome (and qualitative microbiologic analysis) from peritonitis in rats after lavage by laparoscopy with the outcome after lavage by laparotomy., Methods: After determination of the standard innoculum for this study in 30 animals, 120 male Wistar rats received 1 ml of Escherichi coli 10(6) colony-forming unit (CFU), Bacteroides fragilis 10(7) CFU, Enterococcus faecalis 10(7) CFU in a sterile rat feces-barium sulfate suspension adjuvant, were anesthetized with intramuscular ketamine, and then underwent peritoneal lavage by either laparotomy (n = 60) or laparoscopy (n = 60). The duration of peritonitis defined two groups: group A: duration less than 3 h (n = 20) and group B: duration 3 h or more (n = 40). Both groups underwent successive lavage with 10-ml aliquots (total, 50 ml) of 0.9% saline solution at 37 degrees C. Five 2-ml samples of liquid lavage were drawn for culture and microbiologic analysis. Blood (0.2 ml) and peritoneal liquid lavage samples were incubated 48 h at 37 degrees C and cultured., Results: All the animals survived. Mean duration of peritoneal lavage was 13.2 min (range, 6-25 min) for laparoscopy and 9.7 min (range, 6-15 min) and for laparotomy. The difference was not statistically significant. The mean duration of operation was significantly longer with laparoscopy than with laparotomy: 44.5 min (range, 35-62 min) and 25 min (range, 16-40 min), respectively (p = 0.0001). The collected lavage volumes were not statistically different: 48.5 ml (range, 40-54 ml) and 46.7 ml (range, 37-56 ml), respectively. No statistically significant differences were found between the laparoscopy and laparotomy groups in terms of E. coli bacteremia, irrespective of peritonitis duration. The rates of positive blood culture for B. fragilis and E. faecalis were signficantly lower after laparoscopy than after laparotomy, both in the overall group (p = 0.025 and p = 0.045, respectively) and when duration of peritonitis exceeded 3 h (p = 0.001 and p = 0.044, respectively)., Conclusions: In this animal model of secondary peritonitis, lavage by laparoscopy was associated with less bacteremia for B. fragilis and E. faecalis than peritoneal lavage by laparotomy.

At the time of cholecystectomy for symptomatic cholelithiasis, 7-20% of patients have common bile duct stones. Nearly one third of them are asymptomatic. Routine cholangiography during cholecystectomy allows the diagnosis and treatment of common bile duct stones during the same operation. Selective indication for the diagnosis of common bile duct stones based on the positive predictive value of indicators limits treatment to symptomatic cases. No single indicator is however completely accurate in predicting common bile duct stones and the natural history of asymptomatic cases is uncertain. Endoscopic stone extraction preceding cholecystectomy is not superior to one-stage surgical treatment. Diagnosis and treatment of common bile duct stones are feasible laparoscopically. Complications of common bile duct stones are cholangitis and acute pancreatitis; if severe, they require specific therapeutic approaches.

Background: The prognosis of early gastric cancer (EGC) is considered better than that of invasive gastric carcinoma, with a 5-year survival rate of more than 90% after surgery. The prevalence of lymph node metastasis in EGC ranges from 8% to 20% and is associated with a poor prognosis., Hypothesis: The main prognostic factor of EGC in patients in France is lymphatic involvement., Design, Setting, and Patients: From January 1979 to December 1988, 332 patients with EGC were operated on in 23 centers of 2 of the French Associations for Surgical Research. Clinical, pathological, and therapeutic data were reviewed, and the reckoning point was in June 1996., Main Outcome Measures: The cumulative 5- and 7-year specific survival rates of EGC with or without lymphatic involvement., Results: The cumulative 5- and 7-year specific survival rates of 332 patients with EGC (mean follow-up time, 80 months), excluding both operative and unrelated mortality, were 92% and 87.5%, respectively. Thirty-four patients (10.2%) had metastatic lymphatic spread: 13 exclusively in the lymphatic vessels close to the tumor, 17 in at least 1 lymph node, and 4 in both the lymphatic vessels and nodes. The rate of lymph node involvement (regardless of lymphatic vessel involvement) correlated significantly with submucosal invasion (P =. 05) and histologic undifferentiation (P =.03). Lymphatic vessel involvement correlated positively with lymph node involvement (P =. 003). Since 5- and 7-year survival rates of the 13 patients with EGC who had lymphatic vessel involvement without lymph node involvement did not differ significantly from those of patients who had EGC with lymph node involvement (85% and 84% vs 72% and 63%, respectively [P =.42]), all patients with lymph node and/or lymphatic vessel involvement were considered unique. Prognosis was poorest in these patients according to both univariate analysis (94% for 298 without node or vessel involvement vs 78% for 34 with node and/or vessel involvement; P =.006) and multivariate analysis (P =.01). Submucosal invasion was a prognostic factor independent of lymphatic involvement (P =.05). Five- and 7-year survival rates did not differ when the group of 211 patients for whom less than 15 lymph nodes were retrieved were compared with those (n = 51) for whom 15 or more lymph nodes were retrieved (95.5% vs 92% and 95.5% vs 88%, respectively), whether according to univariate (P =.21) or multivariate (P =.31) analysis., Conclusions: Our results suggest that both lymph node and lymphatic vessel involvement are important prognostic factors in patients with EGC. Lymphadenectomy in EGC is important to identify the high-risk population for whom prognosis is worse. The extent of lymphadenectomy (at least 15 nodes) in these patients, however, does not alter prognosis.

