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Desmoplastic round small cell tumor (DRSCT) is a rare intraabdominal mesenchymal tissue neoplasm in young patients and spreads through the abdominal cavity. Its prognosis is poor despite a multimodal therapy including chemotherapy, radiotherapy, and surgical cytoreduction (CS). hyperthermic intraperitoneal chemotherapy (HIPEC) is considered as an additional strategy in the treatment of peritoneal carcinomatosis; for this reason, we planned to treat selected cases of children with DRSCT using CS and HIPEC.Peritoneal disease extension was evaluated according to Gilly classification. Surgical cytoreduction was considered as completeness of cytoreduction-0 when no macroscopic nodule was residual; HIPEC was performed according to the open technique.We described 3 cases: the 2 first cases were realized for palliative conditions and the last one was operated on with curative intent. There was no postoperative mortality. One patient was reoperated for a gallbladder perforation. There was no other complication related to HIPEC procedure.Surgical cytoreduction and HIPEC provide a local alternative approach to systemic chemotherapy in the control of microscopic peritoneal disease in DRSCT, with an acceptable morbidity, and may be considered as a potential beneficial adjuvant waiting for a more specific targeted therapy against the fusion protein.

BACKGROUND: Peritoneal carcinomatosis (PC) from nonovarian malignancies long has been regarded as a terminal disease. Over the past decade, new locoregional therapeutic approaches combining cytoreductive surgery with perioperative intraperitoneal chemotherapy (PIC) have evolved that have demonstrated improved survival. METHODS: A retrospective, multicenter cohort study was performed in French-speaking institutions to evaluate toxicity and principal prognostic factors after cytoreductive surgery and PIC (hyperthermic intraperitoneal chemotherapy [HIPEC] and/or early postoperative intraperitoneal chemotherapy [EPIC]) for PC from nongynecologic malignancies. RESULTS: The study included 1290 patients from 25 institutions who underwent 1344 procedures between February 1989 and December 2007. HIPEC was performed in 1154 procedures. The principal origins of PC were colorectal adenocarcinoma (N = 523), pseudomyxoma peritonei (N = 301), gastric adenocarcinoma (N = 159), peritoneal mesothelioma (N = 88), and appendiceal adenocarcinoma (N = 50). The overall morbidity and mortality rates were 33.6% and 4.1%, respectively. In multivariate analysis, patient age, the extent of PC, and institutional experience had a significant influence on toxicity. The overall median survival was 34 months; and the median survival was 30 months for patients with colorectal PC, not reached for patients with pseudomyxoma peritonei, 9 months for patients with gastric PC, 41 months for patients with peritoneal mesothelioma, and 77 months for patients with PC from appendiceal adenocarcinoma. Independent prognostic indicators in multivariate analysis were institution, origin of PC, completeness of cytoreductive surgery, extent of carcinomatosis, and lymph node involvement. CONCLUSIONS: A therapeutic approach that combined cytoreductive surgery with PIC was able to achieve long-term survival in a selected group of patients who had PC of nonovarian origin and had acceptable morbidity and mortality. The current results indicated that this treatment should be centralized to institutions with expertise in the management of PC. Cancer 2010. © 2010 American Cancer Society.

The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG.A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG.Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 years) and a mean body mass index at 49.9 kg/m(2) (range 35.9-63 kg/m(2)), underwent laparoscopic conversion of GB (36 patients) and VBG (five patients) into LSG. Indication for revisional surgery was insufficient weight loss in all the cases. All procedures were completed laparoscopically. There was no mortality and five patients (12.2%) developed complications (high leak, one patient; intra-abdominal abscess, three patients; and complicated incisional hernia, one patient). At a mean follow-up of 13.4 months, %EWL is on average 42.7% (range 4-76.1%). Six patients had a second procedure (four had laparoscopic duodenal switch, one had laparoscopic Roux-en-Y gastric bypass, and one had laparoscopic biliopancreatic diversion).Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months. Long-term results of LSG as revisional procedure are awaited to establish its efficacy in the long term.

Obesity is associated with adipose tissue inflammation. The CD40 molecule, TNF receptor superfamily member 5 (CD40)/CD40 ligand (CD40L) pathway plays a role in the onset and maintenance of the inflammatory reaction, but has not been studied in human adipose tissue. Our aim was to examine CD40 expression by human adipocytes and its participation in adipose tissue inflammation. CD40 expression was investigated in human whole adipose tissue and during adipocyte differentiation by real-time PCR, Western blot and immunohistochemistry. The CD40/CD40L pathway was studied using recombinant CD40L (rCD40L) in adipocyte culture and neutralising antibodies in lymphocyte/adipocyte co-culture. CD40 mRNA levels in subcutaneous adipose tissue were higher in the adipocyte than in the stromal–vascular fraction. CD40 expression was upregulated during adipocyte differentiation. Addition of rCD40L to adipocytes induced mitogen activated protein kinase (MAPK) activation, stimulated inflammatory adipocytokine production, and decreased insulin-induced glucose transport in parallel with a downregulation of IRS1 and GLUT4 (also known as SCL2A4). rCD40L decreased the expression of lipogenic genes and increased lipolysis. CD40 mRNA levels were significantly higher in subcutaneous adipose tissue than in visceral adipose tissue of obese patients and were positively correlated with BMI, and with IL6 and leptin mRNA levels. Lymphocyte/adipocyte co-culture led to an upregulation of proinflammatory adipocytokines and a downregulation of leptin and adiponectin. Physical separation of the two cell types attenuated these effects, suggesting the involvement of a cell–cell contact. Blocking the CD40/CD40L interaction with neutralising antibodies reduced IL-6 secretion from adipocytes. Adipocyte CD40 may contribute to obesity-related inflammation and insulin resistance. T lymphocytes regulate adipocytokine production through both the release of soluble factor(s) and heterotypic contact with adipocytes involving CD40.

