[Recklinghausen's disease and gastrointestinal stromal tumors]. / Maladie de Recklinghausen et tumeurs stromales digestives.

Gastro-intestinal stromal tumors associated with Recklinghausen's disease should be considered in the current concept of the stromal tumors with reference to recent advances in immuno-chemistry. In this setting, there is an high potential of maluignancy. For the treatment of these lesions, surgery is the main tool. Frequency of malignant digestive diseases associated with Recklinghausen disease should be kept in mind.

[Video-assisted total proctocolectomy with ileoanal anastomosis]. / Coloproctectomie totale avec anastomose iléoanale vidéoassistée.

The indication for laparoscopy in digestive surgery has evolved with the development of the laparoscopic material as well its increasingly frequent practice in the medical community. Those complex operations such as restorative proctocolectomy require a high level of technical skill as well as a specifically designed operative approach. The study aim was to report our experience of the video-assisted approach to restorative proctocolectomy.

Follow-up of selective endoscopic ultrasonography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy: a prospective study of 300 patients.

BACKGROUND AND STUDY AIMS: This prospective study evaluated the selective use of endoscopic retrograde cholangiography (ERC) and endoscopic ultrasonography (EUS) in the context of laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: Between 1993 and 1998, LC for symptomatic gallstones was indicated in 300 consecutive patients. In order to diagnose and treat choledocholithiasis preoperatively, we performed, on the basis of preoperative criteria, ERC in "high-risk" patients and EUS in "intermediate-risk" patients. Choledocholithiasis was treated by preoperative biliary endoscopic sphincterotomy (BES). LC was performed either after the endoscopic procedure or directly in "low-risk" patients. RESULTS: A total of 104 patients (35%) had 118 preoperative procedures: a) EUS (n = 68; feasibility 100%): choledocholithiasis was observed in 14/68 patients (21%); b) ERC (n = 50; feasibility 94%): 36 ERC were indicated on on preoperative criteria, and 14 on the basis of EUS results. Choledocholithiasis was found in 41/ 50 patients (82%) (13/14 patients with positive EUS), 19% of "intermediate-risk" patients, and 78% of "high-risk" patients; ERC failed in three patients who had no choledocholithiasis on subsequent intraoperative cholangiography (IOC). Clearance of the common bile duct (CBD) was achieved after BES in 41/41 patients. There was no mortality; complications occurred in 4/ 300 patients (1%). No retained stones were found in patients of any of the three groups, after a mean follow-up of 32 months. CONCLUSIONS: Combined endoscopic and laparoscopie management of cholecystolithiasis and choledocholithiasis is a viable option and is optimized by the use of EUS.

[Laparoscopic posterior fundoplication in gastroesophageal reflux: mid-term results]. / Fundoplicature postérieure coelioscopique pour reflux gastro-oesophagien: résultats à moyen terme.

STUDY AIM: The aim of this study was to report the mid-term results of the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic posterior partial fundoplication (Toupet technique) in 100 patients, and to evaluate their post-operative quality of life. PATIENTS AND METHOD: Between November 1993 and January 2000, 100 patients were surgically treated for a medically refractory GERD. Laparoscopic posterior partial fundoplication was performed by the Toupet technique. In the postoperative period, the patients were asked to answer a questionnaire by telephone. The aim of this survey was three-fold: to identify clinical symptoms indicative of recurrence; to evaluate postoperative functional impairment; to assess the postoperative quality of life. pH monitoring was also proposed in asymptomatic patients at a minimum follow-up of two years, and in all patients with clinical symptoms of GERD recurrence. RESULTS: Six laparotomy conversions were necessary. The mean duration of follow-up was 18 months (range: 6 to 57 months). The rate of clinically diagnosed recurrence was 7.6%. Intermittent dysphagia was observed in 2.3% of cases. Postoperative digestive functional disorders were noted in 53% of patients without clinical recurrence, and 95.3% of them were satisfied or very satisfied with the results of surgery. CONCLUSION: Laparoscopic posterior partial fundoplication by the Toupet technique can satisfactorily treat GERD without mid-term recurrence in about 94% of cases. Patient satisfaction seems mainly to depend on the disappearance of clinical symptoms of GERD. It was found that postoperative functional disorders frequently occurred, but were well tolerated. Their etiology has not yet been determined, and it is considered that factors other than the surgical procedure may also play a role.

