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The presence of a hiatal hernia is generally considered a contraindication to gastric banding in the morbidly obese, despite recent reports indicating favorable outcomes following simultaneous repair of sliding hernias and laparoscopic adjustable gastric banding (LAGB). A 66-year-old woman weighing 120 kg (BMI 45) with arterial hypertension and gastroesophageal reflux-related chronic obstructive pulmonary disease underwent repair of a large paraesophageal hernia and LAGB. At 40 months followup, the patient had lost 44% excess body weight (BMI 36) and had no complaints of heartburn, regurgitation or dysphagia. She was no longer hypertensive and her pulmonary condition had improved significantly. Barium swallow at 30 months showed normal anatomy and positioning of the band. Because other minimally traumatic surgical options are lacking, the author believes morbidly obese patients with hiatal hernia should not be denied the advantages of LAGB. Adequate weight reduction, resolution of gastroesophageal reflux and other co-morbidities can be expected if an appropriate surgical technique is used.

Management of the pancreatic remnant following pancreaticojejunostomy remains a technical challenge particularly when the pancreas is soft. A simple technique that consolidates the pancreas in preparation for pancreaticojejunostomy is described. Application of this technique in patients for whom a difficult anastomosis was anticipated has yielded good results.

Creation of an intrahepatic shunt using a metallic prosthesis introduced via a transjugular approach constitutes an alternative to surgery in the treatment of portal hypertension. Although rare, the specific complications of this technique justify close collaboration between radiologists and surgeons. The authors report two serious complications after failure of intrahepatic shunt, requiring emergency laparotomy.

A modified technique of orthotopic hepatic transplantation with inferior vena caval preservation and piggy-back procedure is described. This procedure, used in 14 patients, avoided the need for temporary vena cava clamping in nine cases and reduced the need for venous bypass during orthotopic liver transplantation. The indications, results and advantages of this procedure are described.

From 1983 to 1989, 96 oesophagectomies (30% of all oesophagectomies performed during this period) were performed without thoracotomy and then analyzed retrospectively. Most were performed due to contraindications including age (17%), respiratory disease (47%), heart disease (37%) or for superficial oesophageal lesions (35% were stage T1). Operative mortality was 3.1%. Fistulization of the anastomosis occurred in 7.5% of the cases. Actuarial survival rate at 5 years was 29% and was independent of age but dependent on localization, the size of the tumour, presence of parietal invasion and TNM classification. However, patient selection introduced bias and a prospective randomized study comparing oesophagectomy without thoracotomy and oesophagectomy via right thoracotomy and midline incision demonstrated that mortality and complications were similar with the two techniques. Long term survival was not dependent on access route, but on the stage of the disease.

Mucoceles of the appendix and associated pseudomyxoma peritonei are a heterogeneous group comprising various histopathologic lesions with differing prognoses. Between 1983 and 1990, we treated eight patients with appendiceal mucocele, three cystadenomas and five cystadenocarcinomas, three of which had accompanying pseudomyxoma peritonei. All patients were more than 50 years of age. Women outnumbered men by seven to one. Preoperative diagnosis was acute appendicitis or appendiceal abscess in all instances of mucocele unaccompanied by pseudomyxoma peritonei. Ultrasound of the abdomen, together with paracentesis, diagnosed pseudomyxoma peritonei in two of three patients. Elevated carcinoembryonic antigen levels were found in six of the eight patients and monitoring of this parameter was useful in the early detection of the two recurrences observed. The three patients with cystadenomas remain free of disease after appendectomy. Of the five patients treated for cystadenocarcinoma by right colectomy, two underwent reoperation after recurrence of disease. One patient died 41 months later of intestinal obstruction caused by pseudomyxoma peritonei. Pseudomyxoma peritonei significantly decreases survival of patients with appendiceal mucocele. In these patients, aggressive initial surgical management, repeated if need be, is indicated.

From 1975 to 1989, 51 patients presenting with hepatocellular carcinoma complicating genetic haemochromatosis were managed in our institution. Twenty-one patients underwent a laparotomy. Laparotomy was limited to surgical exploration or palliation in 8 patients in whom the tumour was deemed unresectable. Thirteen patients underwent either a partial hepatectomy (11 patients) or a total hepatectomy and liver transplantation (2 patients). Actuarial survival at 1 and 3 years following partial hepatectomy was 56% and 40% respectively. There was one hospital death in the resection group and in the transplant group. Only 3 patients have remained free of tumour recurrence after a mean follow-up of 18 months. Common clinical and histological features for patients with this condition included masculine gender, age 50 years or above, 10 or more years of history of diagnosed genetic haemochromatosis, high alcohol intake, and grade III or IV hepatic fibrosis.

