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Resume But La resection intra-gastrique laparoscopique (RIGL) de lesions benignes et malignes est une approche mini-invasive interessante notamment pour les lesions de la jonction oeso-gastrique ou antro-pyloriques. Le but etait d’en evaluer la faisabilite technique et les resultats a long terme. Methodes De 2000 a 2013, 25 RIGL etaient realisees pour lesions gastriques benignes ou malignes. Les indications chirurgicales, la technique operatoire, les complications postoperatoires, les resultats anatomopathologiques et le suivi a long terme etaient evalues retrospectivement. Resultats Dix-neuf lesions (76 %) etaient localisees sur la jonction oeso-gastrique, trois (12 %) sur la petite courbure gastrique, deux (8 %) sur la face posterieure de l’estomac et une (4 %) sur la region pre-pylorique. Une approche multi-trocarts a ete utilisee pour 15 patients (60 %) et mono-trocart pour 10 (40 %). La duree operatoire moyenne etait de 140 minutes (extremes 50–210). Aucune conversion en laparotomie n’etait necessaire. Une complication severe est survenue (4 %) mais la mortalite etait nulle. Aucun patient n’a presente de stenose ou de retrecissement. L’anatomopathologie montrait 11 adenocarcinomes (44 %), six tumeurs stromales gastro-intestinales (GIST) (24 %) et huit lesions benignes (32 %). La resection mono-bloc etait realisee chez 24 patients (96 %) et etait R0 pour 23 patients (92 %). Sur un suivi median de 89 mois (extremes 26–177) quatre patients (16 %) ont presente une recidive et un patient est decede de la maladie (4 %). Conclusion La RIGL est une technique sure avec une morbidite et des resultats a long terme acceptables. Elle constitue une alternative interessante chez des patients selectionnes permettant d’eviter des resections gastriques majeures lorsqu’une exerese endoscopique n’est pas accessible.

Background: The validity of laparoscopic distal pancreatectomy in left-sided pancreatic adenocarcinoma (PDAC) is still unclear. However, a meticulous surgical dissection through a “no-touch” technique might allow a radical oncological resection with minimal risk of tumor dissemination and seeding. This study aims to evaluate the oncological outcomes of the laparoscopic “no touch” technique versus the “touch” technique Methods: From 2001 to 2020, we analyzed retrospectively 45 patients undergoing LDP (laparoscopic distal pancreatectomy) for PDAC from two centers. Factors associated with overall (OS), disease-free (DFS) survival and Time to recurrence (TTR) were identified. Results. The OS rates in the ‘no-touch’ and ‘touch’ groups were 95% vs 78% (1-year OS); 50% vs 50% (3-year OS), respectively (p=0.60). The DFS rates in the ‘no-touch’ and ‘touch’ groups were 72 % vs 57 % (1-year DFS); 32% vs 28 % (3-year DFS), respectively (p=0.11). The TTR rates in the ‘no-touch’ and ‘touch’ groups were 77 % vs 61 % (1-year TTR); 54% vs 30 % (3-year TTR); 46% vs 11 % (5-year TTR); respectively (p=0.02) In multivariate analysis the only factors were Touch technique (OR= 2.62, p= 0.02) and lymphovascular emboli (OR= 4.8; p=0.002). Conclusion. We advise the ‘no-touch’ technique in patients with resectable PDAC in the pancreatic body and tail. Although this study does not provide definitive proof of superiority, no apparent downsides are present for the ‘no-touch’ technique in this setting although there could be oncological benefits.

Summary Background Technological and operative advancements have allowed laparoscopic intragastric surgery (LIGS) to be applied in the treatment of superficial gastric or submucosal lesions. The aim of this study was to evaluate short- and long-term outcomes following LIGS. Methods From 2000 to 2013, 25 LIGSs were performed for superficial gastric lesions. Clinical records were reviewed retrospectively for peri-operative course and long-term outcomes with particular attention to the oncological follow-up for patients with malignant lesions. Results Nineteen (76%) lesions were located close to the EGJ, three (12%) in the lesser curvature, two (8%) in the posterior wall and one (4%) in the prepyloric-antral region. A multiport technique was used in 15 (60%) patients and a single-access approach in 10 (40%) patients. The median operative time was 140 (50–210) minutes. No conversion to open or conventional laparoscopic surgery was needed. Mortality was nil, and severe morbidity occurred in one (4%) patient. The median length of stay was 6 (3–10) days. Indications of LIGS were adenocarcinoma in 11 (44%) patients, gastrointestinal stromal tumors (GISTs) in 6 (24%) patients and benign lesions in eight (32%) patients. En bloc resection was obtained in 24 (96%) patients with R0 margins in 23 (92%) patients. After a median follow-up of 76 (26–171) months, recurrence was detected in 4 (36%) patients with advanced malignant adenocarcinoma. Conclusion LIGS provides an interesting alternative to major gastric and EGJ resection when endoscopic resection is not suitable for highly selected patients with superficial gastric lesions.

Among the criteria used to diagnose metabolic syndrome (MS), obesity and diabetes mellitus (DM) are associated with poor postoperative outcomes following colectomy. MS is also associated with colorectal cancer (CRC) and diverticulosis, both of which may be treated with colectomy. However, the effect of MS on postoperative outcomes following laparoscopic colectomy has yet to be clarified. In an academic tertiary hospital, data from all consecutive patients undergoing laparoscopic colectomy from 2005 to 2014 were prospectively recorded and analysed. Patients presenting with MS [defined by the presence of three or more of the following criteria: elevated blood pressure, body mass index > 28 kg/m2, dyslipidemia (decreased serum HDL cholesterol, increased serum triglycerides) and increased fasting glucose/DM] were compared with patients without MS regarding peri-operative outcome [mainly anastomotic leaks, severe postoperative complications (Clavien–Dindo III and IV)] and mortality. Overall, 1236 patients were included: 508 (41.1%) right colectomies and 728 (58.9%) left colectomies. Seven hundred seventy-two (62.4%) of these procedures were performed for CRC. MS was diagnosed in 85 (6.9%) patients, who were significantly older than the others (70 vs. 64.2 years, p

