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An audit of the French national health insurance system would be justified by economic considerations alone, but this would risk overlooking the notions of solidarity and freedom to which the French are rightly attached. European comparisons suggest, however, that our system could be made more efficient without undermining public health. The national health insurance system allows each member of the population to receive high-quality medical care. Practitioners have near-total freedom of prescription and practice. Medical care contributes to the ongoing increase in life expectancy, which is currently 73 years and second only to Japan. Healthcare is also a source of a million jobs. Macro-economic spending controls have failed, owing to medical progress and population aging, and also to medical consumerism favored by an unprecedented range of examinations and treatments, the increasing reimbursement of medical care, and the extension of direct payment by the insurer. Many ineffective measures have been implemented, such as tarification according to activity, and hospital certification. Health spending is also increased unnecessarily by bureaucratisation of healthcare spending and the transfer of professionals to posts for which they are not qualified. Some controversial medical prescriptions are not adequately controlled by the health service. Many reforms are based on over-optimistic economic predictions that fail to take related overheads into account. Lobbying by special interests groups undermines reform and the public interest. Too many independent administrative bodies have been created, and many are less efficient than the public structures they replaced. In sum, the French national health insurance system has become less and less efficient over the years.

Duodenopancreatectomie cephalique pour cancer M. Huguier, A. Barrier, C. Gouillat, B. Suc, D. Jaeck, B. Launois De nombreuses propositions ont ete faites pour ameliorer les resultats de l’operation de Whipple. Des etudes prospectives controlees (essais), des meta-analyses ou, a defaut, des etudes retrospectives permettent d’evaluer ces propositions. Les pancreatectomies totales et les curages cellulo-lymphatiques etendus ne semblent pas ameliorer les durees de survie des malades dans des comparaisons retrospectives ou dans des essais. Un envahissement veineux apparent, mesenterique superieur ou portal, ne contre-indique pas a lui seul une exerese dont les resultats sont similaires a ceux observes lorsqu’il n’existe pas d’envahissement. Des essais et une meta-analyse n’ont montre ni avantages ni inconvenients majeurs a la conservation antro-pylorique. Trois essais et une meta-analyse n’ont pas montre que l’anastomose pancreatico-gastrique diminuait le risque de fistule par rapport a l’anastomose pancreatico-jejunale. Deux essais suggerent que, pour la realisation de celle-ci, l’intubation du pancreas dans le jejunum ou le drainage externe temporaire du canal de Wirsung diminuraient ce risque de fistule ce qui, pour cette seconde technique, n’a pas ete confirme par un autre essai. Les resultats sur l’utilisation de la somatostatine sont contradictoires. Les resultats benefiques lorsque le critere de jugement de fistule est biologique n’ont pas ete confirmes par quatre essais sur cinq lorsque le critere de fistule etait clinique et/ou radiologique. Enfin, l’occlusion des canaux pancreatiques par de la fibrine ou l’utilisation de colle sur la surface de l’anastomose pancreatico-digestive n’ont pas diminue le risque de fistule. En conclusion, la duodeno-pancreatectomie cephalique decrite par Whipple reste la technique de reference d’exerese des cancers de la tete du pancreas. L’essai montrant l’interet de l’intubation du pancreas dans le jejunum merite d’etre confirme. En l’absence de resultats convergents, la somatostatine ou le drainage externe du canal de Wirsung peuvent etre reserves aux cas pour lesquels l’anastomose pancreatique semble precaire. Enfin, il a ete suggere par plusieurs etudes que l’experience des equipes semblait le meilleur moyen, non seulement de diminuer la morbidite et la mortalite peri-operatoires, mais aussi d’augmenter les chances de survie des malades.