[Laparoscopic replacement of the abdominal aorta. Experimental study in the pig]. / Remplacement laparoscopique de l'aorte abdominale. Etude expérimentale chez le porc.

BACKGROUND: Progress in abdominal laparoscopy led us to study end-to-end anastomoses performed laparoscopically. METHOD: An experimental protocol in 10 castrated male pigs weighing 74-95 kg was approved by the ethics committee. After conventional anesthesia, each animal was positioned in lateral decubitus and a retropneumoperitoneum was created. CO2 inflation was maintained at 14 mmHg for insertion of 3 trocars, 5 to 10 mm width. The entire infrarenal aorta was dissected and resected with insertion of a 6 mm dacron prosthesis. Postoperative arteriography was performed in all cases. The animal was sacrificed for direct examination. RESULTS: One animal died during anesthesia induction and the entire protocol was conducted in 9 animals. Mean operative time was 397 min (305-535 min) including a mean 123 min (65-150) for aortic dissection, 82 min (30-155) for proximal anastomosis and 70 min (45-105) for distal anastomosis. Total blood loss varied from 100 to 450 cc (mean 252 cc). Mean difference between pre- and postoperative hematocrits was 4% (0-6%). Among the 18 aortic anastomoses performed, arteriography showed one with moderate leakage and one anastomotic thrombus. Stenosis > 50% was found in 4 cases and < 50% in 4 cases. Analysis of the different operative parameters showed a learning curve with decreasing operative time and improved quality of the anastomoses. CONCLUSION: This study demonstrates the feasibility of aortic reconstruction via retroperitoneal laparoscopy in the animal. This procedure could be introduced in man.

Colonic perforation due to colonoscopy: a retrospective study of 48 cases.

BACKGROUND AND STUDY AIMS: The aim of this retrospective study was to analyze data on the treatment of 48 cases of colonic perforation, with a view to defining the criteria for choosing between medical and surgical treatment. PATIENTS AND METHODS: A questionnaire requesting information about complications of colonoscopy and their treatment was sent out to four hospital gastroenterological and surgical units. RESULTS: From January 1979 to December 1993, we reviewed the records of 48 cases of colonic perforation following colonoscopy (24 perforations occurred after diagnostic colonoscopy and 24 after therapeutic colonoscopy). Diagnosis of perforation was delayed in 42% of the patients, with a mean delay of two days (range 0.5-7 days). The treatment was surgical in 35 cases, including eight in which previous medical treatment had been unsuccessful. The perforation was in the sigmoid colon in 74% of the surgical population. Operations were carried out using two procedures, including colostomy, in the case of 20 patients (57%). Colostomy closure was performed in 12 patients (60%) with no mortalities. Surgical mortality occurred in five patients (14%), in four cases due to preexisting medical diseases. Medical treatment was attempted in 21 cases, and was successful in 13, mainly in cases in which perforation had occurred after therapeutic colonoscopy (12 patients). CONCLUSION: The choice of the right type of treatment for colonoscopic perforation seems to depend on the size of the lesion. Surgical treatment is appropriate when the perforation has occurred during diagnostic colonoscopy, since the lesion in this case is usually a large colonic laceration, whereas nonsurgical treatment seems to be justified after polypectomy, as long as there is rapid clinical improvement.

Post-operative faecal continence in patients with ulcerative colitis after ileo-anal anastomosis with preservation of the transitional zone: a report from a low-incidence region.

The aim of this prospective study was to analyse post-operative faecal continence by carrying out a manometric and clinical follow-up on ten patients previously suffering from ulcerative colitis, who underwent total proctocolectomy and double-stapled ileo-anal anastomosis with preservation of the transitional zone. An annual histological analysis of the transitional zone was performed post-operatively. A 13% reduction in the length of the high-pressure zone of the anal canal (P = 0.04) was observed without any significant change in the resting anal pressure or the maximal squeeze pressures. Fifty percent of the patients showed histological signs of inflammation, without any clinical manifestations. The median number of bowel movements was 4 per day and 1 per night, and only 1 patient had occasional nocturnal soiling (less than once a week). On being questioned, 9 patients replied that they rated their continence as good or very good and 1 patient, as reasonable. These findings show that ileo-anal anastomosis, without mucosal resection preserves the normal resting anal pressure and anal function despite the reduction in the length of the high pressure zone it involves.