A case of tumor seeding in an abdominal trocar hole after laparoscopic extraction of an incidental gallbladder carcinoma is reported. The high incidence of occult tumors of the gallbladder and appendix warrants caution when dissecting and extracting operative specimens.

Human alveolar echinococcosis is a rare parasitic disease caused by larvae of the tapeworm E. multilocularis that colonizes the intestines of foxes. The disease predominantly affects the liver and mimics slow growing liver cancer. With a mere 13 reports coming mostly from southern rural regions Belgium has so far been spared from the disease. However alveolar echinococcosis appears to be slowly spreading to non-endemic European countries like Belgium and to urban centres. We report the first autochthonous case involving a patient having lived exclusively in downtown Brussels. Heightened awareness by the medical community is necessary to detect this lethal disease at an early curable stage. In patients with an undetermined focal liver lesion--especially if calcified--and no firm evidence of malignancy, serological screening should be performed to exclude alveolar echinococcosis.

Focal nodular hyperplasia remains a difficult diagnostic and clinical dilemma. Over a 10-year period, 20 patients with this diagnosis underwent surgery in our service. Eight of the patients had focal nodular hyperplasia discovered incidentally as part of investigation or surgery for other unrelated conditions. Seventeen of the patients were female, with 64% receiving oral contraceptives. In the 12 patients without concomitant disease all but one had upper abdominal pain. Despite the use of CT scan, isotope studies, NMR, angiography, ultrasound and biopsy, a firm preoperative diagnosis of focal nodular hyperplasia was made in only one patient. Resective surgery was performed without complication in all cases. During a mean follow-up of 42 months (range 6-128 months) one patient died from lymphoma and two patients had recurrent abdominal pain. This study highlights the difficulty in preoperative diagnosis of focal nodular hyperplasia. Conservative treatment can be considered or resective surgery safely performed for symptomatic or suspect lesions.

Hemangiopericytoma is an uncommon vascular tumor with variable malignant potential. The origin, structure and function of pericytes remains controversial. Intra-abdominal hemangiopericytomas are highly aggressive soft tissue tumors with a great propensity for malignant transformation. We report on a case of hemangiopericytoma of the pancreas in a 53-year-old female presenting with abdominal pain. Ultrasonography and CT scan revealed a cystic tumor of the head of the pancreas. The patient underwent successful pancreaticoduodenal resection and is alive with no signs of recurrence 25 months following surgery. Ultrastructural studies are necessary to differentiate hemangiopericytomas from other sarcomas. Malignancy may be ascertained only in the presence of metastases or local recurrence. Routine surveillance is advocated.

Controversy persists regarding digestive reconnection following subtotal gastrectomy for carcinoma. A randomized prospective trial comparing Billroth I and Billroth II procedures for mortality, digestive comfort, survival, and patterns of recurrence was conducted.Thirty patients underwent Billroth I and 32 patients underwent Billroth II procedures. Stages I, II, III, and IV of the tumor-node-metastasis (TNM) staging system accounted for 27, 16, 47, and 10 percent of tumors, respectively. Billroth I and II groups were well-matched for clinicopathologic variables.Duration of surgery, volume of blood transfused, and abdominal drainage were similar in the two groups. The duration and volume of gastric drainage were greater in patients following Billroth I procedures. Four fistulas were noted in the Billroth I group and one fistula developed in a patient following Billroth II gastrectomy. Billroth I gastrectomy and low preoperative serum albumin were independent risk factors for fistula development. Fistula development accounted for an increase in the duration of hospital stay following Billroth I procedures. Hospital mortality was similar in the two groups. Five-year actuarial survival rate was 42 and 40 percent for patients undergoing Billroth I and Billroth II procedures, respectively. Long-term survival was similar for patients having each procedure, and this was verified for all TNM stages. There were seven recurrences at the hepatic pedicle in the Billroth I group and one recurrence of this type in the Billroth II group, requiring four reinterventions.Digestive comfort and long-term survival are similar after Billroth I and Billroth II gastrectomy for carcinoma. Billroth I gastrectomy is associated with an increased risk of fistula development and of recurrence of carcinoma at the hepatic pedicle.

