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Objective: To assess with a single-blinded, multicenter, randomized trial, the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation (MBP). Background: The collective evidence from literature strongly suggests that MBP, before elective colonic surgery, is of no benefit in terms of postoperative morbidity. Very few data and no randomized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP. Methods: From October 2007 to January 2009, patients scheduled for elective rectal cancer sphincter-saving resection were randomized to receive preoperative MBP (ie, retrograde enema and oral laxatives) or not. Primary endpoint was the overall 30-day morbidity rate. Secondary endpoints included mortality rate, anastomotic leakage rate, major morbidity rate (Dindo III or more), degree of discomfort for the patient, and hospital stay. Results: A total of 178 patients (103 men), including 89 in both groups (no-MBP and MBP groups), were included in the study. The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group, 44% versus 27%, P = 0.018, and 34% versus 16%, P = 0.005, respectively. Regarding both anastomotic leakage and major morbidity rates, there was no significant difference between no-MBP and MBP group: 19% versus 10% (P = 0.09) and 18% versus 11% (P = 0.69), respectively. Moderate or severe discomfort was reported by 40% of prepared patients. Mortality rate (1.1% vs 3.4%) and mean hospital stay (16 vs 14 days) did not differ significantly between both groups. Conclusions: This first randomized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate. Thus, it suggests continuing to perform MBP before elective rectal resection for cancer. This study is registered with ClinicalTrials.gov, number NCT00554892.

Earlier meta-analyses of small randomized trials suggested that mechanical bowel preparation (MBP) should be omitted before colorectal surgery because it does not affect complication rates 0 mortality and may be even harmful; however, more recent large randomized trials suggested an increased occurrence of pelvic abscesses in the absence of MBP. Therefore, an updated large meta-analysis was conducted to re-evaluate the role of MBP in colorectal surgery. Furthermore, the influence of different kind of MBP regimes on infectious outcomes was examined.The meta-analysis was conducted according to the QUOROM statement; the inclusion criteria were randomized clinical trials comparing MBP with no MBP before colorectal surgery. The primary outcome was anastomotic leakage; secondary outcomes were other septic complications.Fourteen trials were included with a total number of 4859 patients: 2452 in the MBP group and 2407 in the no MBP group. We found no statistical difference between the groups for anastomotic leakage [OR = 1.12 (0.82-1.53), P = 0.46], pelvic or abdominal abscess (P = 0.75), and wound sepsis (P = 0.11). When all surgical site infections were considered, the meta-analysis favored no MBP [OR = 1.40 (1.05-1.87), P = 0.02].Sensitivity analyses showed similar results for all subgroups but when poor or small trials were excluded, there was a slightly higher risk of deep abdominal abscesses with no MBP, however, the number needed to harm was as high as 333 patients, suggesting this difference to be not clinically relevant. The use of different MBP regimes did not influence primary and secondary outcomes. The main limitation concerned rectal surgery for which the limited data preclude any interpretation.Although it did not confirm the harmful effect of mechanical bowel preparation (suggested by previous meta-analyses), this meta-analysis including almost 5000 patients, demonstrates with a high level of evidence that any kind of mechanical bowel preparation should be omitted before colonic surgery.

The discovery of a liver nodule during postcancer follow-up suggests malignancy recurrence. However, patients previously treated for pediatric cancers are at greater risk of developing benign hepatic tumors, raising the problems of getting an accurate noninvasive diagnosis. Here we report 3 cases of focal nodular hyperplasia of the liver in patients previously treated for pediatric neoplastic diseases. Radiologic findings and needle-biopsies remained insufficient in 2 cases to rule out metastasis or a potentially threatening tumor. Only surgical resection led to positive diagnosis and prevented complications. However, a review of the literature shows that if the nodule presents with typical features of focal nodular hyperplasia a close imaging follow-up is all that is recommended.

