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Resume Contexte La majorite des etudes portant sur la gastrectomie cœlioscopique provient d’Asie et les resultats ne sont pas forcement transposables. L’objectif de cette etude etait de comparer les resultats apres gastrectomie pour cancer par cœlioscopie (GC) ou par voie ouverte (GO) dans un centre francais. Methodes Entre 2005 et 2015, l’ensemble des patients atteints de cancer gastrique operes d’une gastrectomie etait inclus. La morbi-mortalite postoperatoire etait evaluee selon la classification de Dindo-Clavien. Resultats Parmi 164 patients, 60 (âge median : 62 ans) etaient operes d’une GC et 104 (âge median : 65 ans) une GO. La gastrectomie totale representait 58 % des GC et 54 % des GO (p = 0,749). La duree operatoire n’etait pas differente dans les deux groupes (160,8 vs. 174,2 min, p = 0,780), de meme que les pertes sanguines (111 vs. 173 mL, p = 0,057). Le taux de complications severes (Clavien ≥ 3), incluant l’hemorragie postoperatoire, etait significativement plus eleve dans le groupe GC (40 % vs. 23 %, p = 0,012), de meme que le taux de reinterventions (27 % vs. 6 %, p Conclusion La GC pour cancer semble etre realisable avec cependant un taux plus eleve de complications severes par rapport a la GO.

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

Laparoscopic approach in colorectal surgery has demonstrated to give advantages in terms of postoperative outcomes, particularly in high-risk patients. The aim was to assess the impact of patients' age on the short-term outcomes after laparoscopic right colectomy for cancer.From January 2004 to September 2014, all patients who underwent laparoscopic right colectomy for cancer in a single institution were divided into four groups (A:64 years; B: 65-74 years; C: 75-84 years; D ≥85 years). Risk factors for postoperative complications were determined on multivariable analysis.Laparoscopic right colectomy was performed in 507 patients, including 171 (33.7%) in A, 168 (33.1%) in B, 131 (25.8) in C and 37 (7.4%) in D. Patients in Group C and Group D had higher ASA score (p0.0001) and presented more frequently with anaemia (20.6% and 29.7%, p=0.001). Stages III and IV were more frequently encountered in groups C and D. Overall morbidity was 27.5% without any difference in the four groups (24.5%, 29.1%, 7.5% and 18.4% respectively, p=0.58). The rate of minor complications (such as wound infection or postoperative ileus) was higher in Group D compared to other groups (p=0.05). The only independent variable correlated with postoperative morbidity was intraoperative blood transfusion (OR 2.82; CI 95% 1.05-4.59, p0.0001).The present series suggests that patient's age did not significantly jeopardize the postoperative outcomes after laparoscopic right colectomy for cancer.

The majority of laparoscopic gastrectomy (LG) reports arise from Asia and the benefit of this approach in western countries remains unclear. The objective of this study was to compare the postoperative outcomes between LG and open gastrectomy (OG) for gastric cancer in a western center.Between 2005 and 2015, all consecutive patients with gastric cancer who underwent either LG or OG were enrolled. Postoperative morbimortality was evaluated according to Dindo-Clavien classification.Over 164 patients, 60 had LG and 104 OG with a mean age of 62 and 65 years, respectively. Total gastrectomy represented 58% of LG and 54% of OG (P=0.749). Operative time was not different in the two groups (160.8 vs. 174.2min, P=0.780) so as intraoperative blood loss (111 vs. 173mL, P=0.057). The rate of severe complications (including postoperative bleeding) was significantly higher in the LG group (40% vs. 23%, P=0.012) so as reoperation rate (27% vs. 6%, P0.001). There was no statistical difference in terms of postoperative mortality (0 vs. 3%, P=0.252) or length of hospital stay (20 vs. 16 days, P=0.116).Laparoscopic gastrectomy for the treatment of gastric cancer in western countries appears to be feasible but with a higher rate of severe complications compared to open gastrectomy.

Summary 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.

Laparoscopic pancreatic enucleation is increasingly performed worldwide. Few small-sized series show encouraging results, especially after enucleations performed for lesions located in the left part of the pancreas. The outcome of laparoscopic pancreatic enucleations was retrospectively evaluated by the analysis of prospectively collected parameters. Results of right-sided (head/uncus) and left-sided (neck/body/tail) enucleations were compared. From 1997 to 2010, 25 patients underwent laparoscopic pancreatic enucleation. The conversion rate was 12%, mean operating time was 158 minutes, and mean blood loss was 106 mL. Morbidity was 56% and the rate of pancreatic fistula 32%. Outcome differed between patients undergoing right-sided and left-sided enucleations, the operative time being 178 versus 132 minutes, morbidity 64% versus 45%, and median hospital stay 26 versus 9 days, respectively. Pancreatic enucleation is feasible by laparoscopy, with a high success rate and no mortality but significant morbidity. Laparoscopy seems to be of no use in right-sided procedures. Pancreatic fistula is still the main cause of long-lasting morbidity.