Background Multivariable analysis best identifies independent risk factors. Study Design We conducted a prospective evaluation of 2,605 patients through univariate analysis followed by nonconditional multiple logistic regression analysis on 39 pre-, intra-, and postoperative factors, analyzed according to preoperative factors alone, preoperative and intraoperative factors together, and all 3 combined. The purpose was to identify surgeon-dependent independent risk factors for mortality after elective colorectal surgery, with immediate anastomosis for cancer and nonacute diverticular disease. Results Overall mortality was 3.5%. Through multivariable analysis, five risk factors were found when preoperative data were analyzed alone. Four remained (age between 60 and 75 years, age greater than 75 years, male gender, and heart failure) and 4 new factors (palliative resection, total colectomy, respiratory failure, and surgeon-dependent fecal soiling [the only surgeon-dependent factor]) appeared when pre- and intraoperative factors were analyzed together. Of the latter, two remained stable when all three categories of risk factors were combined and analyzed (palliative resection and total colectomy), and the two others disappeared. Of the eight pre-, intra-, and postoperative factors combined, two new factors appeared: extrasurgical site (ESS) and surgeon-dependent, organ space surgical site (O/SSS) morbidity. Conclusions Every effort must be made to collect specific, surgeon-dependent (technical and clinical) data, along with administrative data, for multivariable analysis of risk factors. Classification into three periods (pre-, pre- and intraoperative together, and pre-, intra-, and postoperative combined) enables determination of relevant, surgeon-dependent risk factors (fecal soiling and postoperative morbidity) for which there are direct preventive actions.

Background Gastric bypass (GBP) is more efficient than adjustable gastric banding (AGB) on weight loss and comorbidities, but potentially induces more nutritional deficits. However, no study has compared the prevalence of nutritional deficiencies after these two bariatric procedures. We prospectively compared To prospectively compare the prevalence of nutritional deficiencies after AGB and GBP. Methods We have performed a 1-year prospective study of nutritional parameters in 70 consecutive severe obese patients, who had undergone bariatric surgery, 21 AGB and 49 GBP. After GBP, multivitamin supplements were systematically prescribed and vitamin B12 supplementation was introduced if a deficiency was observed. Results Patients lost more weight after GBP than after AGB (40±13 vs 16±8 kg, p

OBJECTIVE—The expansion of adipose tissue is linked to the development of its vasculature. However, the regulation of adipose tissue angiogenesis in humans has not been extensively studied. Our aim was to compare the angiogenesis associated with subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) from the same obese patients in an in vivo model. RESEARCH DESIGN AND METHODS—Adipose tissue samples from visceral (VAT) and subcutaneous (SAT) sites, obtained from 36 obese patients (mean BMI 46.5 kg/m2) during bariatric surgery, were layered on chick chorioallantoïc membrane (CAM). RESULTS—Both SAT and VAT expressed angiogenic factors without significant difference for vascular endothelial growth factor (VEGF) expression. Adipose tissue layered on CAM stimulated angiogenesis. Angiogenic stimulation was macroscopically detectable, with engulfment of the samples, in 39% and was evidenced by angiography in 59% of the samples. A connection between CAM and adipose tissue vessels was evidenced by immunohistochemistry, with recruitment of both avian and human endothelial cells. The angiogenic potency of adipose tissue was not related to its localization (with an angiogenic stimulation in 60% of SAT samples and 61% of VAT samples) or to adipocyte size or inflammatory infiltrate assessed in adipose samples before the graft on CAM. Stimulation of angiogenesis by adipose tissue was nearly abolished by bevacizumab, which specifically targets human VEGF. CONCLUSIONS—We have established a model to study the regulation of angiogenesis by human adipose tissue. This model highlighted the role of VEGF in angiogenesis in both SAT and VAT.

With the increasing prevalence of obesity, non-alcoholic fatty liver disease (NAFLD) has become a major cause of liver diseases. Small intestinal bacterial overgrowth (SIBO) could be related to NAFLD. Our aim was to determine the prevalence of SIBO and its relationship with liver lesions in morbidly obese patients. A glucose hydrogen (H2) breath test (positive if fasting breath H2 concentration > 20 ppm and/or an increase of > 10 ppm over baseline within the first 2 h) was performed in obese patients referred for bariatric surgery (body mass index [BMI] > 40 kg/m2 or > 35 in association with comorbidities) and in healthy non-obese subjects. In obese patients, a surgical liver biopsy was performed. One hundred and forty-six patients (129 women, age [mean±SE]: 40.7 ± 11.4 years) were prospectively included in the study. The mean BMI was 46.1±6.4 kg/m2. A liver biopsy was available in 137 patients and a breath test in 136. The frequency of positive breath tests was higher in obese patients (24/136, 17.1%) than in healthy subjects (1/40, 2.5%; P=0.031). In the univariate analysis, SIBO was not associated with clinical variables, but tended to be associated with more frequent severe hepatic steatosis (26.3 vs. 10.3%, P=0.127), whereas the frequency of sinusoidal or portal fibrosis, lobular necrosis and non-alcoholic steatohepatitis (NASH) were not different. In the multivariate analysis, SIBO (P=0.005) and the presence of a metabolic syndrome (P=0.006) were independent factors of severe hepatic steatosis. In morbidly obese patients, bacterial overgrowth prevalence is higher than in healthy subjects and is associated with severe hepatic steatosis.

Introduction The aim of this article was to evaluate the role of hyperthermic intraperitoneal chemotherapy (HIPEC), associated or not to cytoreductive surgery (CS) in the treatment of different stages of advanced gastric cancer (AGC). Patients and methods Thirty seven patients with AGC who underwent 43 HIPEC from June 1992 to February 2007 were included. HIPEC used Mitomycin-C and Cisplatin for 60–90 min at 41–43 °C intra-abdominal temperature. The main endpoints were long-term survivals, morbidity and mortality rates. Results Eleven patients had no demonstrable sign of PC and constituted the Prophylactic -group, while 26 patients had macroscopic PC ( PC -group). Five patients were Gilly 1 or 2 (nodules PC -group a complete curative CS was achieved before HIPEC in 8 ( PC-curative subgroup) and a palliative HIPEC in 18 patients ( PC-palliative subgroup). The overall 30-days mortality was 5% (2 patients). Two patients in the Prophylactic group died within 6 months after hospital discharge (overall mortality 11%). The estimated risk of death per procedure was 9%. Ten patients (27%) presented one or more complications. The median survival was 23.4 months in the Prophylactic group, and 6.6 months in the PC -group ( p PC-curative subgroup was 15 vs 3.9 months in the PC - palliative subgroup ( p = 0.007). The median survival according to Gilly classification was significantly different (Gilly 1&2 vs Gilly 3&4, 15 vs 4 months respectively, p = 0.014). The global recurrence rates between the Prophylactic group and the PC-curative subgroup at 2 years were 36% vs 50% respectively. The median delay to recurrence was 18.5 vs 9.7 months respectively. Conclusion HIPEC might be useful to improve the survival in selected patients with ACG only when a complete cytoreduction can be achieved. Despite encouraging data, prospective studies, based on larger cohorts of patients are required to assess the role of this procedure as a prophylactic treatment in patients with AGC.

