Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series.

OBJECTIVE: To review the outcome of resection of the suprarenal or infrarenal inferior vena cava (IVC) and possible indications for prosthetic replacement. SUMMARY BACKGROUND DATA: Involvement of the IVC has long been considered a limiting factor for curative surgery for advanced tumors because the surgical risks are high and the long-term prognosis is poor. Prosthetic replacement of the IVC is controversial. METHODS: The authors retrospectively reviewed a 7-year series of 14 patients who underwent en bloc resection including a circumferential segment of the IVC. The tumor was malignant in 12 patients and benign in 2. The resected segment of the IVC was located above the kidneys in eight patients and below in six. Resection was performed without extracorporeal circulation in all patients. RESULTS: In all but one patient, IVC resection was associated with multivisceral resection, including extended nephrectomy (n = 8), major hepatic resection (n = 3), digestive resection (n = 3), and infrarenal aortic replacement (n = 2). Prosthetic replacement of the IVC was performed in eight patients cases and was more common after resection of a suprarenal (6/8) than an infrarenal segment of the IVC (2/6). One patient died of multiorgan failure. Major complications occurred in 29% of patients. Symptomatic complications of prosthetic replacement occurred in one patient (acute postoperative thrombosis, successfully treated by surgical disobstruction). Graft-related infection was not observed. Marked symptoms of venous obstruction developed in three of the six patients who did not undergo venous replacement. In patients undergoing surgery for malignant disease, the estimated median survival was 37 months and the actuarial survival rate was 67% at 1 year. CONCLUSION: Multivisceral resection including a segment of IVC is justified to achieve complete extirpation in selected patients with extensive abdominal tumors. Prosthetic replacement of the IVC may be required, particularly in cases of suprarenal resection. It is a safe procedure with a low complication rate and good functional results.

[Analgesic effect of transhiatal splanchnectomy in pain from cancer of the pancreas. Apropos of 51 operated cancers]. / L'effet antalgique de la splanchnicectomie trans-hiatale dans les douleurs du cancer du pancréas. A propos de 51 cancers opérés.

The greater splanchnic nerves are responsible for sympathetic innervation of the supra mesocolic viscera, and total bilateral neurotomy is efficient to relieve pancreatic pain. Their dissection is easy by a midline transperitoneal route used for pancreatic cancer surgery. The aim of this study was to evaluate the pain relief related to transhiatal bilateral splanchnicotomy in patients with pancreatic cancer. The tumor was unresectable for all the patients, and nobody was operated only to make neurotomy. Twenty two patients had single bilateral splanchnicotomy, and other had an associated biliary and/or digestive diversion. There was not postoperative specific mortality, and postoperative mortality rate was 3.9%. Specific postoperative morbidity rate was 6%. Most of the patients (83.3%) had immediate pain relief, with or without diversion (respectively 80.7% and 86.3%, p = 0.6). Our data suggest that pain recurs for some patients three months after surgery (pain control in respectively 69.2% and 72.7%), but difference was not significant (p = 0.14). Our results demonstrate that transhiatal bilateral splanchnicotomy relieves pain in patients with pancreatic cancer, with a poor specific morbidity.

Transhiatal bilateral splanchnicotomy for pain control in pancreatic cancer: basic anatomy, surgical technique, and immediate results in fifty-one cases.

The greater splanchnic nerves are largely responsible for innervation of the supramesenteric viscera; their section is known to be efficient to relieve pancreatic pain. Transhiatal splanchnicotomy (THS) is easily performed through a midline laparotomy. The nerve trunks are readily identified in the submediastinal space, far from the pancreatic cancer motivating splanchnicotomy, and can be sectioned safely and completely. After carrying out an anatomic study to determine the level of origin and mode of constitution of the greater splanchnic nerve trunk and its relations to the posterior and lower mediastinum, 51 patients underwent THS for intractable pain caused by unresectable pancreatic adenocarcinoma. THS alone was performed in 22 cases. THS was performed in association with biliary tract diversion or gastroenteroanastomosis in the other cases. All tumors were considered unresectable during surgery, and no patient was operated on with the sole purpose of performing THS. Two deaths (3.9%) were unrelated to THS. Specific morbidity was 6% (one pneumothorax, one chylothorax, and one splenic injury). Immediate postoperative functional results were good in 86.3% of patients treated by THS alone (group 1) and in 80.7% of patients treated by THS and bypass (group II). Functional results decreased to 72.7% in group I and 62.1% in group II, 3 months after surgery. In conclusion, THS appears to be an efficient technique for relief of pancreatic neoplastic pain and need not be combined or confused with medical percutaneous methods of neurolysis.