To evaluate the magnitude of the morbidity related to the system used for gastric banding Methods Between January 1997 and December 2004, 286 consecutive patients underwent laparoscopic gastric banding (LAGB) in one center. We used 4 models of LapBand 9.75, 10, 11 and Vanguard with pars flacida route. Recalibration of band was performed in our consultation unit without systematic radiologic control. We considered four kinds of complication: port displacement, port rupture, band rupture and others problems.The mean follow up was 3.3+/-2.8 years with a median 2.9 years. Complications occurred within a mean time of 2.2+/-1.9 years. For the models vanguard and size 11, there were no rupture and 15 (27.7%) displacements whereas for size 9.75 and 10 there were 39 ruptures (14.7%) and 15 (5.6%) displacements. Types of complications were related to the bands used i.e. more port displacements for the models vanguard and size 11 and more band and port ruptures for the models size 9.75 and 10. But when we considered the respective follow up according to the type of band these differences were no longer significant. Moreover rupture rate was significantly high but decreased after March 2002 because of changing of junction between port and catheter. Mean excess weight loss (35.2+/-27.7%) was not different in group whether the patients were reoperated or not.Band and port related morbidity is an important aspect of bariatric surgery. We have to pay attention to material evolution and to our follow up for calibration. Some new recent technical advancement could improve the management of these patients.

BackgroundMechanical bowel preparation is used routinely before colorectal surgery, but some randomized clinical trials have suggested that it is of no benefit. This study assesses whether such bowel preparation may safely be omitted before elective colorectal surgery.MethodsA search of the literature was performed; the inclusion criteria were randomized clinical trials comparing bowel preparation with no preparation in colorectal surgery. The methodological quality of included trials was assessed. The primary outcome was anastomotic leakage; secondary outcomes were other septic complications. The meta-analysis was conducted using the Peto one-step method.ResultsEleven trials were retrieved, of which seven, containing 1454 patients, were included in the meta-analysis. There was no heterogeneity between the trials. Significantly more anastomotic leakage was found after mechanical bowel preparation (5·6 versus 3·2 per cent; odds ratio 1·75 (95 per cent confidence interval 1·05 to 2·90); P = 0·032). All other endpoints (wound infection, other septic complications and non-septic complications) also favoured the no-preparation regimen, but the differences were not statistically significant. Sensitivity analysis showed that these results were similar when trials of poor quality were excluded. Subgroup analysis showed that anastomotic leakage was significantly greater after bowel preparation with polyethylene glycol (PEG) compared with no preparation, but not after other types of preparation.ConclusionThere is good evidence to suggest that mechanical bowel preparation using PEG should be omitted before elective colorectal surgery. Other bowel preparations should be evaluated by further large randomized trials.

Background: Because of specific methodological difficulties in conducting randomized trials, surgical research remains dependent predominantly on observational or non-randomized studies. Few validated instruments are available to determine the methodological quality of such studies either from the reader's perspective or for the purpose of meta-analysis. The aim of the present study was to develop and validate such an instrument. Methods: After an initial conceptualization phase of a methodological index for non-randomized studies (MINORS), a list of 12 potential items was sent to 100 experts from different surgical specialities for evaluation and was also assessed by 10 clinical methodologists. Subsequent testing involved the assessment of inter-reviewer agreement, test-retest reliability at 2 months, internal consistency reliability and external validity. Results: The final version of MINORS contained 12 items, the first eight being specifically for non-comparative studies. Reliability was established on the basis of good inter-reviewer agreement, high test-retest reliability by the κ-coefficient and good internal consistency by a high Cronbach's α-coefficient. External validity was established in terms of the ability of MINORS to identify excellent trials. Conclusions: MINORS is a valid instrument designed to assess the methodological quality of non-randomized surgical studies, whether comparative or non-comparative. The next step will be to determine its external validity when used in a large number of studies and to compare it with other existing instruments.

