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To our knowledge, the association of a pancreatico-pleural fistula and an esophageal carcinoma has never been previously reported. We report the case of a 48 year old man, who presented with a squamous-cell carcinoma of the esophagus associated with a right pancreatico-pleural fistula. This association raises the problem of the surgical strategy. In our case, we chose to treat the two lesions during the same operation. We performed left pancreatectomy with splenectomy and an Ivor-Lewis procedure, with an uneventful post-operative course.

The aim of this study is to present current management of duodenal trauma. Duodenal lesions following penetrating injuries are rare, but more serious, than those following blunt injuries. the severity is mostly due to delay in the diagnosis and associated intraabdominal injuries. Diagnosis is based on abdominal plain film, gastroduodenography, and more recently US scan and CT-scan. Surgical procedures depend on the type of lesion. In patients operated early, a duodenal wound can be treated by suture-closure with duodenal decompression tube. If suture-closure is not available, with a wound affecting proximal or distal duodenum, resection with anastomosis can be performed. In the second portion of the duodenum, the best treatment is a jejunal plasty with a Roux-en-Y loop. When there is an associated pancreatic injury, treatment depends on whether biliary or pancreatic ducts are injured, and a pancreatico-duodenectomy could be necessary. In patients operated on later, closure with duodenal exclusion by diverticulization is associated due to the high risk of leaking.

The purpose of this study was to compare heterotopic jejunal and ileal allografts in the dog under cyclosporine A. Fourteen allografts (8 ileal and 6 jejunal) were successfully performed. There was no case of graft-versus-host disease in this series. Six allografts (42.5 percent), 3 jejunal (50 percent) and 3 ileal (37.5 percent), were rejected during the first 3 months (NS). Eight allografts, 5 ileal and 3 jejunal, were tolerated up to 3 months and then removed; 2 ileal and 2 jejunal were normal; 2 ileal and 1 jejunal showed signs of chronic rejection, and 1 ileal signs of advanced rejection. It is concluded that there is no major difference between jejunal and ileal allografts in the dog.

Segmental small-bowel grafts have been advocated as a means of reducing the incidence of rejection and graft-versus-host disease in small-bowel transplant recipients. This study compared the results achieved with heterotopic segmental allografts of the jejunum and the ileum that used 120 cm Thiry-Vella loops in a dog model. Immunosuppressive therapy consisted of 25 mg cyclosporine/kg/day. Results were monitored by histologic examinations, function tests (maltose and xylose absorption), and brush-border enzyme assays. Thirty-three dogs were randomized for use as a donor (n = 11) or recipient of a jejunal allograft (n = 11) or an ileal allograft (n = 11). Eight allografts were technical failures and were excluded from analysis. Fourteen allografts were successful (eight ileal, six jejunal). No case of graft-versus-host disease was observed. Six allografts (42.5%, three jejunal [50%] and three ileal [37.5%]) were rejected during the first 3 months (not statistically significant). Eight allografts (five ileal, three jejunal) were tolerated for up to 3 months and were removed. Two ileal and two jejunal allografts appeared grossly normal at surgical removal, but two ileal and one jejunal allografts exhibited signs of chronic rejection, and one ileal allograft showed advanced rejection. The jejunal and ileal allografts had similar clinical courses, as were revealed by immunologic reactions and functional parameters. We conclude that there is no major difference between jejunal allografts and ileal allografts in the dog.

The immediate infectious pancreato-biliary complications of endoscopic retrograde cholangiopancreatography (ERCP) warranting transfer to a surgical unit are analyzed, in order to evaluate their frequency and severity as well as means of treatment and prevention. Thirty complications of this type were observed in a series of 3226 ERCP performed with or without endoscopic sphincterotomy (ES) over a six year period (0.9%). ES had been performed in 12 of 30 cases, but the complication could not be attributed to the procedure. Post-ERCP complications included: acute cholangitis: 16 cases (53%); acute cholecystitis: 8 cases (26%); acute pancreatitis: 4 cases (13%); infected pancreatic pseudocyst: 2 cases (6%). The global mortality rate was 16.6% (five patients): Four of the deaths were due to septic complications. Twenty-seven of the 30 patients underwent surgery, and three of them died (11%). Acute cholangitis was responsible for most of the deaths (four of five) and the mortality appeared related to the long interval before surgery (three of four deaths). Strict adherence to good endoscopic procedures (aseptic conditions, injection without excessive pressure, antibiotic prophylaxis) and decompression of the biliary tract (nasobiliary drain or transhepatic catheter) should help reduce the frequency of post-ERCP complications, and especially cholangitis, which appears to benefit from early surgical treatment.

