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The use of abdominal binders after laparotomy is a question of habit. Scientific evidence of their usefulness is limited. The aims of this work were to review the scientific literature and to depict the practices of French surgeons regarding the use of these devices.A systematic review of the literature about the use of abdominal binders after laparotomy was conducted. In order to depict surgeons' habits, an anonymous questionnaire was sent to all surgical departments affiliated to the FRENCH network (Federation of Surgical Research) and their surgical contacts. They were all asked about their use of binders, the type of binders they ordered, the expected benefit, the cost and the need for a randomized trial in this field.Only four trials have been published regarding the use of abdominal binders after laparotomy, all with a small number of patients. Some authors suggested that wearing binders procured a benefit in terms of postoperative comfort, but no significant difference was found. One study also suggested an improvement in respiratory volumes. No study focused on incisional hernia. Regarding the survey of practices, 50 questionnaires were retained for the final analysis (one questionnaire per department of surgery). The use of this device is really very frequent in France (94 % of surgeons order them), a habit usually acquired during the training in surgery. The main expected benefit is the prevention of abdominal wall dehiscence (83 %), but also an improvement in patients' postoperative comfort and pain (66 %). Although some surgeons order an abdominal binder for all their patients, most use them in selected patients (according to the operation and the patients' characteristics).Abdominal binders are frequently ordered by French surgeons after laparotomy. The expected benefit is the prevention of abdominal-wall complications, even though no data actually support this practice. Binders might have a benefit in terms of postoperative pain relief, but this needs to be analyzed. A prospective randomized trial is warranted.

Prosthetic reinforcement is the gold standard treatment for inguinal hernia and reduces the risk of recurrence. Yet up to one-third of patients complain of post-surgical pain due to irritation and inflammation caused by the mesh and the fixation materials. Of these patients, 3-4% will experience severe and disabling chronic pain. We performed a prospective multicenter clinical study of a self-adhering prosthesis, consisting of a lightweight polypropylene mesh (40 g/m²) coated on each side with synthetic glue, to evaluate early postoperative complications and patient outcomes.Between August 2008 and June 2010, 186 patients underwent hernia repair using the Lichtenstein technique and the self-adhering prosthesis. Primary endpoints were the frequency of disabling complications and quality of life (QoL) at 3-month follow-up. Pain, numbness, and groin discomfort were evaluated pre- and postoperatively (1 week, 1 and 3 months) using a visual analogue scale (VAS). Patients' pre- and postoperative QoL were measured using the SF12 questionnaire. Secondary endpoints were number of complications and recurrence rate, use of analgesic drugs, length of hospital stay, delay to return to normal activities, and patient satisfaction. The quality of the self-adhering mesh and its clinical utility were also evaluated by the participating surgeons.A total of 186 patients were enrolled and followed for at least 3 months after inguinal hernia repair. A total of 174 (95%) primary hernias and 12 (5%) recurrent hernias were treated. There were no intraoperative complications, no recurrences, and no repeat interventions performed during the study. The post-surgical complication rate was 4.5%. The mean delay to recover normal physical activity was 4 days. For the primary endpoint of pain, a VAS of zero was reported by 93/184 (50.5%) patients at 1 week, 130/171 (76.0%) patients at 1 month and 119/132 (90.2%) patients at 3 months' follow-up (P 0.0001). The postoperative SF12 scores showed a significant improvement in patient QoL following surgery (P 0.0001).Adhesix( ® ) self-adhering mesh for prosthetic reinforcement following inguinal hernia repair is atraumatic and associated with infrequent post-surgical complications or pain, a rapid recovery rate, and a high patient-reported QoL. A longer follow-up is underway to assess the frequency of post-surgical recurrence.

