Surgical attitude towards carcinoid tumour of the appendix. Review of the literature.

Carcinoid tumours of the gastrointestinal tract are most frequently located at the appendix. We report two cases: In the first case, we realized a simple appendicectomy. In the second case, two weeks after the appendicectomy was performed, according to the histological characteristics of the tumoral specimen, the patient underwent a laparoscopic right hemicolectomy with regional lymphadenectomy. In both cases, 5-HIAA (5 HydroxyIndolAceticAcid) is assayed regularly and remains normal.

Guidelines to laparoscopic management of acute cholecystitis.

OBJECTIVE: The present work aims at identifying preoperative variables that may help the surgeon choosing the most appropriate operative approach in various clinical presentation of acute cholecystitis. SUMMARY BACKGROUND DATA: Conversion rates up to 60% have been reported for laparoscopic management of acute cholecystitis. Previous works indicate that the severity of the gallbladder inflammatory process represents the main cause of laparoscopic conversion. The influence of converting a laparoscopic cholecystectomy for acute cholecystitis to open surgery on the post-operative course remains questionable. Objective preoperative variables correlated to the severity of cholecystitis and predictive of laparoscopic cholecystectomy failure remain to be identified. METHODS: Seven preoperative and five post-operative variables were compared among a continuous series of 62 patients operated for acute cholecystitis either by a successful laparoscopic procedure (37 patients) or by a laparoscopic procedure converted to open surgery (14 patients) or directly by open surgery (11 patients). The post-operative outcome of patients in the 3 groups were compared. Determinant preoperative factors correlated with the need to convert a laparoscopic procedure were searched by the CHI square test for independance and by a multivariate logistic regression analysis. RESULTS: Converting a laparoscopic cholecystectomy for acute cholecystitis to open surgery does not worsen the patients early post-operative course as long as conversion is decided rapidly and before peroperative complications arise. Three preoperative independent variables predictive of the need to convert a laparoscopic cholecystectomy for acute cholecystitis were identified: The thickness of the gallbladder wall, preoperative C reactive protein seric levels and finally the delay between the start of acute symptoms of cholecystitis and surgery. CONCLUSIONS: The post-operative outcome of patients operated for acute cholecystitis depends more on the severity of the disease than on the type of the surgical procedure. Patients with a perforated cholecystitis (grade III) should better be handled immediately by open surgery. Patients with acute edematous cholecystitis (grade I) or with empyema or gangrenous cholecystitis (grade II) coming early to surgery (within 72 hrs) and having seric preoperative CRP levels less than 10 mg/% represent the best candidates to laparoscopic surgery.

Mucinous cystadenocarcinoma of the appendix. A rare tumour of the right iliac fossa.

A case of mucinous cystadenocarcinoma of the appendix is presented. The clinical feature is a painful syndrome of the right iliac fossa. In our observation, the diagnosis was not allowed by preoperative imaging. Appendectomy was initially performed and completed by right hemicolectomy and lymphadenectomy after histological diagnosis of the appendicular malignant tumour was forwarded. The prognosis of this tumour is generally excellent providing early diagnosis and wide enough surgery.

Laparoscopic repair of perforated duodenal ulcer. A prospective multicenter clinical trial.

BACKGROUND: A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated. METHODS: All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%. RESULTS: The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study. CONCLUSIONS: Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery.

Laparoscopic treatment of nonparasitic liver cysts: adequate selection of patients and surgical technique.

Results of laparoscopic fenestration in patients with a highly symptomatic solitary liver cyst (17 patients) or polycystic liver disease (PLD) (9 patients) were prospectively evaluated in a multicenter practice of general surgeons. Conversion to laparotomy was required in two patients because of inaccessible deep liver cyst in one and a diffuse form of PLD in the other. There was no mortality or major morbidity. Mean postoperative hospital stay was 4.6 days after successful laparoscopic procedures. During a mean follow-up of 9 months, 23% of the patients had recurrence of symptoms and 38% had radiographic reappearance of cysts. Factors predicting failure included previous surgical treatment, deepsited cysts, incomplete deroofing technique, location in the right posterior segments of the liver, and a diffuse form of PLD with small cysts. Adequate selection of patients and type of cystic liver disease and meticulous and aggressive surgical technique are recommended.

Roxithromycin versus doxycycline in the treatment of acute exacerbations of chronic bronchitis.

The efficacy and safety of roxithromycin (300 mg once daily) and doxycycline (200 mg once daily) in the treatment of acute exacerbations of chronic bronchitis in general practice were compared in a multicenter, double-blind, double-dummy trial. The data presented here are the results of an interim analysis of 76 patients. A satisfactory clinical response was obtained in 81% of patients treated with roxithromycin and 80% of those treated with doxycycline. Among patients receiving roxithromycin, 12.2% volunteered adverse events, compared with 33% of those receiving doxycycline; the test treatments were considered possibly or probably responsible for the adverse events in 9.8% and 21.2% of cases, respectively. Though patient numbers are too small for statistically significant differences to be detected, we conclude that the results to date suggest that roxithromycin and doxycycline are equivalent in terms of efficacy, but that roxithromycin is better tolerated.

Elective cholecystectomy without drainage and without prophylactic antibiotics. A prospective randomized trial with clinical and bacteriological aspects.