Between May and December 1991, 12 patients with spontaneous pneumothorax were treated surgically, using video-thoracoscopy. With this technique bullous lesions could be excised in 10 cases and pleurodesis could be performed in all patients. Morbidity and mortality were nil. The cosmetic and functional advantages of video-thoracoscopy were obvious. Long-term results remain to be evaluated. This technique has shown that it is possible in all cases to create pleurodesis (pleural poudrage or pleurectomy) and to treat parenchymatous lesions (excision of bullous systems). This suggests that the long-term results will be the same as those obtained with conventional surgery.

From November 1990 to April 1992, 32 patients were operated on by video thoracoscopic surgery (VTS). Included were 22 males and 10 females, mean age 47.6 years. VTS has been used therapeutically on 25 occasions: 20 spontaneous pneumothoraxes; two recurrent pleuritis; two cysts; one mediastinal; one pulmonary; and one thoracic sympathectomy. VTS was also used diagnostically seven times: five lung biopsies and two mediastinal lymph node biopsies. It was necessary to perform a mini-thoracotomy in one patient and proceed to immediate thoracotomy in three patients. There were no deaths in this series, the morbidity was two patients with collapsed lungs, one of which required drainage. VTS must be performed under standard thoracic surgical conditions: selective intubation, and fully equipped to make an immediate thoracotomy. The advantages of VTS are aesthetic and functional, the post-operative pain is reduced in intensity and duration. At present, VTS is indicated for the treatment of spontaneous pneumothorax, the assessment and biopsy of mediastinal lymph node and the excision of some lung lesions. Improvements in the apparatus should lead to a broadening of these indications in the future.

We report what is probably the first case of para-oesophageal bronchogenic cyst treated by video-thoracoscopy. The patient was a 26-years old woman who presented with dysphagia to solid foods. Preoperative investigations showed that the lesion was a cyst and that it was located in the superior and posterior mediastinum; they also enabled us to determine its relations with nearby structures, notably the oesophagus, and to make the diagnosis of para-oesophageal bronchogenic cyst. Treatment consisted of excision of the cyst by video-thoracoscopy. The postoperative period was uneventful, and the patient was discharged on the fourth day.

With development of ultra sound, solitary hepatic cyst (SHC) appears as a common and benign affection. Complications can occur in 10 per cent of cases. We report here four cases of complicated SHC: vena caval obstruction, intracystic bleeding, rupture, intracystic infection. Those four patients were successfully treated by partial excision of the cyst in the first 3 cases, and by percutaneous drainage with CT scan guidance in the latter. Complications of SHC occur only in large cysts, with a diameter up to 8 cm. So, small SHC do not require any treatment, while large SHC must be treated to avoid complications. Percutaneous aspiration and direct injection of alcohol can lead to recurrence. Surgical therapy by partial excision is successful, with low rates of mortality and morbidity.

The aim of this study was to evaluate the short-term results of surgical treatment of pharyngoesophageal diverticulum (POD). From 1970 to 1988, 41 patients underwent diverticulectomy for POD and in 10 cases, myotomy was associated. Patients were divided into two groups: group I (10 cases) in which patients required nutritional and/or respiratory preparation before surgery; group II (31 cases) in which patients underwent surgery without delay. In group I, the mean age was 79.8 years and the delay before diagnosis and treatment was 80.6 months versus 66 years and 34.6 months in group II. In group I, all patients presented with weight loss and suffered from pulmonary infections. Mortality in this series was 3 patients (7.3%) and 4 complications occurred. In group I, mortality was 2 patients (20%) and 3 complications occurred (30%), while in group II, mortality was one patient (3.2%) and one complication occurred (p less than 0.05). Long-term results showed 90% of good results. Local complications might be avoided by perfect surgical procedure. The mortality can be explained by the patients' previous status and the long history of disease.