We report the death of a young man during a laparoscopic partial splenectomy performed with an argon plasma coagulator to remove a benign cyst. The report analyzes the very particular mechanism of a gas embolism, which caused death here. This analysis leads us to recommend a close attention on the use of argon coagulators during laparoscopy. The aim of this article is to draw surgeons' attention to the conclusions of a court-ordered expert assessment intended to elucidate the mechanisms responsible for the death of a 20-year-old man during a laparoscopic partial splenectomy performed with an argon plasma coagulator to remove a benign cyst.

Background Randomized controlled studies of surgical procedures are difficult, but can be done to acceptable standards. There are few published objective assessments of such trials. Methods The original articles that involved a randomized controlled trial including at least one laparoscopic procedure were reviewed and evaluated with special interest in their methodology. An assessment form containing 11 generic questions and three additional criteria (assessment of quality of life, cost analysis and laparoscopic experience required) was used. Forty trials were retrieved including 12 on cholecystectomy, 12 on hernia repair and 12 on appendicectomy. Each trial was scored by two assessors. Results The agreement among the two independent assessors was very good. Six of the trials were well conducted but 22 had a poor score. The trials on cholecystectomy were scored the best in contrast to those on hernia repair or appendicectomy. Few trials provided an adequate prospective calculation of the sample size, an unbiased assessment of endpoints, evaluation of the quality of life and a study of the economic aspects. Conclusion Readers should be cautious when interpreting the results of some of these trials and their impact on daily surgical practice.

We report for the first time the treatment of an early rectal cancer by laparoscopically assisted rectosigmoidectomy with pullthrough. The low colorectal anastomosis was constructed using a double-stapling technique. We believe that this procedure might offer a promising new option for the treatment of midrectal cancer with sphincter saving. Further investigation is recommended.

Epidemiological evidence suggests that dietary calcium and 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) might have a protective effect against colorectal cancers. Since the presence of receptors is required for steroid action, specific 1,25-(OH)2D3 receptors (RD3) were investigated in biopsies taken at different levels of the colon. The study involved 90 biopsies from patients operated on for colorectal adenocarcinoma. They were paired biopsies from adenocarcinoma tissue and adjacent normal mucosa. In addition, 26 normal intestinal mucosa biopsies from patients without cancer were examined. RD3 receptors were assayed in tissue extract by the dextran-coated charcoal technique and also characterized by sucrose density gradient sedimentation. Scatchard analysis showed a single class of specific high affinity—low capacity sites binding for 1,25-(OH)2D3. The incidence of RD3 was 86 per cent in normal mucosa (n = 77) and lower in carcinoma (n = 34), for which the incidence decreased significantly (P

International audience; BACKGROUND/AIMS: No agent has been consistently effective in preventing formation of peritoneal adhesions and postoperative bowel obstruction after abdominal surgery. The aim of this prospective multicenter study was to assess clinical safety and efficiency of a new adhesion-reduction barrier METHODOLOGY: Between September 2000 and April 2001, Prevadh was used in 78 patients. Operative procedures included 25 hepatic resections, 7 cholecystectomies, 32 colonic resections, 7 protectomies, 3 colostomy or recovery of continuity, 1 gynaecologic surgery and 3 others. Eleven patients were operated on by laparoscopy and 67 by laparotomy. RESULTS: The overall incidence of abscesses and wound complications was 2.4% and 9% respectively. After a mean follow-up of 36 months (range: 4-51 months), no patients experienced adverse events related to the adhesion barrier. Surgical reoperative procedures were performed in 10 patients for unrelated causes and no bowel obstruction occurred within the protected area. CONCLUSIONS: This study confirmed the safety of Prevadh adhesion barrier and suggested that this resorbable barrier might provide prevention from adhesion formation on peritoneal injured surfaces. However, a large randomized controlled trial remains necessary to prove the real effectiveness of adhesion barriers on clinical long-term outcome.

