Search

Presentation du cas clinique Cette observation a ete presentee au 3 e Congres francophone de chirurgie digestive et hepatobiliaire, a Marne-la-Vallee, le 8 decembre 2007 lors de la seance de dossiers cliniques. Le presentateur ( Docteur Justine Prost a la Denise ) fait des propositions, discutees par les animateurs ( Docteurs Sauvanet et Mariette) qui encouragent la salle a prendre la parole.

Most pseudoaneurysms (PsA) of the peripancreatic arteries cause direct erosion of the arterial wall from pancreatic enzymes that are usually in contact with or in a pseudocyst (PC). Rupturing is a rare and serious complication (90% mortality if untreated). We report the case of a 56-year-old patient with chronic alcoholic pancreatitis who developed a cephaloisthmic PC, complicated with a PsA of the gastroduodenal artery revealed by pain and deglobulization associated with cholestasis. After a diagnostic scan, emergency selective arteriography with coil embolization was performed. Five days later, hemorrhage recurred and a cephalic duodenopancreatectomy was performed. PsA of the gastroduodenal artery occur in the first 10 years of chronic pancreatitis. They are revealed by abdominal pains and/or gastrointestinal hemorrhage or shock from rupture. A scan with arterial reconstruction provides diagnosis. Arteriography is the most sensitive technique to locate the aneurysm and its branches and to perform selective embolization with coils. The failure rate is between 0 and 23%. Surgical treatment (elective ligation of the artery or partial pancreatic excision) should be limited to when embolisation fails and/or recurrent hemorrhage.

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Resume But de l’etude : Au cours de ces dernieres annees, la chirurgie colorectale par laparoscopie s’est averee faisable et fiable avec l’utilisation de pinces mecaniques pour la realisation de l’anastomose. Le but de cette etude a ete d’evaluer la fiabilite et la faisabilite des anastomoses manuelles intracorporelles sous videolaparoscopie en chirurgie colorectale. Patients et methodes : Sept malades (quatre hommes et trois femmes, d’âge moyen 41 ans) ont ete etudies. Il y a eu deux resections ileocoliques pour maladie de Crohn recidivee, deux colectomies droites (une pour maladie de Crohn et une pour tumeur carcinoide de l’appendice), deux colectomies sigmoido-iliaques pour sigmoidite diverticulaire et une resection sigmoidienne pour volvulus du colon pelvien. Il y a eu quatre anastomoses ileocoliques laterolaterales, deux colorectales lateroterminales et une colocolique terminoterminale. Les anastomoses ont ete realisees en un plan au fil resorbable a points separes dans quatre cas (deux ileocoliques et deux colorectales), et par un surjet extramuqueux dans trois cas (deux ileocoliques et une colocolique). La piece etait exteriorisee dans un sac a travers une mini-incision de 3 a 5 cm dans cinq cas et a travers le rectum dans deux cas. Resultats : Le temps moyen additionnel de realisation de l’anastomose a ete de 90 ± 15 minutes. La mortalite operatoire etait nulle. Il n’y a pas eu de complication peroperatoire. Les suites postoperatoires ont ete simples dans six cas. Les malades ont ete realimentes des le 2e jour et sont sortis au 5e jour postoperatoire, a l’exception d’un cas (sorti au 8e jour) ; un malade porteur d’une maladie de Crohn a eu une hemorragie anastomotique abondante au 2e jour postoperatoire ; l’hemostase a ete realisee par laparotomie a travers une courte colotomie, sans refection de l’anastomose. Conclusion : Les anastomoses manuelles intracorporelles sous videolaparoscopie sont faisables et semblent fiables. Elles representent une etape supplementaire qui rapproche les methodes laparoscopiques de celles realisees en chirurgie conventionnelle par laparotomie. Une evaluation sur des series plus importantes est necessaire.