In the absence of randomized controlled data and even propensity-matched data, indications for, and outcomes of, laparoscopic repeat liver resection for hepatocellular carcinoma (HCC) remain uncertain. This study aimed to clarify the current indications for laparoscopic repeat liver resection for HCC, and to evaluate outcomes.Forty-two liver surgery centres around the world registered patients who underwent repeat liver resection for HCC. Patient characteristics, preoperative liver function, tumour characteristics, surgical method, and short- and long-term outcomes were recorded.Analyses showed that the laparoscopic procedure was generally used in patients with relatively poor performance status and liver function, but favourable tumour characteristics. Intraoperative blood loss (mean(s.d.) 254(551) versus 748(1128) ml; P 0·001), duration of operation (248(156) versus 285(167) min; P 0·001), morbidity (12·7 versus 18·1 per cent; P = 0·006) and duration of postoperative hospital stay (10·1(14·3) versus 11·8(11·8) days; P = 0·013) were significantly reduced for laparoscopic compared with open procedures, whereas survival time was comparable (median 10·04 versus 8·94 years; P = 0·297). Propensity score matching showed that laparoscopic repeat liver resection for HCC resulted in less intraoperative blood loss (268(730) versus 497(784) ml; P = 0·001) and a longer operation time (272(187) versus 232(129); P = 0·007) than the open approach, and similar survival time (12·55 versus 8·94 years; P = 0·086).Laparoscopic repeat liver resection is feasible in selected patients with recurrent HCC.Dado que no existen ensayos clínicos controlados ni estudios de datos emparejados por puntaje de propensión, todavía hay dudas sobre las indicaciones y los resultados de la resección iterativa laparocópica de un carcinoma hepatocelular (hepatocellular carcinoma, HCC). Este estudio tuvo como objetivo esclarecer las indicaciones actuales y los resultados de la resección hepática laparoscópica iterativa del HCC. MÉTODOS: Se incluyeron los pacientes de 42 centros de cirugía hepática a nivel mundial en los que se había realizado una resección hepática iterativa por HCC. Se analizaron las características del paciente, la función hepática preoperatoria, las características del tumor, el abordaje quirúrgico y los resultados a corto y largo plazo.El análisis demostró que la vía laparoscópica generalmente se utilizaba en pacientes con carácteristicas tumorales favorables, pero con estado funcional y función hepatica relativamente peores. La pérdida de sangre intraoperatoria (254,3 ± 551,2 versus 748,0 ± 1127,7 mL, P 0,001), la duración de la intervención (247,6 ± 155,8 versus 285,1 ± 167,0 minutos, P 0,001), la morbilidad (12,7 versus 18,1%, P = 0,005) y la estancia hospitalaria postoperatoria (10,07 ± 14,29 versus 11,80 ± 11,79 días, P = 0,010) fueron significativamente menores para los pacientes tratados por via laparoscópica en comparacion con la vía abierta, mientra que el tiempo de supervivencia fue comparable (mediana 10,04 versus 8,94 años, P = 0,297). El estudio de emparejamiento por puntaje de propensión mostró que la resección hepática iterativa por vía laparoscópica de un HCC (frente a la vía abierta) conllevaba una menor pérdida sanguínea intraoperatoria (268,0 ± 730,2 versus 496,5 ± 784,2 mL, P = 0,01), una mayor duración de la intervención (272,1 ± 187,2 versus 231,8 ± 129,1 minutos , P = 0,07) y un tiempo de supervivencia similar (mediana 12,55 versus 8,94 años, P = 0,0855). CONCLUSIÓN: La resección hepática iterativa por vía laparoscópica es factible en pacientes seleccionados con HCC recidivado.

The sequential FOLFOX7–FOLFIRI combination is not superior to FOLFOX4 in colorectal cancer patients with resectable metastases. Patients with synchronous metastases preferably received perioperative chemotherapy, while patients with metachronous metastases were given postoperative chemotherapy in preference. We observed the highest long-term survival rates ever reported in this setting. Background Perioperative FOLFOX4 (oxaliplatin plus 5-fluorouracil/leucovorin) chemotherapy is the current standard in patients with resectable metastases from colorectal cancer (CRC). We aimed to determine whether a sequential chemotherapy with dose-dense oxaliplatin (FOLFOX7) and irinotecan (FOLFIRI; irinotecan plus 5-fluorouracil/leucovorin) is superior to FOLFOX4. The chemotherapy timing was not imposed, and was perioperative or postoperative. Patients and methods In this open-label, phase III trial, patients with resectable or resected metastases were randomly assigned either to 12 cycles of FOLFOX4 (oxaliplatin 85 mg/m2) or 6 cycles of FOLFOX7 (oxaliplatin 130 mg/m2) followed by 6 cycles of FOLFIRI (irinotecan 180 mg/m2). Randomization was done centrally, with stratification by chemotherapy timing, type of local treatment (surgery versus radiofrequency ablation with/without surgery), and Fong's prognostic score. The primary end point was 2-year disease-free survival (DFS). Results A total of 284 patients were randomized, 142 in each treatment group. Chemotherapy was perioperative in 168 (59.2%) patients and postoperative in 116 (40.8%) patients. Perioperative chemotherapy was preferentially proposed for synchronous metastases, whereas postoperative chemotherapy was more frequently used for metachronous metastases. Two-year DFS was 48.5% in the FOLFOX4 group and 50.0% in the FOLFOX7–FOLFIRI group. In the multivariable analysis, more than one metastasis [hazard ratio (HR) = 2.15] and synchronous metastases (HR = 1.63) were independent prognostic factors for shorter DFS. Five-year overall survival (OS) rate was 69.5% with FOLFOX4 versus 66.6% with FOLFOX7–FOLFIRI. Conclusions FOLFOX7–FOLFIRI is not superior to FOLFOX4 in patients with resectable metastatic CRC. Five-year OS rates observed in both groups are the highest ever reported in this setting, possibly reflecting the pragmatic approach to chemotherapy timing. Clinical trials number NCT00268398.

Background The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease. Methods Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics. Results Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017). Conclusion NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

La morbidite des fistules apres chirurgie colorectale est elevee et leur traitement est difficile. Leur obturation par injection de colle de fibrine a ete ponctuellement publiee. Ce travail presente les resultats d’une etude prospective chez 14 patients. De juin 2004 a janvier 2008, les patients ayant une fistule postoperatoire ont ete inclus, a l’exclusion des fistules impliquant le vagin, celles de grand diametre (> 1 cm) ou communiquant avec une cavite non drainee. Quatorze patients (10 H), d’âge moyen 63,5 ans, ont ete traites; soit 11 cancers du rectum, 2 diverticulites et une tumeur stromale de la cloison recto-vaginale; trois sur 13 avaient recu une radiotherapie preoperatoire. Il s’agissait d’anastomoses colorectales (ACR), basses (n = 6) ou hautes (n = 4), dont neuf latero-terminales, de trois anastomoses colo-anales (CA) et d’une suture rectale sans anastomose. Dix etaient des anastomoses mecaniques. Sept patients avaient d’emblee une stomie (CA + ACR basses). Le diagnostic de fistule etait porte 11 fois sur l’imagerie (TDM, IRM), deux fois en endoscopie et une fois a l’examen clinique; neuf fois, il etait porte precocement ( 57 jours). Six fois, une stomie secondaire a ete necessaire, toujours pour des fistules precoces. L’encollage a ete effectue 1,5 fois en moyenne avec 1 a 3 ml de colle (Beriplast®); l’efficacite etait jugee sur un scanner ou une IRM. Douze fois sur l’imagerie, la fistule a ete consideree comme obturee et la stomie a pu etre retiree dans un delai moyen de 389 jours apres sa mise en place, en moyenne 44 jours apres le premier essai d’encollage pour les formes tardives et 168 pour les formes precoces. Dans deux cas, malgre une fermeture de la fistule, une infiltration presacree persistait au scanner sans recidive tumorale. Le retard a la fermeture des stomies pouvait etre lie a la necessite d’une chimiotherapie postoperatoire. Cette serie, la plus grande rapportee d’encollage de fistules post-chirurgie colorectale coelioscopique, montre l’efficacite d’une prise en charge endoscopique. L’atout essentiel de cette technique est son absence de morbidite et une reelle efficacite, surtout en regard de l’alternative chirurgicale, notamment dans les fistules chroniques. Elle a permis une fermeture de la fistule dans 12 cas sur 14.