Resume But du travail. – Rapporter des observations vietnamiennes de tuberculoses du tube digestif, affection que l'on peut aussi observer dans les pays occidentaux. Materiel et methode. – Soixante-seize malades ont ete inclus dans cette etude retrospective. L'âge moyen etait de 40 ans et le sex-ratio H/F de 6. Le diagnostic a ete affirme par l'examen anatomopathologique ou bien sur la presence de Mycobacterium tuberculosis ou bien par « polymerase chain reaction » (PCR). Resultats. – Un syndrome occlusif ou subocclusif etait le plus frequent (68 %), suivi d'un syndrome peritoneal (17 %). Cinq patients ont fait une hemorragie digestive. Trente-six patients n'avaient pas d'antecedent de tuberculose pulmonaire, ni de tuberculose pulmonaire (47 %). Les anomalies observees sur les examens morphologiques et a l'intervention n'etaient pas specifiques. Soixante-deux malades ont ete operes (82 %) et 14 malades ne l'ont pas ete. Les interventions ont ete tres variees selon la symptomatologie : resections intestinales dans pres de la moitie des cas, stomies, enterolyses dans les autres. Il y a eu huit deces postoperatoires (13 % des operes) dont sept de cachexie. Tous les malades ont ensuite ete traites medicalement et suivis au centre antituberculeux de Hanoi. Conclusion. – La symptomatologie et l'aspect operatoire sont tres proches de ceux d'une maladie de Crohn, voire d'un lymphome ou d'un amoebome. Si la probabilite a priori d'une tuberculose du tube digestif est plus forte que ces autres affections dans les zones d'endemie, il convient d'y penser aussi dans les pays occidentaux, notamment chez les immigres, les malades immunodeprimes, meme s'ils n'ont pas d'antecedents de tuberculose pulmonaire.

Are we going to change the way we practice medicine? There are two kinds of medical knowledge: one is impersonal and results from research based on scientific methodology and scientific reasoning; the other is personal and results from learning and apprenticeship with seniors and from individual experience. Evidence-based medicine (EBM) is a new approach to teaching the practice of medicine. Instead of using personal knowledge, intuition, unsystematic clinical experience, and pathophysiological reasoning, it stresses evidence from clinical research. With this new paradigm in mind, clinicians should regularly consult the original literature, critically appraise the methods and the results, and then apply to the patient the optimal knowledge they have at their disposal. This new approach to medicine is gaining worldwide adoption, even if it more or less strictly interpreted. In France, even the translation of the English word "evidence " is controversial. There are two different translations for EBM. The most common is "Medecine fondee sur les preuves", and the other is "Medecine factuelle". The French word "Preuves" is the literal translation of "evidence" Some people argue against this term because its meaning is ambiguous for two reasons: --it does not express the full meaning of the English word "evidence", --there is a fear that the epistemological significance of "preuves" could be misinterpreted, giving birth to legal quibbles. Some people prefer the term "meilleures donnees acquises de la science". Other problems are linguistic and organizational. How can a busy French-speaking practitioner locate, retrieve and critically appraisal original articles, most of which are in English, unless he/she has a library containing the combined international medical literature? French meta-analyses, systematic reviews and books dedicated to evidence-based subjects are alternative options. Even when these practical problems can be solved, the proper place of research-based evidence must be clarified. When evidence is lacking, practitioners have to rely on other forms of medical reasoning for their decisions. Moreover, decision-making is not automatic: in addition to taking scientific knowledge into consideration, each medical decision is the result of a series of judgments based on human and environmental factors.