Anevrisme des arteres pancreatico-duodenales G. Virzi, A. Joudinaud du Passage, S. Scaringi, E. Facchiano, C. Leroy, Y. Flamant, S. Msika, R. Kianmanesh L’âge moyen au moment du diagnostic est de 50 ans. Le mode de revelation est fait de douleurs abdominales, d’un etat de choc, d’une hemorragie digestive, d’une douleur biliaire, d’un ictere ou d’une anemie aigue. Plus rarement, ces anevrismes sont reveles fortuitement sur l’imagerie. La rupture d’un anevrisme des arteres pancreatico-duodenales est une complication grave avec un taux de mortalite elevee. Dans ces conditions, le diagnostic de rupture d’un anevrisme des arteres pancreatico-duodenales est une urgence therapeutique. L’embolisation arterielle est le traitement de choix, et la chirurgie doit etre reservee aux echecs de l’embolisation. Nous rapportons le cas d’une patiente qui a ete traitee avec succes par embolisation arterielle, mais qui a pose un probleme diagnostique et therapeutique.

Resume Le traitement et l'analyse automatique des signaux electrocardiographiques (ECG) pendant les epreuves d'effort sont tres difficiles, ces signaux etant fortement bruites. Dans ce contexte et en vue d'obtenir des donnees ECG exploitables, nous avons fait un pretraitement de ces derniers en utilisant une onde P modelisee permettant la reconnaissance des ondes P par la methode des moindres carres, et par la suite l'estimation et l'elimination de l'artefact de respiration. Les bruits hautes frequences ont ete minimises par la methode des moyennes temporelles. Le telescopage des ondes P et T en fin d'epreuve a ete estime par la superposition de l'onde P modelisee.

Aliment Pharmacol Ther 28, 312–325 Summary Background Post-operative ileus (POI) affects most patients undergoing abdominal surgery. Aim To evaluate the effect of alvimopan, a peripherally acting mu-opioid receptor antagonist, on POI by negating the impact of opioids on gastrointestinal (GI) motility without affecting analgesia in patients outside North America. Methods Adult subjects undergoing open abdominal surgery (n = 911) randomly received oral alvimopan 6 or 12 mg, or placebo, 2 h before, and twice daily following surgery. Opioids were administered as intravenous patient-controlled analgesia (PCA) or bolus injection. Time to recovery of GI function was assessed principally using composite endpoints in subjects undergoing bowel resection (n = 738). Results A nonsignificant reduction in mean time to tolerate solid food and either first flatus or bowel movement (primary endpoint) was observed for both alvimopan 6 and 12 mg; 8.5 h (95% CI: 0.9, 16.0) and 4.8 h (95% CI: −3.2, 12.8), respectively. However, an exploratory post hoc analysis showed that alvimopan was more effective in the PCA (n = 317) group than in the non-PCA (n = 318) group. Alvimopan was well tolerated and did not reverse analgesia. Conclusion Although the significant clinical effect of alvimopan on reducing POI observed in previous trials was not reproduced, this trial suggests potential benefit in bowel resection patients who received PCA.

Most pseudoaneurysms (PsA) of the peripancreatic arteries cause direct erosion of the arterial wall from pancreatic enzymes that are usually in contact with or in a pseudocyst (PC). Rupturing is a rare and serious complication (90% mortality if untreated). We report the case of a 56-year-old patient with chronic alcoholic pancreatitis who developed a cephaloisthmic PC, complicated with a PsA of the gastroduodenal artery revealed by pain and deglobulization associated with cholestasis. After a diagnostic scan, emergency selective arteriography with coil embolization was performed. Five days later, hemorrhage recurred and a cephalic duodenopancreatectomy was performed. PsA of the gastroduodenal artery occur in the first 10 years of chronic pancreatitis. They are revealed by abdominal pains and/or gastrointestinal hemorrhage or shock from rupture. A scan with arterial reconstruction provides diagnosis. Arteriography is the most sensitive technique to locate the aneurysm and its branches and to perform selective embolization with coils. The failure rate is between 0 and 23%. Surgical treatment (elective ligation of the artery or partial pancreatic excision) should be limited to when embolisation fails and/or recurrent hemorrhage.

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Acute abdominal pain is frequent and often distressing. This symptom must start a clinical investigation with mostly questioning and abdominal palpation for correct diagnosis and decision making. Half of the patients have either appendicitis or non-specific abdominal pain.

