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The current reference treatment for upper urinary tract transitional cell carcinoma is open nephroureterectomy via a lumbar incision and an iliac incision with resection of a large bladder cuff: Since the first laparoscopic nephroureterectomy performed in 1991, several teams have studied this approach for the treatment of urinary tract tumours. Laparoscopy has the advantage of decreased morbidity for the patient and allows early return to work. Recent published series do not demonstrate any difference in terms of cancer control between open and laparoscopic nephroureterectomy. However, the follow-up of laparoscopic nephroureterectomy is still limited and the safety of this technique has not been fully demonstrated. It therefore appears preferable to limit the indications for laparoscopic nephroureterectomy to small and/or low-grade tumours to avoid excessive manipulation of large transitional cell carcinomas in a gaseous atmosphere that can predispose to dissemination during dissection. Diagnostic ureteroscopy has therefore become a useful tool in the preoperative assessment. Biopsies can determine the tumour grade and guide the surgeon's choice of surgical approach.

Aims of the Study: To evaluate and compare management practices in France for bleeding peptic ulcers using a national inquiry of university and non-university hospitals., Method: Responses to questionnaires sent to 812 gastroenterologists, 496 practicing in non-university hospitals and 316 in university hospitals, were compared., Results: An analysis was possible in 279 (34% response rate) of the questionnaires. Forrest classification was used more frequently in university hospitals (83% vs 60%, P<0.01). Endoscopic hemostatic therapy was used more frequently in university hospitals for Forrest Ib (92% vs 81%, P=0.02), IIa (93% vs 73%, P<0.001), and IIb (58% vs 29%, P<0.001) ulcers. Injection therapy, mainly epinephrine, was the first-intention treatment for 99% of the responding gastroenterologists. Proportions of clinicians employing hemoclips (27%) or argon plasma coagulation (21%) were similar in both types of practice. Anti-secretory treatment included mainly omeprazole (82%), given intravenously (76%), sometimes as bolus i.v. doses followed by i.v. high-dose continuous infusion (15%) with some variations according to the type of hospital. In the event of recurrent or persistent bleeding, surgery was more frequent in non-university hospitals. When rebleeding occurred, a second endoscopic treatment was performed in about one quarter of patients., Conclusion: In France, management practices for bleeding peptic ulcer vary between university and non-university hospitals.

Aims of the Study: To evaluate the diagnosis, treatment and outcome of patients with pancreatic metastases., Patients and Methods: We retrospectively reviewed the records of patients with pancreatic metastasis managed in the Paris area between 1990 and 2000., Results: The series analyzed included 22 patients, 10 men and 12 women, mean age 61 years (range: 35-76). The primary tumors were renal-cell carcinoma (N=10), colorectal cancer (N=4), lung cancer (N=4), breast cancer (N=2), cutaneous melanoma (N=1) and ileal carcinoid (N=1). The mean interval between primary treatment and presentation was 73.5 months (range: 2-151). Diagnosis was established because of clinical symptoms (N=15) or during surveillance (N=7). Computed tomography (N=19) and endoscopic ultrasound (EUS) (N=18) mainly showed solitary and hypodense/or hypoechoic masses. Histological diagnosis was obtained before surgery by EUS-guided fine needle aspiration (N=6), ultrasound-guided biopsy (N=3) or duodenoscopy (N=3). Among 10 patients with primary renal-cell carcinoma, 7 were treated by surgery. Median global survival was 33 months. Median survival was 61 months in the event of surgical treatment and 20 months in the other patients (ns). Mean survival depended on the type of primary tumor, 61 months for renal-cell carcinoma and 33 for colorectal cancer (P=0.06)., Conclusions: Most pancreatic metastases develop from renal-cell carcinoma and can occur several years after nephrectomy. Histological diagnosis is often obtained before surgery. Surgical resection must be discussed as it can allow long-term survival.

INJECTIONS OF ADRENALINE: More than one third of upper gastrointestinal haemorrhages are still of ulcerous origin. In the case of active bleeding ulcers or ulcers with non-haemorrhagic visible vessels, endoscopy should be performed to stop bleeding. Injections of adrenaline, which combine efficacy, simplicity and absence of morbidity represent the treatment of choice for many. THE USE OF THERMAL METHODS: Spurting haemorrhages are probably the only haemorrhages that would benefit from injections of adrenaline combined with another haemostatic method, notably thermal. THE NEED FOR ASSOCIATED MEDICAL TREATMENT: Whatever the haemostatic method used, a powerful anti-secretory treatment administered intravenously must be associated since it will enhance the effects of endoscopic treatment.