[Adenoma of Brunner's gland: a rare cause of duodenal obstruction]. / Adénome Brünnerien: une cause rare d'obstruction duodénale.

Pseudo-tumoral hyperplasia of the Brünner glands is an exceptional dysembryoplastic or hyperplastic lesion which develops in the submucosa of the supra papillary proximal duodenum. We report a case of Brünner adenoma which led to duodenal obstruction. In 50% of the cases, the adenoma was asymptomatic but non-specific signs may lead to barium studies. CT scan of the abdomen or esogastroduodenal endoscopy which rarely provides formal histological proof. Major complications (hemorrhage, duodenal obstruction) and lack of formal diagnosis often leads to surgery, ideally with tumor resection after duodenotomy. Other prodecures (simple observation, endoscopic polypectomy, duodenopancreatectomy, biliary or digestive bypass without tumorectomy) may be entertained depending on the functional status, the volume of the tumor, presence of complications and overall general status.

[Atrio-caval shunt in injury to the suprahepatic vena cava. Apropos of a case and review of the literature]. / Shunt atrio-cave pour désinsertion cavo-sus-hépatique. A propos d'un cas et revue de la littérature.

Mortality in cases of trauma-induced lesions of the suprahepatic vena cava is high because it is difficult to expose the lesions, and consequently to control blood loss. Several techniques have been reported for treating this type of lesion. We report a case in which both suprahepatic veins were sutured after installing an atrio-cava shunt via a sternotomy. The limitations of this technique and other surgical possibilities are also discussed.

[A case of pure unilobar Caroli disease]. / Un cas de maladie de Caroli pure, unilobaire.

We describe a new case of pure Caroli disease and review of the literature. Although often sporadic, this disease is usually considered an autosomal recessive hereditary disease. It is often either associated with another congenital hepatorenal fibrocystic disease or with extrahepatic bile duct dilatation. The clinical examination and laboratory tests are of not specific if congenital hepatic fibrosis or congenital cysts of the coleduct is lacking. Certain echographic and scan images are however very specific. Complications are related to intrahepatic stone formation and to superinfections. The long-term course appears to involve increased risk of cholangiocarcinoma. Treatment of the localized form includes priority resection. In diffuse disease, treatment may be more medical with antibiotics and sometimes bile solvents. In case of failure, transplantation may be entertained.

[The perforation of the small intestine into the free peritoneum revealing Crohn disease]. / La perforation du grêle en péritoine libre révélatrice d'une maladie de Crohn.

A new case of Crohn's disease was discovered due to a perforation of the small bowel into the free peritoneum. We recall the epidemiological, clinical and pathogenic features of this rare incident. On the basis of the data in the literature, we propose a discussion of the surgical techniques used. Resection appears to be preferred Anastomosis is usually performed later except in exceptional selected cases.

The value of histological study by surface analysis of preserved and injected pancreatic grafts: a prospective controlled study in dogs.

To evaluate the effects of pancreas preservation and pancreatic duct obliteration on the endocrine pancreas, three groups of dogs were used: a control group (six) in which histologic analysis of normal pancreas was performed and two randomized groups (seven) from which the caudal pancreas was auto-transplanted, injected with fibrin glue and removed on the 28th day. In Group A, each graft was flushed out with Euro-Collins' solution and immediately transplanted. In Group B, each graft was preserved 24 hours in a preservation solution and transplanted. Islet surface ratios on the sections and mean islet surfaces were greater in the control group than in Group A (p = 0.011 and 0.023) and no different between control group and Group B (p = 0.334 and 0.099). This surface analysis study suggests that the mode of management of grafts in itself explains the alteration of endocrine pancreas and that obliteration of the pancreatic ducts has little influence on this alteration.

[Pancreas transplantation in dogs, effect on the endocrine pancreas of pancreatic duct obliteration and the mode of pancreas preservation. Histological study by surface analysis in dogs]. / Transplantation pancréatique chez le chien, retentissement sur le pancréas endocrine de l'oblitération des canaux pancréatiques et du mode de conservation du pancréas. Etude histologique par analyse de surface chez le chien.