Irinotecan (CPT-11) is a new drug of the camptothecin family which has shown significant activity in the treatment of metastatic colorectal cancer. Hyperthermia has been shown to enhance the cytotoxic effect of some anticancer drugs and has been combined with intraperitoneal chemotherapy for the treatment of colorectal peritoneal carcinomatosis. The purpose of this study was to evaluate the cytotoxic effect of CPT-11 alone and in combination with mitomycin C (MMC) and hyperthermia on three colorectal cancer cell lines: CACO-2, HT-29, and DHD/K12/TRb (PROb).The cytotoxic effect of CPT-11 was tested at seven different concentrations (from 2.5 to 160microg/mL) for each type of cell line at 37, 39, 42.5 and 44 degrees C. Combined cytotoxic effect of MMC with CPT-11 was tested at 37 and 42.5 degrees C.The cytotoxic effect of CPT-11 alone increased with concentration (p0.001) and with increasing temperature (p0.001) at concentration above 5microg/mL in all three cell lines. CPT-11 (20microg/mL) significantly increased the cytotoxicity of MMC (8microg/mL) at 42.5 degrees C on the CACO-2 line. The combination of CPT-11 and MMC had at least 92% cytotoxicity on the three cell lines.The combination of CPT-11 and MMC at 42.5 degrees C had a large spectrum of cytotoxicity in these in vitro models. Our findings support the clinical use of this combination and provide a rationale for the design of a clinical trial using intraperitoneal chemohyperthermia with MMC and CPT-11 to treat colorectal peritoneal carcinomatosis of colorectal origin.

Background Studies of risk factors after pancreatoduodenectomy are few: some concern restricted populations and others are based on administrative data. Methods Multicenter clinical data were collected for 300 patients undergoing pancreatoduodenectomy to determine (by univariate and multivariate analysis) preoperative and intraoperative risk factors for mortality and intra-abdominal complications (IACs), including pancreatic fistula. Fourteen factors including the center and volume effect were analyzed. Results In univariate analysis, mortality was increased with age 70 years or more, extended resection(s), and volume and center effects. IACs occurred more often with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, extended resection(s), and the center effect. Pancreatic fistula was more frequent with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, and the center effect. In multivariate analysis, independent risk factor(s) for mortality were age greater than 70 years (odds ratio [OR], 3; 95% confidence interval [CI], 1.3-8) and extended resection (OR, 5; 95% CI, 1.2-22), risk factors for IACs were extended resection (OR, 5; 95% CI, 1.2-22) and main pancreatic duct diameter of 3 mm or less (OR, 2; 95% CI, 1.1-3), and the risk factor for pancreatic fistula was main pancreatic duct diameter of 3 mm or less (OR, 2.5; 95% CI, 1.2-4.6). Conclusions Age more than 70 years, extended resections, and main pancreatic duct diameter less than 3 mm are independent risk factors that should be considered in indications for and techniques of pancreatoduodenectomy.

The French Society of Digestive Surgery conducted a survey among its members to assess whether or not the routine practice of gastrointestinal surgery is evidence based. The questionnaire included 13 questions focusing on several aspects of gastrointestinal surgery and for which strong evidence exists. The participants (n = 379) were asked to respond according to their usual practice. The response rate was 75%. Only 57% +/- 15% of the responses were in accordance with the evidence. That rate of evidence-based responses did not differ according to the age of participants but was higher at university hospitals (P = 0.05).

