[Management of visceral artery aneurysms. Retrospective study of 23 cases]. / Prise en charge des anévrismes des artères digestives. Etude rétrospective de 23 cas.

STUDY AIM: To evaluate symptoms and results of the treatment of aneurysms of digestive arteries. PATIENTS AND METHOD: Retrospective study of 23 patients (14 male and 9 female, mean age = 51 years) treated in two departments of academic hospital. We studied the aneurysms characteristics (location, number, size, etiology) the type of treatment, and occurrence of post-operative complications. RESULTS: The aneurysms involved the splenic artery in 13 patients (56%), the superior mesenteric artery in 5 patients (22%), the hepatic artery in 3 patients (13%), the gastroepiploic artery in 2 patients (9%). There were thirty-one aneurysms (24 true aneurysms and 7 pseudo-aneurysms) in 23 patients. Diagnosis was mainly done by the CT-scan. An aneurysm rupture occurred in 7 patients (30%). Treatment was surgery for 26 aneurysms (84%) or a radiological embolization in 3; abstention was decided for 2 aneurysms (6%). No death was observed. CONCLUSION: The bad prognosis after rupture, the lack of predictive factors of rupture combined with the good results of surgical treatment suggest to prefer a surgical treatment at first. Embolization could be reserved for the contra-indication of surgery and when aneurysms are poorly accessible to surgery.

Operative and long term results after surgery for chronic radiation enteritis.

BACKGROUND: About one third of patients with chronic radiation enteritis will need to be operated on during follow-up. Morbidity and life expectancy after resection and conservative surgical management for chronic radiation enteritis have not been well documented. METHODS: From 1984 to 1994, 109 patients were operated on with a mean follow-up of 40 months (range 1 to 293). Postoperative mortality, early and late morbidity, long-term survival were studied in patients after resection (n = 65) and after conservative surgical management (n = 42), and in patients after planned or emergency procedure. Existence of possible risk factors for reoperation after a first surgical procedure was analyzed. RESULTS: Five (5%) patients died in the postoperative course. Operative mortality was significantly higher when the procedure was performed as an emergency (P <0.05). Although not statistically significant, mortality was higher in the resection group (5% versus 0%). Thirty-three (30%) patients experienced postoperative complications including anastomotic leak in 11. Morbidity was not statistically related to the nature of the treatment (ie, conservative versus resection) or to the indication (emergency versus elective). During follow-up, reoperation was required in 40% of the patients, because of recurrence of digestive symptoms suggestive of chronic radiation enteritis; the reoperation rate was higher in the patients of the conservative group (50% versus 34%). Overall survival, after a mean follow-up of 40 months in patients without cancer recurrence was 85% at 1 year and 69% at 5 years after surgery, respectively. Overall survival was influenced by the nature of the treatment with 51% and 71% 5-year survival after conservative and resection treatment, respectively. CONCLUSIONS: Despite high initial mortality and morbidity rates, life expectancy in patients with chronic radiation enteritis without recurrence of their previous neoplastic disease was good. Resection seems to provide a smaller reoperation rate and a better 5-year survival, but a higher postoperative mortality.

[Stomach cancer: have changes in surgical strategy influenced the results? 20-year retrospective study]. / Cancer de l'estomac: les changements dans la stratégie chirurgicale ont-ils une influence sur les résultats? Etude rétrospective sur 20 ans.