A b s t r a c t Introduction: A few retrospective, small, often multicentric studies show encouraging results of laparoscopic minor pancreatic surgery, but do not allow for an evaluation of feasibility and effectiveness. Aim: Evaluation of the results of laparoscopic minor pancreatic resections (LMPR), including atypical resections and enucleations. Material and methods: The outcome of all consecutive patients undergoing LMPR in a tertiary care university hospi- tal specializing in the laparoscopic approach to solid organs (I.M.M., Paris - France) was retrospectively evaluated by the analysis of operating time, blood loss, conversion, morbidity, stay and late outcome. Results: Thirty-three patients underwent LMPR (29 enucleations and 4 atypical resections) for various diseases. The conversion rate was 21%, mean operating time 189 min, and mean blood loss 133 ml. Morbidity was 60%; 10 pa - tients (30%) presented a pancreatic fistula. Pancreatic fistula was independent of type of resection, technique of pan - creas section, management of enucleated surface and somatostatin administration. Median stay for enucleations was 18 days. Mean follow-up was 61 months. Conclusions: Laparoscopic pancreatic enucleation is feasible and safe, with no mortality, no lengthening of operating time and a high success rate. Conversely, it does not imply a reduction in complications or hospital stay at the present state of the art.

Lower gastrointestinal bleeding after left colectomy is an uncommon complication that can lead to critical situation. Diagnostic and therapeutic manoeuvres should be performed in emergency with step-by-step strategy in order to avoid reoperation. This study aims to identify bleeding risks factors and describe a management strategy. This is a retrospective study of patients who underwent left colectomy with primary anastomosis, from May 2004 to December 2013. We studied their demographic characteristics, surgical procedures and postoperative courses, more specifically hemorrhagic complications, management of bleeding and outcomes. Hemorrhagic anastomotic complication occurred in 47 of the 729 (6.4 %) patients after left colectomy. Neither anticoagulant nor antiaggregant treatment was associated with postoperative bleeding. Among the 47 patients with bleeding, endoscopy was performed in 37 (78.7 %). At the time of endoscopy, the bleeding was spontaneously stopped in nine (24.3 %). Therapeutic strategy used clips in 10 (27.0 %) cases, mucosal sclerosis in 11 (29.7 %) and both in 7 (18.9 %) cases. Four (8.5 %) patients required blood transfusion for treatment of this gastrointestinal bleeding. Five (10.6 %) patients with bleeding were reoperated in this group because early endoscopy showed associated anastomotic leakage. Based on a multivariate analysis, stapled anastomosis and diverticular disease were independent factors associated with anastomotic bleeding. Postoperative anastomotic bleeding is not so uncommon after left colectomy. This complication should be particularly dreaded in patients who underwent stapled colorectal anastomosis for diverticular disease. With the use of clip or mucosal sclerosis, early endoscopy is a safe and efficient treatment.

OBJETIVO: Avaliar a morbidade pós-operatória e investigar a existência de seus fatores preditivos. MÉTODOS: O estudo foi realizado de forma retrospectiva, a partir de uma base de dados mantida de forma prospectiva. De 1994 a 2008, 100 pacientes consecutivos foram submetidos à ressecções pancreaticas esquerdas. A principal variável de interesse foi a morbidade pós-operatória, tendo diversas outras características da população sido registradas simultaneamente. Posteriormente, para a análise de fatores preditivos de morbidade pós-operatória o subgrupo de pacientes que foi submetido aos procedimentos de pancreatectomia distal com preservação do baço (n=65) foi analisado separadamente quanto à relevância das diferentes técnicas de secção do parênquima pancreático, assim como, outros possíveis fatores preditivos à ocorrência de morbidade pós-operatória. RESULTADOS: Considerando-se juntamente todas as ressecções pancreáticas esquerdas realizadas, a ocorrência de complicações globais, de complicações relevantes e graves foi 55%, 42% e 20%, respectivamente. Os fatores que se mostraram preditivos à ocorrência de morbidade pós-operatória após pancreatectomia distal com preservação do baço foram a técnica de secção do parênquima pancreático, idade, índice de massa corporal e a realização de operação abdominal concomitante. CONCLUSÃO: A morbidade associada às ressecções pancreáticas, à esquerda dos vasos mesentéricos superiores, foi importante. De acordo com a estratificação adotada baseada na gravidade das complicações, alguns fatores preditivos foram identificados. Estudos futuros com coortes maiores de pacientes são necessários para confirmar tais resultados.