The creation of an intrahepatic portosystemic shunt using an expandable stent introduced by a transjugular route constitutes an alternative to surgical shunts for the management of portal hypertension. A 61-year-old woman with Child C cryptogenic cirrhosis and acute variceal bleeding presented a massive haemoperitoneum due to a tear at the portal vein confluence during a failed attempt at TIPS. Surgical salvage consisting in an end-to-side portocaval shunt was performed under adverse conditions because of massive haemorrhagic infiltration of the hepatic pedicle. The patient died shortly after surgery of irreversible shock. A 61-year-old male with Child C alcoholic liver disease underwent an urgent TIPS procedure for recurrent variceal bleeding. However, the stent was placed too distally, at the splenomesenteric junction, causing splenic and portal vein thrombosis. After surgical removal of the impacted stent and thrombectomy, an end-to-side portocaval shunt was performed. The patient died 1 month later of infected ascites. Although serious procedural complications are uncommon in expert hands, transjugular intrahepatic portosystemic shunting is an invasive technique that is associated with potentially fatal complications.

We report the case of a patient who, at 28-week amenorrhea, presented with spontaneous hemoperitoneum in a pre-eclamptic syndrome. When caesarean section was performed, abdominal exploration revealed a liver hematoma which caused the rupture of Glisson's capsule. The related literature is reviewed.

The authors describe a musculocutaneous flap which can be used in trochanteric pressure sores in paraplegics. Described by Little and Lyons (1983), this reconstructive unit combines the proximal muscular segment of the tensor fasciae latae (TFL) and gluteus medius muscles in a round shaped flap pedicled on the lateral circumflex femoral artery. The anatomical basis of this muscle combination is found in the anastomotic network between the superior gluteal artery which supplies gluteus medius muscle and lateral circumflex femoral artery, the principal vascular pedicle of the TFL muscle. Cutaneous defects of the trochanter and associated osteitis are frequent complications in paraplegic patients which often require ostectomy and coverage of the bony prominence by well vascularised, padded skin. Musculocutaneous flaps are well suited for this purpose and we review various reconstructive units that may be brought into trochanteric defects. Among these, the gluteus medius-TFL flap appears to be an interesting option for, in case of recurrent ulcers, other donor areas are left intact, and the flap itself could give rise to a subsequent "traditional" TFL flap.

Between 1980 and 1990, 25 patients were treated for large incisional hernias using the skin lacing technique. Twenty-four hernias were midline and one was at the site of a McBurney incision. Hernia defects were greater than 10 cm in diameter for 24 patients. A 1 cm-wide uninterrupted segment of skin was harvested from excess skin overlying the hernia and was then alternatively passed through the left and right fascial margins of the hernia. The operative mortality was nil. Two wound abscesses were drained locally and did not mandate removal of the skin lace. After a mean follow-up of 4.9 years, 3 recurrences were observed. Among 22 patients who had a successful repair of their incisional hernia, 20 returned to their previous occupations and two others reported improvement in performing their daily tasks. The skin lacing technique is an interesting alternative to other more sophisticated techniques in the management of large incisional hernias.

Using the traditional technique for liver transplantation, there are two supra and subhepatic anastomoses to the vena cava. With the piggy-back method, the donor's inferior vena cava is implanted terminolaterally into the recipient's inferior vena cava. The aim of this work was to evaluate results in two matched groups. PATIENTS AND METHODS. From June 1992 to May 1993, 13 patients underwent piggy-back liver transplantation (group 1) and 14 others underwent traditional liver transplantation (group 2). There were 17 men and 10 women, mean age 48 years (range 25-65 years). There was no significant difference between the groups for age, sex, indications, number of rejections and retransplantations. RESULTS. There were no deaths in group 1 and 2 deaths in group 2 within the first 30 days postoperatively. There was no significant difference between groups 1 and 2 for duration of cold ischaemia (552 +/- 323 vs 463 +/- 345 min respectively), the number of packed cell transfusions (9.8 +/- 11 vs 11.1 +/- 5.5), duration of the operation (474 +/- 151 vs 500 +/- 95 min), duration of anastomosis (56 +/- 17 vs 66 +/- 20 min), creatinine levels at day 30 (140 +/- 79 vs 200 +/- 145 min). But there was a significant difference in the anhepatic phase (56 +/- 17 vs 66 +/- 20 min). CONCLUSION. Unexpectedly, there was no significant difference between the two types of transplantation with the exception of the anhepatic phase.