The practice of laparoscopic liver surgery has developed gradually, and most liver resections seem currently feasible and safe for selected patients in centers where surgeons are experienced both in liver surgery and in laparoscopic surgery. However, further studies would be required, especially for long-term oncological results and for major hepatectomy follow-up, before laparoscopic hepatectomy becomes a common alternative to open liver surgeries. Laparoscopic major hepatectomy is a recent technique, due to its significant complexity. In this review, we showed that patients undergoing laparoscopic hepatectomy for liver metastases experienced decreased rates of overall and major postoperative complications without any compromise on long-term outcomes compared to patients treated by open resection.

Despite staging laparoscopy (SL) with peritoneal lavage is recommended in US Guidelines in patients with potentially resectable gastroesophageal adenocarcinoma, this procedure is not systematically proposed in French Guidelines. Therefore, we decided to analyze the results of systematic SL in patients considered for preoperative chemotherapy. From 2005 to 2011, 116 consecutive patients with distal esophagus, esogastric junction, and gastric adenocarcinoma ≥T3 or N+ without detectable metastatic dissemination by computed tomography (CT) scan imaging underwent SL before neoadjuvant chemotherapy. Positive and negative SLs were compared according to tumor characteristics. SL was positive in 15 cases (12.9%) including 14 with peritoneal seeding (localized in five, diffuse in nine). SL was positive in 7 (24.1%) of 29 patients with poorly differentiated tumor, in 9 (32.1%) of 28 patients with signet ring cells, in 7 (50%) of 14 patients with gastric linitis tumor, and in 15 (16.3%) of 92 patients with T3 or T4 tumor. All the lesions of distal esophagus extending to the cardia had a negative SL. Among the 14 patients with peritoneal carcinomatosis at SL, nine (65%) had signs of peritoneal seeding on initial CT scan. One (0.8%) patient had a small bowel perforation closed laparoscopically. If systematic SL before preoperative chemotherapy does not seem justified because of its low accuracy, it should be performed in patients with poorly differentiated tumor, signet ring cell, and gastric linitis plastica components on biopsy and when CT scan is suggestive of T4 tumor, ascites, or peritoneal nodule.

Resume Nous rapportons un cas d’anevrisme sacculaire sur une fenestration de l’artere basilaire, survenu chez une femme de 47 ans hospitalisee pour hemorragie meningee peri-mesencephalique. Les anomalies de la media de la tunique arterielle au niveau des bifurcations expliquent l’association entre les anevrismes vertebro-basilaires et les fenestrations de l’artere basilaire. L’arteriographie cerebrale a mis en evidence un anevrisme en situation termino-vertebrale a orientation ventrale. Le traitement a consiste en une embolisation. Ce cas clinique nous permet de revoir la morphogenese de l’artere basilaire, les anomalies parietales interessant les fenestrations, et de discuter les deux prises en charges therapeutiques envisageables.

Resume Dans les cancers du haut rectum, l'exerese du mesorectum se fait de facon extrafasciale, toujours en dehors du fascia recti, et la section se fait 5 cm sous le pole inferieur de la tumeur. Pour les cancers du bas rectum, la resection comporte une exerese extrafasciale de tout le mesorectum et une section du rectum 2 cm sous le bord inferieur de la tumeur, distance mesuree en salle d'operation sur la piece operatoire fraiche. Les cancers dont le pole inferieur est trop proche du canal anal (cancers de la jonction anorectale) et a plus forte raison ceux qui envahissent l'appareil sphincterien imposent une amputation abdominoperineale. Quelques cas selectionnes de lesions de la jonction anorectale, pris en charge par des centres specialises, peuvent relever d'un traitement conservateur avec resection intersphincterienne et anastomose coloanale. Schematiquement, et selon le siege de la tumeur, on decrit quatre techniques differentes de proctectomie avec conservation du sphincter anal : la proctectomie partielle avec exerese partielle du mesorectum suivie d'une anastomose colorectale haute manuelle ou mecanique ; la proctectomie partielle avec exerese totale du mesorectum suivie si le moignon rectal mesure plus de 2 cm d'une anastomose colorectale basse et si le moignon rectal mesure moins de 2 cm d'une anastomose mecanique colo-sus-anale avec reservoir colique ; la proctectomie totale avec exerese totale du mesorectum suivie d'une anastomose coloanale manuelle et ses variantes, sur reservoir, faite par voie perineale ; une nouvelle technique, adaptee de celle de Babcock, qui associe la proctectomie totale et la descente du colon a travers l'anus suivie, 5 jours plus tard, d'une resection du colon abaisse et d'une veritable anastomose manuelle coloanale directe par voie perineale. L'amputation abdominoperineale du rectum ajoute l'exerese du canal anal et de l'appareil sphincterien suivie d'une colostomie definitive. Certains points lui sont particuliers : elle ne necessite pas de decrochement de l'angle gauche ; on peut preserver, chez les sujets âges notamment, le pedicule sigmoidien ou sa premiere branche ; il est classique de lui associer une epiplooplastie pediculee sur les vaisseaux gastroepiploiques gauches. La cœlioscopie peut s'appliquer a toutes ces techniques. Elles peuvent aussi etre commencees par cœlioscopie puis converties par laparotomie, soit de principe, notamment si l'operation se prolonge, soit de necessite devant une difficulte technique, un defaut d'exposition ou un doute sur la qualite des marges laterales. L'amputation abdominoperineale une tres bonne indication d'approche cœlioscopique car la seule incision est celle de la stomie, l'exteriorisation de la piece pouvant se faire par le perinee.