[Immediate and late results of surgical treatment for chronic pancreatitis. Apropos of 127 operated cases]. / Résultats immédiats et tardifs du traitement chirurgical des pancréatites chroniques. A propos de 127 cas opérés.

From 1960 to 1987, 127 patients (105 males and 22 females, mean age: 45.9 years) underwent surgical treatment for CP. The aim of this study was to assess the results of surgical treatment intentionally oriented towards conservative surgical procedures (CPS). Ninety-one patients benefited from either pancreato-intestinal bypasses (84 cases) sometimes associated with other intestinal bypasses and/or transhiatal splanchnicotomy (THS) or isolated biliary (5 cases) or gastric (2 cases) bypasses. Thirty-one resections were carried out: 26 pancreatoduodenal resections (PDR) associated 3 times with TSH and 5 distal pancreatectomies. Other types of conservative treatment were performed in 5 cases. There were 5 post-operative deaths (3.9%): 1 after resection (6.6%) and 4 after CSP (p greater than 0.7). Postoperative complications occurred twice after resections (6.6%) and in 13 cases (16.2%) after CSP (p greater than 0.3). A further surgical procedure was required in 3 cases after pancreatic resection (3/25.12%) and in 14 cases after CSP (14/71, 19.7%) (p greater than 0.5). In the late postoperative course 15 deaths occurred but only 6 of them were directly related to the course of the pancreatitis. Five and 10 year overall survival probability after surgical treatment was respectively 81.5% and 64.7%. This probability was 70.4 and 60.4% after resections and 87.1% and 68.8% after CSP (p = 0.29). After CSP 75% of good functional results were observed between 1 and 4 years and 60% afterwards. Although non statistically significant these results suggest that: CSP and resections have the same operative risk, late reoperations are more frequent after CSP, the chance of late survival rate is better after CSP than after resection.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cancers of the sigmoid and upper rectum extending to the bladder or ureter, treated by monobloc resection. Apropos of 13 cases]. / Les cancers due sigmoïde et du haut rectum étendus à la vessie ou à l'uretère, traités par exérèse monobloc. A propos de treize observations.

The aim of this retrospective study is to assess the operative and functional risks and the results of "en bloc resection" performed for tumors of the sigmoid colon or of the rectum extending to the bladder. Thirteen patients required this resection, the sigmoid was involved in ten cases, the rectum in three. The urinary tract involvement was an operative finding in ten cases, while recurrent cystitis was observed in three cases. This extension reached the dome of the bladder in 11 cases, and the terminal portion of the ureter in 2 cases. All the patients underwent curative "en bloc resection" including colectomy and partial cystectomy or cysto-ureterectomy: operative mortality was 7.6%. Precise histological staging of lymph node and bladder involvement was only obtained in 11 cases; all were Astler Coller's stage B2. In 9 cases the malignant tissue involved the urinary tract; in 2 cases there were only inflammatory adhesions. In all cases the functional urinary results were good. The 5 year direct survival rate was 50%; following Kaplan Meier's actuarial method this rate was 68%. Bladder involvement by a colonic or rectal adenocarcinoma does not seem to have any "en bloc resection" is worthwhile for this kind of extensive prognostic valve.

[Malignant tumors of the ampulla of Vater treated by cephalic duodenopancreatectomy. Apropos of 20 case reports]. / Les tumeurs malignes de l'ampoule de Vater traitées par duodéno-pancréatectomis cephaliques. A propos de 20 observations.