A new case is described of a recurrent pleural effusion during the course of chronic pancreatitis. The diagnosis of the effusion was not established and a pleural talcage was performed. The pleurisy did not recur but a peritoneal effusion subsequently appeared. The potential responsibility of the pleural talcage was discussed.

The aim of this study was to determine immediate and long term prognostic factors after resection of stage III lung cancer. From 1981 to 1987, 188 consecutive patients (136 stage III A and 52 stage III B) underwent resection of a primary lung cancer. Mortality (5.8 per cent) and morbidity were not influenced by age of the patient, the type of procedure (lobectomy or pneumonectomy) or the stage A or B of the cancer. But mortality was significantly increased by alteration of four ventilatory parameters. Actuarial survival was significantly better for stage III A (56%, 34 or 7 at 1, 2 and 5 years) than for stage III B (35, 18, 0 respectively). Survival was also influenced by: the quality of the resection: 15 months median survival if curative, 5 months if palliative; the tumour volume: 65%, 47, 18 at 1, 2 and 5 years if the diameter of the tumour was less than 5 cm, and 49, 31, 0 respectively if the diameter was greater than 5 cm. The authors conclude that identification of these factors is determinant to discuss prognosis and to plan treatment.

Two cases of bronchogenic cysts involving esophagus are reported. The first case concerns a 30 year-old man, who admitted for dysphagia, regurgitation and abdominal pain. Barium esophagography, esophagoscopy and CT scan showed a cystic mass involving the lower third of the esophageal wall. Treatment consisted in the resection of the cyst by left thoracic approach. The second case concerns a 26 year-old woman, admitted for dysphagia. MRI and endoscopic ultrasonography had contributed to define the exact nature, internal composition and location of the cyst: upper and posterior mediastinum, close to the esophagus but respecting all the esophageal layers. Treatment consisted in the resection by video-thoracoscopy. Histologically, these two cysts were typical bronchogenic cysts. These two cases allowed us to discuss the benefits of new imaging methods (CT scan, MRI, endoscopic US) in the diagnosis of cystic masses of the mediastinum, and to emphasize video-surgery in their treatment.

The retrospective analysis of 331 files relating to primary bronchial cancer shows that 30% of the patients are 70 years old or over. This patient group is compared to younger subjects who were operated during the same period. For this surgical series, the disease studied is the same whichever the age (detection conditions, excision types, TNM classification). Mortality for excision is comparable (5.1% vs 8.2%), but the type of mortal complications differs according to the age. Our analysis allows isolating two factors of risk (cardiovascular defects and obstructive chronic respiratory failure). Provided that a pre-operation rigorous selection of the patients over 70 years has been made, pneumonectomy does not seem more serious than lobectomy (mortality 3.7% vs 10.3%). For identical stages, remote survival after excision can be compared to that of operated patients under 70 years old. Excision beyond 70 years old seems justified provided that: a selection of patients, from which subjects having major defects (cardiovascular and respiratory) should be excluded, is carried out by appreciating physiological age and not actual age, a pre-operation respiratory preparation is performed, a careful operating technique which allows avoiding surgical complications is used, a peri-operating assistance is provided.