Laparoscopic colectomies have been recently shown to be feasible and safe, with the use of stapling devices to fashion the anastomosis. The aim of this study was to evaluate the feasibility and safety of laparoscopic intra-abdominal hand-sewn anastomosis.Seven patients (four males and three females, mean age 48 years) were included. There were two ileocolic resections for recurrence of Crohn's disease, two right colectomies (one for Crohn's disease and one for carcinoid tumor of the appendix), two left colectomies for diverticulitis and one segmental colectomy for sigmoid volvulus. There were: four side-to-side anastomoses, two side-to-end anastomoses and one end-to-end anastomosis. Anastomoses were fashioned with interrupted single layer sutures in four cases (two ileo-colic and two colorectal anastomoses) and with single layer running sutures in three cases (two ileo-colic and one colo-colic anastomoses). The specimens were retrieved by means of a plastic bag through a 3 to 5 cm long minilaparotomy in five cases and through the rectum in two cases.Mean additional time to perform hand-sewn intra-corporeal anastomosis was 90 +/- 15 min. There was no operative mortality and no intraoperative complications. Postoperative course was uneventful in six patients. Patients were started on an oral fluid diet on day 2 and discharged on day 5, except for one patient with Crohn's disease who had a severe anastomotic bleeding on postoperative day 2 and who required laparotomy for hemostasis through a service colotomy with a single suture. He was discharged on day 8.Intra-abdominal hand-sewn anastomoses are feasible and seem reliable. This represents a new step making laparoscopic procedures even closer to conventional techniques. This technique must be evaluated in larger series.

In recent years, laparoscopy has had a significant impact on colorectal surgery. However, to date, totally laparoscopic procedures have required the use of stapling devices to fashion the anastomosis. Herein we report a case of totally laparoscopic sigmoid colectomy with intracorporeal hand-sewn anastomosis for diverticulitis. We describe the surgical technique, focusing on the advantages of and indications for the laparoscopic hand-sewn anastomosis.

We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula).Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 +/- 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality.After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups.Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Senna is more efficient than polyethylene glycol as mechanical preparation before elective colorectal surgery.Prospective, randomized, single-blind study.Multicenter study (18 centers).Five hundred twenty-three consecutive patients with colonic or rectal carcinoma or sigmoid diverticular disease, undergoing elective colonic or rectal resection followed by immediate anastomosis.Two hundred sixty-two patients were randomly allotted to receive senna (1 package diluted in a glass of water) and 261 to receive polyethylene glycol (2 packages diluted in 2-3 L of water), administered the evening before surgery. All patients received 5% povidone iodine antiseptic enemas (2 L) the evening and the morning before surgery. Ceftriaxone sodium and metronidazole were given intravenously at anesthetic induction.Degree of colonic and rectal cleanliness.Colonic cleanliness was better (P=.006), fecal matter in the colonic lumen was less fluid (P=.001), and the risk for moderate or large intraoperative fecal soiling was lower (P=.11) with senna. Overall, clinical tolerance did not differ significantly between groups, but 20 patients receiving polyethylene glycol (vs 16 with senna) had to interrupt their preparation, and 15 patients (vs 8 with senna) complained of abdominal distension. Senna, however, was better tolerated (P = .03) in the presence of stenosis. There was no statistically significant difference found in the number of patients with postoperative infective complications (14.7% vs 17.7%) or anastomotic leakage (5.3% vs 5.7%) with senna and polyethylene glycol, respectively.Mechanical preparation before colonic or rectal resection with senna is better and easier than with polyethylene glycol and should be proposed in patients undergoing colonic or rectal resection, especially patients with stenosis.

OBJECTIVE: To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection. SUMMARY BACKGROUND DATA: It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this. METHODS: Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths. RESULTS: Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups. CONCLUSION: OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

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

Perforated diverticulitis is an uncommon but severe complication of diverticular disease. Whatever the type of the contamination, whether bacterial or fecal, the peritonitis is responsible for septic shock, which necessitates emergent and aggressive medical and surgical treatment. Intensive intravenous perfusion under monitoring, adapted antibiotherapy should come before surgical decision. The aim of surgery is twofold: to suppress the infectious source and to clean the peritoneum. After all, the peritonitis has a tendency to recur and therefore postoperative abscesses have to be searched systematically and if the case arises, these abscesses have to be reoperated or drained. Best results were obtained with immediate sigmoidectomy and colo-rectal anastomosis associated with loop colostomy; that procedure should be preferred to Hartmann technique. If the morbidity remains high, the mortality should decrease under 10% with intensive therapy.