A POTENTIALLY SEVERE EVENT: Upper gastrointestinal haemorrhage in a cirrhotic patient is always extremely serious, particularly in the case of rupture of the oesophageal varices, which is the most frequent cause. THE TWO POLES OF TREATMENT: Early vasoactive treatment permits elastic ligature in optimal conditions using an endoscope. The prevention of other complications of cirrhosis is an essential element in the management of these patients.

FOR DIAGNOSIS AND FOR TREATMENT: Endoscopy for upper gastrointestinal haemorrhage has a double objective. It is difficult and to be optimal, it must be conducted at the right time and in the best technical conditions as possible. Depending on the etiology, identification of the cause of bleeding precedes the choice of the haemostatic method to be used, preferentially injections of adrenaline in the case of bleeding ulcers and elastic ligature in the case of ruptured oesophageal varicose veins. In general the aim of endoscopic treatment is to stop the haemorrhage and to reduce as far as possible the risk of recurrent haemorrhage, which represents a factor of high deathrate.

IN MALLORY-WEISS SYNDROME: With fissuring of the cardial area, probably subsequent to a rapid increase in intra-gastric pressure, hemorrhagic Mallory-Weiss syndrome may justify haemostatic endoscopic treatment. However, one should not forget that the majority of these syndromes usually regress spontaneously. IN DIEULAFOY'S ULCERS: Loss of substance destroying the muscle mucosa, Dieulafoy's ulcer would be at the origin of around 2% of upper gastrointestinal haemorrhages. Initial haemostasis can be obtained using endoscopic treatment in 85% of cases. The mechanical methods (clips, elastic ligature) are probably more effective than injections, but they are still under assessment.

Recent data have confirmed that non-steroidal anti-inflammatory drugs can cause serious damage to the gastrointestinal tract involving localizations other than the well-known gastroduodenal complications. Perforation and hemorrhage of the small bowel have been reported as well as ulcerations, stenoses and diaphragm disease. The same type of lesions can occur in the large bowel in addition to ischemia and collagen colitis. Diverticular diseases of the colon can be complicated by use of non-steroidal anti-inflammatory drugs which may also trigger flare-ups of inflammatory diseases. Use in suppository form can complicate rectitis and rectal stenosis. Non-steroidal anti-inflammatory drugs apparently increase intestinal permeability by inhibiting the cyto-protective effect of prostaglandins. The exact frequency of such complications remains to be determined, but prolonged treatment in elderly subjects appears to increase risk. Current data have not shown greater or lesser toxicity for any specific drug. Non-steroidal anti-inflammatory drugs should be entertained as the cause of intestinal disorders in patients under long-term treatment.

Pseudocysts of the pancreas are collections of liquid more or less completely composed of pancreatic secretions. Patients with acute pancreatitis without underlying chronic pancreatitis may develop necrotic pseudocysts while those with chronic pancreatitis may develop either necrotic or retention pseudocysts. The prevalence and localization are largely dictated by the cause of the pancreatitis. Ultrasonography and computed tomography give the diagnosis and reveal the size, localization and relations of the pseudocyst. Some pseudocysts may regress spontaneously, usually within a few weeks, especially necrotic pseudocysts measuring less than 6 cm. In others, complications include acute infection, intracystic bleeding, rupture, fistulization and compression of neighboring organs. Surgery was classically proposed for all pseudocysts, but puncture-evacuation and percutaneous or endoscopic drainage have also been successful. The risk of recurrence is higher with puncture-evacuation. Today, complicated forms and unsuccessful medical treatment are good indications for surgery. Cystodigestive drainage is preferred although exeresis may be required in specific cases.