Prophylactic administration of octreotide acetate decreases the rate of postoperative intra-abdominal complications (IACs) after elective pancreatic resection.Single-blind, controlled, randomized trial.Multicenter (N = 20) trial in France.Of 230 randomized patients undergoing pancreatoduodenectomy and pancreatic enteric anastomosis or distal pancreatectomy for either malignant or benign tumor or chronic pancreatitis, 122 were allotted intraoperatively to receive octreotide; 108 served as controls.All 230 patients were analyzed. Both groups were comparable except that significantly more patients in the octreotide group had biological glue injected into the main pancreatic duct alone (P.001) or reinforcing the pancreatic enteric anastomosis (68% [83/122] vs 39% [42/108]; P =.002). Fewer patients (P =.08) in the octreotide group sustained 1 or more IACs (22% vs 32%). In subgroup analysis, octreotide significantly reduced the rate of patients sustaining 1 or more IACs when the main pancreatic duct diameter was less than 3 mm (P.02), when pancreatojejunostomy was performed (P.02), or both (P.02). No significant differences were found regarding IAC severity. Twenty-three patients (10%) died postoperatively, 16 (70% of deaths) of whom had 1 or more IACs. The only independent risk factor for IACs found on multivariate analysis was pancreatoduodenectomy compared with distal pancreatectomy (P.01) (odds ratio, 3.54 [95% confidence interval, 1.44-8.65]).Our results suggest that octreotide is not necessary for all patients undergoing pancreatic resection; it could be useful when the main pancreatic duct is less than 3 mm in diameter and when pancreatoduodenectomy is completed by pancreatojejunostomy.

Because of specific methodological difficulties in conducting randomized trials, surgical research remains dependent predominantly on observational or non-randomized studies. Few validated instruments are available to determine the methodological quality of such studies either from the reader's perspective or for the purpose of meta-analysis. The aim of the present study was to develop and validate such an instrument.After an initial conceptualization phase of a methodological index for non-randomized studies (MINORS), a list of 12 potential items was sent to 100 experts from different surgical specialties for evaluation and was also assessed by 10 clinical methodologists. Subsequent testing involved the assessment of inter-reviewer agreement, test-retest reliability at 2 months, internal consistency reliability and external validity.The final version of MINORS contained 12 items, the first eight being specifically for non-comparative studies. Reliability was established on the basis of good inter-reviewer agreement, high test-retest reliability by the kappa-coefficient and good internal consistency by a high Cronbach's alpha-coefficient. External validity was established in terms of the ability of MINORS to identify excellent trials.MINORS is a valid instrument designed to assess the methodological quality of non-randomized surgical studies, whether comparative or non-comparative. The next step will be to determine its external validity when used in a large number of studies and to compare it with other existing instruments.

Background The aim of the study was to evaluate the efficacy of adjuvant chemotherapy on survival after resection for gastric cancer. Methods Patients were enrolled if they underwent resection of gastric cancer but had lymph node or serosal involvement or both. Surgical resection was either total or partial gastrectomy according to the site of the tumor, and surgeons were allowed to perform either D1 or D2 gastrectomy. The subjects were random assigned in two treatment groups as follows: surgery alone as the control group, or surgery and adjuvant chemotherapy. Nine cycles of 5 days protocol every 4 weeks was proposed to the patients of the chemotherapy group. The protocol included a daily administration of 200 mg/m 2 of folinic acid, 5-fluorouracil (375 mg/m 2 during the first session increasing 25 mg by session until reaching 500 mg/m 2 ) and CDDP 15 mg/m 2 . Two hundred patients were required. Kaplan-Meier survival curves were compared according to the log-rank and the Mantel-Haenszel methods. Results In all, 205 patients were enrolled in the study; 104 had surgery alone and 101 had surgery and adjuvant chemotherapy. The patients' characteristics were similar except for the mean age, which was 4 years less in the control group. Because of toxicity, 54% of the patients stopped the protocol before the end of the nine courses, and 46% of the patients received the nine courses including 32% with a decreased dose and 14% with a full dose. The 5-year survival rate was 39% in the control group and 39% in the chemotherapy group. Conclusions This protocol of adjuvant chemotherapy failed to improve the 5-year survival after resection for gastric cancer.