Resume Dans ce chapitre est rapporte le compte rendu du symposium Nycomed intitule « 60 minutes pour comprendre : de l’hemostase aux regles du management »

BACKGROUND AND STUDY AIMS: To summarize the published literature on assessment of appropriateness of colonoscopy for surveillance after polypectomy and after curative-intent resection of colorectal cancer (CRC), and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. METHODS: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of surveillance colonoscopy after polypectomy and after resection of CRC was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. RESULTS: Most CRCs arise from adenomatous polyps. The characteristics of removed polyps, especially the distinction between low-risk adenomas (1 or 2, small [> 1 cm], tubular, no high-grade dysplasia) vs. high-risk adenomas (large [< or = 1 cm], multiple [< 3], high-grade dysplasia or villous features), have an impact on advanced adenoma recurrence. Most guidelines recommend a 3-year follow-up colonoscopy for high-risk adenomas and a 5-year colonoscopy for low-risk adenomas. Despite the lack of evidence to support or refute any survival benefit for follow-up colonoscopy after curative-intent CRC resection, surveillance colonoscopy is recommended by most guidelines. The timing of the first surveillance colonoscopy differs. The expert panel considered that 56 % of the clinical indications for colonoscopy for surveillance after polypectomy were appropriate. For surveillance after CRC resection, it considered colonoscopy appropriate 1 year after resection. CONCLUSIONS: Colonoscopy is recommended as a first-choice procedure for surveillance after polypectomy by all published guidelines and by the EPAGE II criteria. Despite the limitations of the published studies, colonoscopy is also recommended by most of the guidelines and by EPAGE II criteria for surveillance after curative-intent CRC resection.

Frequency of local and distant failures after gastrectomy has led to extended lymph nodes dissection to obtain a better locoregional control. However, five year survival rates were not significantly different between patients undergoing D2 and D1 lymphadenectomy, and higher morbidity and post operative deaths were reported in large randomised trials (respectively 25% vs 48% and 4 vs 13%). Additionally, several metanalysis failed to demonstrate a significant survival advantage with adjuvant chemotherapy. The results of the first trial demonstrating one advantage to adjuvant post-operative chemoradiotherapy should modify the standard care. Disease free and overall survival after surgery alone and after surgery and concurrent chemoradiotherapy were respectively 31% vs 48% and 41% vs 50%. The intergroup trial demonstrate that better local control improve survival if radiation fields include stamps, tumour bed, proximal nodal chains and nodes corresponding to D2 extended lymph nodes dissection. Treatment was feasible with few severe toxic effects (1%). Of the 281 patients, 17% stopped treatment because toxic effects. Technical modalities of radiotherapy and post-operative nutrition support, which are critical points of interest for this treatment, are also discussed.

F. Lacaine Lymph node metastasis carries enormous prognostic weight in the evaluation of colon cancer and raises the question of how extensive a lymph node dissection should be. Lymph node dissection has several goals: 1) staging of the cancer at the time of intervention; 2) improving the chances for complete resection and cure; 3) evaluating the thoroughness and quality of a particular surgical procedure. The prognostic value of lymphadenectomy is evident from the direct practical decisions it entails: evidence-based recommendations (Level A) have proposed adjuvant chemotherapy for all patients with Stage III colon cancer since 1990. Studies have shown a statistically significant correlation between the number of nodes examined in an operative specimen and long-term survival in patients with Stage II disease. The more closely lymph nodes are examined, the more metastasis is found; one can then see the aberrations of stage migration described as the "Will Rogers Phenomenon." Without randomized studies, it is impossible to say whether resection of a larger number of lymph nodes actually improves the prognosis or whether that number is simply a marker of better surgical management including the quality of the surgical gesture, the careful pathologic examination of the specimen, and subsequent choices for adjuvant chemotherapy. The recovery of 12 lymph nodes correlates with a better global prognosis. At the very least, it is an effective marker for the quality of the surgical resection and can be used in the evaluation of professional practice.