Resume Objectif La chirurgie ambulatoire de la hernie n’est pas encore de pratique courante en France. L’objectif de cette etude a ete d’evaluer prospectivement la faisabilite de la cure de hernie en ambulatoire sur une serie continue de patients non selectionnes. Patients et methodes De juin 2008 a octobre 2009, 257 patients (238 hommes et 19 femmes, d’âge median 65 ans) ont ete pris en charge avec l’intention de les traiter en ambulatoire. Ils ont ete operes pour 270 hernies (244 hernies de l’aine, une hernie de Spiegel et 25 hernies epigastrique et ombilicales). Resultats Pour les hernies de l’aine, les techniques utilisees ont ete la voie endoscopique extraperitoneale (TEP) dans 108 cas et la voie transinguinale preperitoneale (TIPP) dans 106 cas et une autre technique dans 30 cas ; pour les hernies epigastriques et ombilicales, une suture par abord direct dans 20 cas, une prothese par abord direct dans quatre cas et par cœlioscopie dans un cas. L’anesthesie a ete generale dans 145 cas, locale dans 121 cas et rachidienne dans quatre cas. La chirurgie a ete realisee en ambulatoire dans 242 cas (89,6 %), il y a eu 21 (7,8 %) hospitalisations programmees, sept (2,6 %) hospitalisations non programmees et deux (0,7 %) readmissions. Il est survenu neuf (3,3 %) complications postoperatoires benignes. Conclusion Ces resultats suggerent que la chirurgie des hernies de l’aine et des hernies epigastriques et ombilicales peut etre realisee en ambulatoire dans pres de 90 % des cas sur des patients non selectionnes.

BackgroundSeveral scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score—the Elderly (E) POSSUM—has been developed and its accuracy compared with these scores.MethodsFrom 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration.ResultsThe mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0·86) and good calibration (P = 0·178) in predicting mortality and a reasonable discrimination (AUC = 0·77) and good calibration (P = 0·166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (Pc = 0·014 and Pc < 0·001 respectively).ConclusionThe E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

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 aim of this study was to assess the performance and tolerance of an innovative disposable instrument delivering resorbable clips (I-ClipTM, Sofradim, France) intended for mesh fixation in inguinal, incisional and umbilical hernias of the abdominal wall. The fixation device was designed to be resorbable in 1 year, with reduced trauma to the underlying tissues or the mesh, and with initial mechanical properties equivalent to those of conventional metal staples. The study involved 105 patients with inguinal, umbilical or incisional hernias enrolled from 11 centres. Inguinal totally extra peritoneal (TEP) or trans abdomino pre-peritoneal (TAPP) repair was performed with Parietex® mesh, incisional or umbilical hernias were treated via the intraperitoneal route with Parietex® composite. I-ClipsTM were used for mesh fixation in both indications according to the surgeon’s habits. Efficacy was the principal assessment criteria evaluated by two parameters: quality of fixation evaluated subjectively at the time of procedure and recurrence rate according to the follow up at 1, 6 and 12 months. Pain evaluated by the patients using a visual analogue scale (VAS) was the principal secondary assessment criteria. Other tolerance criteria were also evaluated during surgery and follow up. The surgeons’ evaluation of the fixation quality was assessed as good to very good in 100% of ventral hernias and good to very good in 85–92% of inguinal hernias. At 1 month, 90% of patients (94/104) were totally pain-free (VAS score: 0) and only ten patients reported low pain (VAS scores: 0.3–3.1). At 1 year, the pain described by those ten patients finally disappeared, 98% of patients (102/104) were totally pain-free. The rate of minor complications not related to the device concerned 5% of the patients at 1 month, which was reduced to 2% at one year and no recurrence or mesh sepsis was observed. The ease of use of this device, combined with the absence of recurrence related to the investigated device and the good pain-free outcome in this group of patients confirmed the effectiveness and tolerance of the resorbable fixation concept of I-ClipTM.

Background Since the first laparoscopic cholecystectomy was performed in 1987, the surgical applications of laparoscopy have grown to involve most areas of general surgery. Until recently, however, major liver surgery remained outside of the scope of minimally invasive surgery. Building on advances in laparoscopic equipment, techniques, and ongoing experience in hepatic surgery, major liver resection has been performed laparoscopically in some select centers. At our institute, a safe and standardized approach to minimally invasive major hepatectomy has been developed. This article illustrates the relevant technical maneuvers in the performance of a totally laparoscopic right hepatectomy. Common pitfalls and areas of concern are discussed. Methods A detailed description of a standardized procedure is presented. The technique was developed from a single-institution experience of 41 laparoscopic right hepatectomies performed in a tertiary care referral center for laparoscopic digestive surgery. The prevention of bleeding and gas embolism are discussed. Conclusions The laparoscopic right hepatectomy is feasible and safe if the appropriate expertise and equipment are available. In selected patients, this new approach can be proposed by a surgeon experienced in laparoscopic and hepatic surgery as an alternative to conventional open liver 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 But de l'etude. – La mise en place d'une prothese parietale dans le traitement des eventrations postoperatoires permet de reduire le risque de recidive. Une seule etude prospective randomisee a compare l'abord cœlioscopique a l'abord par laparotomie : la morbidite postoperatoire et les recidives etaient moindres dans le groupe de malades operes par cœlioscopie. Le but de ce travail prospectif etait de controler ces resultats. Patients et methodes. – De janvier 2000 a mai 2002, 51 eventrations postoperatoires consecutives ont ete traitees par cœlioscopie. L'eventration etait unique chez 41 malades et double chez cinq malades. L'eventration etait mediane 41 fois et laterale dix fois. Elle avait deja ete operee dans 33,3 % des cas. Le critere principal de jugement etait la recidive. Nous avons cherche si les criteres suivants etaient associes a un risque de recidive : le sexe, l'obesite, un antecedent de reparation anterieure, les dimensions pre- et peroperatoires de l'eventration, son caractere uni- ou multiloculaire, son siege median ou lateral, les dimensions de la prothese, le rapport entre la surface de la prothese et celle de l'eventration. Les criteres secondaires etaient : la mortalite et la morbidite postoperatoires, la duree d'hospitalisation et la survenue d'evenements a distance. Resultats. – Tous les malades ont ete revus a deux ans, 23 a trois ans et neuf a quatre ans. Sept recidives ont ete observees (13,7 %). Aucun des facteurs etudies n'a ete associe de facon significative a une recidive. La mortalite a ete nulle. La douleur postoperatoire moyenne aux premier, deuxieme et troisieme jours postoperatoires a ete chiffree a 3,1 ± 1,9, 2,9 ± 2,3, et 2,3 ± 2,1. La duree moyenne d'hospitalisation a ete de 4,1 ± 1,9 jours. Sept complications postoperatoires, benignes, sont survenues. Dix-neuf evenements sont survenus a distance dont des douleurs chroniques chez huit malades. Conclusion. – Cette technique nous semble applicable a tout malade et a tout type d'eventration en dehors les eventrations peristomiales, non testees ici. Des ameliorations techniques doivent etre trouvees pour reduire le taux de recidives.