Morbid obesity is a risk factor of nonalcoholic steatohepatitis (NASH). Obstructive sleep apnea (OSA) could also be an independent risk factor for elevated liver enzymes and NASH. The relationships between liver injuries and OSA in morbidly obese patients requiring bariatric surgery were studied prospectively.Every consecutive morbidly obese patient (BMIor =40 kg/m2 oror =35 kg/m2 with severe comorbidities) requiring bariatric surgery was included between January 2003 and October 2004. Polygraphic recording, serum aminotransferases (ALT, AST), gamma-glutamyltransferase (GGT) and liver biopsy were systematically performed. OSA was present when the apnea-hypopnea index (AHI) was10/h.62 patients (54 F; age 38.5 +/- 11.0 (SD) yrs; BMI 47.8 +/- 8.4 kg/m2) were included. Liver enzymes (AST, ALT or GGT) were increased in 46.6%. NASH was present in 34.4% and OSA in 84.7%. Patients with OSA were significantly older (P = 0.015) and had a higher BMI (P = 0.003). In multivariate analysis, risk factors for elevated liver enzymes were the presence of OSA and male sex. The presence of NASH was similar in patients with or without OSA (32.7% vs 44.4% of patients, P = 0.76).In this cohort of morbidly obese patients requiring bariatric surgery, one-third of patients had NASH, a prevalence similar to previous studies. OSA was found to be a risk factor for elevated liver enzymes but not for NASH.

The aim of this study was to evaluate the results of an aggressive strategy in patients presenting peritoneal carcinomatosis (PC) from colorectal cancer with or without liver metastases (LMs) treated with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC).The population included 43 patients who had 54 CS+HIPEC for colorectal PC from 1996 to 2006. Sixteen patients (37%) presented LMs. Eleven patients (25%) presented occlusion at the time of PC diagnosis. Ascites was present in 12 patients (28%). Seventy-seven percent of the patients were Gilly 3 (diffuse nodules, 5-20 mm) and Gilly 4 (diffuse nodules20 mm). The main endpoints were morbidity, mortality, completeness of cancer resection (CCR), and actuarial survival rates.The CS was considered as CCR-0 (no residual nodules) or CCR-1 (residual nodules5 mm) in 30 patients (70%). Iterative procedures were performed in 26% of patients. Three patients had prior to CS + HIPEC, 10 had concomitant minor liver resection, and 3 had differed liver resections (2 right hepatectomies) 2 months after CS + HIPEC. The mortality rate was 2.3% (1 patient). Seventeen patients (39%) presented one or multiple complications (per procedure morbidity = 31%). Complications included deep abscess (n = 6), wound infection (n = 5), pleural effusion (n = 5), digestive fistula (n = 4), delayed gastric emptying syndrome (n = 4), and renal failure (n = 3). Two patients (3.6%) were reoperated. The median survival was 38.4 months (CI, 32.8-43.9). Actuarial 2- and 4-year survival rates were 72% and 44%, respectively. The survival rates were not significantly different between patients who had CS + HIPEC for PC alone (including the primary resection) versus those who had associated LMs resection (median survival, 35.3 versus 36.0 months, P = 0.73).Iterative CS + HIPEC is an effective treatment in PC from colorectal cancer. The presence of resectable LMs associated with PC does not contraindicate the prospect of an oncologic treatment in these patients.

Aims To review our experience of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of malignant ascites from advanced gastric cancer in order to discuss benefits, problems and possible indications. Methods From June 2000 to May 2003 laparoscopic approach was used to perform HIPEC on five patients affected by malignant ascites secondary to unresectable peritoneal carcinomatosis of gastric origin, in order to associate the benefits of a definitive palliation of ascites with a minimal invasiveness. All patients had ascites related symptoms requiring iterative paracenteses. Intraperitoneal perfusion of mitomycin-C and cisplatin was delivered for 60–90min with an inflow temperature of 45°C. Results Complete clinical regression of ascites and related symptoms was achieved in all the five patients treated. Intraoperative course was uneventful in all cases. Mean operative time was 181min. No postoperative deaths, related to the procedure, occurred. Only a case of delayed gastric empting was recorded as a minor postoperative complication. Conclusions Laparoscopic HIPEC appears to be a safe and effective procedure to treat debilitating malignant ascites from unresectable peritoneal carcinomatosis.

Bariatric surgery has developed substantially in France over the past 15 years. It has numerous complications that vary according to the type of procedure. Adjustable gastric banding and gastric bypass are the most common bariatric surgery techniques in France. The adjustable gastric band is particularly subject to surgical and mechanical complications long after surgery. Early postoperative complications are more frequent after gastric bypass and generally more serious than with the gastric band. Longer after surgery, the gastric bypass has essentially nutritional complications. The role of the general practitioner is fundamental in coordinating follow-up of patients, in collaboration with the medical-surgical team that performed the operation. Long-term follow-up of patients is essential because of the risk of late complications.