Are physicians and their relatives at risk of postoperative complications when they are scheduled for surgery? With the aim to answer this question, a case control study was performed from a cohort of 11,756 patients scheduled for surgery from 01/01/1987 to 12/31/2002. Fourty seven patients were physicians and 122 were a close relative to a physician. The percentage of physicians in the current series is comparable to that in the general urban population in France. Each of these patients was matched with 5 patients as controls regarding sex, age, diagnosis, procedure, and date of surgery.No statistically significant difference was observed between the 47 physicians and their 235 controls in the occurence of postoperative complications: 6% vs 6% (Odds ratio (OR)=1,07; CI(95%): 0,28-3,74), unplanned return to the operative room: 2% vs 2% (OR=1,00; CI: 0,11-8,8), and postoperative mortality: 0% vs 0,5% (p=0,07). No stastistically significant difference was observed between the 122 close relatives to a physician and their 610 controls in the occurence of postoperative complications: 6% vs 6% (OR=1,00; CI: 0,43-2,3), unplanned return to the operative room: 2% vs 3% (OR=0,55; CI: 0,18-3,4), and postoperative mortality: 1% vs 0,5% (OR=1,67; CI: 0,13-12,12).this study does not confirm the widespread opinion that postoperative course would be worse in physicians as patients and in their close relatives. Their recovery is not different from that to other patients if they are treated as well as other patients.

Contrary to the fears raised in surgical publications of the 1950's and 60's, the prognosis of porcelain gallbladder is not automatically associated with an increased risk of gallbladder carcinoma. Two recent cohort studies have allowed a better definition of the appropriate therapeutic attitude for a patient with a calcified gallbladder. In cases of "true" porcelain gallbladder, i.e., the presence of complete transmural calcification of the entire gallbladder wall, indications for cholecystectomy are based on biliary symptoms, all the more so since choledocholithiasis is often associated with porcelain gallbladder. In the case of partial calcification of the gallbladder, i.e., focal plaques of calcification involving the mucosa, prophylatic operative treatment is indicated. In these cases, the incidence of malignancy is markedly increased (14 times that of a control population). Cholecystectomy can still be performed laparascopically as long as the rules for prevention of peritoneal dissemination of tumor cells are scrupulously observed--the gallbladder should not be opened nor bile spilled, the specimen should be placed in a bag for removal through the abdominal wall, the pneumoperitoneum should be evacuated with the trocars still in place and the specimen should be opened and examined after removal with immediate frozen section pathologic exam if there is any question of tumor.

Frequency of local and distant failures after gastrectomy has led to extended lymph nodes dissection to obtain a better locoregional control. However, five year survival rates were not significantly different between patients undergoing D2 and D1 lymphadenectomy, and higher morbidity and post operative deaths were reported in large randomised trials (respectively 25% vs 48% and 4 vs 13%). Additionally, several metanalysis failed to demonstrate a significant survival advantage with adjuvant chemotherapy. The results of the first trial demonstrating one advantage to adjuvant post-operative chemoradiotherapy should modify the standard care. Disease free and overall survival after surgery alone and after surgery and concurrent chemoradiotherapy were respectively 31% vs 48% and 41% vs 50%. The intergroup trial demonstrate that better local control improve survival if radiation fields include stamps, tumour bed, proximal nodal chains and nodes corresponding to D2 extended lymph nodes dissection. Treatment was feasible with few severe toxic effects (1%). Of the 281 patients, 17% stopped treatment because toxic effects. Technical modalities of radiotherapy and post-operative nutrition support, which are critical points of interest for this treatment, are also discussed.

Item does not contain fulltext GENERAL DESIGN: Presentation of a new type of a study protocol for evaluation of the effectiveness of an immune modifier (rhG-CSF, filgrastim): prevention of postoperative infectious complications and of sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). A randomised, placebo controlled, double-blinded, single-centre study is performed at an University Hospital (n = 40 patients for each group). This part presents the course of the individual patient and a complication algorithm for the management of anastomotic leakage and quality management. OBJECTIVE: In part three of the protocol, the three major sections include: The course of the individual patient using a comprehensive graphic display, including the perioperative period, hospital stay and post discharge outcome. A center based clinical practice guideline for the management of the most important postoperative complication--anastomotic leakage--including evidence based support for each step of the algorithm. Data management, ethics and organisational structure. CONCLUSIONS: Future studies with immune modifiers will also fail if not better structured (reduction of variance) to achieve uniform patient management in a complex clinical scenario. This new type of a single-centre trial aims to reduce the gap between animal experiments and clinical trials or--if it fails--at least demonstrates new ways for explaining the failures.