Resume Objectif de l'etude Rapporter trois observations de rupture de l'isthme du pancreas et souligner l'interet de la conservation du pancreas gauche grâce a une anastomose pancreatodigestive. Patients et resultats Dans les deux premieres observations, un hemoperitoine dans l'une et un epanchement intra-abdominal riche en amylase dans l'autre ont fait decouvrir une rupture isthmique du pancreas qui a ete traitee par suture du cote cephalique et par anastomose entre le pancreas corporeocaudal et une anse jejunale en Y. Les malades allaient bien avec un recul de huit et six mois. Dans la troisieme observation, le diagnostic a ete suspecte sur une scanographie. En l'absence de rupture apparente du pancreas au cours de la lapararotomie, un simple drainage a ete mis en place. L'abondance du drainage a fait realiser une wirsungographie qui a montre une extravasation du contraste au niveau de l'isthme. Une endoprothese a ete placee dans le canal de Wirsung. Trois mois plus tard, des douleurs ont fait decouvrir une migration de la prothese qui n'a pu etre replacee a cause d'une stenose canalaire. L'isthme du pancreas a ete reseque, le segment cephalique suture et le segment caudal implante dans l'estomac. Le malade allait bien huit mois plus tard. Sa glycemie etait normale. Conclusion Lorsque l'on soupconne, apres contusion de l'abdomen, une lesion pancreatique, une wirsungographie est souhaitable si les circonstances le permettent, mais le meilleur examen est actuellement la resonance magnetique nucleaire. En l'absence de rupture canalaire, le simple drainage peritoneal suffit. S'il existe une rupture canalaire incomplete, la mise en place d'une endoprothese peut assurer la guerison. En cas de rupture complete, la suture du pancreas du cote cephalique et l'anastomose du pancreas gauche avec une anse jejunale en Y ou mieux avec l'estomac semble facile a realiser et a donne un bon resultat a moyen terme dans les trois observations rapportees.

Resume But de l'etude Les nombreux examens dont on dispose pour explorer l'extension d'un cancer du pancreas doivent faire reflechir a des choix pour ne pas les multiplier inutilement. Materiel et methodes Cette etude prospective a inclus 44 malades qui avaient une lesion pancreatique ou periampullaire. Trente ont eu un echodoppler couleur, 43 une echoendoscopie. Des criteres precis d'envahissement de la veine mesenterique superieure ou de la veine porte ont ete etablis pour chaque examen. A l'intervention, l'envahissement de l'axe veineux ( n = 10) ou son absence ( n = 34) ont ete verifies par la dissection. Une duodenopancreatectomie cephalique a ete realisee chez 30 malades. Les diagnostics definitifs retenus ont ete un adenocarcinome de la tete du pancreas ( n = 15), un cholangiocarcinome intrapancreatique ( n = 3), un ampullome vaterien ( n = 11), une tumeur benigne de la tete du pancreas ( n = 3), un adenocarcinome du corps du pancreas ( n = 5) et une pancreatite chronique ( n = 7). Resultats L'echoendoscopie a eu une sensibilite de 90 %, une specificite de 88 %, une valeur predictionnelle positive de 69 % et negative de 97 %, superieures a celles de l'echodoppler couleur qui avait une sensibilite de 50 %, une specificite de 85 %, une valeur predictionnelle positive de 33 % et negative de 92 %. Conclusions La multiplication des examens dont on dispose dans l'appreciation de l'extension d'une tumeur de la tete du pancreas peut les faire prescrire dans des algorithmes complexes et onereux. L'echoendoscopie, pour chercher un envahissement mesenterique superieur ou portai, est l'examen qui semble avoir la meilleure valeur informationnelle. En revanche, dans une perspective decisionnelle, son interet comme celui des autres examens morphologiques est discutable. Paris

PURPOSE A multicentric randomized study that compared patients who received intrahepatic arterial infusion (HAI) to a group of patients who did not receive HAI (control group) was performed for unresectable hepatic metastases from primary colorectal carcinoma. PATIENTS AND METHODS One hundred sixty-six patients were assigned randomly to HAI of floxuridine (5 fluoro-2'deoxyuridine [FUDR]) 0.3 mg/kg/d for 14 days every 4 weeks or to the control group; this latter group, depending on the investigator's choice, was either under observation or received systemic fluorouracil (5-FU). The same regimen of systemic 5-FU also was administered to the HAI group in the event of extrahepatic progression. No crossover from the control group to the HAI group was permitted. The mean duration of follow-up was 54 months (range, 31 to 72), and 163 patients were analyzed. RESULTS A significant improvement was observed in the survival rate for the 81 patients assigned to HAI group (P less than .02) with a 1-year survival rate of 64% versus 44% in the control group (82 patients). The 2-year survival rate was 23% versus 13%. The median survival was 15 months versus 11 months for the HAI group and the control group, respectively. Survival was better for patients with a less than 30% liver involvement, and for those treated in more specialized centers. The hepatotoxic effects of HAI were observed in 47 patients (chemical hepatitis [n = 28], and biliary sclerosis [n = 19]). The 1-year rate of sclerosing cholangitis was equal to 25%. Gastrointestinal toxicity was infrequent and consisted of gastritis or diarrhea. CONCLUSIONS Therapy with HAI of FUDR improves the survival of patients with liver metastases over colorectal carcinoma. However, the methods that are used to diminish the toxicity of HAI and efficient systemic chemotherapy, such as a combination of 5-FU and leucovorin, are required to prevent extrahepatic metastases.