Introduction Le decubitus ventral (DV), utilise comme strategie de recrutement alveolaire au cours du SDRA permet une amelioration de l’oxygenation et de la survie. Les urgences chirurgicales abdominales figurent parmi les etiologies extrapulmonaires du SDRA. En cas d’hypoxemie severe en postoperatoire, les reanimateurs sont confrontes a la decision de mettre ou non ces patients en DV. Nous avons cherche a connaitre les complications liees a la mise precoce en DV dans les suites d’une chirurgie abdominale. Patients et methodes Etude retrospective sur 5 ans, approuvee par le comite d’ethique de la SRLF (no 14–31), realisee dans 3 reanimations dont l’objectif etait de comparer la prevalence des complications chirurgicales potentiellement favorisees par le DV entre les patients ayant eu au moins une seance de DV et les patients n’ayant eu aucune seance de DV dans le contexte de SDRA dans les suites d’une chirurgie abdominale. Nous avons inclus des patients adultes ayant presente un SDRA dans un contexte de chirurgie abdominale recente ( Le critere de jugement principal etait le nombre de patients ayant eu au moins une complication chirurgicale potentiellement liee au DV. Cette liste a ete definie a priori : desunion de cicatrice, syndrome du compartiment abdominal, desinsertion de stomie, necrose de stomie, necrose de la cicatrice, abces de paroi, arrachage d’un systeme de drainage (drain peritoneal, drain biliaire), arrachage d’une gastrostomie ou d’une jejunostomie d’alimentation, fistule digestive, eventration. Resultats Parmi les 98 patients inclus (âge 64[± 18] ans, IGS2 53[± 17]), 79 (81 %) avaient ete operes dans un contexte d’urgence dont 41 peritonites. Trente-six patients (37 %) ont eu au moins une seance de DV (nombre de seances : 1 [1–2]) et 62 (63 %) aucune. Les patients mis en DV avaient un rapport PaO2/FiO2 minimal plus faible que ceux du groupe temoin (74[±24] vs 101[± 43] mmHg, p = 0,0005). La premiere seance de DV (duree moyenne 19 [± 10] heures) a permis une augmentation du rapport PaO2/FiO2 moyen de 95 (± 47) a 189 (± 92) mmHg (p = 0,001). Dans le groupe DV, 14 patients (39 %) ont presente au moins une complication chirurgicale contre 27 (44 %) dans le groupe temoin (p = 0,65). Apres application d’un score de propension, l’absence de difference persistait (OR 0,72 [0,26–2,02], p = 0,54). Ces complications ont eu pour consequence une reprise chirurgicale chez 2 (6 %) patients du groupe DV et 4 (6 %) du groupe temoin (p = 0,89). La mortalite en reanimation etait de 42 % dans le groupe DV et de 45 % dans le groupe temoin (p = 0,43). Discussion Ces resultats confirment l’efficacite du DV en terme d’amelioration de l’oxygenation chez des patients ayant eu une chirurgie abdominale recente sans augmentation significative du nombre de complications chirurgicales. Chez les patients presentant un SDRA dans le contexte d’une pathologie abdominale chirurgicale, la mise en DV en postoperatoire ne devrait pas etre limitee.

S S11 Exclusive I.O.R.T. for early stage breast cancer: Results after 93 cases using GEC-ESTRO criteria G. Gambula*, M. Dessena, B. Demontis, L.P. Grosso, S. Porru, M. Dess i, M. Fiorbelli, G. Lay, G. Murenu 1 Oncology Hospital UOC Experimental Surgery, Cagliari, Italy Oncology Hospital UOC Health Physics, Cagliari, Italy Oncology Hospital UOC Oncologic Radiotherapy, Cagliari, Italy * Corresponding author: Giuseppe Gambula, Oncology Hospital UOC Experimental Surgery, Cagliari, Italy. E-mail address: gambul75@yahoo.it (G. Gambula) Study objectives: To evaluate feasibility, tolerability, cosmetic outcome and local control of intra-operative radiation therapy (IORT) as an exclusive treatment of early stage breast cancer in patients selected according to GEC-ESTRO criteria (good candidates). Materials and methods: From October 2008 to December 2013, 93 patients underwent wide breast cancer excision or quadrantectomy followed by IORT on tumor bed with accelerated electrons (Novac 7 NRT) at the dose of 21Gy. Patients were aging at least 50 years with unicentric, unifocal, pT1-2 ( 5) associated to occurrence of major morbidity after the first-step were predictive factors of second-step failure. Major hepatectomy with the need of transfusion in pts who received more than 8 cycles of (bio)chemotherapy were associated to significant postoperative morbidity. The overall mortality rate after liver resection was 9%. The overall 3eyear survival rate in pts who underwent complete radical liver surgery were 65% versus 0% for those who could not undergo radical surgery. Conclusion: The results suggest that in highly selected pts with initially not easily resectable LM from CRC, radical (one or two-step) hepatectomy can increase the 3-year survival rate after down-sizing biochemotherapy with consequent mortality. http://dx.doi.org/10.1016/j.ejso.2014.10.031 Long-term follow up in patients with IPMN-branch duct type (BDT) not submitted to surgery S. Molfino*, G.L. Baiocchi, N. Portolani, M. Bartoli, D. Lomiento, G. Merigo, S.M. Giulini Surgical Clinic, University of Brescia, Brescia, Italy * Corresponding author: Sarah Molfino, Brescia, Italy. E-mail address: sarahmolfino@gmail.com (S. Molfino) Study objective: Even if International Guidelines contemplate surgery for IPMN-BDT larger than 3 cm of diameter, with wall-thickness >3 mm, with parietal nodules, however some data suggest that a lot of these tumors could only be followed-up. The aim of this article is to analyze the implications of long-term follow-up in patients with IPMN-BDT not submitted to surgery, with particular attention on clinical and morphological evolution. Material and methods: During the period 2006e2011, two-hundred and thirty-four patients with IPMN have been observed. Surgery was directed to patients with IPMN MDT and BDT + MDT (92 patients) and to other 13 patients with IPMN-BDT with a strong suspect of malignancy (by cytology with EUS and/or 18FDG-PET), independently from Sendai Criteria.

Hypothesis The anti-infective actions of povidone-iodine (PVI) and sodium hypochlorite enemas are different. Design Prospective, randomized, single-blind study. Setting Multicenter. Patients Five hundred seventeen consecutive patients with colorectal carcinoma or sigmoid diverticular disease undergoing elective open colorectal resection, followed by primary anastomosis. Intervention All patients received senna (1-2 packages diluted in a glass of water) at 6PMthe evening before surgery. Patients were administered two 2-L aqueous enemas of 5% PVI (n = 277) or 0.3% sodium hypochlorite (n = 240) at 9PMthe evening before surgery and at 3 hours before operation. Intravenous ceftriaxone sodium (1 g) and metronidazole (1 g) were administered at anesthetic induction. Main Outcome Measure Rate of patients with 1 infective parietoabdominal complication or more. Results The percentages of patients with 1 infective parietoabdominal complication or more did not differ between the 2 groups (13.7% in the PVI-treated group vs 15.0% in the sodium hypochlorite–treated group). Tolerance was better in the PVI-treated group than in the sodium hypochlorite–treated group (79.4% vs 67.9%), with fewer patients experiencing abdominal pain (13.0% vs 24.6%) or discontinuing their preparation (3.0% vs 9.0%) ( P =.02 for all). There were more patients with malaise in the PVI-treated group than in the sodium hypochlorite–treated group (9.1% vs 4.9%, P Conclusion When antiseptic enemas are chosen for mechanical preparation before colorectal surgery, PVI should be preferred over sodium hypochlorite because of better tolerance and avoidance of necrotic ulcerative colitis.