Background This paper describes a 10-year experience of laparoscopic liver surgery, including several major hepatectomies for malignant tumours. Methods Of 243 hepatectomies carried out between January 1995 and December 2004, 113 (46·5 per cent) were performed by laparoscopy and 89 were included in this retrospective study. Results Twenty-four laparoscopic hepatectomies (27 per cent) were for benign disease and 65 (73 per cent) for malignant tumours, including hepatocellular carcinoma (HCC) in 16 patients and colorectal metastasis (CRM) in 41. Minor hepatectomy was performed in 51 patients and major hepatectomy (three or more Couinaud segments) in 38. Conversion to laparotomy was necessary in 12 patients and perioperative blood transfusion in eight. One patient with cirrhosis who underwent right hepatectomy for HCC with conversion to open surgery died 8 days after surgery. Major morbidity occurred in eight patients (16 per cent) having minor hepatectomy and in 11 (29 per cent) of those having a major resection. The 3-year overall and disease-free survival rates for patients with CRM (mean follow-up 30 months) were 87 (11 patients at risk) and 51 (6 patients at risk) per cent respectively. Corresponding values for patients with HCC (mean follow-up 40 months) were 85 (10 patients at risk) and 68 (5 patients at risk) per cent. Conclusion In experienced hands, the results of laparoscopic liver surgery are similar to those for laparotomy.

Resume Le diverticule de Zenker represente la tres grande majorite des diverticules pharyngo-œsophagiens et œsophagiens. C'est une hernie de la muqueuse pharyngee a travers la couche musculaire de la jonction pharyngo-œsophagienne. Il est actuellement considere comme la consequence d'un defaut d'ouverture du muscle cricopharyngien. Il se manifeste par une dysphagie, des regurgitations, et moins frequemment par des manifestations respiratoires (toux, infections bronchopulmonaires). Son diagnostic est fait par opacification barytee. Son traitement peut etre chirurgical – resection du diverticule avec myotomie du cricopharyngien – ou endoscopique, par confection d'une œsophagodiverticulostomie. Les diverticules du corps de l'œsophage sont des hernies de la muqueuse œsophagienne a travers la musculeuse et sont secondaires a un trouble moteur de l'œsophage. Ils sont la plupart du temps peu ou asymptomatiques. Certains donnent lieu a une dysphagie, des regurgitations, des symptomes respiratoires, un pyrosis. Leur diagnostic est fait par opacification de l'œsophage. Il n'y a pas de traitement medical. En raison d'une mortalite et d'une morbidite postoperatoires importantes ainsi que d'un faible taux de tres bons resultats fonctionnels a distance, seuls les diverticules tres symptomatiques doivent etre operes. Les principes du traitement sont la section longitudinale de la musculeuse œsophagienne en aval du diverticule et la resection du diverticule s'il est de grande taille. Il n'existe pas de consensus sur la realisation pratique de ces gestes ni sur la voie d'abord a utiliser. Les techniques « mini-invasives » pourraient devenir des techniques de reference dans le traitement des diverticules epiphreniques.