One hundred and five defunctioning loop colostomies were performed using a subcutaneous bridge support. Two complications were observed: a peristomal abscess and a bridge migration into the peritoneal cavity. This technique facilitates the fitting of stoma appliances. Glass bridge support can be removed under local anesthesia. This technique can be recommended in view of the good results.

Many modifications of the original technique have been proposed to try to improve the results of the pancreaticoduodenectomy described by Whipple. To evaluate these modifications, we have reviewed randomized controlled trials, meta-analyses, and well-conducted retrospective series. Neither total pancreatectomy nor extended lymph node dissections have shown an improve of survival in retrospective studies. Preoperative evidence of mesenteric or portal vein involvement does not contraindicate pancreatic resection and survival rates are similar to those of patients with no venous involvement. Prospective trials and one meta-analysis have shown neither advantage nor disadvantage of pylorus-preserving pancreaticoduodenectomy or of pancreatico-gastric anastomosis. Three trials and one meta-analysis of pancreatico-gastric anastomosis have failed to demonstrate a decrease in the risk of pancreatic fistula. Two trials suggest that the risk of fistula formation is decreased by implantation of the pancreatic remnant into the jejunum or by trans-jejunal stenting of the pancreatico-jejunal anastomosis with external drainage; but these findings are not supported by a third trial. The results of the antisecretory use of somatostatin are contradictory. Leak and fistula formation were decreased when the criteria for leakage was based on laboratory findings; but in 4 out of 5 trials, somatostatin did not decrease the incidence of clinical fistula. The use of fibrin glue to occlude the pancreatic duct or seal the cut surface of the pancreas did not decrease the rate of intra-abdominal complications. In conclusion, the pancreaticoduodenal resection described by Whipple may still be considered the gold standard for resection of pancreatic cancer. The technical experience of surgeons and their institutional support staff resulted in lower perioperative morbidity and mortality and in higher survival rates.

To report cases from Vietnam of intestinal tuberculosis disease, which is uncommon but did not disappear in occidental countries.Seventy-six patients were included in this retrospective study. Mean age was 40 years and sex ratio M/F was 6. Diagnosis was established on pathological examination of resected specimen or on presence of Mycobacterium tuberculosis or by polymerase chain reaction.Intestinal obstruction or subobstruction was the most usual symptom (68%), and thereafter peritoneal symptoms with pain and tenderness (17%). Five patients had intractable digestive haemorrhage. Thirty-six patients had no past history or active pulmonary tuberculosis (47%). Lesions of stenosis on barium enema and thickness of intestinal wall on CT-scan were not specific. Sixty-two patients were operated on (82%) and 14 were not. Surgical techniques differed according symptoms, site and type of lesions. Intestinal resections were performed in half of the patients, others undergoing stomies or enterolysis. There were eight postoperative deaths (13% of patients operated on), seven out of these deaths were attributable to cachexy. In the postoperative period, all the patients were medically treated and follow-up in the antituberculosis centre of Hanoi.Symptomatology and operative findings of intestinal tuberculosis are similar to those observed in Crohn's disease, and sometimes in amoeboma or lymphoma. In face of stenosis and intestinal wall thickness, probability of intestinal tuberculosis is high in endemic area, but diagnosis must be suspected in occidental countries, mainly in patients immigrated coming from these areas, patients with immuno-deficiency even if they did not have past or present pulmonary tuberculosis.