Using a data base of 7,000 acute abdominal pains, we have described the assessed clinical features of acute diverticulitis of the sigmoid colon. Percentages of sensitivities have been replaced by adverbs or adjectives, applying a scale of equivalence. The modifications of the positive predictive values have been also replaced by verbs or typical expressions. In this article, abscesses, fistulas, generalized peritonitis and hemorrhage arising from an acute diverticulitis of the sigmoid colon were not studied.

This study was developed to compare median and actuarial survival after left hemicolectomy vs. left segmental colectomy.Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64 +/- 12 (range, 18-91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmental colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested.After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survival curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.

The prevalence of signs and symptoms of acute intestinal obstruction in the adult was studied in a prospective study of 600 cases extracted from a data base on acute abdomen in 7,000 patients. This study of prevalence allows a precise definition of intestinal obstruction syndrome and to differentiate two types of presentations according to the site of obstruction on the small bowel or the colon. However, it is more difficult to differentiate simple bowel obturation from vascular strangulation. Surgical treatment depends mainly on the cause of obstruction.

Incarcerated hernia or wound dehiscence are responsible for more than 10% of small bowel obstructions. The complication is easily recognized when hernia or wound dehiscence was previously diagnosed. Difficulties occur when mass is deeply located in a thick abdominal wall or inside the inguinal canal. Femoral hernias and direct inguinal hernias are those which strangulate the most. Strangulation in wound dehiscence is the most severe. Strangulated hernia should be routinely excluded in patient with intestinal obstruction, to avoid inappropriate surgical approach.

Each year in France, 75,000 appendectomies are carried out for normal or fibrous appendix and another 75,000 for a mere inflammation of the mucosa of submucosa. To decrease the incidence--four times higher than in other countries--it is suggested to keep under observation the patient with RIQ tenderness if they have neither rebound nor guarding, a temperature below or equal to 38 degrees C and a white blood cell count lower than 10,000/mm3. By following these guidelines, there is no risk to miss perforated or suppurated appendicitis.

A computer aid diagnosis of acute abdominal pain has been constructed on a 7,000 cases data base, using a Bayesian model. The system is used as a paraclinic test, increasing the reliability of the physician's clinical diagnosis or questioning that diagnosis in case of discrepancy.

Using a data base of 7,000 acute abdominal pains, we here described the assessed clinical manifestations of the main diseases responsible for right lower quadrant pain. However, percentages of sensibilities have been replaced by adverbs or adjectives, applying a scale of equivalence. The possible modifications of the positive predictive values have been also replaced by verbs or typical expressions. We first described the acute appendicitis syndrome (which covered congestive endoappendicitis and suppurated appendicitis) with the clinical shades or the gathered and gangrenous forms or even of the diffuse peritonitis. Features of the acute appendicitis contrast with those of the so called "non specified abdominal pains" (a new entity), and those of the subacute or chronic appendicitis. We found a good correlation between clinical and pathological findings. One of the difficulties has been to determine if a subgroup of subacute appendicitis should be or not included into the acute appendicitis.

The effectiveness of cefazolin or cefotaxime as antibiotic therapy was compared with that of ceftriaxone in a multicentre prospective randomized trial involving 1,254 consecutive patients operated upon for abdominal diseases. Patients about to undergo surgery of the colon or who had localized or generalized peritonitis at the time of operation were excluded from the study. The patients entered were divided into 4 strata according to the degree of operative contamination and to risk factors. In each stratum, the patients were allocated at random to one or the other of 2 treatment groups. Group 1 patients received cefazolin or cefotaxime in 3 doses of 1 g administered 8-hourly, the first dose being injected during induction of general anaesthesia. Group 2 patients received one single 1 g dose of ceftriaxone injected during induction of anaesthesia. There was no significant difference between the two groups in the wound infection rate and in the frequency of post-operative intra-abdominal abscesses. Although the percentage of post-operative pulmonary and urinary tract infections was lower in the ceftriaxone group than in the cefazolin/cefotaxime group, no significant difference was observed between the two groups in the number of patients who required curative antibiotic therapy. This study shows that one single dose of ceftriaxone is as effective as three doses of cefazolin or cefotaxime in preventing would infections and post-operative intra-abdominal abscesses, and that it is more effective in preventing extra-abdominal infections complicating surgery.