We report two cases of metastatic non-functioning pancreatic endocrine tumour with very elevated plasma levels of alpha-fetoprotein. In these two cases, serial plasma levels of alpha-fetoprotein, initially normal, correlated well with hepatic tumour progression and were associated with fatal outcome. These results suggest that elevated plasma concentration of alpha-fetoprotein may be caused by metastatic pancreatic endocrine tumour and than alpha-fetoprotein serial measurement may be useful in prognostic evaluation.

The oesophagus is a rare localization of extrapulmonary tuberculosis. We report 2 cases of tuberculous mediastinal lymph nodes revealed by dysphagia and fever in immunocompetent subjects. With the actual outbreak of tuberculosis, this localization is worth mentioning, as the precocity of the diagnosis and the therapeutic handling is an important prognostic factor.

Objectives: The aim of the present study was to assess the relative contribution of duodenal and biliopancreatic bicarbonate secretion to acid neutralization in the duodenum, in basal conditions, during stimulation by PGE2 and during acid infusion in the duodenum., Methods: Forty rats were anaesthetized and the duodenum was infused with 0.9% saline. Bicarbonate originating from duodenal mucosa and from biliopancreatic secretion was independently collected and measured. In neutralization studies, HCl was infused in the duodenum, and the amount of residual acid escaping from the duodenum was determined with and without bile and/or pancreatic juice diversion., Results: Basal duodenal and biliopancreatic bicarbonate outputs were respectively 10.0 +/- 0.66 and 2.4 +/- 0.31 mumol/10 min. PGE2 increased duodenal mucosal bicarbonate by about 100%. Eighty-five percent of infused HCl was neutralized by duodenal mucosal bicarbonate. In neutralizing the remaining 15%, pancreatic secretion was slightly predominant, 46% for a HCl concentration of 5 mM and 71% for a HCl concentration of 40 mM., Conclusions: These results shows that in the anaesthetized rat, available bicarbonate in the duodenal lumen and HCl neutralization ability are mainly dependent upon bicarbonate secreted by the duodenal mucosa.

In the course of alcoholic chronic pancreatitis, increased serum alkaline phosphatase level is usually caused by common bile duct stenosis but may also be due to alcoholic liver disease. The aims of this prospective study were to investigate whether clinical, biochemical and radiological factors could predict liver histopathological appearance. The study comprised 48 patients with chronic alcoholic pancreatitis, common bile duct stenosis and increased serum alkaline phosphatase levels; clinical, biochemical, radiological and histological data were recorded in all cases. Liver biopsy examination (surgical [n = 45] or intercostal [n = 3]) showed (a) biliary obstructive liver abnormalities (n = 33), which were severe in 20 cases (biliary fibrosis in 15, secondary biliary cirrhosis in 3, secondary sclerosing cholangitis in 2) and moderate in 13 cases; (b) alcoholic liver disease in 9; and (c) normal liver in 6. Clinical, biochemical and radiological data were not statistically different between patients with biliary obstructive liver disease and those with alcoholic liver disease. Forty-five patients underwent surgery; two patients with alcoholic hepatitis died after surgery, at the beginning of this study. We conclude that in chronic alcoholic pancreatitis with common bile duct stenosis and increased serum alkaline phosphatase levels, clinical, biochemical and radiological data cannot be used to predict the type of liver lesions. Therefore liver biopsy is warranted to identify (a) alcoholic hepatitis, which increases operative risk; and (b) biliary obstructive liver disease, frequent and often severe, in which surgical biliary decompression should be considered.

The aim of this study was to assess the prevalence, presentation, cause, and location of symptomatic duodenal stenosis, and its relation to the natural course of chronic pancreatitis in a medical-surgical series of 306 patients (86% alcoholics). Mean follow-up of the series was 7.9 years. Symptomatic duodenal stenosis occurred in 17 patients (5.6%). Diagnosis was confirmed by a barium series. The cause of stenosis was compression by the pancreatic head in all patients, associated with a pancreatic abscess in two. No pseudocysts were found at the time of diagnosis. The location was the 1st and 2nd part of the duodenum or the entire duodenal loop in 4, 6, and 7 patients, respectively. Cholestasis due to common bile duct stenosis occurred in association with duodenal stenosis in 9 patients. Fifteen patients were treated surgically; 11 for gastroenterostomy, and 4 for duodenopancreatectomy. Two patients were not treated surgically. We conclude that during the course of chronic pancreatitis, symptomatic duodenal stenosis occurred in 5.6% of patients, mainly during the first years of the clinical course of chronic pancreatitis, was due to pancreatic head compression and not pseudocysts, usually involved the 2nd part of the duodenum and, was associated with biliary stenosis in half of the cases. Since these two complications require surgery, common bile duct stenosis should be investigated when symptomatic duodenal stenosis is diagnosed.