Before the laparoscopic era, detection of CBD stones in patients with lithiasis of the gallbladder has been made, preferably, by intraoperative cholangiography. Development of laparoscopy gives the necessity of a preoperative detection of CBD stones, especially when a previous endoscopic treatment is preferred. Tenon's multifactorial score, in the Author's opinion, is able to detect patients "at risk" for CBD stones. This score includes the following parameters: age, CBD diameter, size of gallstones, colic pain and cholecystitis. The chance of CBD stones was 2% for a score lower than 3.5 and 81% for a score greater than 5.9. In this way, patients with high probability of CBD stones can be submitted to a preoperative ERCP or to a intraoperative cholangiography, according to the choices of the surgeon.

In patients with symptomatic cholelithiasis, preoperative diagnosis of common bile duct (CBD) stones can modify the therapeutic strategy. The aims of this prospective, controlled multicenter study were to assess the feasibility, concordance, discordance, and indexes such as sensitivity, specificity, positive and negative predictive values, and accuracy of preoperative endoscopic ultrasonography compared with those of intraoperative cholangiography (IOC) in the diagnosis of asymptomatic CBD stones (i.e., patients undergoing cholecystectomy with no clinical or biologic evidence of CBD stones).From October 1993 to October 1995, 240 consecutive patients with symptomatic cholelithiasis, scheduled for cholecystectomy in 14 surgical centers, were enrolled in this study. All patients were selected for this study according to a preoperative high-risk CBD stone predictive score. Each patient underwent both endoscopic ultrasonography and IOC, as well as surgical exploration of the CBD when stones were detected during one or both preoperative investigations. All patients were seen 1 months and 1 year after operation to check for residual stones.The feasibility of endoscopic ultrasonography was significantly higher overall than that of IOC (99% vs 90%; p0.001), except when IOC was through a laparotomy (97% vs 93%; p = 0.16). The number of patients available for study was 215. In 198 cases (92%), results of both investigations were in concordance (161 negative and 37 positive values). Seventeen cases (8%) were discordant. There was overall concordance between the two investigations (kappa coefficient 0.764; 95% confidence interval 0.66 to 0.87), but the percentage of discordance was in favor of IOC. Sensitivity and specificity of IOC were significantly higher than those of endoscopic ultrasonography (1.00 and 0.98 vs 0.85 and 0.93, respectively). With a prevalence of CBD stones of 19%, positive and negative predictive values of IOC were significantly higher than those of endoscopic ultrasonography (0.93 and 1.00 vs 0.75 and 0.96, respectively).Although endoscopic ultrasonography is feasible more often than IOC, IOC is associated with a slightly lower degree of discordance and better information indexes and remains an efficient method of investigation for CBD stones. Endoscopic ultrasonography can be suggested in preference to endoscopic retrograde cholangiography when postoperative residual stones are suspected but need not be performed routinely before cholecystectomy.

The aim of this study was to identify prognostic factors in patients with esophageal cancer after curative resection, and to establish a predictive model of their long-term prognosis.Eighty-nine patients operated on for neoplasia of the esophagus, who underwent a curative resection, an who did not die within one month or during the hospital stay, were included in this study. Twenty-one variables were studied by univariate analysis. The variables linked with survival were include in a Cox model. Regression coefficient of independent prognostic factors allowed to compute a score.Life table analysis of the entire population, showed 2 and 5 year survival rates of 48% and 28%, respectively. In univariate analysis, 5 out of 21 factors were statistically linked with survival. In multivariate analysis (Cox model), 4 independent factors were linked with survival: age (P = 0.02), the American Society of Anesthesiologist classification (P = 0.01), parietal invasion (P = 0.03), and lymph node invasion (P = 0.009). The score established with these 4 factors allowed to distinguish 3 sub-groups, discriminated by their long term prognosis. Life table analysis of the 3 sub-groups were at 2 and 5 years 83%, 55%, 20% and 60%, 32%, 0%, respectively.This model may be useful for the assessment of prognosis in patients with esophageal cancer after curative surgical treatment.

