Clinical trial: alvimopan for the management of post-operative ileus after abdominal surgery: results of an international randomized, double-blind, multicentre, placebo-controlled clinical study.

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.

[Aneurysm of the pancreatico-duodenal artery]. / Anévrisme des artères pancréatico-duodénales.

The mean age is 50. Symptoms include acute abdominal pain, hypotensive shock, GI bleeding, biliary colic, jaundice, and/or acute anemia. Less often, pancreatico-duodenal aneurysms may be fortuitously diagnosed by abdominal imaging. Rupture of a PDAA is a grave complication with high mortality and demands urgent intervention. Arterial embolization is the treatment of choice; surgical intervention should be reserved for failures of embolization. We report a case of PDAA successfully treated by arterial embolization but which posed problems in both diagnosis and treatment.

[Fissure syndrome of a gastrointestinal artery pseudoaneurysm in contact with a pseudocyst of the pancreas: rare, but serious complication of chronic pancreatitis]. / Syndrome fissuraire d'un pseudoanevrisme de l'artere gastroduodenale au contact d'un faux-kyste pancreatique: une complication rare mais grave de la pancreatite chronique.

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.

Advanced gastric cancer with or without peritoneal carcinomatosis treated with hyperthermic intraperitoneal chemotherapy: a single western center experience.

INTRODUCTION: The aim of this article was to evaluate the role of hyperthermic intraperitoneal chemotherapy (HIPEC), associated or not to cytoreductive surgery (CS) in the treatment of different stages of advanced gastric cancer (AGC). PATIENTS AND METHODS: Thirty seven patients with AGC who underwent 43 HIPEC from June 1992 to February 2007 were included. HIPEC used Mitomycin-C and Cisplatin for 60-90 min at 41-43 degrees C intra-abdominal temperature. The main endpoints were long-term survivals, morbidity and mortality rates. RESULTS: Eleven patients had no demonstrable sign of PC and constituted the Prophylactic-group, while 26 patients had macroscopic PC (PC-group). Five patients were Gilly 1 or 2 (nodules <0.5 cm) and 21 Gilly 3 or 4 (nodules >or=0.5 cm). In the PC-group a complete curative CS was achieved before HIPEC in 8 (PC-curative subgroup) and a palliative HIPEC in 18 patients (PC-palliative subgroup). The overall 30-days mortality was 5% (2 patients). Two patients in the Prophylactic group died within 6 months after hospital discharge (overall mortality 11%). The estimated risk of death per procedure was 9%. Ten patients (27%) presented one or more complications. The median survival was 23.4 months in the Prophylactic group, and 6.6 months in the PC-group (p<0.05). The median survival in the PC-curative subgroup was 15 vs 3.9 months in the PC-palliative subgroup (p=0.007). The median survival according to Gilly classification was significantly different (Gilly 1&2 vs Gilly 3&4, 15 vs 4 months respectively, p=0.014). The global recurrence rates between the Prophylactic group and the PC-curative subgroup at 2years were 36% vs 50% respectively. The median delay to recurrence was 18.5 vs 9.7 months respectively. CONCLUSION: HIPEC might be useful to improve the survival in selected patients with ACG only when a complete cytoreduction can be achieved. Despite encouraging data, prospective studies, based on larger cohorts of patients are required to assess the role of this procedure as a prophylactic treatment in patients with AGC.

Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of malignant ascites secondary to unresectable peritoneal carcinomatosis from advanced gastric cancer.