The authors have studied the natural history of duodenal ulcer from published data, in an attempt to determine precisely the evolutive potential of this disease both spontaneously and during its treatment. They deal successively with the risk of complication and the short- or long-term influence of medical and surgical treatment on the occurrence of exacerbations and complications. The role played by Helicobacter pylori in healing of the ulcer and in the long-term course of the ulcerous disease, as well as the problems concerning its duration and mortality, are discussed. The data clearly show that the medical and surgical treatment of duodenal ulcer can slow down, at least temporarily, the course of the disease. Other studies are needed before drawing firm conclusions concerning the relationship between H. pylori and duodenal ulcer, even though numerous studies seem to have demonstrated that eradication of this micro-organism is associated with a substantial decrease in the risk of recurrent ulcer.

Liver metastases are frequent, often large and sometimes very late in skin or choroid metastatic melanoma. Hepatic failure is a rarely described complication in metastatic liver melanoma. We report a case of liver failure in a metastatic liver melanoma in a woman 76 years old, treated 16 years before for a choroid melanoma. About this case, we discuss the frequency, the location of primitive tumors and mechanism of liver failure in metastatic liver.

In order to assess the responsibility of medicinal drugs for the disorders in electrolytes observed in elderly people, the prevalence of abnormal natraemia and kalaemia was prospectively established in 631 subjects aged 70 or more on the first day of hospitalization. Among 337 subjects not taking drugs likely to create problems (diuretics, angiotensin-converting enzyme inhibitors, anti-inflammatory agents) 3.6 percent had hyponatraemia (below 130 mmol/l) and 12.2 percent had hypokalaemia (below 3.5 mmol/l). Subjects with normal renal function who were taking angiotensin-converting enzyme inhibitors or non-steroidal anti-inflammatory agents showed no more electrolytic abnormalities than those who did not take them. Conversely, subjects on thiazides were more frequently hyponatraemic (11.8 percent) or hypokalaemic (16.2 percent; 20 percent in the absence of associated distal diuretics). These abnormalities were more frequent in women than in men (21.7 and 13 percent). This, together with the fact that 68 percent of subjects taking thiazides were women accounts for the marked female predominance of electrolytic abnormalities reported in the literature.

Asymptomatic bacterascites is defined as the presence of bacteria in ascitic fluid without clinical features of peritonitis or increased ascitic fluid polymorphonuclear cells. Asymptomatic bacterascites is a controversial entity, and little information is available regarding its spontaneous evolution. Clinical features, bacteriological data and outcome in 22 cirrhotic patients with asymptomatic bacterascites are reported and are compared with those of a group of 36 cirrhotic patients with spontaneous bacterial peritonitis. Eleven patients had gram-negative bacteria and 11 had one gram-positive bacteria. Only in three patients (13.6%) did peritonitis develop. Twelve patients received no antibiotic therapy, and in none did peritonitis develop. At 1 month, 27% of patients with asymptomatic bacterascites had died. Patients with asymptomatic bacterascites had less-severe liver disease; they more frequently had gram-positive bacteria in ascitic fluid and had a lower 1-mo mortality rate than did patients with spontaneous bacterial peritonitis. We conclude that asymptomatic bacterascites is usually the transient residence of bacteria in ascitic fluid. Peritonitis rarely develops in patients with asymptomatic bacterascites and, in most of them, antibiotic therapy is not required.

We report about one case of cholecystoduodenal fistula complicated by antropyloric lithiasic obstruction, which was treated surgically with gastrotomy and extraction of the calculus, in an 82-year-old woman. This case represents an anatomic variant of Bouveret's syndrome, which is classically defined as a duodenal lithiasic obstruction. On the basis of this case, the authors discuss the diagnostic and possibly therapeutic merits of digestive endoscopy and define the main clinical, anatomical and evolutive characteristics of this unfrequent complication of biliary lithiasis.