To indicate options in a surgical university team in Vietnam for treatment of ascaris-induced acute pancreatitis.From January 1998 to April 2001, 33 patients (mean age 46 years) were admitted with a diagnosis of acute pancreatitis based on elevated serum amylase in 29 patients (88%), and elevated urinary amylase in all patients and a compatible clinical picture. The pancreatic ultrasonography was abnormal in 79% of cases. Biliary and pancreatic ultrasonography shown ascaris in 31 patients (94%). In other two patients ascaris was detected with duodenal endoscopy.In 24 patients, the worms from the duodenum and/or across the ampullary orifice was trapped and withdrawn during duodenoscopy and failed in three patients. Nine patients were operated on, three after failure of endoscopic treatment, five for lithiasis of the common bile duct associated to the ascariasis, and one for necrotic pancreatitis. Seven patients operated on underwent a choledocotomy with a T-tube drainage, two patients underwent a left pancreatectomy to withdraw the ascaris, and one patient a resection of pancreatic necrosis. All patients recovered without complications except the patient with a necrotic pancreatitis who developed a pancreatic fistula for 23 days. Mean discharge times were 5.6 days after endoscopic treatment and 12.2 days after surgery. Effective antihelminthic therapy was administered in all patients.Endoscopic treatment was effective in 24 out of 33 patients. Surgery was indicated for failures of endoscopic treatment, association of ascariasis and common bile duct stones, migration of ascaris in intra pancreatic duct, and pancreatic necrosis.

The self-expandable metallic stents are a good alternative to surgery for the palliative treatment of malignant colonic obstructions. The aim of this paper was to emphasize the causes which could increase the risk of perforation.From November 2000 to November 2001, 6 patients with malignant colonic obstruction, to whom surgery was denied due to tumor extension and/or poor general condition, have had a palliative treatment (N = 5) or an attempt (N = 1) with self-expandable metallic stents placed by endoscopy.Only one patient did not developed any complication and died 5 months later of cancer. Five out of the 6 patients (83%) developed a colonic perforation following stenting (N = 4) or the attempt to place the stent (N = 1), two into the first 24 h after the procedure, and three 3, 5, and 10 months later. Subsequent colostomy was done in 2 patients while the 3 others have had an external drainage of the perforation and died postoperatively.The self-expandable metallic stents seems to be a less aggressive alternative therapy to surgery for malignant colonic obstructions. Nevertheless, the high rate of colonic perforations, suggests reconsidering the indications in the definitive palliation of malignant colonic obstructions.

Gallbladder carcinomas were usually considered to be radioresistant. So far, the role of radiotherapy has not been adequately evaluated. The aim of this report is to assess the value of radiotherapy in carcinoma of the gallbladder.We reviewed publications concerning the role of radiation therapy in gallbladder carcinoma from 1974 to 2000. External radiation therapy, intraoperative radiation therapy, and brachytherapy were evaluated in two different groups: one group of patients underwent surgery, with apparently complete resection of the tumor; and another group underwent palliative treatment.Local control of the tumor and reduction of tumor size were reported in several publications. Collected data suggested a slight improvement in survival after adjuvant or palliative radiotherapy. The best benefit was obtained in tumors resected with only microscopic residual tissue. If possible an intraoperative "boost" (15 Gy) is recommended on the gross lesion, residual lesion, or tumor bed. Additional postoperative external radiotherapy (45-50 Gy) must be delivered.Radiotherapy appears to be a safe procedure that slightly improves the survival time of patients treated for gallbladder carcinoma. Further trials are needed to assess the role of combined radiotherapy and chemotherapy.

One hundred and five defunctioning loop colostomies were performed using a subcutaneous bridge support. Two complications were observed: a peristomal abscess and a bridge migration into the peritoneal cavity. This technique facilitates the fitting of stoma appliances. Glass bridge support can be removed under local anesthesia. This technique can be recommended in view of the good results.