Background: Laparoscopic fundoplication is a well-established surgical option for the treatment of gastroesophageal reflux disease. The aim of this study was to assess the surgical outcomes from the patient’s point of view by using a validated quality of life instrument. Methods: Fifty patients have been prospectively included. All patients underwent a standardized 270-degree posterior fundoplication. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36-item-questionnaire. The patients received the questionnaire before surgery, and 3 months and 1 year after surgery. Results: Preoperative score was 95.6 ± 21 points. The score increased significantly (P

Previous studies have suggested that gas temperature has an influence on postlaparoscopy pain. This trial therefore was conducted to study the effect of gas warming on pain after upper abdominal laparoscopic surgery.Patients who underwent laparoscopic cholecystectomy, fundoplication, or Heller's myotomy were included and randomly allocated to receive either warm or cold gas. Primary end point was shoulder tip pain, and secondary end points were subcostal, trocar wound, and visceral pains, as well as other postoperative events. Criteria of pain assessment were the visual analog scale, verbal rating scale, and amount of analgesics.A total of 100 patients were suitable for postoperative evaluation. The groups were well matched. Shoulder tip and subcostal pains were significantly more intense after gas warming (p0.05). The three assessment criteria showed the same differences. No difference was observed concerning trocar wound and visceral pains and the other secondary end points. Subdiaphragmatic temperature was not significantly different (34.4 degrees with warming vs. 34 degrees without warming).Gas warming does not reduce, and probably increases, postoperative shoulder tip and subcostal pains.

Using a high-resolution chromosome-banding technique, the authors karyotyped a patient with spontaneous colorectal tumors. They reported a specific chromosome abnormality consisting of a microdeletion

The purpose of this study was to validate the use of intraoperative manometry for assessing fundoplication and to search for predictive manometric criteria. This prospective study concerned 48 patients operated for gastroesophageal reflux. The manometry was carried out pre- and intraoperatively for all patients and postoperatively as well for 30 patients. The operative procedures were total fundoplication (n = 25) and posterior (partial) fundoplication (n = 5). The lower esophageal sphincter (LES) pressures and lengths were similar in the preoperative and intraoperative measurements before any esophageal mobilization, whereas the intraoperative LES pressure was significantly higher after fundoplication. The mean postoperative LES pressure decreased by 50 +/- 19% compared with the intraoperative pressure after fundoplication. The final intraoperative pressures of two dysphagic patients were not the highest of the study. More importantly, their final intraoperative pressures were 7.5 and 8.2 times the initial pressure, respectively, which was significantly greater than the intraoperative pressure increase of the nondysphagic patients (4.6 +/- 2.0 times). The final intraoperative pressure of the only patient with recurrence (18.2 mmHg) was the lowest of the study. In conclusion, intraoperative manometry is an effective method for evaluating the LES, and it could have predictive value for the surgical management of gastroesophageal reflux disease.

Sixteen of 65 laparoscopically assisted colorectal operations were converted to an open procedure, usually because of dissection difficulties. Conversion was decided early in the procedure in four cases without perioperative morbidity and later in 12 cases, after a mean of 56 min. The results in patients undergoing converted operation were compared with those in 252 having a planned open colorectal procedure during the same period. The groups were comparable with regard to age, health status, factors influencing intestinal healing and grade of surgeon. A higher postoperative morbidity rate (50 versus 21 per cent) and more anastomotic leakages (25 versus 8 per cent) were apparent in the converted group. Operating time, postoperative ileus and hospital stay were longer in those requiring a converted operation. These poor results suggest that careful preoperative patient selection for laparoscopic procedures and a rapid decision to convert in case of difficulty are important.

Laparoscopic surgery is part of the minimally invasive surgery. Its aim is to make the operation as valuable as the open one, or even better, without remarkable invasion or injury of the body. With the instruments' improvement the operation would be possible without any remarkable organism injury. At the other hand, modifications of the operations' techniques lead to progress. European technique of laparoscopic cholecystectomy using four trocars has been changed. Procedure was performed with one trocar less. Two groups of two hundreds patients each have been laparoscopic cholecystectomised. The operation in the first group was performed using four and in the second group using three trocars. The aim of the investigation was to compare these two methods of laparoscopic cholecystectomy. The results' analysis showed that laparoscopic cholecystectomy using three trocars did not cause either a higher complications rate, prolonged average operation time or longer duration of hospitalisation. The analgesic's consumption was lower, sick-leaves were shorter, with smaller total costs, and cosmetic effect was better.