Primary epiploic appendagitis (PEA) is characterized by the association of localized abdominal pain with guarding. Depending on its localization, it may simulate acute appendicitis or diverticular sigmoiditis. Symptoms correspond to necrosis of the epiploic appendix due the torsion and vascular occlusion of the main epiploic pedicle.A 34-year-old man (BMI=29.38) was examined for persistent localized abdominal pain of the left lower quadrant three days after receiving systemic antibiotic therapy for what was diagnosed as mild diverticular sigmoiditis. Abdominal examination showed localized guarding in the left lower quadrant, with no fever, vomiting or diarrhea. Laboratory results showed no inflammatory response. Abdominal ultrasound showed no evidence of left hydronephrosis. Helical CT showed a localized zone of necrosis of the epiploic appendix of the sigmoid colon and thus confirmed the diagnosis without surgical exploration. Symptoms regressed after a week of analgesic treatment.PEA is a rare disease. It often occurs in mildly overweight adult men (around 35 years of age). The combination of acute abdomen with localized abdominal guarding and no evidence of fever or inflammation is the typical presentation. Surgical exploration (laparoscopy) can be avoided for diagnosis if helical CT shows a localized fatty zone situated outside the colon wall with a high attenuating dot point that corresponds to central necrosis of the epiploic appendix.

Obesity is an increasingly serious health problem in nearly all Western countries [76, 108, 320]. Although various preventive and conservative treatment options are available, it has been estimated that obesity-related illnesses, such as diabetes mellitus, knee osteoarthritis, systemic hypertension and heart failure, are responsible for an estimated 36% of total health care costs [6, 230, 279]. A recent study on the association between different grades of obesity and the number of life-years lost indicated that life expectancy can be up to 20 years shorter in severe obesity [104]. The consequences of obesity are by far more severe than those of smoking or alcohol [319]. Definition and classification of obesity is based primarily on the body mass index (BMI), calculated as weight divided by the square of height with kilograms per square meter as the unit of measurement [17]. For Caucasians, a BMI of 3035 is considered as class 1 obesity, 3540 as class 2, and over 40 as class 3. Morbid obesity is usually defined as a BMI of over 40 or a BMI over 35 in combination with comorbidities [238]. In addition, some surgeons speak of super- and mega-obesity, if a patients BMI exceeds 50 or 70, respectively. Alternatively, absolute or relative increases in body weight may be used to define obesity. Given the enormous importance of morbid obesity and the limited efficacy of dietetic and pharmacological treatments, surgical treatment has become increasingly popular. The number of procedures performed has more than doubled within a few years [64, 78, 289]. This dramatic growth can be attributed in part also to the introduction of new surgical techniques, e.g. the adjustable silicone gastric band (AGB), and the rise of laparoscopic surgery. Traditionally, there are two types of operations for morbid obesity: Gastric restrictive operations (where food intake is restricted) and malabsorptive operations (where aliments are diverted from absorption via a gastrointestinal shortcut). Both types of obesity surgery are now being performed laparoscopically [38]. The aim of these guidelines is to systematically review the clinical effectiveness of the various surgical procedures and to support surgeons and other physicians in the provision of high-quality care for morbidly obese patients. © Springer Berlin Heidelberg 2006.

BACKGROUND: The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery. METHODS: A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued. RECOMMENDATIONS: After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Prophylactic administration of octreotide acetate decreases the rate of postoperative intra-abdominal complications (IACs) after elective pancreatic resection.Single-blind, controlled, randomized trial.Multicenter (N = 20) trial in France.Of 230 randomized patients undergoing pancreatoduodenectomy and pancreatic enteric anastomosis or distal pancreatectomy for either malignant or benign tumor or chronic pancreatitis, 122 were allotted intraoperatively to receive octreotide; 108 served as controls.All 230 patients were analyzed. Both groups were comparable except that significantly more patients in the octreotide group had biological glue injected into the main pancreatic duct alone (P.001) or reinforcing the pancreatic enteric anastomosis (68% [83/122] vs 39% [42/108]; P =.002). Fewer patients (P =.08) in the octreotide group sustained 1 or more IACs (22% vs 32%). In subgroup analysis, octreotide significantly reduced the rate of patients sustaining 1 or more IACs when the main pancreatic duct diameter was less than 3 mm (P.02), when pancreatojejunostomy was performed (P.02), or both (P.02). No significant differences were found regarding IAC severity. Twenty-three patients (10%) died postoperatively, 16 (70% of deaths) of whom had 1 or more IACs. The only independent risk factor for IACs found on multivariate analysis was pancreatoduodenectomy compared with distal pancreatectomy (P.01) (odds ratio, 3.54 [95% confidence interval, 1.44-8.65]).Our results suggest that octreotide is not necessary for all patients undergoing pancreatic resection; it could be useful when the main pancreatic duct is less than 3 mm in diameter and when pancreatoduodenectomy is completed by pancreatojejunostomy.

Only 2 large (more than 100 patients) prospective trials comparing pancreatogastrostomy (PG) with pancreatojejunostomy (PJ) after pancreatoduodenectomy (PD) have been reported until now. One nonrandomized study showed that there were less pancreatic and digestive tract fistula with PG, whereas the other, a randomized trial from a single high-volume center, found no significant differences between the two techniques.Single blind, controlled randomized, multicenter trial. The main endpoint was intra-abdominal complications (IACs).Of 149 randomized patients, 81 underwent PG and 68 PJ. No significant difference was found between the two groups concerning pre- or intraoperative patient characteristics. The rate of patients with one or more IACs was 34% in each group. Twenty-seven patients sustained a pancreatoenteric fistula (18%), 13 in PG (16%; 95% confidence interval [CI] 8-24%) and 14 in PJ (20%; 95% CI 10.5-29.5%). No statistically significant difference was found between the 2 groups concerning the mortality rate (11% overall), the rate of reoperations and/or postoperative interventional radiology drainages (23%), or the length of hospital stay (median 20.5 days). Univariate analysis found the following risk factors: (1) ageor =70 years old, (2) extrapancreatic disease, (3) normal consistency of pancreas, (4) diameter of main pancreatic duct3 mm, (5) duration of operation6 hours, and (6) a center effect. Significantly more IAC, pancreatoenteric fistula, and deaths occurred in one center (that included the most patients) (P = .05), but there were significantly more high-risk patients in this center (normal pancreas consistency, extrapancreatic pathology, small pancreatic duct, higher transfusion requirements, and duration of operation6 hours) compared with the other centers. In multivariate analysis, the center effect disappeared. Independent risk factors included duration of operation6 hours for IAC and for pancreatoenteric fistula (P = .01), extrapancreatic disease for pancreatoenteric fistulas (P.04), and ageor =70 years for mortality (P.02).The type of pancreatoenteric anastomosis (PJ or PG) after PD does not significantly influence the rate of patients with one or more IAC and/or pancreatic fistula or the severity of complications.

