[Gastrojejunocolic fistula, report of two recent cases with original management]. / Fistule gastrojéjunocolique: prise en charge originale de deux patients.

Gastrojejunocolic fistulae, ultimate complication of anastomotic peptic ulceration, are presently uncommon. We report two recent cases of postoperative gastrojejunocolic fistulas (after duodenal ulcer surgery and total duodenopancreatectomy), which were complicated at time of diagnosis (acute peritonitis and liver cirrhosis) and required a two-stage treatment.

Functional results of delayed coloanal anastomosis after preoperative radiotherapy for lower third rectal cancer.

BACKGROUND: The aim of this study was to assess functional outcomes of patients who had a delayed coloanal anastomosis for a lower third rectal cancer after preoperative radiotherapy. STUDY DESIGN: From January 1988 to December 1997, 35 patients with an adenocarcinoma of the lower third of the rectum received preoperative radiotherapy (45Gy) followed by a rectal resection, combining an abdominal and transanal approach. Colorectal resection was performed about 32 days after the end of the radiotherapy. The distal colon stump was pulled through the anal canal. On postoperative day 5 the colonic stump was resected and a direct coloanal anastomosis performed without colostomia diversion. RESULTS: There was no mortality. There was no leakage. One patient had a pelvic abscess. One patient had a necrosis of the left colon requiring reoperation. Another delayed coloanal anastomosis could be performed. Median followup was 43 months (range 6 to 113 months). Functional results were evaluated with a new scoring system including 13 items. Function was considered good in 59% and 70% at 1 and 2 years, respectively. CONCLUSIONS: This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma for patients with rectal cancer of the lower third of the rectum. This technique is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results. Further adaptation could be imagined for a coelioscopic approach.

[Hepatic portal venous gas]. / L'aéroportie.

STUDY OBJECTIVE: Hepatic portal venous gas is a radiological symptom associated with a poor prognosis (75% to 90% mortality). The aim of this retrospective study was to report 7 cases observed over a 2-year period. PATIENTS AND METHOD: From June 1997 to November 1999, hepatic portal venous gas was diagnosed in 6 patients by CT scan and in one patient by echosonography. It was not detected in any case by plain abdominal X-rays. Three patients had small bowel obstruction with necrosis, three had extensive superior mesenteric infarction and one had preperforative necrosis of the colon. RESULTS: One patient with extensive intestinal infarction and a metastatic head and neck cancer was not operated. Two patients were operated, but the extensive mesenteric infarction was not amenable to surgical management. Three of the 7 patients died, while the other four patients survived after resection of the necrotic small intestine (n = 3) and left colectomy extended to the transverse colon (n = 1). CONCLUSION: Hepatic portal venous gas was associated with intestinal necrosis in the seven cases of this series. The severity of portal venous gas is only correlated with the severity of the disease causing portal venous gas.

[Oncologic and functional results of resections with direct delayed coloanal anastomosis in previously irradiated cancers of the lower rectum]. / Résultats oncologiques et fonctionnels des résections avec anastomose coloanale directe différée dans les cancers du bas rectum préalablement irradiés.

AIM OF THE STUDY: The aim of this study was to assess the oncology and functional outcome after preoperative radiotherapy and delayed coloanal anastomosis for cancers of the lower third of the rectum. PATIENTS AND METHODS: From January 1988 to December 1997, 35 patients received preoperative radiotherapy (45 Gy) followed by rectal resection through a combined abdominal and transanal approach. Thirty patients had preoperative tumor staging with endorectal ultrasonography: uT1N0 = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, and uT3N+ = 14. Colorectal resection was performed on average 32 days after the conclusion of radiotherapy, and the distal colon stump was pulled through the anal canal. On postoperative day 5, the colonic stump was resected and a direct coloanal anastomosis performed. RESULTS: Pathological examination of the specimens revealed complete tumor sterilization in two cases, pT1N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, and pT3N+ = 9. There was no postoperative mortality and there was no leakage. One patient had a pelvic abscess, and another one had left colon necrosis which required re-operation. Median follow-up was 43 months (range 6-113). Two patients had locoregional recurrence, seven had distant metastasis, and 3 had both. Actuarial survival rate at 1, 3 and 5 years was 97%, 86%, and 72% respectively. The rate of local control at 5 years was 78%. Functional results were evaluated by a new scoring system. Function was considered good in 59 and 70% at 1 and 2 years respectively. CONCLUSION: This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma. It is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results.

[Results of reoperations for goiter]. / Résultats des réinterventions pour goitres.

We report 47 reoperations for benign thyroid goiters between February 1994 and October 1995 out of a total of 1125 thyroidectomies. These operations concerned 42 women and 5 men with an average age of 54 years. The mean time between the 2 operations was 19 years. On 45 occasions, the reoperation included a totalisation of the previous partial thyroidectomy. In 2 cases a near total thyroidectomy was performed leaving a minimal thyroid remnent on one side. The mean weight of the resected gland was 73 grs. The morbidity included 2 temporary recurrent laryngeal nerve palsies resolving within 2 months and 7 cases of temporary hypocalcemia without permanent hypocalcemia. In the case of repeated surgery, the risks of recurrent laryngeal nerve damage and parathyroid gland resection are typically increased. The risk varies according to the initial surgical resection: unilateral lobectomy versus bilateral subtotal lobectomy. Surgical risks can be significantly decreased with a safe surgical technique. Indications for reoperations in case of benign thyroid goiter are rare and can probably still be reduced. Treatment with thyroxin is sometimes ineffective and is questionable after sub total thyroidectomy for nodular goiter. A primary total thyroidectomy can be indicated in such selected cases.