The spleen is the intraabdominal organ the most often injured in case of blunt abdominal trauma. Cases of fulminant infection after splenectomy, both in children and in adults, point to the importance of developing a conservative approach to spleen trauma: abstention from surgery, conservative surgery. Total splenectomy does have its indications resulting either from the general condition of the injured patient, or peroperative observations. Approximately 30% of patients operated for spleen trauma undergo total splenectomy. Over the last 10 years, the proportion of conservative surgery cases has declined as abstention is increasingly favored, being adopted in 50 to 70% of cases with a success rate of at least 90%. Currently two initial criteria and one evolution criteria guide the decision to abstain from surgery: hemodynamic stability and absence of another intraabdominal lesion requiring laparotomy; and limit number of packed red cell units transfused. The decision to abstain from surgery implies very rigorous clinical monitoring. Imaging protocols vary. Computed tomography signs predictive of recurrent bleeding and the development of arteriography techniques with embolization may further raise the rate of success after abstention from surgery.

Limitation for preoperative ERCP/ES before laparoscopic cholecystectomy in patients scheduled for laparoscopic cholecystectomy are (1) Additional invasiveness of endoscopic procedures in patients supposed to be fitted for surgery, (2) A high rate of useless procedures due to the low predictive value of suspicion criteria for common bile duct stones (CBDS), (3) an inability to detect and treat all patients with CBDS, and (4) so far, an absence of demonstration of the superiority of this split therapeutic approach versus a one stage surgical treatment. Published series of CBDS extraction during laparoscopic cholecystectomy have included more than 2000 patients. Results and complications of this one stage laparoscopic approach compares favourably to the conventional open surgical treatment. In one randomized trial endoscopy plus laparoscopy was not demonstrated superior to laparoscopy alone. Intraoperative diagnosis and treatment of CBDS during laparoscopic cholecystectomy is the most cost efficient approach for patients with or without preoperative suspicion of CBDS, provide they are fitted for surgery.

Indications for surgery of duodenal ulcer (DU) have changed radically because of the efficacy of H(2)-antagonists, endoscopic procedures, and eradication of Helicobacter pylorus. The aim of this study was to analyze the current literature to determine if definitive surgery is still relevant for complicated DU (bleeding, perforation, gastric outlet obstruction). Two studies have compared early to late surgery in terms of bleeding. One recommended early surgery (significant reduction in mortality) in the elderly, but no statistically significant difference was found when analyzed with "intention to treat." In the other, mortality with early surgery was five times higher than with expectant therapy (when it was possible). Two studies comparing different surgical techniques for bleeding favored the radical procedure. Of at least 15 studies comparing endoscopic treatments, however, none has compared endoscopic therapy to surgical intervention for bleeding DU. One trial, comparing nonoperative to surgical treatment for perforation, found similar rates of morbidity, intraabdominal abscess, and mortality; but the hospital stay was longer (p < 0.001). Nonoperative treatment failed more often (p < 0.05) in patients over age 70. In three trials, postoperative morbidity (excepting wound sepsis in one) was not significantly increased by definitive surgery, with less ulcer recurrence (p < 0.05) compared with simple closure. Laparoscopy (versus laparotomy) was shown to take longer (p < 0.001) but required less postoperative analgesics (p < 0.03); there were no statistically significant differences as concerns the duration of nasogastric aspiration, intravenous drips, hospital stay, time to resume normal diet, Visual Analogous Scale pain scores for the first 24 hours after surgery, morbidity, reoperation rate, or mortality. Of 48 laparoscopic patients, 11 (23%) underwent conversion to open surgery. Three surgical techniques [highly selective vagotomy (HSU) + gastrojejunostomy (group 1), HSV + Jaboulay gastroduodenostomy (group 2), or selective vagotomy (group 3) + antrectomy) for gastric outlet obstruction (GOO)] showed that although postoperative results were similar (except wound sepsis in one trial), long-term Visick scores were significantly (p < 0.01) better in group 1 than in group 2, but not in group 3. Further studies are needed to determine the exact prevalence of Helicobacter pylori in complicated DU and to compare (1) definitive to minimal surgery (stop the bleeding or close the perforation) combined with antisecretory drugs and eradication of H. pylori; (2) surgery to endoscopic treatment combined with eradication of H. pylori; and (3) for GOO, surgery to balloon dilatation combined with eradication of H. pylori.