The effects of organ preservation and of canal obliteration on the endocrine pancreas were investigated in three groups of dogs. A control group of 6 animals were used for the histological examination of the normal pancreas. Two randomized groups (A and B) of 7 dogs the caudal pancreas was autotransplanted; a fibrin glue was injected into the pancreas canals 28 days before organ removal. In the group A, each graft was rinsed in a Euro-Collins solution and immediately transplanted. In group B, each graft was rinsed and held in a preservation solution for 24 hours before transplantation. On histological slices the ratio between of the total surface area of Langerhans islets to the mean surface area of each islet was greater in the control group than in group A (p = 0.011 and 0.023); the ratio was not significantly different between the control group and the group B (p = 0.334 and 0.099). The histological surface area study suggested that the mode of organ preservation affects the endocrine pancreas and that blocking the canals has little effect.

[Treatment of recurrent ulcers after parietal cell vagotomy. Analysis of 18 cases]. / Traitement des récidives ulcéreuses après vagotomie fundique. Analyse de dix-huit observations.

One hundred and twenty seven patients had a follow-up of more than 4 years after parietal cell vagotomy for duodenal, pyloric or prepyloric ulcer. The recurrence rate is 15.8% (20 on 127). Eighteen patients who have recurred, had a follow-up of 2 years or more after treatment of the recurrent disease. Ten patients had a early recurrence (within 2 years); eight had a late one (more than 2 years). One patient had been operated as an emergency for perforation. Seventeen patients had first received a medical treatment. This treatment was sufficient for 10 out of 17. Seven patients were reoperated (3 partial gastrectomy), 4 partial gastrotomy associated with truncal vagotomy. Seven out of the 10 early recurrences was reoperated and only one of the 8 late recurrences was reoperated. The early recurrences seem to be more serious that the late ones. Medical treatment is always prescribed as first line therapy and a partial gastrectomy alone or with vagotomy is necessary in unsuccessful cases.

[Obstruction of pancreatic ducts with a fibrin glue. Study after segmentary autotransplantation in dogs]. / Oblitération des canaux pancréatiques par une colle de fibrine. Etude après autotransplantation segmentaire chez le chien.

The effects of the main pancreatic duct with a fibrin sealant have been investigated on an experimental model of segmental pancreatic transplantation in the dog. Fourteen segmental pancreatic transplantations were performed. A cephalic pancreactectomy was performed during the same operating time. The main duct was obstructed with a fibrin sealant (Tissucol modified by addition of a solution of aprotinine concentrated at 10,000 KUI per mL). Biological follow-up consisted in: 1) Intravenous Glucose Tolerance Testing at Day 0 and Day 28 with glycaemia's integral calculus and K V Alues. 2) Measurements of glycaemia and serum amylase every three days from day 0 to day 28. Histological examination of the pancreatic tissue before and after transplantation involved a microscopy analysis reporting the degree of fibrosis and necrosis. The areas of the Langherans islets and of the fibrosis were calculated with informatic area analysis. The study was carried on non diabetic dogs at Day 28. The glycaemia's calculus of IVGTT were not significantly different before and after transplantation (p = 0.291). On the other hand, there was a significant difference of the K Values before and after transplantation (p = 0.006). Histology after transplantation revealed important lesions of fibrosis and normal or hypertropic Langherans islets in most cases. Pancreatic ducts presented with linings thickened with fibrosis. There was no fibrin sealant in the lumen. Obstruction of pancreatic ducts with a fibrin sealant induces an important fibrosis of the pancreatic exocrin tissue allowing the preservation of a satisfactory endocrine function. This technic may be used in clinical practice during the segmental pancreatic transplantations or after cephalic pancreatico-duodenectomy.

[A technic of fundus vagotomy]. / Technique de la vagotomie fundique.

High recurrence rates after fundic vagotomy are mainly related to incomplete vagotomy at the level of abdominal oesophagus or antrum. 5-7 cm of oesophagus must be denudated and 6-7 cm of the antrum are left innervated, the most proximal branch of the "crow's foot" being divided. Finally, anterior and posterior peritonealized surfaces are approximated with fundoplicature around the oesophagus.

[Hemorrhagic gastric ulcer: which procedures should be performed?]. / Les ulcères gastriques hémorragiques: quels gestes effectuer?

Gastrectomy retains an important place in the treatment of haemorrhagic gastric ulcer, but conservative surgery in the form of haemostasis alone or associated with vagotomy also has indications depending on the type of ulcer, its site and the clinical context.