Resume But de l’etude : Une dysphagie severe ou une hernie para-œsophagienne peuvent compliquer les suites immediates d’une fundoplicature par cœlioscopie. Le but de ce travail etait d’analyser les malfacons techniques responsables de ces complications. Patients et methode : Quatre patients, traites pour reflux gastro-œsophagien par fundoplicature partielle posterieure cœlioscopique, ont eu en postoperatoire une dysphagie majeure (n = 2) ou une hernie para-œsophagienne (n = 2). Le transit œsogastroduodenal a permis de diagnostiquer la complication dans trois cas, une mauvaise interpretation de cet examen a retarde dans un cas le diagnostic de hernie para-œsophagienne qui a ete fait par un examen tomodensitometrique. La reintervention a ete faite par cœlioscopie a j3 (n = 2) et j6 (n = 2). Resultats : La dysphagie etait liee a un effet billot de la fundoplicature sur l’œsophage abdominal plaque contre l’hiatus. La reintervention a ete simple et a permis de refaire une fundoplicature plus souple. La dysphagie a disparu immediatement apres la reintervention. Avec six et 12 mois de recul, les deux operes etaient asymptomatiques. En cas de hernie para-œsophagienne, il existait une dechirure de la base des piliers du diaphragme. Chez le patient opere a j3, l’intervention a ete facile, les suites simples, et avec un recul de 20 mois, il etait asymptomatique. Chez le patient opere a j6, la moitie superieure de l’estomac etait herniee dans la cavite pleurale gauche, l’intervention a ete rendue difficile par le caractere tres inflammatoire de la paroi gastrique, les suites ont ete simples mais le reflux gastro-œsophagien avait recidive 18 mois plus tard Conclusion : En cas de dysphagie importante ou de hernie paraœsophagienne survenant immediatement apres fundoplicature partielle posterieure par cœlioscopie, la reintervention, possible par cœlioscopie, permet d’identifier la malfacon technique responsable et de la corriger. Cette correction est d’autant plus facile que la reintervention est plus precoce, particulierement en cas de hernie paraœsophagienne.

Laparoscopic treatment of small intestinal obstruction is associated with immediate advantages and it may be expected that the recurrence rate will be decreased because of the reduction of wound scars. Between September 1989 and October 1994, 30 patients (19 men and 11 women), mean age 54.4 years, underwent initial laparoscopy for acute small intestinal obstruction. These patients had undergone a total of 52 (1.6 per patient) laparotomies, 15 years before, on average. One patient had never been operated on, 15 had one previous laparotomy, seven had two, five had three, and two had four previous laparotomies. Laparoscopic treatment of intestinal obstruction was possible in 10 cases, including three cases of bands, and six instances of adhesion and one small bowel strangulation in a trocar hole from a previous laparoscopy. In 20 cases, laparoscopy had to be completed by laparotomy, 17 immediately and three secondarily. The cause of immediate failure was the impossibility of finding and/or treating the cause...

Summary Objective Ambulatory surgery is not commonly practiced in France today. The aim of this study was to prospectively evaluate the feasibility of ambulatory hernia repair in a consecutive series of unselected patients. Patients and methods From June 2008 to October 2009, 257 patients (238 men and 19 women, median age 65 years) were treated in a same-day surgery unit for 270 hernias (244 groin hernias, 25 ventral hernias and one Spiegelian hernia). Results For groin hernia, the techniques included the totally extraperitoneal repair (TEP) in 108 cases, the transinguinal preperitoneal (TIPP) approach in 106 cases and other alternative techniques in 30 cases; for ventral hernias, the technique was an open suture in 20 cases, an open prosthetic repair in four cases and laparoscopic repair in one case. Anesthesia was general in 145 cases, local in 121 cases and spinal in four cases. Repair was completed in a same-day surgery setting in 242 (89.6%) cases; hospital stay greater than 23 hours was planned for 21 (7.8%) patients while non-programmed hospitalizations were necessary for seven (2.6%) patients. There were two (0.7%) readmissions and nine (3.3%) benign postoperative complications. Conclusion These results suggest that groin and ventral hernia repair can be performed in an outpatient setting in nearly 90% of unselected patients.

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.

Laparoscopic surgery is thought to promote early recovery and quicker return to bowel function. The objective was to evaluate the rate and predictive factors of success, the causes of failure, the morbidity, and mortality during and after hospitalization, as well as to determine whether laparoscopic treatment of acute small bowel obstruction offers the same benefits as for other laparoscopic procedures.The records of 308 patients with acute small bowel obstruction treated laparoscopically in 35 centres between 1 October 1988 and 30 September 1996 were retrospectively reviewed.Treatment was implemented completely by laparoscopy ('success' group) in 168 patients (54.6%). Conversion to laparotomy ('failure' group) was required in 140 patients (45.4%; during the same operation in 126 patients and after a median delay of 4 days (range: 1-12 days) in 14 patients). There were significantly more successes in patients with a history of one or two surgical interventions than in those with more than two (56% vs 37%; P0.05). There were significantly more successes in patients who had undergone appendectomy only (67/94; 71%) than in patients who (i) had no antecedent surgery (52%; P0.05), or (ii) underwent other surgery (33%; P0.001). The rate of success was significantly higher (P0.001) in patients operated on early (24 h) and in patients with bands (54%), than in those with adhesions (31%) or with other causes of obstruction (15%). The median duration of postoperative ileus was significantly shorter in the 'success' group than in the 'failure' group (2 days vs 4 days; P0.001). The median duration of postoperative hospital stay was shorter in the 'success' group than in the 'failure' group (4 days vs 10 days; P0.001). Fewer immediate wound complications were sustained in the 'success' group than in the 'failure' group (1.2% vs 10.7%; P0.001). The total number of immediate or delayed complications and particularly the number of recurrent obstructions after hospitalization as well as the number of deaths did not differ significantly between the two groups.Successful laparoscopic treatment of small bowel obstruction can be expected in patients who are seen early, and who have had one or two previous interventions (particularly appendectomy, especially if bands are found).