Survival improvement in patients operated on for colorectal cancer might be the consequence of early diagnosis, rather than improvement in the treatment and follow-up. Therefore the question is: how to follow-up patients operated on for colorectal cancer? And even: is it necessary to follow-up these patients? Follow-up has two intentions, to diagnose metachronous tumors (adenomas and cancers), and to reveal a relapsing disease. However more than a relapse, diagnosis of a "residual" disease is questioned. This residual disease was present after what was thought to be a "curative" treatment, but lack of sensitivity of our diagnosis tools delayed the diagnosis. Follow-up is worthwhile if prognostic of patient treated of their "residual" disease is better when diagnosis is made during this follow-up, rather than when it is postponed until the disease become symptomatic. This has never been proved. Exams which should not be performed anymore are: CA 19-9, liver tests, systematic CT scan (as a diagnosis exam, but CT scan is worthwhile when a curative treatment is expected), systematic repeated colonoscopy. Conclusions on follow-up proposed at a recent consensus conference reached consensus in that it justified exams which effectiveness was never proved....

Background: Prophylactic cranial irradiation in patients with small-cell lung cancer decreases the overall rate of brain metastases without an effect on overall survival. It has been suggested that this treatment may increase neuropsychological syndromes and brain abnormalities indicated by computed tomography scans. However, other retrospective data suggested a beneficial effect on overall survival for patients in complete remission., Purpose: Our purpose was to evaluate the effects of prophylactic cranial irradiation on brain metastasis, overall survival, and late-occurring toxic effects in patients with small-cell lung cancer in complete remission., Methods: We conducted a prospective study of 300 patients who had small-cell lung cancer that was in complete remission. The patients were randomly assigned to receive either prophylactic cranial irradiation delivering 24 Gy in eight fractions during 12 days (treatment group) or no prophylactic cranial irradiation (control group). A neuropsychological examination and a computed tomography scan of the brain were performed at the time of random assignment and repeatedly assessed at 6, 18, 30, and 48 months. Patterns of failure were analyzed according to total event rates and also according to an isolated first site of relapse, using a competing-risk approach., Results: Two hundred ninety-four patients who did not have brain metastases at the time of random assignment were analyzed. The 2-year cumulative rate of brain metastasis as an isolated first site of relapse was 45% in the control group and 19% in the treatment group (P < 10(-6)). The total 2-year rate of brain metastasis was 67% and 40%, respectively (relative risk = 0.35; P < 10(-13)). The 2-year overall survival rate was 21.5% in the control group and 29% in the treatment group (relative risk = 0.83; P = .14). There were no significant differences between the two groups in terms of neuropsychological function or abnormalities indicated by computed tomography brain scans., Conclusions: Prophylactic cranial irradiation given to patients with small-cell lung cancer in complete remission decreases the risk of brain metastasis threefold without a significant increase in complications. A possible beneficial effect on overall survival should be tested with a higher statistical power., Implications: The results of the trial favor, at present, the indication of prophylactic cranial irradiation for patients who are in complete remission. A longer follow-up and confirmatory trials are needed to fully assess late-occurring toxic effects. The possible effect on overall survival needs to be evaluated with a larger number of patients in complete remission, and a meta-analysis of similar trials is recommended.

Two patients with enterocutaneous fistulas (ileal and duodenal) were successfully treated with bowel rest, total parenteral nutrition and the somatostatin analogue octreotide (150 micrograms.day-1 and 300 micrograms.day-1 respectively). At the time octreotide was started the first patient had a high output fistula (1 000 mL.day-1), the second had a low output fistula (120 mL.day-1). Within 24 hours of treatment, a reduction of at least 40% of the output was observed. The time intervals to fistula closure were respectively 6 days and 10 days after initiation of octreotide therapy. Glucose intolerance was not observed. The efficacy of octreotide combined with total parenteral nutrition supports its routine use instead of somatostatin, more expensive, less tolerated and presenting the risk of rebound effect.

The olfactory bulb responses induced by nasal infusion of three pesticides (Atrazine, Lindane, Ethyl Parathion) were studied in the rainbow Trout, Salmo gairdneri. Amplitude and frequency changes were characteristic for each solution tested at concentrations ranging between 10 ng/l and 1 mg/l.