Resume Le rectum est le segment terminal du tube digestif. Il comporte deux parties : le rectum pelvien, encore appele ampoule rectale, qui mesure 12 a 15 cm, derive de l'intestin primitif ayant donc un meso dorsal (le mesorectum) et le rectum perineal ou canal anal, qui mesure 3-4 cm et correspondant aux sphincters parfaitement reperables par le toucher rectal, derive de l'ectoderme et n'ayant donc pas de meso. Le peritoine recouvre la face anterieure et les faces laterales de la moitie superieure du rectum qui est donc dite, a tort, intraperitoneale par opposition a la moitie inferieure situee sous le cul-de-sac de Douglas entierement sous-peritoneale. Le rectum pelvien est donc entoure soit par le peritoine soit par le feuillet visceral du fascia pelvien ou fascia propria encore appele fascia recti. Le feuillet parietal est parfois appele fascia presacre bien qu'il recouvre la totalite des parois de la cavite pelvienne et pas seulement le sacrum. C'est le fascia de Waldeyer des Anglo-Saxons. La vascularisation, sanguine et lymphatique, du rectum pelvien se fait dans le mesorectum, l'espace cellulograisseux compris entre le fascia recti et le rectum pelvien ; il disparait sur les 2 derniers centimetres de l'ampoule rectale. Les techniques actuelles de proctectomie comprennent une resection « totale » du mesorectum ; il s'agit d'une expression ambigue melangeant l'exerese extrafasciale, en dehors du fascia recti et toujours justifiee, et l'ablation de tout le mesorectum jusqu'au plan des releveurs qui n'est justifiee que pour les tumeurs de la moitie inferieure du rectum. Les deux feuillets, visceral et parietal, du fascia pelvien se rejoignent et fusionnent en avant et en arriere. Pour faire une exerese totale du mesorectum, il est donc necessaire au moins deux fois, de changer de plan en emportant l'aponevrose de Denonvilliers en avant et le ligament rectosacre en arriere. Les nerfs pelviens, sympathiques et parasympathiques, sont toujours recouverts par le fascia parietal, en arriere puis en dehors puis en avant et en dehors du rectum. Ils sont donc preserves par l'exerese extrafasciale, mais ils sont tres proches de la zone de liberation sur les faces anterolaterales basses ou des branches nerveuses penetrent le fascia recti pour innerver le rectum terminal. Le rectum perineal n'a pas de fascias propres, une vascularisation peu systematisee vers la peau et les fosses ischiorectales en partie a travers les muscles elevateurs de l'anus. D'un point de vue chirurgical, le repere de la marge anale est peu utile pour les tumeurs de l'ampoule rectale car trop variable selon la position du malade, son adiposite et la longueur du canal lui-meme ; le bord superieur des releveurs est beaucoup plus facile a reperer et l'on verra que c'est par rapport a lui que l'on decide de tel ou tel type de resection. Les distances « par rapport a la marge anale » sont encore faussees selon que l'on mesure la face anterieure tres courte avec un cul-de-sac de Douglas a 5,5 cm de la marge - mais parfois a 4 cm chez la femme - ou le bord posterieur tres long ce qui se traduit en coloscopie par une charniere colorectale parfois mesuree a 18, voire 19 cm de la marge anale. La localisation des tumeurs les plus basses par rapport a la marge anale est importante mais elle doit etre confirmee par rectoscopie ou anuscopie. Cliniquement, on peut diviser le rectum en trois parties : le haut rectum, moitie superieure de l'ampoule rectale, grossierement situe au-dessus du cul-de-sac de Douglas, s'etend de 6-8 cm a 15-19 cm de la marge anale selon les conditions de mesure ; le bas rectum, moitie inferieure de l'ampoule rectale qui se termine au bord superieur des releveurs et correspond au rectum sous-peritoneal ; il est explorable par le doigt ; le canal anal de 0 a 3-4 cm de la marge anale – egalement le siege des carcinomes epidermoides d'origine tegumentaire exclus de ce chapitre.

Resumen En los canceres de la porcion alta del recto, la exeresis del mesorrecto se hace de forma extrafascial, siempre por fuera de la fascia rectal, y la seccion se realiza 5 cm por debajo del polo inferior del tumor. En los canceres de la porcion baja del recto, la reseccion conlleva la exeresis extrafascial de todo el mesorrecto y una seccion del recto 2 cm por debajo del borde inferior del tumor, distancia que se mide en el quirofano en la pieza quirurgica fresca. Los canceres cuyo polo inferior esta demasiado cerca del conducto anal (canceres de la union anorrectal), y con mayor razon los que invaden el aparato esfinteriano, exigen una amputacion abdominoperineal. En algunos casos seleccionados de lesiones de la union anorrectal, tratados por centros especializados, se puede aplicar un tratamiento conservador con reseccion interesfinteriana y anastomosis coloanal. Esquematicamente, y segun el lugar donde se encuentre el tumor, se han descrito cuatro tecnicas diferentes de proctectomia con conservacion del esfinter anal: proctectomia parcial con exeresis parcial del mesorrecto y a continuacion anastomosis colorrectal alta manual o mecanica; proctectomia parcial con exeresis total del mesorrecto y posteriormente, si el munon rectal mide menos de 2 cm, anastomosis mecanica colo-supra-anal con reservorio colico; proctectomia total con exeresis total del mesorrecto seguida por una anastomosis coloanal manual y sus variantes, con reservorio, realizada por via perineal; una nueva tecnica, adaptada de la de Babcock, en la que se asocia la proctectomia total y el descenso del colon a traves del ano y a continuacion, cinco dias mas tarde, una reseccion del colon descendido y una autentica anastomosis manual coloanal directa por via perineal. En la amputacion abdominoperineal del recto se anade la exeresis del conducto anal y del aparato esfinteriano, seguida por una colostomia definitiva. Tiene algunas caracteristicas particulares: no es necesaria la desinsercion del angulo izquierdo; se puede preservar, sobre todo en los pacientes ancianos, el pediculo sigmoideo o su primera rama; es clasico asociar una epiploplastia pediculada sobre los vasos gastroepiploicos izquierdos. La laparoscopia puede aplicarse en todas estas tecnicas. Tambien es posible iniciarlas con una laparoscopia y convertirlas por laparotomia, ya sea por principio, sobre todo si la operacion se prolonga, ya sea en caso de necesidad ante una dificultad tecnica, una exposicion defectuosa o cualquier duda sobre la calidad de los margenes laterales. La amputacion abdominoperineal es una excelente indicacion de acceso laparoscopico, ya que la unica incision es la del estoma, siendo posible exteriorizar la pieza por el perine.