In lower gastrointestinal bleeding, the first step is the exclusion of an upper gastrointestinal cause, responsible in 15 to 20% of cases, and the assessment of the severity of blood loss, so that an adequate resuscitation can be rapidly performed. Eighty percent of these bleeding episodes stop spontaneously; among these, 25% recurs, sometimes severely. When bleeding episode stops, it is essential to repeat the examinations to find out the cause of bleeding. The therapy may be endoscopic, radiologic, surgical or medical. For patients who require an emergent surgical procedure, intraoperative endoscopic techniques can be helpful. In 95% of cases, the source of bleeding is the colon or the rectum: the most common causes are diverticular disease, in particular from the right colon, colorectal tumours, angiodysplasia and colitis, but there are some simple causes easy to diagnose such as hemorrhoids, anal fissures and thermometric ulcerations.

Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates.One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8 +/- 12.1 years) were randomized to undergo hand-sewn (n = 74) or circular stapled (n = 85) supraperitoneal colorectal anastomosis after left colectomy.Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n = 10) and hemorrhage (n = 5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p0.001), but this time gain did not significantly influence the overall duration of operation (identical median times). The median duration of hospitalization was 13 and 14 days, respectively (NS). At 8 months there were 2 of 74 strictures in the hand-sewn group and 4 of 85 strictures in the stapled group (NS).According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.

The current randomized study was done to compare the results of choledochoduodenostomy (CD) and choledochojejunostomy (CJ) for choledocholithiasis, with special reference to long term results and the risk of ascendant cholangitis. From January 1978 to January 1990, 130 patients were included in the study--64 with CD (side to side, in all patients) and 66 with CJ (side to side in 25 patients and end to side in 41). No significant difference was observed between the CD and CJ groups for postoperative mortality (3.8 percent) and morbidity rates. One hundred and twenty patients (58 CD and 62 CJ) were available for long term follow-up evaluation (mean follow-up period of 29 +/- 11 months). One hundred and seven patients had no symptoms attributable to biliary disease or operation. Five patients in this group died of unrelated causes. Thirteen patients experienced biliary symptoms suggestive of cholangitis, or at least related to the bilioenteric anastomosis--six patients in the CD group and seven in the CJ group. Cholangitis was observed in the first postoperative year in eight of these 13 patients and during the second year for the five others. In the CD group, cholangitis was the result of sump syndrome (n = 3), anastomotic stricture (n = 1) and unknown causes (n = 2). In the CJ group, cholangitis was the result of anastomotic stricture (n = 3), residual intrahepatic stones (n = 1) and unknown causes (n = 3). The results of the current study confirm the good long term results of both procedures. However, it suggests that CD is preferable for choledocholithiasis for two reasons--it is technically easier and faster to perform than CJ and, unlike CJ, CD permits easy access to further endoscopic exploration or treatment if necessary.

In patients operated on for gastric carcinoma, the main purpose of a follow-up program is to diagnose recurrent disease and initiate treatment at an early stage. One hundred and ninety-seven consecutive patients were studied, 43 of whom had not received a resection (27%). Resections were carried out in 144 patients, in either palliative (N = 20), or curative (N = 122) intent. The follow-up program included visits to the outpatient clinic at one month, six months, one year, and every year during the five post-operative years. Shorter intervals were employed as indicated by the functional or general status of the patients. One patient has been lost to follow-up. In palliative surgery, median survival was 3 months in patients undergoing laparotomy, 6 months following palliative surgery without resection, and 8 months following palliative resection. In patients who underwent curative resection, 65 are still alive without recurrent disease (57%). Thirty-six of them have been followed-up for more than 5 years. Seven patients died without recurrence. Of 42 patients with recurrence, 10 underwent a reoperation. The only resection was performed for liver metastasis. This patient died 14 months later. Survival in the 9 other patients did not exceed 6 months. This experience suggests that a follow-up program of patients operated on for gastric carcinoma is disappointing.