From January 1979 to December 1988, 18 patients with pulmonary metastases from colorectal cancers were operated in our division. This series included 11 men and 7 women (average age 57 years). The primary cancer was colic in 6 cases and rectal in 12. In 3 cases, the metastases were synchronous and discovered during the initial assessment. In 15 cases, they were metachronous, without symptoms in 12 cases and symptomatic in 3. These metastases were single in 14 cases, multiple in 3, bilateral in 1. They were peripheral in 15 cases. The histological diagnosis was obtained preoperatively in 5 cases (27.7%). The procedures uses were lobectomy for 11 patients, segmentectomy for 1, wedge resection for 10. Postoperative chemotherapy was given to 7 patients. Benign complications occurred in 2 cases during the postoperative period. No perioperative death was noted. One patient was lost to follow-up without recurrence after 1 year, 6 patients died from neoplastic evolution 4, 8, 15, 17, 22 and 28 months after being operated. In May 1989, 11 patients were still living: -2 scheduled for the excision of a contralateral lesion, -2 with pulmonary recurrence. 7 patients were alive without recurrence 12, 14, 17, 46, 52, 68 and 108 months after being operated. The probability of occurrence of pulmonary metastases in the evolution of colorectal cancer is estimated between 20 and 50%. Only 1% of the patients can be treated surgically. When screening these lesions, one must bear in mind that their appearance is sometimes quite delayed, and often asymptomatic. The repeated use of tracers is necessary but not sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study is to evaluate the role of bronchoscopy in the assessment of resectability of esophageal carcinomas. From 1981 to 1986, 125 patients were referred for a carcinoma of the esophagus. Bronchoscopy was performed in 105 cases. Patients were classified into 3 groups: group I: normal bronchoscopy (58 cases: 55.2%); group II: compression, localized inflammation (35 cases: 33.3%); Group III: invasion (12 cases: 11.5%). Tracheo-bronchial abnormalities were found whatever the site of the esophageal carcinoma: 60% of cases for the upper third, 40% for the middle third and 36% for the lower third. They were significantly more frequent when the esophageal tumor was larger than 5 centimeters. Correlation with CT scan was good in 75% of cases. Sensitivity and specificity of these two exams were similar and they appeared to be complementary. In group I, resection was impossible or palliative for bronchial reasons in 10% of cases, while resection was impossible or palliative in 35% of cases in group II. Lastly, resection was curative in 73.5% of cases in group I and in only 39% of cases in group II. Bronchoscopy must be systematically performed in carcinoma of esophagus. It may predict the palliative nature of resection if abnormalities are present, and may contraindicate the resection when invasion of the bronchial tree is discovered.

The aim of this study was to determine the efficacy and long term results of straight colo-anal anastomosis (CAA) after resection for rectal carcinoma as described by Parks. From January 1986 to June 1989, 40 patients underwent this operation: 27 men and 13 women with a mean age of 63.5 years (range 37-81). In 36 cases, the indication was for carcinoma of mid and low rectum and in 4 cases for carcinoma of the upper rectum associated with a low rectal benign tumour (3 Dukes A, 19 Dukes B, 13 Dukes C, and 5 Dukes D). A diverting colostomy was constructed in all cases. Operative mortality was one patient (2.5 per cent) by pulmonary embolism. Anastomotic dehiscence occurred in four patients. None of these patients required reoperation and all colostomies have been closed. 6 patients presented a local recurrence (15.4 per cent) 6 to 34 months after CAA, of whom two were treated by abdomino-perineal resection. 5 patients died 6 to 34 months after CAA from local recurrence (2 cases) or distant metastasis (3 cases) and one patient has liver disease. All others patients are alive free of disease with a mean follow-up of 21.7 months (range 3-46 months). Actuarial survival is 77 per cent at 40 months. Functional results were assessed in the 26 patients followed up more than one year. The mean stool frequency was 2.4 per day (range 0, 3-6). All patients are continent, with a good discrimination gas-stool. 4 patients (15.4 per cent) suffer from soiling, 5 (19 per cent) from stool frequency, and 2 (7.7 per cent) from urgency. In conclusion, CAA is a good alternative of abdominoperineal resection for some mid and low rectal carcinomas. Functional results might be improved by the construction of a colonic reservoir.

A rare case of leiomyoblastoma developing in Meckel's diverticulum and revealed by massive rectorrhagia is reported. The characteristic clinicopathologic features of these tumors in their small intestine localization are described and the value of celiomesenteric arteriography emphasized for their topographic and even nosologic diagnosis.