AIMS: To review our experience of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of malignant ascites from advanced gastric cancer in order to discuss benefits, problems and possible indications. METHODS: From June 2000 to May 2003 laparoscopic approach was used to perform HIPEC on five patients affected by malignant ascites secondary to unresectable peritoneal carcinomatosis of gastric origin, in order to associate the benefits of a definitive palliation of ascites with a minimal invasiveness. All patients had ascites related symptoms requiring iterative paracenteses. Intraperitoneal perfusion of mitomycin-C and cisplatin was delivered for 60-90min with an inflow temperature of 45 degrees C. RESULTS: Complete clinical regression of ascites and related symptoms was achieved in all the five patients treated. Intraoperative course was uneventful in all cases. Mean operative time was 181min. No postoperative deaths, related to the procedure, occurred. Only a case of delayed gastric empting was recorded as a minor postoperative complication. CONCLUSIONS: Laparoscopic HIPEC appears to be a safe and effective procedure to treat debilitating malignant ascites from unresectable peritoneal carcinomatosis.

[Precancerous lesions of the gallbladder]. / Lésions précancéreuses de la vésicule biliaire.

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.

Can laparoscopy reduce hospital stay in the treatment of Crohn's disease?

PURPOSE: The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohn's disease who underwent laparoscopy compared with open surgery. METHODS: Among 51 consecutive patients with inflammatory bowel disease (1996-2000), 46 with Crohn's disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures). RESULTS: There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes) vs. the open group (244.7 minutes) (P < 0.05), but this difference disappeared when data were adjusted for the extra time required to perform the laparoscopic hand-sewn anastomoses (288.2 minutes vs. 244.7 minutes). Bowel function returned more quickly in the laparoscopic group vs. the open group in terms of passage of flatus (3.7 vs. 4.7 days) (P < 0.05) and resumption of oral intake (4.2 vs. 6.3 day) (P < 0.01). There were significantly fewer postoperative complications in the laparoscopic group (9.5 percent) vs. the open group (18.5 percent) (P < 0.05); the length of stay was significantly shorter in the laparoscopic group (8.3 days) vs. the open group (13.2 days) (P < 0.01); and the cost of hospital admission was significantly lower in the laparoscopic group ($6106, United States dollars) vs. the open group ($9829, United States dollars) (P < 0.05). CONCLUSION: There is a reduction in the postoperative ileus, length of stay, cost of hospital admission, and postoperative complication rate in the laparoscopic group. Laparoscopic surgery for Crohn's disease is safe, and it is potentially more cost-effective than traditional open surgery.

Harmonic scalpel in laparoscopic colorectal surgery.

PURPOSE: With advances in laparoscopy, various hemostatic procedures have been advocated with variable results. Using currently available tools, some steps in laparoscopic colorectal surgery still represent technical challenges. Our aim was to investigate the feasibility and reliability of the Harmonic Scalpel in laparoscopic colorectal surgery. METHODS: In this nonrandomized prospective study, 34 consecutive patients (15 males; mean age, 46 (range, 24-80) years) underwent laparoscopic colorectal surgery for benign disease (27 patients) and colorectal cancer (7 patients). Dissection, hemostasis, coagulation, and division of several types of vascular pedicles were performed exclusively with the Harmonic Scalpel. The 10-mm-blade Harmonic Scalpel device was used at full power mode for all purposes through a 10-mm port. Coagulation of vascular pedicles was always achieved with the blades in the flat position. The large pedicles (inferior mesenteric, right and left colic, and ileocolic) were coagulated for 20 seconds in several locations along the length (1 cm) before final division. Smaller vascular pedicles were coagulated for ten seconds before division. When the vein and the artery of major pedicles were divided at their origin, either for malignancy or for technical reasons, they were dissected and coagulated separately. For more limited resection of the mesentery, as in the case of benign disease, vascular pedicles were coagulated together as a single bundle. Operative time, minor or major intraoperative or postoperative hemorrhage, need for conversion to laparotomy, bowel injury, and trocar complications were recorded. All anastomoses were checked on Day 8 by a diatrizoate sodium enema. RESULTS: There was no mortality. Mean operative time was 276 (range, 200-520) minutes. Neither minor nor uncontrollable hemorrhage occurred; no conversion to laparotomy and no vascular or bowel injury were recorded. There was one port-site hematoma. Neither hemoperitoneum, intraperitoneal hematoma, fistula, nor intra-abdominal abscess was observed. CONCLUSION: Coagulation and division of minor as well as major vascular pedicles in laparoscopic colorectal surgery with the Harmonic Scalpel" are technically easy, feasible, and reliable.