STUDY AIM: The aim of this retrospective study was to compare a group of patients who underwent resection for gastric adenocarcinoma (cancer of cardia excluded) and to assess the influence of radical lymphadenectomy on postoperative mortality and morbidity and 5-year survival rate. PATIENTS AND METHOD: One hundred and six patients were operated on from 1975 to 1985 and 99 from 1986 to 1995 for gastric adenocarcinoma located in the distal portion of the stomach in 56% and 61% respectively and, undifferenciated in 56%. Gastric resection was a subtotal gastrectomy for cancers of the lower third and total gastrectomy for cancers of the middle and superior thirds. In the first group (1975-1985), a D1 lymphadenectomy was performed in all patients. In the second group (1986-1995) a D1.5 lymphadenectomy without systematic splenectomy and pancreatectomy was applied to 49 patients. RESULTS: In the second group, the proportion of curative resection was higher (85% versus 75%) along with a higher rate of total gastrectomy (42% versus 17%). The postoperative mortality rate was 2% in the first group and 1% in the second group. The morbidity rate was 33% in the first group and 15% in the second group with a rate of anastomotic leak of 11% and 2% respectively. Among the second group, the morbidity rate was 20% after D1,5 lymphadenectomy versus 10% after D1 lymphadenectomy. The overall 5-year survival rate was 29% in the first group versus 38% in the second group. In this latter group, the overall 5-year survival was 32% after D1 lymphadenectomy and 46% after D1,5 (p = 0.038). CONCLUSION: Radical lymphadenectomy without associated splenic or pancreatic resection in good general status patients may provide a better staging of resected gastric cancer without increase of the postoperative mortality. However, the influence of radical lymphadenectomy on long-term survival remains to be proven.

Imaging of diffuse esophageal leiomyomatosis: two case reports and review of the literature.

Diffuse esophageal leiomyomatosis is a rare disorder which may be found in association with leiomyomas in other locations or with other disorders. We report two cases in men, one with associated tracheobronchial involvement, which illustrate the value of imaging in differentiating this entity from other causes of dysphagia and in establishing a diagnosis.

[Percutaneous drainage of infected pancreatic necrosis: an alternative to surgery]. / Drainage percutané des nécroses pancréatiques infectées: alternative à la chirurgie.

AIM OF THE STUDY: To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series. PATIENTS AND METHODS: Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration. RESULTS: Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enterococcus, staphylococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical procedure including two necrosectomies was necessary in six patients. CONCLUSION: This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.

[Recent progress in the curative surgical treatment of stomach cancer]. / Acquisitions récentes dans le traitement chirurgical curatif du cancer de l'estomac.

Surgical resection is currently the only potentially curative treatment for gastric cancer. Nodal extension, present in 3/4 of the patients, is related to topography and penetration of the tumor and is progressive, beginning by the perigastric proximal lymph nodes N1 to the perivascular distal nodes N2. A subtotal gastrectomy is possible for distal cancers and total gastrectomy is necessary for cancers of the middle and upper portions. D1 lymphadenectomy is the resection of the N1 perigastric nodes (> 15) and D2 lymphadenectomy is the resection fo the N2 perivascular nodes (> 25). In Japan, 5 year survival after D2 resection is very high, around 60%, but all the series are retrospective with a high proportion of superficial cancers. In several recent European controlled studies, D2 resection is responsible for a high mortality rate (> 10%) and the reported 45% survival is not statistically different from the D1 resection. In Western patients an "in-between" lymphadenectomy without spleno-pancreatectomy can be recommended with analysis of at least 15 nodes, and with a mortality lower than 5%. Pathological analysis of the operative specimen allows to use the new TNM classification where the number of positive lymph nodes is the main independent prognostic factor.

[Late morbidity after esophagectomy for cancer: is partial esophagectomy preferred?]. / Morbidité tardive après oesophagectomie pour cancer: faut-il préférer les oesophagectomies partielles?

PURPOSE: The aim of this study is to report late postoperative complications occurring after oesophagectomy for cancer over a 12-month period and to compare the incidence of these complications according to the level of the anastomosis. PATIENTS AND METHOD: This study included 106 consecutive patients 51% with subtotal oesophagectomy (thoracic anastomosis), and 49% with total oesophagectomy (cervical anastomosis). The two groups were comparable for age, mean weight loss before surgery, life expectancy, number of positive margins, TNM grading, size and tumour differentiation. RESULTS: Late morbidity concerned 67.9% of the 106 patients. Predominant complications were dysphagia (32.1% of the 106), gastro-esophageal reflux (25.5% of the 106), and diarrhoea (18.8% of the 106). Among all the factors causing dysphagia, evaluated by logistic regression, the level of anastomosis was only found significant with a 20.4% occurrence for thoracic anastomosis and 44.2% for cervical anastomosis (P = 0.012). All the other complications were similar in the two groups. CONCLUSION: Functional results of oesophagectomy for cancer are poor. As partial oesophagectomy morbidity is lower, total oesophagectomy should not be proposed in all cases of oesophageal cancer.