Resumen El recto es el segmento terminal del tubo digestivo. Se compone de dos partes: el recto pelvico, tambien denominado ampolla rectal, que mide 12-15 cm, derivado del intestino primitivo, por lo que posee un meso dorsal (el mesorrecto) y el recto perineal o conducto anal, que mide 3-4 cm y corresponde a los esfinteres perfectamente palpables en un tacto rectal, derivado del ectodermo, de ahi que no tenga meso. El peritoneo recubre las caras anterior y lateral de la mitad superior del recto. Esta porcion se denomina de forma incorrecta intraperitoneal, en contraposicion a la mitad inferior, localizada bajo el fondo de saco de Douglas, completamente infraperitoneal. Asi pues, el recto pelvico esta recubierto sea por el peritoneo, sea por la hoja visceral de la fascia pelvica o fascia propia, tambien llamada fascia rectal. La hoja parietal se denomina a veces fascia presacra, aunque en realidad recubre todas las paredes de la cavidad pelvica, y no solo el sacro. Los anglosajones la denominan fascia de Waldeyer. La vascularizacion sanguinea y linfatica del recto pelvico discurre dentro del mesorrecto, en el espacio celulograso comprendido entre la fascia recti y el recto pelvico, y desaparece en los 2 ultimos centimetros de la ampolla rectal. Las tecnicas actuales de proctectomia consisten en una reseccion «total» del mesorrecto, expresion ambigua, ya que incluye la exeresis extrafascial, siempre justificada, por fuera de la fascia recti y la ablacion de todo el mesorrecto, solo justificada en los tumores de la mitad inferior del recto. Las dos hojas, visceral y parietal, de la fascia pelvica se unen y fusionan por delante y por detras. Por tanto, para efectuar una exeresis total del mesorrecto, hay que cambiar de plano al menos dos veces, y llevar la aponeurosis de Denonvilliers hacia delante y el ligamento recto sacro hacia atras. Los nervios pelvicos simpaticos y parasimpaticos estan siempre recubiertos por la fascia parietal, hacia atras, hacia fuera, por delante y por fuera del recto. Por tanto, se encuentran conservados en la exeresis extrafascial, si bien se situan muy proximos a la zona de liberacion, sobre las caras anterolaterales bajas, donde las ramas nerviosas penetran en la fascia recti para inervar el recto terminal. El recto perineal no posee fascia propia, y la vascularizacion esta poco sistematizada a traves del musculo elevador del ano hacia la piel y las fosas isquiorrectales. Desde un punto de vista quirurgico, resulta poco util localizar el margen anal en los tumores de la ampolla rectal, pues este varia mucho en funcion de la posicion del enfermo, su adiposidad y la longitud del conducto anal. El borde superior del elevador del ano es mucho mas facil de localizar y, como se vera, en funcion de la distancia al mismo se elegira el tipo de reseccion. Las distancias definidas “respecto al margen anal” seran falseadas en funcion de que se mida la cara anterior, muy corta con el fondo de saco de Douglas situado a 5,5 cm del margen (a veces a 4 cm en la mujer), o la cara posterior, muy larga, por colonoscopia. La distancia hasta la union colorrectal mide 18 cm, a veces incluso 19 desde el margen anal. La localizacion de los tumores mas bajos con respecto al margen anal es importante, pero debe confirmarse por rectoscopia o anoscopia. Desde el punto de vista clinico, el recto puede dividirse en tres partes: el recto superior, que corresponde a la mitad superior de la ampolla rectal, se situa por encima del fondo de saco de Douglas, y mide de 6-8 cm a 15-19 cm, dependiendo de las condiciones en las que se haya medido; el recto inferior, mitad inferior de la ampolla rectal, que se termina en el borde superior de los elevadores y corresponde al recto infraperitoneal y se puede explorar con el dedo; el conducto anal, de 0 a 3-4 cm desde el margen anal, donde suelen localizarse carcinomas epidermoides de origen cutaneo, no incluidos en este articulo.

We report a case of a mucinous cystadenoma of the pancreas communicating with the main pancreatic duct. To our knowledge, this is the first case in which a communication between the mucinous cystadenoma and the main pancreatic duct could be demonstrated by MRI.

Resume Objectif de l'etude Cette etude retrospective a pour objectif de rapporter cinq observations de lesions spleniques traitees sous cœlioscopie par splenorraphie avec la prothese perisplenique resorbable qui etait utilisee en chirurgie ouverte. Patients et methode De juillet 1996 a fevrier 1998, trois hommes et deux femmes (âge moyen: 52 ans) ont ete inclus dans l'etude. La lesion splenique etait liee a une chute ( n = 3), un accident de la circulation ( n = 1) et a une ponction pleurale pour mediastinite apres pose d'une valve cardiaque. La lesion splenique a ete reconnue par l'echographie. Tous les patients avaient un etat hemodynamique stable. Deux interventions ont ete realisees d'urgence et les trois autres dans les 24 heures. La rate a ete completement liberee. La prothese placee en arriere de la rate, recouvrant bien les poles superieur et inferieur de la rate, a ete deroulee d'arriere en avant et les trois bourses successivement serrees. Resultats II n'y a eu aucune conversion, ni mortalite, ni morbidite. Chez les quatre traumatises, la duree moyenne de l'intervention a ete de 120 minutes (extremes: 70–180 minutes), il n'y a eu aucune transfusion sanguine et les patients sont sortis a j4 ou j5. Le cinquieme patient apres pose d'une valve a ete opere sous traitement anticoagulant. La duree de l'operation a ete de 270 minutes. Il a recu quatre culots globulaires et est sorti a j26. Conclusion Cette technique associe les avantages de la prothese perisplenique qui est efficace et sure et les avantages de la cœlioscopie qui simplifie les suites operatoires. Elle ne peut etre envisagee qu'en cas de lesion splenique isolee chez des patients ayant un etat hemodynamique stable.

Pancreatic surgery was reported as early as 1898. Since then significant developments have been made in the field of pancreatic resections. In addition, advances in laparoscopic surgery in general have seen the description of this approach in pancreatic surgery with increasing frequency. Although there are no randomized controlled trials, several large series and comparative studies have reported on the short and long term outcome of laparoscopic pancreatic surgery. Furthermore, in the last decade published systematic reviews and meta-analyses have reported on cost effectiveness and outcomes of these procedures.

In the past two decades there has been an enormous increase in laparoscopic liver surgery. There is a trend from limited to laparoscopic major resections and more centres are adopting laparoscopic liver surgery as a standard of care. Although no randomized clinical trials are published, different reports on minor and major hepatectomies and meta-analyses suggest (at least) equal outcomes and cost-effectiveness compared to open procedures.

Intraabdominal cystic lymphangioma occurs rarely, and lymphangioma of the diaphragm has not been previously reported in the literature. The authors herein report the clinical features, radiographic findings, and treatment of one encountered case of lymphangioma of the diaphragm.

The aim of this study was to evaluate the place of pancreaticogastrostomy (PG) in reducing pancreatic fistula after pancreatoduodenectomy. From January 1988 to June 1991, 32 consecutive patients (mean age, 57 years) were operated on, 25 for malignant disease (78%). The pancreatic remnant was normal in 17 patients (53%) and sclerotic in the others. There was one operative death (3.1%) unrelated to PG. Post-operative complications occurred in five patients (16%). Only two complications were related to PG: 1 patient had anastomotic intra-gastric bleeding and was reoperated on, 1 patient with a normal pancreatic remnant developed a pancreatic fistula (3.1%) treated conservatively.Reported series of PG, as well as our results, demonstrates that PG is associated with a dramatic decrease of both pancreatic fistula and mortality rates. The risk of anastomotic haemorrhage can be reduced by preventative ligation of submucosal gastric vessels.In conclusion, PG appears as a simple and reliable method of management of the pancreatic remnant after pancreatoduodenectomy.