[Semiology, etiology and pitfalls in acute abdominal pain]. / Sémiologie, étiologie et pièges des douleurs abdominals aiguës.

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.

[Hand-sewn intra-abdominal anastomosis performed via video laparoscopy during colorectal surgery]. / Anastomose manuelle intracorporelle sous vidéolaparoscopie au cours de la chirurgie colorectale.

STUDY OBJECTIVE: 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. PATIENTS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Laparoscopic sigmoid colectomy with intracorporeal hand-sewn anastomosis.

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.

Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research.

OBJECTIVE: 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). METHODS: 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. RESULTS: 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. CONCLUSION: Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Senna vs polyethylene glycol for mechanical preparation the evening before elective colonic or rectal resection: a multicenter controlled trial. French Association for Surgical Research.

HYPOTHESIS: Senna is more efficient than polyethylene glycol as mechanical preparation before elective colorectal surgery. DESIGN: Prospective, randomized, single-blind study. SETTING: Multicenter study (18 centers). PATIENTS: 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. INTERVENTION: 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. MAIN OUTCOME MEASURES: Degree of colonic and rectal cleanliness. RESULTS: 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. CONCLUSION: 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.

Survey of the impact of randomised clinical trials on surgical practice in France. French Associations for Research in Surgery (AURC and ACAPEM). Association Universitaire de Recherche en Chirurgie. Association des Chirurgiens de l'Assistance Publique pour l'Evaluation Médicale.

OBJECTIVE: To evaluate the impact of randomised clinical trials (RCT) on decision-making and therapeutic policies among general and gastrointestinal surgeons in France. DESIGN: Telephone questionnaire. SETTING: Multicentre study, France. SUBJECTS: A random sample of 152 surgeons, mean (SD) age 50 (8) years. INTERVENTIONS AND MAIN OUTCOME MEASURE: Surgeons were asked 12 questions about their knowledge of RCT and how trials were conducted; influence of RCT on their treatment policies; means of obtaining information about treatments; how they evaluated their own results; whether they were willing to take part in RCT; and personal details including age, speciality, and type of practice. Surgeons were stratified according to age and type of practice. RESULTS: 148 questionnaires were suitable for analysis. 83 surgeons (56%) were under 50 years old, 38 (26%) were exclusively gastrointestinal surgeons, 82 (56%) worked in private practice, and 36 (24%) worked in teaching and university hospitals. The rest undertook mixed duties. When asked to say where they obtained their knowledge about antibiotics, 91 (61%) referred to RCT; these were mainly hospital-based, gastrointestinal, and younger surgeons. Asked to name a RCT-based policy, 81 (55%) gave medical rather than operative examples. 80 (54%) had already participated in a RCT; 79 (53%) said that they were willing to participate in a RCT that included random allocation of patients (there were no statistically significant differences in answers according to speciality or type of practice, although younger surgeons answered "yes" to both questions). Specialised journals were the main source of information for 115 (78%), and surgeons read a mean of 40 issues/year. 142 (96%) read journals in French and 66 (45%) in English, but this number fell to 10 (15%) of the 65 surgeons aged 50 or more. Personal experience was considered a more important source of therapeutic knowledge by older and specialist surgeons. 109 surgeons (74%) recalled patients during the first month postoperatively to evaluate their results. CONCLUSIONS: French surgeons, particularly those aged 50 or over, are not well informed about the nature, conduct, and value of RCT. Most of their information is acquired through reading and attending scientific meetings and congresses. Surgeons tended to attach more importance to the fame of the author than to the conduct of the study. The overall impact of RCT was weak among the surgeons questioned.

Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research.

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.

Management of the pelvic space with or without omentoplasty after abdominoperineal resection for carcinoma of the rectum: a prospective multicenter study. The French Association for Surgical Research.