Between 1966 and 1986, 27 tumors of the ampulla of Vater were operated on and 20 patients underwent potentially curative pancreatico-duodenal resection (PDR) (74% of resecability). The retrospective study of those 20 cases (13 men, 7 women, mean age: 59.9 +/- 9.8 years old) was done to evaluate the risks and the results of this type of wide resection. 15 patients (75%) had jaundice and gallbladder was palpable among 20 p. cent (4 cases) of the patients without cholecystectomy. Endoscopy was performed in 13 cases; endoscopic biopsies, done in 12 cases, were positive in 5 cases (45.4%), uncertain in three (25%) and falsely negative in four (33.3%). All the patients underwent Child's procedure. Histological analysis pointed out 15 adenocarcinomas and 5 malignant villous tumors; lymph node involvement was present in 11.1 p. cent; the staging following Martin's classification listed 6 stage 1, 3 stage II, 10 stage III and 1 stage IV. Operative mortality was of 5 p. cent; one patient died after an emergency procedure performed for massive bleeding but no death was observed in the group of patients treated out of emergency. Post-operative complications occurred in 5 patients (26.3%); none of the patient had pancreatico-jejunal or hepatico-jejunal anastomotic leakage. Hospitalisation had a mean duration of 22.8 +/- 6.4 days. The age over 65 years old, preoperative jaundice and preoperative endoscopic or surgical biliary drainage done to improve jaundice had no statistical influence upon post-operative morbidity. The 5 years survival rate following Kaplan Meier's method reached 44.5 p. cent.(ABSTRACT TRUNCATED AT 250 WORDS)

[Retro-pancreatic inflammatory pseudotumor]. / Pseudo-tumeur inflammatoire rétro-pancréatique.

The authors report a case of retro-pancreatic tumor in a 65 year-old man associated with impaired general condition. At gross examination by the surgeon, the pancreatic gland seemed to be enlarged. Histologic analysis found fibrous tissue and inflammation with lymphoid cells. The diagnosis of inflammatory pseudotumor was based on similar aspects found in some orbital lesions. The "tumor" disappeared under steroid therapy but recurred as soon as the treatment was stopped. Several etiologic factors related to the unusual location of the lesion were discussed.

[Splanchnicectomy using the Dubois transhiatal approach. Current technical modifications]. / La splanchnicectomie par voie trans-hiatale de Dubois. Modifications techniques actuelles.

Technical modifications were applied during 47 splanchnicectomies using Dubois' trans-hiatal approach, with major simplification of the method, mainly by the absence of freeing of the abdominal esophagus. The approach to the right and left greater splanchnic nerves involved displacement of the esophagus to the left, avoiding the need to perform a gastro-esophageal antireflux procedure at the end of the operation. Furthermore, the most effective plane for pleural detachment is situated in fact in contact with the aortic adventitia. The simplicity and safety of this modified surgical method makes it an indication of choice for the treatment of intractable supramesocolic pain.

Anatomical bases of the transhiatus approach to the greater splanchnic nerve.

The level of origin and mode of constitution of the greater splanchnic nerve and its relations in the posterior mediastinum were studied. The aim of this work was to identify the anatomical basis of the transhiatus approach to the right and left greater splanchnic nerves. The azygos venous system was seen to be the main anatomical relation of these nerves. The results of this study should allow the surgeon to perform total bilateral neurotomy.

[Splanchnicectomy by Dubois' transhiatal approach. Technics, indications and results. Apropos of 25 nerve sections for visceral abdominal pain]. / La splanchnicectomie par voie trans-hiatale de Dubois. Techniques, indications, résultats. A propos de 25 sections nerveuses pour algies viscérales abdominales.

Splanchnicectomy through Dubois, transhiatal approach was performed in 25 patients with abdominal pain of mainly pancreatic origin. The four stages of the operation are described and are facilitated by the use of a Fruchaud type of retractor and rigid, long, narrow valves to enable lateral displacement of the aorta and abdominal esophagus. After dissection of the esophageal hiatus, the Xth nerves and abdominal esophagus are isolated and the pleura detached, beginning with the anterior surface of the aorta. The greater splanchnic nerves are then isolated and sectioned and a final-stage esophageal hiatus reconstruction performed. This simple, rapid technique produces immediate, total, lasting pain relief, particularly spectacular in patients with cancer of the body of the pancreas, this representing the indication of choice for this neurectomy. Splanchnicectomy does not affect survival duration but improves the comfort and quality of this period. In hyperalgic forms of chronic pancreatitis, this nerve section can be combined with conventional surgery. There was no operative mortality in this series of 25 cases.