A retrospective study of 302 patients hospitalized for gastric adenocarcinoma in the period between 1976 and 1987 revealed that 133 of the patients (44%) were over 75 years of age. In order to bring out the characteristics of stomach cancer in the elderly, these patients were compared with younger subjects, as a comparison with a population of under seventies emphasizes the existing differences. Clinical signs, the time necessary for reaching diagnosis, as well as the evolutive stage of the pathology at the time of diagnosis were the same. The incidence of the intestinal histological type, which has a better prognosis, was significantly higher after the age of 75. Operability was decreased due to contraindications related to the patients' general status. Resectability (86 patients, i.e., 77.2%) did not differ significantly. Complications imputable to surgery did not occur more frequently. Anastomotic fistulas were rare, although invariably fatal in the over-seventy-five group. Overall mortality for excision patients over 75 was 12.8%, and did not rise significantly (or exponentially) before the age of 79. Mortality was 14.3% in case of palliative excision versus 9.8% for curative excision. This parameter was nil for the 48 patients classified ASA 1 and 2, and 30% for the 38 patients classified ASA 3 and 4. In this latter group, it was 20% when the operation was curative versus 43% in palliative surgery situations. Post-surgery survival rates were similar to those obtained for the younger subjects. In conclusion, the course of stomach cancer is the same for both the elderly and younger subjects. This study permits to set up certain rules for excision surgery after the age of 75.

The authors reviewed the emergency treatment of 64 duodenal ulcers operated during the haemorrhagic period in order to evaluate the results of an approach adapted to the site of the ulcer and to the lesions observed. Twenty-four ulcers were situated in the post-bulbar region (37.5%) and need to be considered separately as their anatomical situation and the frequently callous and burrowing nature raise difficult problems in the diagnosis and surgical approach. Conservative treatment (vagotomy, pyloroplasty, direct suture) was possible in 75% of cases. Sixteen gastrectomies (25%) were necessary because of the severity of the duodenal disease with a significantly higher rate in the case of post-bulbar ulcers. The overall postoperative mortality was 25%; it was due to a surgical cause in one half of cases. The surgical morbidity was dominated by recurrent haemorrhages (11%) with 85% mortality. The authors believe that suture vagotomy, which is the basic treatment for bulbar ulcers, also constitutes treatment of choice in the post-bulbar variety when the duodenum appears to be suturable after haemostasis. In the opposite case, duodenal resection is necessary and should extend beyond the ulcer crater. In every case, identification of the common bile duct and the papilla constitutes an essential precaution.

The authors report a case of Congenital Diverticulum of the common bile duct treated by surgery. Literature reviews are giving detailed reports on this rare affection which falls within the scope of Congenital Diverticulum of the common bile duct, it has only a small share in this report. The comments relate the anatomic, pathogenic, diagnostic and evolutive data. The treatment appears to be possible in any case: surgical exeresis of the diverticulum.

There are two principal aetiologies for oesophago-tracheal fistulae: cancer of the oesophagus opening into the airways and assisted ventilation (tracheotomy or nasotracheal intubation). Oesophago-tracheal fistulae are rare. Over a period of 6 years, the authors have treated 9 neoplastic oesophago-tracheal fistulae in a series of 150 cases of oesophageal cancer and 2 inflammatory oesophago-tracheal fistulae out of a series of more than 20 stenoses of the same nature. The two types of oesophago-tracheal fistulae have the same degree of severity but very different significance, treatment and prognosis: neoplastic oesophago-tracheal fistulae, an advanced, often terminal form of oesophageal cancer, justify palliative treatment to exclude the respiratory tract. Endoscopic intubation of the oesophagus is generally appropriate treatment. Exceptionally, a surgical bypass of the oesophagus may be proposed. Inflammatory oesophago-tracheal fistulae require treatment to restore the continuity of the trachea and oesophagus in patients with respiratory autonomy. In agreement with H. Grillo, we consider treacheal resection-suture and repair of the oesophageal defect to constitute the most satisfactory procedure.