OBJECTIVE: To compare perineal healing with or without omentoplasty after abdominoperineal resection for carcinoma of the rectum. DESIGN: Prospective multicentre study. SETTING: 15 centres (three university, nine non-university teaching hospitals and three private clinics), France. SUBJECTS: 186 consecutive patients (between January 1983 and August 1990): 21 were withdrawn because of protocol violation leaving 165 for analysis. INTERVENTIONS: Abdominoperineal resection for adenocarcinoma of the distal third of the rectum followed by omentoplasty (n = 64) to the pelvic space or not (n = 101). MAIN OUTCOME MEASURES: Number of healed perineums at one month, and the time interval to complete healing. RESULTS: 7 patients (4%) died, 4 of whom had had omentoplasty and 3 who had not (one perineal abscess). The number who developed immediate postoperative complications (11/64, 17% and 18/101, 18%) and median duration of hospital stay (21 days, range 8-191, and 22 days, range 8-132) were similar. The median time to complete healing (20 and 21 days), the rate of healed perineums at one month (42/62 and 67/99, both 68%) and the number of persisting sinuses at 12 months were also similar. The number of dehiscences of the perineum was significantly higher (p = 0.04) in the no omentoplasty group (16 compared with 3). There were 3 late deaths in the omentoplasty group and 7 in the no omentoplasty group, 1 and 5 with local recurrence, respectively. There were more recurrences in the no omentoplasty group but not significantly so. CONCLUSIONS: Although this study was not randomised, the results suggest that omentoplasty to the pelvic space promotes perineal healing after abdominoperineal resection for carcinoma of the rectum by significantly reducing the need for secondary opening.

Shouldice inguinal hernia repair in the male adult: the gold standard? A multicenter controlled trial in 1578 patients.

BACKGROUND: Hernia repair is the second most frequently performed operation in France and in the United States, the prevalence being 36 for every 1000 males. Lowering the recurrence rate by 1% would mean 1000 fewer operations for hernia repair per year in France. METHODS: Between 1983 and 1989, 1578 adult males with a total of 1706 nonrecurrent inguinal hernias were prospectively and randomly allotted to undergo either a Bassini's repair, Cooper's ligament, or Shouldice repair with polypropylene or a Shouldice repair with stainless steel for determination of which technique was associated with the lowest recurrence rate. Fifty-nine hernia repairs were withdrawn after inclusion. Of the 1647 remaining hernias, 52.2% were indirect, 25.6% were direct, and 23.2% were combined. Patients were seen every 6 months for 3 years and then every year. Median follow-up was 5 years 8 months (range, 3 months-8.5 years). RESULTS: At 8.5 years, 5.6% of hernias were lost to follow-up. Ninety-seven hernia repairs failed, 50% during the first 2 years. The actuarial recurrence rate was 7.94% at 8.5 years. The Shouldice repair (stainless steel or polypropylene) was associated with fewer recurrences (6.1%) than either the Bassini's (8.6%) or Cooper's ligament repair (11.2%) technique (p < 0.001). This difference remained significant even when the maximal bias test was used. Fewer recurrences (5.9%) were observed with the stainless steel wire Shouldice repair than with polypropylene version (6.5%), but the difference was not significant. CONCLUSIONS: Shouldice hernia repair provides the patient with the best chances of nonrecurrence regardless of the anatomical type of hernia. The Shouldice hernia repair should be the gold standard for inguinal hernia repair in men and serves as the basis for comparison with all other techniques, be they prosthetic or laparoscopic.

Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research.

BACKGROUND: 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. METHODS: 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. RESULTS: 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 (p < 0.001), 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). CONCLUSIONS: According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.

[Quantified semiology of acute sigmoid diverticulitis. Associations de Recherche en Chirurgie]. / Sémiologie chiffrée de la poussée de diverticulite sigmoïdienne. Associations de Recherche en Chirurgie.

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.