Management of common bile duct stones by laparoscopic cholecystectomy and endoscopic sphincterotomy: pre-, per- or postoperative sphincterotomy?

BACKGROUND/AIMS: The aim of this study was to evaluate the treatment of common bile duct stones (CBDS) by endoscopic sphincterotomy (ES) and laparoscopic cholecystectomy (LC), ES being performed either pre-, per- or postoperatively. METHODS: Between January 1990 and June 1997, 386 patients with a median age of 60 (range 18-92) years were treated for suspected or confirmed CBDS. The CBDS were uncomplicated in 264 cases (70%) but associated with a complication in 122 cases (30%), namely, cholangitis (69 cases) or acute pancreatitis (53 cases). ES combined with LC was carried out in 233 cases (60%): ES was preoperative (sequential treatment in two stages) in 197 cases (51%); peroperative in 30 cases (7%), or postoperative in 6 cases (2%). Laparoscopic extraction was performed in 58 cases (15%) and conventional surgery in 82 cases (21%). RESULTS: With respect to sequential treatment, endoscopic retrograde cholangiography showed the presence of CBDS in 117 cases (60%) and preoperative ES allowed the release of the CBDS in 82% of these cases. The complication rate of sequential treatment was 8% (15 cases) after ES and 7% (13 cases) after LC, with 1 death (0.5%). A peroperative ES performed after LC enabled evacuation of the CBDS in 28 cases (93%) without any complications or mortality. Postoperative ES was successful in 100% of cases with residual lithiasis in 16% (1 case) and a complication rate of 16% (1 case). CONCLUSION: Along with conventional surgery and laparoscopic extraction, ES combined with LC represents an effective alternative in the management of CBDS. Since it can be performed peroperatively, it allows a one-stage, minimally invasive treatment of most uncomplicated CBDS.

[Laparoscopic treatment of gastroesophageal reflux using fundoplication. Midterm results]. / Traitement laparoscopique du reflux gastro-oesophagien par fundoplicature. Résultats à moyen terme.

UNLABELLED: The aim of this study was to see whether the results of surgical treatment of gastroesophageal reflux disease (GERD) by laparoscopic fundoplication were satisfactory and stable over time. PATIENTS AND METHODS: From July 1992 to September 1996, 161 patients with medical treatment-dependent GERD were operated. 17 patients were excluded from the study (conversion or immediate laparotomy). The group of 144 patients included consisted of 92 men and 52 women with a mean age of 50 (25-77 years). The preoperative work-up included endoscopy, esophageal manometry and 24-hour pH monitoring. The surgical procedures were complete fundoplication without section of the short vessels (Nissen-Rossetti: 122 cases), with section of the shorts vessels (Nissen: 18 cases), or partial fundoplication of 270 degrees (Toupet: 4 cases). The patients were reviewed clinically 3 months after the operation, with repeat manometry and pH monitoring; yearly survey was performed. RESULTS: There was no postoperative mortality. The morbidity consisted of 2 respiratory complications (1.5%) with good recovery. With a follow-up of 3 and 21 months, the dysphagia rate was 24 vs 2% of patients (p < 0.05), the rate of gas bloat syndrome was 18% vs 21% (n.s.), and the GERD recurrence 6% vs 14% (p < 0.05). The mean time to recurrence was 8 months. 2 patients were reoperated: one for incisional hernia and one for slipped-Nissen. CONCLUSION: The results of laparoscopic treatment of GERD with fundoplication procedures at 2 years follow-up showed an 86% cure rate of GERD control and 94% satisfaction rate for the patients who were investigated.

[The remaining indications for open surgery in common bile duct lithiasis]. / Indicatii reziduale ale chirurgiei deschise în litiaza caii biliare principale.