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.

Gastric stromal tumours are not perfectly known. The aim of this retrospective multicenter study (29 centers) was to improve knowledge of these tumours.From 1986 to 1994, 159 patients were operated on for leiomyomas (50), leiomyosarcomas (24), malignant/benign schwann cell tumours (10/29), automatic nerve tumours (4), leiomyoblastomas (28), spindle cell tumours (14). The mean duration of follow-up was 5 years. Presenting symptoms, diagnostic procedures, operative and pathological findings, evolution (recurrence, death) were recorded for each patient.Gastrointestinal bleeding and epigastric pain were the most common presenting symptoms (54% and 50% of patients, respectively). Endosonography was the most sensitive examination (97%). Malignant tumours size was greater than benign tumours size (12.6 cm versus 5.2 cm). Extension to contiguous organs or metastases were frequent (33% and 26% of patients, respectively). In 16 patients, pathological examination could not differentiate between malignant and benign tumour. Seven patients who had been operated on for a benign tumour (6%) developed a local (n = 4) or a metastatic (n = 3) recurrence. The 5-year survival rate was 40% for leiomyosarcomas, 28% for schwannosarcomas and 90% for malignant leiomyoblastomas.The main feature of stromal gastric tumours is the frequent difficulty to differentiate between malignant and benign tumours. The prognosis of malignant tumours depends on pathological types. The prognosis of benign tumours is uncertain since recurrences may develop.

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%.

To compare chemotherapy with no chemotherapy as palliative treatment for oesophageal squamous cell carcinoma.Randomised study.Multicentre trial in France.Of 161 patients with histologically confirmed oesophageal squamous cell carcinoma located more than 5 cm from the mouth of the oesophagus, five were withdrawn because of protocol violation. The remaining 156 patients, 149 men and 7 women, mean (SD) age 58 (9) years range 36 to 77, were randomly allocated to either a control group without chemotherapy (n = 84) or a group treated by chemotherapy (n = 72). Patients were divided into four strata: I = complete resection of the tumour but with lymph node involvement (n = 62); II = incomplete resection of tumour leaving gross tumour behind (n = 58); III = no resection because of local or regional invasion (n = 22) ; and IV = no resection because of distant metastasis (n = 14). Exclusion criteria were histologically confirmed tracheobronchial involvement, oesophagotracheal fistula, Karnosky score50, cerebral metastases, or hepatic metastases occupying more than 30% of the liver, peritoneal carcinomatosis, associated or previously treated ear-nose-throat carcinoma, or complete resection of tumour without lymph node involvement.5 fluorouracil (5FU) and cisplatin (CDDP) were given in 5-day courses, once every 28 days, for a maximum of eight cycles. 5 FU, 1 g/m2, was infused for 24 hours after a water overload, during five days. Cisplatin was given either in one dose of 100 mg/m2 at the beginning of the cycle or 20 mg/m2/day over three hours for five days. Duration of treatment ranged from 6-8 months.Median and actuarial survival. The subsidiary endpoint was quality of survival judged by complications of treatment, swallowing disorders, and the duration of ability to feed normally.There was no difference in survival, either overall (median = 12 months) or in any of the strata. There were however significantly more patients with neurological (p0.003), haematological (p0.0001), and renal (p0.0002) complications in the treated group compared with the control group. Four patients (6%) died of complications of chemotherapy. The course of swallowing disorders did not differ between the two groups. The duration of autonomous oral feeding was exactly the same in both groups (median = 10.5 months).The results suggest that 5FU and CDDP do not help in patients with squamous cell carcinoma of the oesophagus whether or not the tumour has been resected.