[Nasogastric tubes after elective abdominal surgery is not justified]. / La sonde nasogastrique systématique après chirurgie abdominale élective n'est pas justifiée.

There is no need for systematic nasogastric tube after elective abdominal and digestive surgery. Expected benefits are comfort for the patient, reduction of pulmonary morbidity, and rapid oral feeding. Only 5% of the patients will need a subsequent placement of nasogastric tube, due to vomiting and abdominal distention, with no adverse effects.

[Retroperitoneal tumors and surgery of the great vessels]. / Tumeurs de siège rétro-péritonéal et chirurgie des gros vaisseaux.

The great vessels have long been considered as the limiting point for exeresis of abdominal tumors. We report eleven retroperitoneal tumors which led to more or less extensive vascular involvement. There were two benign tumors (neurofibroma, angiolymphoid tumor), 6 primary malignant tumors (liposarcoma, schwannosarcoma, corticoadrenal carcinoma, leiomyosarcoma of the inferior vena cava, leiomyosarcoma of the aorta, hemangiopericytoma) and 3 secondary malignant tumors (melanosarcoma, papillary cystadenocarcinoma, malignant germ cell tumor). Vascular surgery included mobilisation of the aorta or vena cava or total replacement with a prosthesis. There were no major complications and organ resection was limited to that required by tumor invasion. Despite a macroscopically satisfactory resection slice in all cases, local recurrence of malignant tumors was the rule leading to short term mortality (mean survival 30 months for primary sarcomas and 35 days for secondary forms). The therapeutic decision after careful CT and MRI word-up requires a discussion between the radiology, surgery and oncology teams. When the great vessels are involved, advice from a vascular surgeon should be acquired.

[Radiological and endoscopic diagnosis of sigmoid diverticulitis]. / Diagnostic radiologique et endoscopique de la diverticulite sigmoïdienne.

In emergency, the most commonly used examination, other than plain radiographs of the abdomen, is the water-soluble contrast enema (Gastrografin). It demonstrates three different pictures, which may be more or less associated one to the other: "peridiverticulitis", featuring serrate lesions, abnormal stiffness and fixity and, in some cases, a long narrowing or stricture of the colon; diverticula, mainly in the sigmoid colon, becoming sharp-pointed or spark-liked; spillage of contrast material out of the colic lumen or into a neighbouring organ (fistula). Ultrasonography may be a useful emergency procedure to secure a hesitating diagnosis in a patient with a febrile abdominal pain or with a abdominal-pelvic mass, especially in women. Colonoscopy and barium enema are both usually contra-indicated in the acute setting of diverticulitis because of their potential hazards. On the other hand, after resolution of the acute event, these tests may allow to rule out carcinoma or associated adenomas (which coexist in more than 15% of the patients). Endoscopic control appears more especially important as initial accurate diagnosis in sometimes impossible to assess between adenocarcinoma and diverticulitis. CT scan has found an increasing place in both diagnosis and evaluation of infectious complications of diverticular disease. It is most recommended to assess the diagnosis of severe episodes, failing to clearly improve after medical treatment, and most particularly when an abscess in suspected. CT scan may demonstrate a thickening of the colic wall, high densities of pericolic fat and a tissular mass which may enclose gas bubbles.

Indications for right hemicolectomy in carcinoid tumors of the appendix. The French Associations for Surgical Research.

The records of 181 patients with carcinoid tumor of the appendix, seen during a ten year period (1977 to 1987), were analyzed retrospectively to determine the indications for right colectomy and the signification of intermediate histopathologic forms. Appendectomy was the only treatment in 146 patients; while right hemicolectomy was performed upon 35 patients--in seven patients with one postoperative death initially and in 28 patients without any death or morbidity, secondarily. Colectomy was indicated initially in seven patients for bulky tumors of the base of the appendix invading the cecum or for associated carcinoma of the right colon. The 28 secondary colectomies were indicated for tumors that were statistically larger and more invasive than those treated by simple appendectomy or for intermediate forms, or both, in five instances. There were five instances of residual tumor on secondary hemicolectomy specimens. In 11 of the 181 carcinoid tumors (6 percent), the intermediate type tumor was associated with mucinous production--seven adenocarcinoids and four carcinoids with mucocele. Of the seven instances of adenocarcinoid, there was one death at two years and one patient is alive with metastases. Other than size greater than 2 centimeters and base localization, the results of the current study suggest that the presence of mucinous production cells is a further indication for secondary right hemicolectomy.