Hypothesis Infectious complications are the main causes of postoperative morbidity in abdominal surgery. Identification of risk factors, which could be avoided in the perioperative period, may reduce the rate of postoperative infectious complications. Design A database was established from 3 prospective, randomized, multicenter studies. Multivariate analysis was performed using nonconditional logistic regression expressed as an odds ratio (OR). Setting Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). Patients From June 1982 to September 1996, a database was established containing the information of 4718 patients who underwent noncolorectal abdominal surgery. Main Outcome Measures The dependent variables studied included surgical site infection (SSI) (divided into parietal and deep infectious complications with or without fistulas) and global infectious complications (SSI and extraparietal and abdominal infectious complications). Results The rate of global infectious complications was 13.3%; SSI, 4.05%; parietal infectious complications, 2.2%; deep infectious complications with fistulas, 2.18%; and deep infectious complications without fistulas, 1.38%. In multivariate analysis, the following 7 independent risk factors for global infectious complications have been identified: age (60-74 years, OR, 1.64; ≥75 years, OR, 1.45); being underweight (OR, 1.51); having cirrhosis (OR, 2.45), having a vertical abdominal incision (OR, 1.66); having a suture placed or an anastomis of the bowel (OR, 1.48) in the digestive tract; having a prolonged operative time (61-120 minutes, OR, 1.66; 121 minutes, OR, 2.72); and being categorized as having a class 4 surgical site (ie, obese patients or having a risk factor of a healing defect) (OR, 1.66). Ceftriaxone sodium therapy was identified as a protective factor (OR, 0.43). In multivariate analysis, the following 5 independent risk factors for SSI have been identified: the existence of a preoperative cutaneous abscess or cutaneous necrosis (OR, 4.75), having a suture placed or an anastomosis of the bowel (OR, 1.82) in the digestive tract, having postoperative abdominal drainage (OR, 2.15), undergoing a surgicial procedure for the treatment of cancer (OR, 1.74), and receiving curative anticoagulant therapy (OR, 3.33) postoperatively. Conclusions Our data show that risk factors for SSI and for global infectious complications are disparate. Indeed, only the placement of a suture or having an anastomosis of the bowel in the digestive tract is a risk factor for both SSI and global infections. Some of these factors may be modifiable before or during the surgical procedure to reduce the infection rate or to prevent postoperative complications.

In comparison to medical treatment, antireflux surgery is recognized as an effective, efficient and longlasting therapy, as well as the only treatment that is able to modify the natural history of gastroesophageal reflux disease (GERD). The 360 fundoplication is the most widely used surgical procedure for GERD. Although performed in the era of H2-blockers and open surgery, comparison of the so-called Nissen repair to both symptomatic and continuous medical therapies concluded that surgery was superior to medical therapy in every outcome measure used.

Importance Ninety percent of cases of acute calculous cholecystitis are of mild (grade I) or moderate (grade II) severity. Although the preoperative and intraoperative antibiotic management of acute calculous cholecystitis has been standardized, few data exist on the utility of postoperative antibiotic treatment. Objective To determine the effect of postoperative amoxicillin plus clavulanic acid on infection rates after cholecystectomy. Design, Setting, and Patients A total of 414 patients treated at 17 medical centers for grade I or II acute calculous cholecystitis and who received 2 g of amoxicillin plus clavulanic acid 3 times a day while in the hospital before and once at the time of surgery were randomized after surgery to an open-label, noninferiority, randomized clinical trial between May 2010 and August 2012. Interventions After surgery, no antibiotics or continue with the preoperative antibiotic regimen 3 times daily for 5 days. Main Outcomes and Measures The proportion of postoperative surgical site or distant infections recorded before or at the 4-week follow-up visit. Results An imputed intention-to-treat analysis of 414 patients showed that the postoperative infection rates were 17% (35 of 207) in the nontreatment group and 15% (31 of 207) in the antibiotic group (absolute difference, 1.93%; 95% CI, −8.98% to 5.12%). In the per-protocol analysis, which involved 338 patients, the corresponding rates were both 13% (absolute difference, 0.3%; 95% CI, −5.0% to 6.3%). Based on a noninferiority margin of 11%, the lack of postoperative antibiotic treatment was not associated with worse outcomes than antibiotic treatment. Bile cultures showed that 60.9% were pathogen free. Both groups had similar Clavien complication severity outcomes: 195 patients (94.2%) in the nontreatment group had a score of 0 to I and 2 patients (0.97%) had a score of III to V, and 182 patients (87.8%) in the antibiotic group had a score of 0 to I and 4 patients (1.93%) had a score of III to V. Conclusions and Relevance Among patients with mild or moderate calculous cholecystitis who received preoperative and intraoperative antibiotics, lack of postoperative treatment with amoxicillin plus clavulanic acid did not result in a greater incidence of postoperative infections. Trial Registration clinicaltrials.gov Identifier:NCT01015417

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.