This study is concerned with a western series of 521 squamous cell carcinomas of the thoracic esophagus treated over a recent 9-year period. Six points of the preoperative work-up are discussed: (1) t

A case of ruptured middle saccular aneurysm arising from basilar artery fenestration is reported. Defects of the medial wall at the junctures of the fenestrated segments explain the association between vertebrobasilar aneurysms and basilar artery fenestration. A 47 year-old woman had a perimesencephalic subarachnoid hemorrhage. Immediate angiography revealed a ventral vertebrobasilar aneurysm and an endovascular coil occlusion was performed. Embryological development, pathogenesis and therapeutic difficulties are discussed.

Advances in laparoscopic techniques, refinements of instruments and growth of practical experience in liver surgery during the last decade have prompted some surgeons to develop the laparoscopic approach for hepatic metastases of colorectal cancer (MCRC).Primary end points of this clinical study were safety and effectiveness of laparoscopic hepatectomy for MCRC, including early postoperative results and long-term outcomes (overall survival and disease-free survival).Retrospective analysis of data (clinicopathologic, operative, perioperative ad late results) collected in a prospective database.Between January 1997 and December 2004, 37 non-consecutive (selected) patients underwent curative laparoscopic hepatic resection (n = 42) for MCRC at Montsouris Institut of Paris. Resection was considered when all liver metastases can be totally removed with clear margins, and in absence of nonresectable extrahepatic diseases. Among them were 24 males and 13 females with average ages of 63.4 years (range, 42-78).Metastases were metachronous in 18, multiple in 21, bilateral in 12, and5 cm in diameter in 30. There were 21 major hepatectomies (n = 3 Couinaud's segments or more), 4 anatomical minor resections, and 12 wedge resections. Mean operative time was 324 +/- 105 mins. Conversion to laparotomy was necessary in 6 patients (16%), due to massive intractable bleeding in 3 patients, multiples adhesions in 1 patient, technical reasons (location of the lesion) in 1 patient, and for presence of localized carcinosis in 1 patient. Portal triad clamping was performed in 6 patients. Mean operative blood loss was 797 +/- 645 ml, and transfusions were required in 4 patients (11%). Clear resection margins (5 mm) were observed in 94%. Postoperative mortality was nil. The overall morbidity rate was 35%, with 2 early reoperations due to hemorrhage and postoperative ileus. Overall and disease free survival at 36 months were 87% and 55%, respectively. Five patients who had a recurrence of metastatic liver disease were referred to a second laparoscopic resection.This clinical study suggests that laparoscopic liver surgery for metastatic colorectal cancer can be accomplished safely, in selected patients and by experienced surgeons, with good early results and without detrimental consequences on survival.

Insertion of a mesh in treatment of incisional hernias reduces the risk of recurrence. A single prospective randomized trial have compared laparoscopic and open approach: there were less postoperative complications and fewer recurrences in the laparoscopic group. Aim of this prospective trial was to control these results.From January 2000 to May 2005, 51 consecutive incisional hernias were operated on by a laparoscopic approach. Incisional hernia was single in 41 and double in 5. It was median in 41 and lateral in 10. Previous hernia repair was noticed in 33.3%. Main criteria was recurrence. We have considered whether one of the following criteria was associated with the risk of recurrence: sex, obesity, previous repair, pre and preoperative sizes of the hernia, uni or multi orificial aspect of the hernia, median or lateral location, mesh size, ratio mesh surface/hernia surface. Others were postoperative mortality and morbidity, duration of hospitalisation and occurrence of late events.At 2 years all patients were followed. Follow up achieved 3 years in 23 cases and 4 years in 9. Recurrence was observed in 7 (13.7%). None predictive factor was disclosed. No death occurred. Median postoperative pain score at D1, D2 and D3 was respectively 3.1+/-1.9, 2.9+/-2.3 and 2.3+/-2.1. Mean postoperative stay was 4.1+/-1.9 days. Seven postoperative complications occurred, al benign. During follow-up 18 events were noticed and of these 8 were chronic abdominal pain.This technique could be employed for every type of incisional hernia but peristomial hernias (not assessed in this study) and every patient. Technical improvements ought to be find to reduce recurrence rate.

To analyze a unicentric series of 100 consecutive elective laparoscopic colon resections for diverticular disease and to evaluate in intention to treat the early- and middle-term postoperative results.From February 1993 to March 1998, 100 colon resections for complicated diverticular disease were performed through laparoscopy with systematic mobilization of the splenic flexure and resection of the rectosigmoid junction. The colorectal anastomosis was stapled or manual without proximal stoma. In 53 females and 47 males (mean age 60.4 years), indications for surgery were: one or more attacks of acute diverticulitis (n = 70), abscess (n = 17), symptomatic stenosis (n = 8), colovesical fistula (n = 4) and diverticular bleeding (n = 1).Mortality was nil. The conversion rate was 9%, never for anesthetic reasons. The mean operating time was 226 +/- 68 min. There was no splenic or ureteral injury. The morbidity at 30 days was 19% with fistulae rate accounting for 2%, 2 patients were reoperated on. The median time for passage of flatus was 3 days and median length of hospital stay was 7 days. Late morbidity was 10%, one patient complained of retrograde ejaculation.This study demonstrates that laparoscopy is a safe alternative to laparotomy for elective one-stage colectomy for complicated diverticular disease.

To support software project managers for reliability evaluation, the company Mathix and the French telecommunications agency (France Telecom) have developed a CASE tool named M-elopee. The purpose of this tool is not only to provide some reliability growth model computations but, more generally, to propose an approach to do reliability studies, and therefore to offer all the features needed to undertake this approach. M-elopee typically promotes the transfer of software reliability technology to practice. Therefore it runs on PCs under Windows and benefits from the many facilities of this environment. This article describes the functionalites provided by M-elopee and its underlying methodology. Mainly, the following points are developed: the content and structure of the data processed by M-elopee; data processing; trend analysis; comparison of models; and the maximum number of failures to forecast.

Major complications following pancreaticoduodenectomy are thought to be chiefly associated with exocrine secretion of the pancreatic remnant which is not well known. This work aims to assess the exocrine secretion of the pancreatic remnant within the early post-operative period.Seventy-five patients undergoing pancreaticoduodenectomy for presumed tumour were included in a prospective multicentre study. A tube was inserted in the pancreatic duct at the time of construction of the pancreatic anastomosis. Peripancreatic drainage was routinely used. Pancreatic juice and peripancreatic drainage fluid were collected and measured and pancreatic enzyme monitored. For 7 days patients received total parenteral nutrition and continuous infusion of randomly Somatostatin 14 (S-14) at a dose of 6 mg/24 h (days 1-6) and 3 mg/24 h (day 7) or matching placebo. Pancreatic fistula was defined as a daily drainage of more than 100 cc of amylase-rich fluid after day 3, persisting after day 12 or associated with symptoms or needing specific treatment.Daily output of pancreatic juice was low during the first postoperative day and then increased gradually until day 5. A high enzyme concentration was observed in pancreatic juice on the first post-operative day. S-14 infusion resulted in a significant decrease of both pancreatic fistula rate and enzyme concentration in peripancreatic fluid.During the first postoperative days, the outflow of the exocrine secretion of the pancreatic remnant is low but contains a high enzyme concentration with significant leaks within the peripancreatic area. S-14 infusion results in a decrease of pancreatic juice leaks from the pancreatic remnant.