Once with the continuous development of mini-invasive procedures, the open surgery indications in the treatment of CBD stones are decreasing. Between January 1986 and December 1987, 514 patients with average age 60 years old (18-94) were treated for suspected or confirmed CBDS. Three distinctive periods were studied function of how the conventional surgery were either exclusive (group I), either together with the beginning era of laparoscopy (group II), or together with institutionalised laparoscopy (group III). Group I had 110 cases, group II--207 cases and group III--197 cases. The conventional surgery were 100% performed in group I, 26% (52 cases) performed in group II, 14% (28 cases) performed in group III. If the laparotomy was the only therapeutical option in patients with CBDS from group I, the therapeutical procedures become more various after 1990. It was done endoscopic sphincterotomy in 59% (124 cases) in group II and in 64% (126 cases) in group III. The laparoscopic extraction of CBDS was 12% (cases) in group II and 19% (37 cases) in group III. The overall mortality in conventional surgery was 1.5% with 1.8% in group I and 0% in group II and III. The complications rate was 13% with 8% in group II and 21% in group III. The postoperative hospitalisation time average was 16 days for laparotomy of the 3 groups. The conventional surgery is main indicated when laparoscopic surgery for CBDS extractions or endoscopic sphincterotomy is contraindicated or failed; also it is useful in some complicated forms of CBDS.

[Outcome of surgical treatment of cancer of the stomach. Report of 330 cases]. / Risultati della terapia chirurgica del cancro dello stomaco. A proposito di 330 casi.

The study concerned 330 cases of gastric adenocarcinoma operated from January 1969 to June 1996. Clinical, histological and therapeutic features were analyzed and compared during 3 periods (Group 1: 1969-79, Group 2: 1979-88, Group 3: 1989-96). The aim was to evaluate changes and results occurred in gastric carcinoma. The median age was 65 +/- 11 year (range 25-90), the sex ratio 2. The most common location was in the lower third of the stomach and the cancer was often far advanced (71 percent of stages III and IV). Subtotal gastrectomy was replaced by total gastrectomy and large lymph node dissection was systematically performed in group 3. Curative resection rate increased from 28 to 60 percent between group 1 and group 3. Despite the more radical surgery, post-operative mortality rates decreased respectively 22%, 9%, 8% for the groups 1, 2, 3 (p < 0.01) and global morbidity remained stable while the rate of intra-abdominal infection have changed in group 3 (4.8% vs 2.7% and 2.1% in respectively groups 1 and 2; p = ns). Two year survival rates were 20% for group 1.25% for group 2 and 35% for group 3 (p < 0.01). This results can be considered as encouraging but have to be confirmed at 5 year survival.

[The value of peroperative colonic lavage in urgent colonic surgery. Apropos of 54 patients]. / Intérêt du lavage colique per-opératoire dans la chirurgie colique d'urgence. A propos de 54 patients.

UNLABELLED: The effects of on-table colonic irrigation followed by primary large bowel resection and anastomosis for emergency left colonic disease were prospectively studied in 54 patients. PATIENTS AND METHODS: Eighteen patients had a diverticular sigmoiditis complicated by localized (8) or generalized (4) peritonitis, 6 presented a complete sigmoid obstruction. Thirty six patients had a left colonic occlusive (33) or perforated (3) cancer. Anterograde colonic irrigation was carried out with a mean volume of 7.7 l. All patients received a double or triple antibiotic combination. The anastomosis was handsewn in 33 cases and stapled (Knight-Griffen) in 21. Seven patients with severe peritonitis had a proximal transitory stoma which was closed within 4 months. RESULTS: Two patients (3.7%) died postoperatively, one for anastomotic dehiscence and the second for evisceration. We observed 7 cases of hypothermia (< 34 degrees C) during the irrigation. Six patients developed a sepsis of the surgical wound, 2 a septicemia and l an abscess in the right iliac fossa which was percutaneously drained. All complications had a favourable outcome. CONCLUSION: This study confirms that in selected cases a single stage surgery for colonic emergencies preceded by on-table irrigation grants good results and is a safe and effective alternative to Hartmann's procedure.