To identify prognostic factors in advanced pancreatic cancer and to define a predictive score.One hundred and sixty six patients were included in this multicentre study. Seventeen covariables were prospectively collected for each patient. Covariables associated with survival (p0.10) were analysed by a stepwise Cox model.Four prognostic factors were selected on multivariate analysis: pain (RR 1.5; CI: 1.1-2.0), ascites (RR 1.7; CI: 1.0-2.9), weight loss10 kg (RR 1.4; CI: 1.0-2.0), and metastases (RR 2.3: CI: 1.6-3.2). A score was defined by attributing a value of one for pain, ascites and weight loss, and two for metastases. Patients with a score2 had a median survival of 2 months (SE: 0.5), and patients with a scoreor = 2 had a median survival of 6 months (SE: 0.6) (Logrank p0.0001).The proposed score may be helpful in therapeutic decisions concerning surgery, palliative chemotherapy and/or radiotherapy. However, this score must be validated on an independent series of patients.

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.

Gallbladder carcinoma is characterized by late diagnosis, ineffective treatment and poor prognosis. These tumors were usually considered to be radioresistant. So far, the role of radiotherapy has not been adequately evaluated. The aim of this report is to assess the value of radiotherapy in carcinoma of the gallbladder.We reviewed all publications concerning the role of radiation therapy in gallbladder carcinoma. External radiation therapy, intra-operative radiation therapy, and brachytherapy were evaluated in two groups in which the prognosis is quite different; a group operated on, with apparent complete resection of the tumor, and a palliative surgery group.It appears that gallbladder carcinomas are not as radioresistant as was formerly thought. Local control of the tumor and reduction of tumor size was reported in several publications. Collected data showed a slight improvement of survival after adjuvant or palliative radiotherapy, especially in the advanced stage of gallbladder carcinomas. It appears preferable to give a "boost" (15 Gy) to the gross lesion or residual lesion at operation (intra-operative irradiation or brachytherapy), and deliver an additional 45-50 Gy post-operatively.The results published encourage further trials in well defined populations. Radiotherapy seems to be a safe procedure, morbidity is minimal, and a slight effect on survival is observed after curative or palliative surgical procedures.

To report three cases of neck pancreatic disruption caused by blunt abdominal trauma and to emphasize the advantages of conservative surgery with internal drainage.In two cases, one with hemoperitoneum, and the other with intraperitoneal fluid collection with 1,323 U/mL of amylase, laparotomy showed a complete disruption of the neck of the pancreas. The pancreatic head side was sutured whereas the left side was anastomosed to a Roux-en-Y jejunal loop. The clinical results were good at 8 and 6 months after surgery, respectively. For the third patient, a pancreatic trauma (which was suspected on a CT. Scan), was not confirmed at laparotomy. In the postoperative course, the amount of fluid drainage was important and the endoscopic retrograde pancreatography (ERCP) showed a disruption of the neck of the pancreas. An endoprosthesis was placed into the duct of Wirsung. Three months later, the patient complained of pain, and a migration of the prosthesis was detected by X-ray examination. It was not possible to place another endoprosthesis because of a stenosis of the duct. A resection of the neck of the pancreas was performed, the cephalic side was sutured and the left side anastomosed to the posterior gastric wall. Eight months after surgery, the clinical result was good and glycemia was normal.In blunt abdominal trauma, if a pancreas injury is suspected upon clinical presentation an ERCP, or moreover a magnetic resonance imaging, is indicated. When there is no disruption of the Wirsung duct, a simple peritoneal drainage should suffice. In cases with partial disruption, an endoprosthesis may give good results. In patients with a complete disruption, as in the three cases reported, a suture of the head side of the pancreas, and an internal drainage of the left side with a Roux-en-Y jejunal loop (or more easily with the stomach), are indicated.

This prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseases.The study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectability or potential resectability (n = 34) and irresectability (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy.For endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar.Imaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.

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.