One hundred and ten distal splenorenal anastomoses (DSRA) were performed between 1976 and 1988 for gastrointestinal haemorrhages secondary to portal hypertension. Thirty five patients underwent DSRA (Warren's operation) followed by a mesenteric disconnection procedure. Eleven patients (10%) died (nine Child B and two Child A), including two after an emergency shunt. The mortality was influenced by age (p less than 0.01) and by the number of previous episodes of ictero-ascitic decompensation (p less than 0.02). A single anastomotic thrombosis was observed; the high flow rate of the anastomoses (mean: 1200 +/- 650 ml/min) explains the high patency rate (more than 90%). Eleven patients developed partial or total thrombosis of the portal trunk less than 6 weeks after the operation. The quality of hepatic perfusion was not significantly influenced by the mesenterico-splenic disconnection and this was omitted in 75 patients. The mesenterico-splenic collateral venous circulation was more developed in the absence of disconnection (p less than 0.05). The long-term actuarial survival was 83% at one year, 53% at five years, 47% at eight years and 28% at ten years. Survival was not influenced by the disconnection. Warren's operation is more difficult to perform than a porto-caval or mesenterico-caval shunt. DSRA appears to have three advantages: 1) a high flow rate as it is arterialised by the splenic artery, 2) hepatopetal portal perfusion maintained for several days, weeks or months, possibly reducing the risk of encephalopathy, 3) the absence of dissection of the hepatic pedicle preserves the possibilities of liver transplantation.

A prospective multicenter study concerning 30 vocabulary terms was undertaken to determine if: 1) these terms could be equated with specific percentages; 2) observer assessment varied with time; 3) teachers and students used the same words with the same meaning; 4) certain words were more discriminant than others, and 5) terms corresponding to numbers were the same in French as in English. Three hundred and thirty medical professionals, coming from general and digestive units of 45 University, regional, or private institutions, were asked to answer three types of questionnaires pertaining to the same 30 words, but in a different order. One to 3 months later, 170 of them were asked to fill out the same questionnaire with the same words but in a different order. Sixteen percent were University professors, 15 percent were hospital or private surgeons, 19 percent were senior residents, 29 percent were interns or junior residents and 21 percent were medical students.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this multicentric retrospective study was to evaluate survival after resection of non colorectal hepatic metastases (HM). Patients and Methods —Between 1976 and 1990, 91 patients underwent resection of 60 synchronous and 31 metachronous non-colorectal and non-endocrine HM. The most common sites of the primary tumor (PT) were: stomach (n = 16), breast (n = 14), lung (n = 8) and exocrine pancreas (n = 7). The most common histopathologic types were adenocarcinoma (n = 42) and squamous cell carcinoma (n = 15). The surgical procedures were: 20 wedge resections and 71 radical hepatectomies. Results —Resection was curative in 77% of the patients. Operative mortality was 1%. There were seven biliary fistulas and 11 septic complications. Half of the patients underwent adjuvant chemotherapy Cumulative survival following curative resection was 54% at 1 year, 40% at 2 years, 32% at 3 years and 26% at 5 years. After palliative resection, survival was 33% at 1 year. Survival was not influenced by the time elapsed between resection of the PT and resection of the HM. There was no significant difference in survival between synchromous versus metachronous liver metastases, or according to the site of the PT. Wedge resection was as effective as lobectomy. Conclusions Surgical resection of HM in patients with PT other than colorectal cancer is advocated: postoperative morbidity and mortality are low; when resection is performed with curative intent, survival is similar to that obtained after resection of colorectal HM.

To preserve a good resolution at high counting rates we studied and realized a charge-sensitive preamplifier (P.A.C.) operating until 300 000 counts per second. Then, we observed in which conditions it was possible to change a conventional P.A.C. without failure of its intrinsic resolution.