It is not well known if the improvement in operative mortality after surgery for gastric cancer reported in hospital series can be extrapolated to the whole population. The aim of this study was to determine trends in operative mortality over a 20-year period in a nonselected community-based series of patients. A database of 648 patients with gastric cancer resected with curative intent between 1976 and 1995 in a region with a half-million population was divided into two periods: 1976-1983 and 1984-1995. Nonconditional logistic regression was performed to estimate the independent effects of the studied factors. Operative mortality was higher during the 1976-1983 period than during the 1984-1995 period (17.1% vs. 7.1%; p < 0.0001). When comparing the two study periods, operative mortality decreased dramatically from 26.2% to 10.0% in patients over age 70, from 31.8% to 7.9% after total gastrectomy, and from 30.7% to 6.3% after proximal esophagogastrectomy. Operative mortality after total gastrectomy was nearly the same as that after distal gastrectomy (7.9% vs 5.9%) during the second study period. During the first study period, operative mortality was independently associated with age at diagnosis, type of gastrectomy, and to a lesser degree stage at diagnosis; during the second study period, only age and stage at diagnosis were associated with the risk of operative mortality. This study indicates that in this well defined population operative mortality after curative resection for gastric cancer has decreased during the last 20 years. The results should encourage aggressive management of patients with gastric cancer, even in patients over 70 years of age.

In recent years, laparoscopy has had a significant impact on colorectal surgery. However, to date, totally laparoscopic procedures have required the use of stapling devices to fashion the anastomosis. Herein we report a case of totally laparoscopic sigmoid colectomy with intracorporeal hand-sewn anastomosis for diverticulitis. We describe the surgical technique, focusing on the advantages of and indications for the laparoscopic hand-sewn anastomosis.

Objective: This case illustrates the diagnostic problems encountered in a patient with posttraumatic retroperitoneal abscess caused by perforation of the posterior wall of the cecum, simulating a retroperitoneal hematoma. Because standard diagnostic techniques failed to make early diagnosis, delayed laparotomy and right colectomy with primary repair were performed. The mechanism of the lesion is uncertain but could be a compressive force and direct injury to the cecum by the seat belt. Conclusion: Blunt colonic injuries are rare and difficult to diagnose. Septic signs are unexpected in cases of posttraumatic retroperitoneal hematoma and should suggest the diagnosis of retroperitoneal colonic perforation.

Introduction Il est desormais bien etabli que l’accumulation de tissu adipeux visceral influence la survenue des complications metaboliques de l’obesite. Les capacites d’adipogenese du tissu adipeux (TA) sont liees au developpement de sa vascularisation. Tres peu de travaux ont compare les proprietes d’angiogenese des tissus adipeux sous-cutane (SAT) et visceral (VAT) chez l’homme. Notre objectif a ete de tester l’hypothese selon laquelle des differences dans les capacites d’angiogenese du SAT et du VAT pourraient influencer leur expansion, le degre d’hypertrophie adipocytaire et les desordres metaboliques associes. Materiels et methodes Des prelevements de SAT et de VAT ont ete obtenus chez 29 patients obeses, non diabetiques, au cours d’une chirurgie bariatrique. La densite vasculaire et l’infiltrat inflammatoire ont ete analyses par immunohistochimie, et l’expression des genes de l’angiogenese par PCR quantitative. Ces resultats ont ete correles au phenotype clinique et biologique des patients. Resultats Nous avons confirme que la taille des adipocytes etait plus importante dans le SAT que le VAT (2 481 ± 2 vs 2 117 ± 2, p = 0,01). La densite vasculaire (2,58 vs 3,12 vaisseaux/10 000 ± 2, p = 0,03), l’inflammation et l’expression des facteurs pro-angiogeniques etaient plus faibles dans le SAT. De plus, l’expression du recepteur 2 du VEGF, le principal facteur angiogenique implique dans l’angiogenese du tissu adipeux, etait correlee positivement a la taille adipocytaire (r = 0,48, p = 0,01 et r = 0,43, p = 0,02) dans les 2 tissus. Enfin, la densite vasculaire du SAT et du VAT etait correlee au poids, mais seule la densite vasculaire du VAT etait associee au tour de taille. Nous n’avons pas retrouve de relation entre les marqueurs d’angiogenese et les desordres metaboliques quelle que soit l’origine du TA. Conclusion Nos resultats suggerent que les capacites d’angiogenese du tissu adipeux pourraient influencer la repartition des graisses et le degre d’hypertrophie adipocytaire, mais ne semblent pas etre impliquees dans le developpement de l’insulino-resistance.

Introduction Un reflux gastro-œsophagien acide pathologique est present chez environ la moitie des patients ayant une obesite morbide en attente de chirurgie bariatrique, avec cependant une mauvaise concordance entre symptomes cliniques et reflux pH-metrique [1, 2]. Notre but est d’etudier la relation entre les symptomes de reflux et l’existence de reflux acides, non acides mesures par pH-impedancemetrie. Patients et Methodes Des patients ayant une obesite morbide (IMC > 40 kg/m2 ou > 35 kg/m2 associe a une comorbidite) en attente de chirurgie bariatrique ont beneficie, de maniere prospective, d’un interrogatoire standardise a la recherche de signes digestifs et extra-digestifs du RGO, d’une endoscopie digestive haute. Les enregistrements ambulatories couples du pH et de l’impedance oesophagiens sur 24 heures (Sandhill, CO, USA) permettaient de detecter puis caracteriser les reflux acides (pH Resultats (Moyenne ± SD et mediane, IQR) : dix-sept patients (15 femmes et 2 hommes) ont ete inclus. L’âge moyen etait de 41,8 ± 10,1 ans, l’IMC moyen de 44,5 ± 5,3 kg/m2. Un pyrosis, des regurgitations et une toux etaient retrouves respectivement chez 23,5 % (4/17), 17,6 % (3/17) et 29,4 % (5/17) des patients. L’endoscopie retrouvait une hernie hiatale chez 47,1 % (8/17), une œsophagite dans 1 cas. Un reflux clinique defini par un pyrosis et ou des regurgitations etait retrouve chez 29,4 % (5/17) La pH-metrie des 24 h etait pathologique (% de temps passe a pH a 4,2 %) chez 7/17 patients (41 %). La sensibilite et la specificite des symptomes de reflux pour diagnostiquer un reflux pH-metrique etaient respectivement de 42,9 % (3/7) et 60 % (3/5). L’impedancemetrie retrouvait un nombre median d’episodes de reflux de 55 (36-67) dont 72 % (45-78) etaient acides, 28 % (22-55) non acides, avec 60 % (43-67) de reflux proximaux. Le temps d’exposition au reflux etait de 1,1 % (0,7-1,95), dont 0,8 % (0,45-1,55) de reflux acide et 0,3 (0,15-0,5) de reflux non acide. Pendant l’enregistrement 41 pyrosis ou regurgitation ont ete signales correspondant a un reflux acide et non acide pour 8/41 (19,5 %) et 3/41 (7,3 %). Le groupe avec reflux clinique avait une augmentation du temps moyen de clairance du bolus par rapport au groupe sans reflux clinique (13,6 s ± 3,4 s vs 9,5 s ± 3,0 s, p = 0,025). Les autres parametres de l’impedancemetrie n’etaient pas statistiquement differents dans les 2 groupes. Conclusion Dans cette population de patients avec obesite morbide on confirme la mauvaise sensibilite et specificite des symptomes pour le depistage du reflux. Dans ce travail preliminaire, la pH-impedancemetrie semble utile pour etudier ces discordances et suggere un role possible de la clairance œsophagienne du bolus.