A consecutive series of 50 patients undergoing elective cholecystectomy without prophylactic antibiotics entered a prospective randomized trial to compare the post-operative clinical course whether the subhepatic space was drained or not. 26 patients (mean age 58 yrs) were drained and 24 patients (mean age 59 yrs) were not. The incidence of positive gallbladder bile cultures were respectively 8 and 19% (N.S.) in the drained and undrained groups. The incidence of post-operative mortality, thrombo-phlebitis and intra-abdominal sepsis was zero in both groups. In the drained or undrained series, the incidence of wound infection was respectively 4% and 0% (N.S.), that of urinary infection was 8% and 13% (N.S.) and that of pulmonary atelectasis was 15 and 17% (N.S.). A further consecutive series of 100 undrained elective cholecystectomies (18% positive bile cultures) without prophylactic antibiotics was then performed with the same uneventful postoperative course. This study therefore indicates that even in the presence of bacterobilia elective cholecystectomy can be safely performed without subhepatic space drainage and without prophylactic antibiotics.

[Analysis of 66 cases of colorectal side-to-end anastomosis by the Baker method]. / Analyse de 66 cas d'anastomose colo-rectale latéro-terminale selon Baker.

From 1976 to 1985, 66 elective side to end colorectal anastomosis according to Baker's technique were performed. 36 of those 66 anastomoses (54.5%) were performed lower than 10 cm from the anal verge. Our series includes 17 cases of diverticular disease, 1 case of post radiotherapy stenosis of the rectosigmoïd junction and 49 carcinomas. 50% of all carcinomas were Dukes' C or D lesions and more than 34.8% of all lesions were subobstructive. The method of preoperative colonic preparation is described. The results are the following:--clinical fistulas: 2 (3.0%)--wound infections: 3 (4.5%)--deaths: 4 (6.1%). None of the colorectal sutures were protected by a colostomy whereas 4 colostomies previously instaured were suppressed at the time colorectal continuity was restored. This study clearly demonstrates that manual colorectal anastomosis following Baker's technique are as secure as stapled anastomosis although very less expensive.

Effects of surgery and nutritional support on some lymphocyte and PMN leucocyte functions in man.

The purpose of the present study was to evaluate the effect on some leucocyte functions of 1) an elective surgical procedure; 2) nutritional repletion provided by parenteral alimentation (TPN). The rates of cellular proliferation and protein synthesis in lymphocyte cultures were measured by the incorporation of respectively 3H-thymidine and 3H-leucine; both measures were performed without and with additions of mitogenic agents. Random migration and chemotaxis of PMN leucocytes were measured under agarose. In 10 well-nourished patients, both lymphocyte proliferation and protein synthesis in stimulated cultures decreased after elective surgery, respectively by 50% (p < 0.01) and by 32% (p < 0.05) while random migration of PMN leucocytes was increased by 50% (p < 0.02). Stimulated lymphocyte proliferation and protein synthesis measured in 10 nutritionally depleted non-cancer patients prior to TPN were lower in comparison to the values obtained in a control population (respectively p < 0.006 and p < 0.04). These parameters rose progressively during TPN and reached the normal range after 3 weeks. Before TPN, PMN leucocyte random migration was slower in depleted patients than in control subjects; this parameter reached normal values after one week of TPN, while chemotaxis tended to decrease. Both parameters were in the normal range after 3 weeks of TPN. Conclusions 1) an elective operation depresses lymphocyte functions but stimulates PMN leucocyte random migration in well-nourished patients; 2) in depleted patients, previously depressed leucocyte responses are restored within 3 weeks of adequate nutritional support.

[Acute abdomen in octogenarians]. / L'abdomen aigu chez l'octogénaire.

From january 1972 to september 1983, 215 patients of eighty and more (60 M. and 155 F.) entered for acute abdomen, have undergone a clinical analysis to principally define the main factors for morbidity and mortality. The authors insist on the poor value of the clinical and biological symptoms which delayed a correct diagnosis and therefore the correct treatment. For 30.7% of the cases, the treatment was medical and for 69.3% surgical. During the medical treatment, the morbidity rated at 12.1% and the mortality at 46.9%. During the first 30 postoperative days the rate of complications was of 61.7% and the rate of mortality of 46.9%. Both are essentially due to associated illnesses: pulmonary, cardiac and renal. The figures are compared with those of the literature. Besides, a progressively aging population is observed: the rate of patients of more than 80 years went from 7.2% in 1972 to 12.4% in 1983. This is probably due to the present quality of pre- and post surgical treatments and the improving of the medico-surgical reanimation technics.

Cardiac tamponade following penetrating thoracic trauma: unusual evolution.

We report a case of cardiac tamponade following a penetrating wound of the heart treated surgically. The patient developed later on a pericarditis of the immunologic type complicated by new tamponade. The clinical situation was only relieved by corticotherapy.

[Closed abdominal injuries: importance and results of peritoneal puncture-lavage]. / Traumatismes fermés de l'abdomen: intérêt et résultats de la ponction-lavage du péritoine.

In a series of 138 closed abdominal trauma, observed during the past 10 years, the authors report their experience of the peritoneal lavage with a Diacath: the method is 97.8% accurate in determining the presence or absence of abdominal injuries. The abdominal signs and symptoms, with an accuracy of 58.7% are hardly contributive, especially in cases of multiple trauma and patients with altered state of consciousness. The peritoneal lavage, as long as the technique and the contra-indications are respected, is an easy, safe and reliable test for the detection of abdominal damage. Positive diagnostic peritoneal lavage allows an earlier diagnosis and operation, and reduces the mortality for intra-abdominal injuries by eliminating deaths from undiagnosed intra-abdominal lesions. If negative, it avoids unnecessary laparotomies, especially in cases of multiple trauma.