[Posterior fundoplication of 270 degrees. pH results after one and 5 years]. / Fundoplicature postérieure de 270 degrees. Résultats ph-métriques à 1 an et 5 ans.

This prospective study compared pre- and postoperative pH monitoring one and five years after a 270 degrees posterior fundoplication. Thirty-six consecutive patients with gastroesophageal reflux were included over a period of 3 years. All patients had preoperative esophagoscopy and 3 hour post-prandial pH monitoring. Thirty-three patients had esophagitis. At one year follow-up, pH monitoring was performed in 31 patients and esophagoscopy in 29. At five years, 23 patients accepted a new pH control. Appraisal of efficacy was assessed by Kaye's acid reflux score (normal < or = 90) and the percentage of time (t) below pH 5 (normal < or = 10%). Among the 23 patients who were submitted 3 times to pH monitoring, Kaye's acid reflux score evolved from 149 (+/- 68) before fundoplication to 1.1 (+/- 2) and 16 (+/- 29) after one and five years respectively. The value of t decreased from 20% (+/- 16) to 0.4% (+/- 0.8) after one year and to 2.5% (+/- 3) after five years. The 270 degrees posterior valve corrects pH recordings at one year. Its efficacy remained steady after 5 years, although there was a slight increase in acid reflux scores. The mean value of these scores was always within normal limits.

[Left pancreatectomy with preservation of the spleen without its pedicle. Apropos of 13 cases]. / Pancréatectomies gauches avec conservation de la rate sans son pédicule. A propos de treize cas.

Overwhelming post splenectomy infections in childhood were first described by King and Shumaker in 1952. This septic risk, although a matter of controversy, also exists in adults. Thus, splenic conservation must become a surgical concern in left pancreas resections for benign or traumatic diseases. The authors report their experience with a simplified procedure in which the splenic pedicle is resected "en bloc" with the left pancreas. This technique has been employed in thirteen patients, in whom spleen could be preserved in twelve, without operative mortality and a low morbidity rate.

[Giant uterine leiomyoma and pregnancy. Clinical, radiologic, unusual histopathologic aspects]. / Léiomyome utérin géant et grossesse. Aspects cliniques, radiologiques, histopathologiques inhabituels.

The authors report a case of uterine leiomyomas diagnosed during the first trimester of pregnancy. The most unusual presentation of this observation did not allow any diagnosis through clinical exam, either by sonographic and X ray technics (magnetic resonance imaging, computer tomography) or by the classical histological study. The intra abdominal tumors compatible with imagery are argued: ovarian cyst, gelatinous disease of the peritoneum, desmoid tumor, lymphoma, lymphangiomyoma. The right diagnosis has been established as a last resort to immunocytochemistry.

[Mesenterico-atrial shunt in Budd-Chiari syndrome with inferior vena cava thrombosis. Report of 2 cases]. / Le pontage mésentérico-atrial dans le syndrome de Budd-Chiari avec thrombose cave inférieure. A propos de 2 observations.

Two new cases of Budd-Chiari syndrome associated with thrombosis of the inferior vena cava are reported. The predominant clinical sign was ascites, and the diagnosis was suggested by ultrasound and confirmed by angiography and the imaging techniques. In one case, the etiological assessment revealed an association with an oral contraceptive treatment; the etiological research remained negative in the other case. A mesenterico-atrial shunt was performed in both patients, and its patency was controlled with magnetic resonance imaging: both shunts are functional after 38 and 45 months respectively. On the basis of these two cases, the diagnostic process, the surgical indications and the choice of the techniques are discussed. The mesenterico-atrial shunt described by Cameron and Maddrey in 1978 seems to be an interesting and reliable therapeutic choice for the Budd-Chiari syndrome with thrombosis of the inferior vena cava.

Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study.

In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared 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 TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.