The experience reported herein is on our initial 40 cases of laparoscopic-assisted (LA) colorectal resection that were prospectively evaluated. The operations were performed for colonic tumors of the right segment (n = 4), sigmoid (n = 11), or rectum (n = 7), diverticular disease (n = 17), and chronic constipation (n = 1). Among 22 tumors, 11 were malignant. The operative procedures were 4 right hemicolectomies, 28 segmental left colectomies, 5 anterior resections, 2 abdominoperineal resections, and 1 total colectomy. Thirty-one patients (77.5%) had a successfully completed LA resection. The reasons for conversion in the majority of the cases (66.6%) were difficulties in dissection. In the entirely LA procedures, the mean flatus postoperative day was 3, the mean postoperative hospitalization was 10.7 days, and there were 8 complications (25%) in 7 patients. Two patients were reoperated 2 and 3 months later for adhesion and ischemic stenosis of the colon above the anastomosis. There was 1 death in the LA group (3.2%). The length of operative specimen was 19.6 cm, and the mean number of resected lymph node was six. In contrast to laparoscopic biliary surgery, the benefits of LA colorectal surgery are not obvious. A randomized trial comparing LA and open colorectal resection must be carried out.

Background Laparoscopic cholecystectomy (LC) is now the treatment of choice for gallstone disease. The wide acceptance of LC resulted in increased cholecystectomy rates and entailed specific drawbacks such as the missed malignant tumors of other organs. Patients and methods The prospective follow-up of patients who underwent LC was studied, and all patients treated for malignant disease were included regarding a history of LC. Results Of 838 LCs performed, 5 patients underwent reoperation for missed carcinoma of the pancreas (n = 2) and the right colon (n = 3). Two other patients with carcinomas of the pancreas and the right colon had a history of LC performed elsewhere. All 7 patients (median age 72 years) complained of recent atypical pain at the time of the LC. Five tumors were resected (2 palliatively); 2 patients died. Conclusions This study emphasizes the necessity of making a careful semiological analysis of the pain and associated symptoms before performing an LC.

We read with interest the article entitled "Antrectomy: A Safe and Effective Bypass for Unresectable Pancreatic Cancer" by Lucas et al. 1 As they stated, the main disadvantages of antrectomy are prolongation of the procedure and the difficulty in performing antrectomy in some cases. We advocate performing an antral exclusion to simplify the procedure. 2 The aim of antral exclusion (as for antrectomy) is to avoid the effects of antral malfunction on gastric emptying and the duodenal "circulus vitiosus." Antral exclusion is performed by means of a linear stapling device, ie, the 4-row TA90 (Auto Suture, Elancourt, France). The device is fired without dividing any gastric vessel. Then, a retrocolic side-to-side gastrojejunostomy is performed close and proximal to the linear row. This procedure is easier to perform and consumes less time than antrectomy. To date, this procedure has been performed in 8 patients. The postoperative course was uneventful in all

Six patients with gastrointestinal malabsorption and 12 with alcoholic cirrhosis received total parenteral nutrition for 4 wk. Freamine II, the source of the amino acids, is nearly devoid of cystine and tyrosine. We monitored daily nitrogen balance and other nutritional parameters and 22 plasma amino acids. Malabsorbers had a strongly positive nitrogen balance and improvements in nutritional parameters. Plasma amino acids were maintained within or above their normal fasting ranges. Eight of 12 cirrhotics resembled malabsorbing patients in terms of positive nitrogen balance, improved nutritional parameters, and plasma amino acids. In 4 cirrhotics, nitrogen balance remained negative and nutritional repletion failed to occur. Plasma cystine and tyrosine fell to below 30% of their normal fasting means. In 2 of these patients, oral supplements of cystine and tyrosine were given during the fifth week of parenteral nutrition. Plasma cystine and tyrosine were normalized, nitrogen balance became positive, and other repletion indicators demonstrated recovery. We conclude that in 4 cirrhotics, repletion was blocked by deficiencies of cystine and tyrosine, resulting from hepatic inability to synthesize cystine from methionine and tyrosine from phenylalanine.