The controversy about the risk of cancer in patients surgically treated for peptic ulcer is debated in the literature. We analyzed published epidemiological studies, in an attempt to answer the following questions: 1) is there an increased risk of cancer in patients who underwent partial gastrectomy for ulcer disease?; 2) is such a risk influenced by the type of operation performed and by the original pathological lesion?; 3) are there any recommendations for peptic ulcer surgery and for a specific follow-up schedule of the patients? Twelve "prospective" studies have been published on patients operated on for peptic ulcer. These studies are based on the follow-up of a cohort over a certain period of time. Results are expressed and analyzed using the incidence ratio observed in the cohort, comparing observed with expected cases in a similar general population. The results of seven of these studies favor the hypothesis of an increased risk of stomach cancer in patients operated on for peptic ulcer disease, while those of five do not support this hypothesis. The results of two of these studies were obtained by multivariate analyses, which represent the best statistical methodology known for assessing the respective role of confounding variables. We therefore believe that the evidence is good enough to identify patients who underwent partial gastrectomy more than 20 years previously as a high-risk group for the development of carcinoma. We therefore recommend that these patients should be offered regular endoscopy, especially if they underwent a Billroth II surgical procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

La chirurgie ganglionnaire dans le cancer du colon F. Lacaine L’importance pronostique de l’envahissement ganglionnaire pose la question de l’etendue de l’exerese ganglionnaire dans la chirurgie du cancer du colon. Le curage ganglionnaire a plusieurs buts : 1) caracterisation du stade d’evolution de la maladie au moment de l’acte operatoire (« staging » de la maladie) ; 2) meilleure curabilite de la maladie ; 3) appreciation de la qualite de l’exerese chirurgicale per se . Le caractere pronostique, dans une perspective de staging, de l’envahissement ganglionnaire est souligne par son application pratique directe : il est recommande (niveau A) d’administrer une chimiotherapie adjuvante chez les malades de stade III depuis 1990. Des etudes ont trouve une liaison statistiquement significative entre le nombre de ganglions analyses sur une piece operatoire et la survie des malades presentant un cancer stade II. Plus on cherche de ganglions envahis plus on a de chance de les trouver : on illustre alors le « phenomene de Will Rogers » qui decrit la migration de stade. Faute d’essais randomises, impossibles dans cette situation, on ne peut conclure que l’amelioration dans la collecte ganglionnaire suffise par elle-meme a ameliorer le pronostic, ou si cette collecte est simplement un meilleur marqueur d’une meilleure prise en charge du cancer, incluant l’amelioration de la qualite de la chirurgie, de l’examen anatomopathologique et de l’administration d’une chimiotherapie. Le recueil d’un nombre « suffisant » de ganglions ( 12) aboutit donc a un meilleur traitement global des malades. Il devient alors un marqueur efficace de la qualite de l’exerese et peut etre utilise comme une bonne evaluation de pratique professionnelle.

A modified stapling technique for perianal coloanal or ileoanal anastomosis is described. The rectum is everted and transected at dentate line level under direct vision. Anastomosis is performed transanally and through the staple line suture of the anal stump, using the Premium CEEA stapler. We used this technique on five occasions without complications. It makes it easier to perform coloanal or ileoanal anastomosis and provides a better control of carcinomas than the other techniques.

Seven patients have been treated by partial splenectomy, performed with TA 90 linear stapler instrument (U.S. Surgical Corp). Three patients had non parasitic cyst of the spleen, two had malignant disease and two were operated for traumatic injuries. The section and the hemostasis of the spleen was performed with the linear stapler instrument. No patient required blood unit transfusion. Postoperative course was uneventful. Partial splenectomy with the TA 90 stapler, which does not supply the complications of total splenectomy, is an easy and safe procedure. It should be more often indicated.