To propose guidelines for treatment based on the study of early and late outcome after various surgical procedures for sclerosing encapsulating peritonitis (SEP). PRIMARY BACKGROUND DATA: SEP is rare. The main complication is intestinal obstruction. Ideal treatment is resection of the membrane, whenever possible. Mortality and morbidity, however, have not been well analyzed.The case records and histopathological reports of 32 operated cases of SEP (18 centers during 16 years) were retrospectively studied. Patients underwent four types of procedures: group 1 (n = 5), membrane resection; group 2 (n = 12), enterolysis with partial excision of the membrane; group 3 (n = 7), intestinal resection, and group 4 (n = 8), exploratory laparotomy only. Five cases were considered as idiopathic. Medical and surgical antecedent history for the 27 other cases (6 patients had associations) included laparotomy for carcinoma (n = 14) or benign disorders (n = 5), beta-blocker treatment (n = 4), cirrhotic ascites (n = 4), generalized peritonitis (n = 3) and continuous ambulatory peritoneal dialysis (n = 3). Indications for operation included subacute (n = 22) or acute intestinal obstruction (n = 6), abdominal mass (n = 8), other clinical presentations (n = 4) and asymptomatic SEP discovered during surgery for portacaval shunt (n = 1). Seven patients had two associated clinical presentations. All cirrhotic patients with ascites and the asymptomatic patient were in group 4. None of the imaging techniques (plain radiograms, barium follow-through, sonograms and CT scans) were formally contributive to the preoperative diagnosis of SEP.In group 1, both complicated patients, one with an inadvertent intraoperative intestinal wound, the other with a postoperative intestinal leak, healed uneventfully. In group 2, 4 inadvertent intraoperative intestinal wounds led to 4 postoperative leaks with 3 consequent deaths. One further patient died of persistent intestinal obstruction. In group 3, 1 inadvertent intestinal intraoperative wound healed uneventfully and 2 deaths, one due to persistent intestinal obstruction associated with anastomotic leakage and the other due to ventricular fibrillation, were noted. In group 4, there were no intraoperative wounds, no postoperative morbidity or deaths. The median follow-up was 49.5 months (range 4-142 months). Seven patients (1 or 2 in each group) experienced transient episodes of subacute intestinal obstruction between 1 month and 6 years after discharge, none of which required a repeat operation. Eight patients (in all groups) died of their initial cancer between 4 and 75 months after discharge.Our results suggest that: (1) resection of the membrane should be attempted when feasible; (2) in case of inadvertent intestinal wound(s), the most proximal one should be brought out as a stoma, and partial resections should not be anastomosed primarily, but (3) no surgical treatment is required in ascites, asymptomatic SEP or subacute intestinal obstruction.

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.

Retrospective study of 2,665 laparoscopic cholecystectomies (LC) performed between April 1988 and December 1994 in the French technique with selective intra operative cholangiography. Obesity was present in 13% of patients, respiratory insufficiency in 4%, inflammation in 13% and common bile duct (CBD) stones in 4%. Those cases are now good indications for L.C. A conversion to laparotomy occurred in 52 cases (2%). The rate of post operative complications was 1.6%, including 24 non biliary complications with 2 death and 17 biliary ones concerning the CBD in 6 cases. Those results compare favourably with the ones of open cholecystectomy and the cost is about the half.

Buckley's syndrome is a nosologic entity characterized by the presence from birth of extremely elevated levels of circulating immunoglobulin E and an important deficiency of polymorphonuclear chemotaxis. The consequences of such alterations are represented by the premature rising of recurrent cutaneous, pulmonary and articular infections, slowing down of growth and quite significant disturbances of the immune system. We report a case which presents all the characteristics of Buckley's syndrome: familial history for atopy; otorhinolaryngologic, gynecologic and pulmonary recurrent infections from birth (caused by Staphylococcus, Candida albicans but also Proteus, Enterococcus, Pyocyanea and Moraxella) some of which necessitate surgery therapy; immune disturbances. The patient had hospitalized in our Surgery Department for sinus pilonidalis abscess. At a first treatment of removal of the primary orifice and accurate curettage of the cavity (Marti's intervention) there followed another operation of larger exeresis for an abscess relapse of the sinus at a distance of 2 months. In the interval between the two treatments, an eczematous patch of 8 cm diameter appeared on the left buttock, a probable manifestation of the state of hypersensitivity of the patient. We believe, therefore, that in patients with Buckley's syndrome who must be subjected to surgical intervention it is necessary to resort to a radical treatment from the beginning, given the particular tendency to an infection relapse presented in these cases.

Gallbladder extracorporeal lithotripsy was performed on 60 patients before laparoscopic cholecystectomy. Of the 44 cases with solitary stones (range, 17-45 mm; mean +/- SEM, 26.9 +/- 0.1 mm), satisfactory fragmentation was obtained in 77.2%. Of the 16 cases with multiple stones (range, 11-25 mm; mean +/- SEM, 14.9 +/- 0.7 mm), satisfactory fragmentation was obtained in 18.75%. Minimal adverse effects were observed both clinically and macroscopically during surgery. Upon histologic investigation, only two small gallbladder lesions could be attributed to extracorporeal lithotripsy. No changes in blood chemistry tests were recorded. When carried out with high performance equipment, extracorporeal lithotripsy appears to be an interesting procedure that permits an appreciable reduction in the number of parietal wall incisions that need to be widened, therefore simplifying laparoscopic cholecystectomy when dealing with large stones.

The development of laparoscopic cholecystectomy is only justified if it can ensure the good results obtained by laparotomy. The purpose of this work is to study all complications which occurred in a homogeneous group of patients. From May 1988 to January 1993, we operated on 2006 patients by laparoscopy (724 men and 1282 women) with a mean age of 50.6 years. Signs of stones in the common bile duct were noted in 4.1% and acute cholecystitis was detected in 12.5%. A conversion to normal laparotomy was necessary in 2.1% of patients. All complications were systematically investigated restrospectively in any patient hospitalised for more than five days. Residual stones in the common bile duct were not taken into consideration when they were not complications obviously related to the operation. We observed five intraoperative complications (4 hemorrhages, 1 ileum puncture) and 40 postoperative complications (25 non biliary and 15 biliary). The 25 non biliary complications consisted of: 1 death by pulmonary embolism, 9 hemorrhages, 4 cases of acute pancreatitis, 4 subphrenic abscesses, 2 colon punctures, 2 parietal complications, 1 ulcer perforation, 1 myocardial infarction and 1 phlebitis. The 15 biliary complications consisted of: 3 lateral punctures of the common bile duct, 9 fistulas of the cystic duct (4 with a residual stone in the common bile duct and 5 without), 2 punctures of an abnormal right hepatic duct, one of which was treated by "Roux en Y loop" intestinal diversion, and a late stenosis of the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)