The incidence of thrombus formation in the portal vein following distal splenorenal shunt was 4% occlusive and 14% nonocclusive from 1974 to 1977, and 6% occlusive and 22% nonocclusive in 1980. The increased incidence was probably due to more aggressive ligation of collaterals on the portal vein. Ten patients with this complication were evaluated prospectively with clinical and biochemical parameters, angiography, and nutrient hepatic perfusion. In this group, one thrombus was occlusive immediately after operation, and nine were nonocclusive: eight of the latter resolved by six months, but one progressed to total thrombosis. There were no demonstrable adverse clinical or biochemical sequelae. Angiography showed continuing portal perfusion in the face of nonocclusive thrombus, but at six months there was increased collateral formation and significant (p less than 0.05) reduction in portal vein diameter, from 20 +/- 4 mm to 14 +/- 5 mm. Nutrient hepatic perfusion at six months, 896 +/- 257 ml/min, was not significantly different from that seen prior to operation, 848 +/- 92 ml/min. It is concluded that the natural history of nonocclusive portal vein thrombus after distal splenorenal shunt is resolution, and management should be expectant.

Excerpt For hospital patients unable to eat or absorb adequate amounts of nutrients, three routes of nutritional support are available: nasogastric (1), peripheral intravenous, or central intraveno...

Vol. 29 p 642: In column two, sixth line from the bottom, change "25 000" to "54 000." Insert an addition (italicized here) to the next to last line in that column so that it reads".. ., then dialyzed overnight against the same buffer at 4 °C, then divided..." p 843: In line six under Results and Discussion, change "mg" to "µg" p 1537: In revision of this paper a paragraph of introduction was inadvertently omitted (which cites refs. 1-5), as were the first two paragraphs under Materials and Methods, which should read as follows: Human placentas were obtained from the obstetrical department within 12 h of delivery. Fresh human abdominal muscle was obtained within 12 h of autopsy. All tissues were stored at 4 °C and processed, as described below, within 6 h. Placenta and abdominal muscle were stripped free of membranes and blood vessels, cut into small pieces, and extensively washed at 4 °C with cold saline (NaCl, 9 g/L). Muscle CK-MM and placental CK-BB were purified according to the method of Armstrong et al. (6), with the following modifications: we used dithioerythritol (Sigma Chemical Co., St. Louis, MO 63178), 15 mmol/L, instead of 2-mercaptoethanol, omitted the final (NH4)2SO4 precipitation and final Sephadex G-100 fractionation, and used DE-52 (Whatman Ltd., Maidstone, Kent, U.K.) instead of DEAE-cellulose (Cellex-D; Bio-Rad Laboratories, Richmond, CA 94804). p 2026: First paragraph, lines nine and 16: delete "500" (the Dextran used in the cited reference was a 50 000-dalton preparation, not the 500 000-Da Pharmacia preparation). p 2029: In line 10 of the first full paragraph in column two, change "1.171" to "0.117." p 2125: First two columns and Table 1: All lipase results expressed as kU/L should be divided by 3600. Vol. 30 p 170: The next-to-last paragraph was inadvertently omitted in layout and should read as follows: If the sample was first incubated at 37 °C until the serum became clear (i.e., until the cryoprecipitate dissolved) and the enzyme activity immediately determined at 30 °C (Figure 2, curves 1 and 2), normal activity was observed.