The aims of the study were to evaluate the evolution of laparoscopic surgery during the past decade in terms of variations in the quality (complexity) of the procedures performed and of modifications in patient outcome.A retrospective analysis was performed of 3022 consecutive patients undergoing 99 different laparoscopic procedures at a center specialized in laparoscopic abdominal surgery. All the procedures were classified according to three classes of complexity. Results relating to the first 1511 patients were compared to those of the last 1511 patients.In the second group, medium- to high-class complexity procedures significantly increased, conversion rate was higher only for straightforward procedures, duration of low- to medium-class complexity procedures decreased, only the rate of slight complications increased, and mean postoperative hospital stay was longer. Frequency of conversion in medium- to high-class complexity procedures and severe complications was not different in the two periods.The quality of laparoscopic surgery has improved during the past decade, with no increase in the frequency of conversion or of major complications.

Anorexia nervosa and psychogen vomiting are psychiatric eating disorders characterized by unexplained weight loss and induced vomiting. These diagnoses require absence of somatic disease. Achalasia is a primary disorder of the esophagus that can be responsible for the same symptoms. This may occult the real diagnosis, especially as dysphagia is not constant and variable in time. We report four cases of achalasia mistakenly diagnosed and treated as anorexia nervosa or psychogen vomiting. Achalasia was unrecognized because specific symptoms, such as dysphagia, were overlooked or misinterpreted by the patients' physicians and psychiatrists, or by the patients themselves. In patients with such eating disorders considered to be psychiatric, physicians should inquire about signs suggestive of achalasia. The diagnosis of achalasia is suspected by imaging and endoscopy, and confirmed or ruled out by manometry.

To evaluate the indications, feasibility and results of laparoscopic treatment of common bile duct stones without biliary drainage.Between 1992 and 1999, laparoscopic procedures were performed in 70 consecutive patients, mean age 60 +/- 15 years (range: 18-82). Stone removal was attempted via the cystic duct (n=25) or choledocotomy (n=45). The emptiness of the common bile duct was checked by intraoperative cholangiography or endoscopy. After choledocotomy, closure was performed by interrupted or non-interrupted suture with slowly resorbable thread. Transcystic drainage was used whenever necessary.Nine conversions to laparotomy were necessary (12.8%). Among the 61 patients who had an exclusively laparoscopic procedure, 21 were treated via the transcystic route and 40 through choledocotomy. Biliary endoscopy was possible in only 10 of the 21 patients (47.6%) treated via the transcystic route and in all with choledocotomy. No biliary drainage was used in 16 of the 21 patients treated via the transcystic route and in 39 of the 40 treated through choledocotomy. The 30-day mortality was 1/61 (1.6%). Morbidity was 9.8% and 2 patients underwent a second laparoscopic procedure (one fistula on a choledocotomy suture, one hemoperitoneum of unknown origin). An endoscopic sphincterotomy for residual stone was necessary in 4 patients (4/61, 6.5%), 2 after choledocotomy for an unrecognized stone without biliary drainage.These results confirm the feasibility of laparoscopic treatment of common bile duct stones and suggest it can be performed without biliary drainage in most cases.

Preoperative nonresectability criteria for carcinoma of the pancreatic head remain controversial. We sought to assess prospectively the preoperative criteria used currently in clinical practice and to determine the different therapeutic strategies used between gastroenterologists (GEs) and digestive surgeons (Ss). The evaluation comprised all of the registered GEs (n = 3,466) and Ss (n = 687) who were sent a questionnaire surveying nonresectability criteria. The hypothesis in question concerned adenocarcinoma of the pancreatic head in a patient in the absence of general operative contraindication. Six hundred fifteen complete responses to the questionnaire were received (GEs, 426; Ss, 189). The mean estimated percentage of resected tumor was 22% (GEs, 19%; Ss, 31%; p0.0001). Preoperative nonresectability criteria differed between the two groups and included weight loss25% (percentage of GEs using this criterion, 57%; Ss, 48%; p0.04), duodenal wall invasion (GEs, 30%; Ss, 4%; p0.001), gastric extension (GEs, 55%; Ss, 23%; p0.001), invasion of gastroduodenal artery (GEs, 58%; Ss, 19%; p0.001), invasion of superior mesenteric artery (GEs, 85%; Ss, 92%; p0.02), invasion of portal vein (GEs, 78%; Ss, 52%; p0.001), tumor diameter6 cm (GEs, 52%; Ss, 38%; p0.001), peripancreatic lymph nodes (GEs, 33-69% depending on the node area; Ss, 5-52%; p0.02-0.001). Consensual criterion used by85% of GEs and Ss was celiac trunk invasion. Criteria rejected by85% both of GEs and Ss were back pain, weight loss25%, and tumor diameteror = 5 cm. Criteria without consensus (used or rejected by85% of GEs and Ss) were superior mesenteric vein and hepatic artery invasion. The preoperative nonresectability criteria used in determining operative resectability differs significantly between medical and surgical gastroenterologists. This study is the first to quantify this difference. These results underline the need for consensus agreement in the criteria of resectability.

Intraductal papillary-mucinous tumors of the pancreas are characterized by malignant transformation of unpredictable occurrence because of their unknown natural history. Surgical treatment is duodenopancreatectomy or left pancreatectomy even for benign tumors. We report 2 cases of benign intraductal papillary-mucinous tumor confined to the head of the pancreas and treated by enucleation.

Means used by physicians to perform preoperative staging of pancreatic adenocarcinoma are not well known. Therapeutic strategy used relies on knowledge of loco-regional spread criteria.To assess the frequency of prescription of imaging procedures in patients with suspected pancreatic head adenocarcinoma; the use by French gastroenterologists (GE) and digestive surgeons (S) of criteria which lead to suspect lymph node invasion or vascular involvement; the frequency of histological determination in patients with unresectable tumor; if there is a difference between GE and S.All the French GE (n = 3466) and S (n = 687) were sent a survey asking them about their habits.615 answers were received (GE = 426, S = 189). There was no significant difference between GE and S for the prescription of ultrasonography and CT scan. Endosonography and upper digestive endoscopy were more systematically performed by GE than S (44 vs 35% and 50 vs 35%, respectively). Celio-mesenteric angiography was less often used by GE (6 vs 13%). Laparoscopy was electively used by 35% GE and 52% S. None of vascular involvement criteria was used by more than 75% of GE and S. Tumor-vessel interface loss was used by 46% GE and 16% S (P0.001). Intravascular thrombosis and truncular portal hypertension signs were used more often by S than GE (84 vs. 71%: P0.001; 65 vs. 51%: P0.001). None of nodal involvement criteria was used by more than 50% of physicians. All these nodal criteria were used more often by GE than S (P0.001). Percentage of physicians requiring histological confirmation in case of unresectable tumor was 41%.Preoperative staging of suspected pancreatic head adenocarcinoma is performed with grossly the same manner by GE and S. Histological proof is searched for in a low percentage of cases. Imaging criteria of loco-regional spread of pancreatic adenocarcinoma are heterogeneously used by GE and S, the former using them more frequently than the latter. A better use of imaging criteria is necessary to optimise the treatment of patients with pancreatic adenocarcinoma.