Zusammenfassung A complete kinematic study of 11 B(p, 3α) has been done around E p = 2.65 MeV as a bombarding energy, corresponding to the 18.36 MeV resonance in 12 C. We explain the hole in the Dalitz plot near the zero energy of the third particle by assigning 3 − to this 12 C state.

Charged particle identification is made using a fast digitalized device constituted by a simplified computing unit and a wired program.

Seven patients were treated by gastrocolectomy for either ulcers or cancers. Two patients had ulcerating gastrojejunocolic fistulae, four had cancers of the stomach, and one had cancer fistulae, four had cancers of the stomach, and one had cancer of the transverse colon. Two patients treated by immediate colon anastomosis for cancer, died after the anastomosis broke down, while the three other cases, treated by delayed colon anastomosis, survived. Both patients with ulcerating lesions survived, one after immediate and the other after delayed colon anastomosis. This latter procedure appears, therefore, to be imperative in cancer cases and of value, when used prudently, in ulcer cases.

Zwei Faktoren bestimmen die Behandlung: die Art des Hindernisses und die klinischen Gegebenheiten. In Europa und Nordamerika sind 90% der portalen Hypertension (PH) durch intrahepatische Hindernisse bedingt. Davon beruhen wiederum 90% auf einer Lebercirrhose. Blutungen im Verdauungstrakt sind beim Cirrhotiker zu 40% durch eine Ruptur von Oesophagusvaricen, in 30% durch akute Erosionen und in 20% durch ein gastroduodenales Ulcus bedingt. Kombinierte Blutungsursachen sind dabei haufig. Am Anfang der Behandlung steht daher die Lokalisation der Blutung durch eine Endoskopie (vgl. Abb. 39.7).

In a prospective multicentric trial we compared the post-operative mortality and the 5-year survival of elective total gastrectomy (TG) versus subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study: thirty two were excluded after pathological examination (linitis plastica, superficial cancer, lymphoma). One hundred and sixty nine patients remained for analysis with 93 TG and 76 SG. Elective TG did not increase post-operative mortality (1.3%) in comparison with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both operations TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.

En 1972 a Leeds, de Dombal (2) met au point une aide au diagnostic des douleurs abdominales dont la precision diagnostique depasse de lOp cent celle des meilleurs cliniciens. En 1976 a Copenhague, Bjerregaard (1) se heurte aux difficultes d’utiliser, pour ses propres malades, le programme de Leeds. L’experience ici rapportee est celle de l’echec du transfert de la banque de donnees de Leeds a une population Francaise, imposant la constitution d’une banque de donnees locale.

With a bank of data collected locally and a probability program of diagnostic aid, the computer is capable of making the correct diagnosis in 79% of acute abdominal pain syndromes. Its performance in this respect is somewhat superior to that of clinicians (73.5%). Including a computer program in diagnostic procedures would reduce the number of errors by excess or omission. In abdominal emergencies computerization would help either by increasing the reliability of clinical diagnoses or by suggesting that other possibilities should be investigated.

Thirteen patients with intestinal lesions consecutive to radiotherapy for carcinoma of the uterus were operated upon between 1973 and 1979. The small bowel was involved in 9 patients and the colon and rectum in 4 patients. Urinary tract lesions were associated in 3 patients of each group. Intestinal necrosis, progression of the lesions and extensive pelvic fibrosis were the only criteria of poor prognosis. Twenty-two operations were performed: 4 for urinary tract lesions and 18 for intestinal lesions. Five patients died during the immediate post-operative period and five died within 2 to 30 months after surgery, including 4 whose carcinoma recurred. The operative technique should be selected according to the extent and severity of radiation-induced damage, as determined by pre-operative examination and thorough exploration of the abdominal cavity once opened. Limited lesions of the small bowel can be treated by resection, but intestinal bypass with latero-lateral anastomosis seems to be preferable in cases with extensive lesions. Patients with colorectal lesions should have defunctioning colostomy prior to any other procedure dictated by the state of affairs. Multiple anastomosis, extensive resections and excessive dissections should be avoided.