The recent development of mini-invasive surgery includes appendectomy. We report our results of 4 years experience in this type of approach. We have operated on 154 patients (61 men, 93 women), mean age 26.7 years, presenting with clinical signs of appendicitis. The operation was completely carried out by laparoscopy in 144 cases, including treatment of abscess in 13 and peritonitis in 8 cases. Operation was converted into laparotomy in 10 cases, 4 of which because of some difficulty in appendix dissection. No deaths were recorded. Eight (5.2%) post-operative complications occurred: 4 infections of the trocar hole, one of which the cause of readmission; 3 cases of pain and fever (in one a re-laparoscopy was performed because of suspicion of leakage of the appendicular stump); 1 residual hematoma requiring second laparoscopy. Mean duration of hospitalisation was 4.9 days (range 2-25 days): at present, mean hospitalisation is 2 and 6 days respectively in cases with and without peritonitis. In conclusion, laparoscopic appendectomy appears to be feasible in the majority of cases, with better results when the appendix is ectopic and/or in the presence of peritoneal reaction.

The authors report a case of symptomatic cholelithiasis in a patient with situs inversus totalis, in which the surgical treatment was performed by laparoscopy. They discuss the etiopathogenesis of this anomaly and malformations often associated, moreover related clinical and surgical problems. Finally, they describe operative technique stressing the real possibility to perform the operation by laparoscopy on condition that the surgeons have sufficiently experience of biliary and laparoscopic surgery.

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.

The authors relate about a case of symptomatic cholelithiasis, in which the organ was located in the inferior face of III hepatic segment and the surgical treatment was performed by laparoscopy. They discuss about etiopathogenesis of this anomaly, symptomatology referred by the patients and diagnostic procedures. Finally, they stress the necessity, in this case, to perform the cholecystectomy by anterograde approach in order to well visualize the anatomic structures and be safe to avoid injury of hepatic pedicle.

Laparoscopic treatment of small intestinal obstruction is associated with immediate advantages and it may be expected that the recurrence rate will be decreased because of the reduction of wound scars. Between september 1989 and september 1991, 25 patients (16 men and 9 women), mean age 53.8 years, underwent initial laparoscopy for acute small intestinal obstruction. These patients had undergone a total of 43 (1.7 per patient) laparotomies an average of 13 years previously. One patient had never been operated on, 13 had one previous laparotomy, five had two, four had three, and two had four previous laparotomies. Laparoscopic treatment of intestinal obstruction was possible in nine cases including three cases of bands and six cases of adhesions. In sixteen cases, laparoscopy had to be completed by laparotomy, 13 immediately and 3 secondarily. The cause of immediate failure was the impossibility of finding and/or treating the cause in seven instances, four cases of intestinal wounds, on case of intestinal necrosis which required resection, and one case of missed right colonic carcinoma. The cause of secondary failure were incomplete release of adhesions, volvulus, and missed left colonic carcinoma in one case each. Mean hospital stay and postoperative ileus were significantly shorter in the "laparoscopy" group than in the laparoscopy + laparotomy group (p0.001). Two complications, with one death, were noted in the laparoscopy + laparotomy group. In conclusion, laparoscopic treatment of intestinal obstruction seems possible but in less than half of cases. Failures are related to the difficulty with which the abdomen may be explored. Laparoscopic treatment should not be pursued in case of problems.(ABSTRACT TRUNCATED AT 250 WORDS)

When first described in 1983 by Semm, coelioscopic appendectomy had little impact on the surgical community. However, since 1988, the growing widespread use coeliosurgery has lead to renewed interest in the technique. A survey was conducted among the members of the French Association of Surgery. There were 303 responses from 2,437 questionnaires: 195 concerned coelioscopic appendectomy and included a total of 11,086 cases. Most (55.9%) of the surgeons worked in private hospitals and had already gained experience with coelioscopy for gynaecological indications (56.4%). Programmed coelioscopic appendectomies had been performed by 68.3% and peritonitis was the indication in 48.2%. The meso-appendix was treated with coagulation and/or a clip. Peroperative complications were observed in 132 cases (1.19%). Conversion to laparotomy was necessary in 258 cases (2.33%). No deaths were reported. Postoperative complications were reported in 175 cases (1.58%). There were a total of 106 reoperations (0.95%); 43 times by repeat coelioscopy, 59 times by laparotomy and 4 times by Douglas puncture. Discharge was accorded 3.2 (mean) days after the operation. Coelioscopic appendectomy gives results comparable to the laparotomy technique. Its specific advantages are now being assessed in prospective studies.