Laparoscopy is more expensive than Shouldice procedure for inguinal hernia repair. The aims of this study were to evaluate the overcost, to look for its causes and to propose a strategy of cost reduction.One hundred and sixty three unilateral inguinal hernia repairs were performed from January 1995 to June 1996 in our institution, functioning under financial rule of total endowment. Forty five of the 163 procedures were laparoscopic procedures. The mean operative cost of each procedure was calculated from physician, personnel and equipment costs (amortization, consumable products and maintenance).The mean costs were 2,210 FF and 6,779 FF for Shouldice and laparoscopic procedures, respectively. This overcost of 4,569 FF was reduced to 893 FF by increasing surgeon's experience, which shortened operative duration and ward cost, and by the use of a non specific mesh fastened in place with threads. The mean operative cost of laparoscopy was then 3,103 FF.A change in surgical practice allows a reduction in the operative overcost of laparoscopic unilateral inguinal hernia repair by 80.4%.

We report a case of heterotopic pancreas located in the gastric antrum. The cystic formation contained mucus. Tumoral markers in the cyst fluid were within the range pancreatic cystic mucinous tumors. Pathology examination of the resected specimen did not evidence any proliferative lesions but showed papillary hyperplasia probably due to duct occlusion.

In the curative treatment of the adenocarcinoma of the cardia (AC), the extent of the esogastrectomy and the need for lymph node dissection are still debated. The palliative treatment of AC is now currently non-surgical. The aim of this study was (a): to assess early results of palliative surgery; and (b) to evaluate the results of curative resection with reference to the influence of the extent of gastrectomy and lymph node dissection on early results and long-term survival. Methods. From 1979 to 1989, 179 patients (mean age = 60 +/- 12 years) with AC had 45 palliative resections (mean age = 56 +/- 15) and 134 curative resections (mean age = 61 +/- 12). Thirty-eight proximal subtotal esogastrectomy (PSOG) and 7 total esogastrectomy (TOG) were palliative; 72 PSOG and 62 TOG extended to the spleen were curative and associated with lymphadenectomy.The operative mortality rate was 8.9% regardless of the palliative or curative intent of resection. After palliative resection, the mortality rate was 2.6% (1/38) after PSOG and 42.9% (3/7) after OGT = (p = 0.01); the median survival was 8 months. After curative resection, the mortality rate was 12.5% (9/72) after PSOG and 4.8% (3/62) after extended TOG (p = 0.2); actuarial 5-year survival rate was 42% after PSOG and 39% after extended TOG.These results suggests that: (a) palliative PSOG for AC can be performed with a low mortality; and (b) resection with extensive lymphadenectomy allows substantial survival regardless of the extent of gastrectomy.

Intraductal papillary mucinous tumors of the pancreas are rare and characterised by a malignant potential. Their natural history is unknown. We report a case of intraductal papillary mucinous tumor of the pancreas, that was still benign although the first symptom was appeared 30 years before the diagnosis. This case report demonstrate the possible slow course of these tumors, for which malignant degeneration is unpredictable.

To determine to what extent segmental colectomy could be avoided in patients with polyps though to be endoscopically unresectable by using combination laparoscopy and endoscopy.Sixty-five patients referred for colonic polyps though to be unresectably by conventional endoscopy were studied. After analysis of the endoscopic findings, endoscopy was performed in a medicosurgical unit when possible, otherwise a surgical procedure was performed consisting of laparoscopy followed by colonoscopy. Therapeutic strategy depended on laparoscopic and endoscopic findings.Segmental colectomy was avoided in 44 patients (67.7%). Among them, 20 were treated by simple endoscopic polyp removal, 12 by laparoscopy-assisted colonoscopic polypectomy, 9 by laparoscopic wedge colonic resection and 3 by colotomy after colonic exteriorization and polyp resection. Laparoscopic or laparoscopy-assisted segmental colectomy was performed in 16. Segmental colectomy by laparotomy was necessary in 5. No complication occurred.Segmental colectomy for unresectable colonic polyps could be avoided in more than half of the patients using laparoscopy and colonoscopy combinations.

We report the case of a young girl with diffuse peritoneal carcinomatosis due to pseudopapillary and solid tumor of the pancreas. Fourteen months before the diagnosis and treatment of the tumor, an abdominal trauma occurred. Initial treatment was tumor and visible peritoneal carcinomatosis resection. Eight months later, relapse of peritoneal carcinomatosis occurred and the patient was reoperated. All macroscopic lesions were removed. Thirty-seven months after first laparotomy, the patient was well but abdominal ultrasound led to suspicion of hepatic metastasis. Among 17 published cases of metastatic pseudopapillary and solid tumor of the pancreas (including 6 cases with peritoneal carcinomatosis), trauma was described in 11 cases (including 3 cases with peritoneal carcinomatosis). Pseudopapillary and solid tumor of the pancreas may spread outside the pancreas, particularly in peritoneal cavity. Metastatic spread may be promoted by trauma, including tumor biopsies which should never be performed.

In the curative treatment of the adenocarcinoma of the cardia (AC), the extent of the esogastrectomy and the need for lymph node dissection are still debated. The palliative treatment of AC is now currently non-surgical. The aim of this study was: a) to assess early results of palliative surgery; b) to evaluate the results of curative resection with reference to the influence of the extent of gastrectomy and lymph node dissection on early results and long-term survival.From 1979 to 1989, 179 patients (mean age = 60 +/- 12 years) with AC had 45 palliative resections (mean age = 56 +/- 15) and 134 curative resections (mean age = 61 +/- 12). Thirty-eight proximal subtotal esogastrectomies (PSOG) and 7 total esogastrectomies (TOG) were palliative; 72 PSOG and 62 TOG extended to the spleen were curative and associated with lymphadenectomy.The operative mortality rate was 8.9% regardless of the palliative or curative intent of resection. After palliative resection, the mortality rate was 2.6% (1 case out of 38) after PSOG and 42.9% (3 cases out of 7) after OGT (P = 0.01); the median survival was 8 months. After curative resection, the mortality rate was 12.5% (9 cases out of 72) after PSOG and 4.8% (3 cases out of 62) after extended TOG (P = 0.2); actuarial 5-year survival rate was 42% after PSOG and 39% after extended TOG.These results suggest that: a) palliative PSOG for AC can be performed with a low mortality; b) resection with extensive lymphadenectomy allows substantial survival regardless of the extent of gastrectomy.