Hypothesis The prevalence and mechanisms of intestinal obstruction following laparoscopic abdominal surgery have not been studied extensively. Design Retrospective review of cases of intestinal obstruction after laparoscopic surgery. Setting Sixteen surgical units performing laparoscopy in France. Patients Twenty-four patients with intestinal obstruction. Main Outcome Measures Prevalence values and descriptive data. Results The 3 most frequent primary procedures responsible for intestinal obstruction were cholecystectomy (10 cases), transperitoneal hernia repair (5 cases), and appendectomy (4 cases). Prevalences of early postoperative intestinal obstruction after these procedures were 0.11%, 2.5%, and 0.16%, respectively. Intestinal obstruction was due to adhesions or fibrotic bands in 12 cases and to intestinal incarceration in 11 cases. Obstruction was located at the trocar site in 13 cases (9 incarcerations and 4 adhesions), mainly at the umbilicus, and in the operative field in 10 cases (2 incarcerations in a wall defect after transperitoneal inguinal hernia repair, 4 adhesions, and 4 fibrotic bands). The small intestine was involved in 23 of 24 cases; the other was due to cecal volvulus following unrecognized intestinal malrotation. Intestinal obstruction was treated by laparoscopic adhesiolysis in 6 patients and by laparotomy in 18 patients, 6 of whom required small intestine resection. Three postoperative complications but no deaths occurred. Conclusion Intestinal obstruction following laparoscopic abdominal surgery can occur irrespective of the type of operation; the prevalence is as high as (cholecystectomy and appendectomy) or even higher than (transperitoneal hernia repair) that seen in open procedures.

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.

• Sclerosing cholangitis has been reported after surgical treatment of hydatid disease of the liver and has been hypothetically attributed to the caustic effect of the parasiticide solution injected into the cyst and diffusing into the biliary tree through a cystic-biliary fistula. In this experimental study, we showed that, in rats, injection into the biliary tract of 20% hypertonic saline solution or 2% formaldehyde solution, the most commonly used scolicidal solutions, was followed by lesions of the biliary epithelium. As compared with 20% hypertonic saline solution, the 2% formaldehyde solution caused more severe lesions of the biliary epithelium and, in addition, induced the development of sclerosis. This experimental study confirms the deleterious effect of scolicidal solutions to the biliary epithelium, shows that their effect is mainly related to the causticity of the scolicidal solution, and indicates that intracystic injection of 2% formaldehyde solution should be abandoned. (Arch Surg. 1990;125:1059-1061)

The aim of this study was to evaluate the independent influence of clinical and pathological variables on survival of patients with gastric carcinoma using the Cox regression proportional hazard model. Of 156 patients operated on for gastric carcinoma, 46 (29.5%) underwent palliative operation, 24 (15.5%) had a palliative resection, and 86 (55%) had a curative resection. The overall 5-year survival rate was 25 +/- 4%. After curative resection, the 5-year survival rate was 44 +/- 6%. Univariate analysis applied to these patients showed that poor survival was related (p less than 0.01) to: age (over 80 years), absence of epigastric pain, vomiting and dysphagia, total gastrectomy, tumor size (more than 4 cm), lymph node involvement (LNI), invasion through the muscularis propria, absence of intestinal metaplasia near the tumor, and linitis plastica. In multivariate analysis, lymph node involvement was found to be the only independent prognostic factor. The 5-year survival rate was 75.5 +/- 8% without LNI, 28 +/- 10% with proximal LNI, and 7 +/- 6% with distal LNI. Our results suggest that classification into 3 LNI groups is the best staging system for curative resection in gastric carcinoma.

From 1964 to 1985, a total of 114 patients (94 men and 20 women) were operated on. The resectability rate was 71%, and 53% of the patients were thought potentially curable. Either abdominal or combined abdominal and thoracic approaches were preferred. Proximal esophagogastrectomy (54 cases) was performed in cases with wide esophageal extension and total gastrectomy (27 cases) was performed for tumors localized in the gastric cardia. There was intraoperative examination of the esophageal margin. There was lymph node involvement in 57% of cases and esophageal extension in 59%. Three patients died in the postoperative course, none after curative resection. There was 1 (1.2%) clinical anastomotic leak. The overall 5-year survival rate was 18.5%. The actuarial 5-year survival rate was 29±8% after resection and 40±7% after curative resection, and the 10-year survival rate was 20±7 and 28±7, respectively. Symptom duration, age, or sex had no significant influence on prognosis. Lymph node involvement, tumor depth penetration, and esophageal extension were the main prognostic factors.

Early diagnosis of acute mesenteric ischemia (AMI) remains a clinical challenge, and no biomarker has been consistently validated. We aimed to assess the accuracy of three promising circulating biomarkers for diagnosing AMI—citrulline, intestinal fatty acid-binding protein (I-FABP), and d-lactate. A cross-sectional diagnostic study enrolled AMI patients admitted to the intestinal stroke center and controls with acute abdominal pain of another origin. We included 129 patients—50 AMI and 79 controls. Plasma citrulline concentrations were significantly lower in AMI patients compared to the controls [15.3 μmol/L (12.0–26.0) vs. 23.3 μmol/L (18.3–29.8), p = 0.001]. However, the area under the receiver operating curves (AUROC) for the diagnosis of AMI by Citrulline was low: 0.68 (95% confidence interval = 0.58–0.78). No statistical difference was found in plasma I-FABP and plasma d-lactate concentrations between the AMI and control groups, with an AUROC of 0.44, and 0.40, respectively. In this large cross-sectional study, citrulline, I-FABP, and d-lactate failed to differentiate patients with AMI from patients with acute abdominal pain of another origin. Further research should focus on the discovery of new biomarkers.