Surgery for left-sided pancreatic cancer.

A total of 590 exocrine pancreatic cancers of the body or tail of the pancreas, operated on between January 1982 and December 1988, were analysed. There were 128 pancreatic resections (group 1), 164 palliative bypasses (group 2) and 293 exploratory laparotomies which included 74 splanchnicectomies (group 3). The mortality rate was lower in group 1 (9 per cent) than in group 2 (19 per cent) (P = 0.012). The mortality rate exceeded 40 per cent in groups 1 and 2 for patients aged more than 70 years with pre-existing organ failure. The morbidity rate was 32 per cent in group 1 and 29 per cent in group 2. Patients with metastases had a median survival of 3.4 months, whatever the operative treatment. In the presence of lymph node involvement there was no significant difference in survival between groups 1 and 2. Patients with no metastases and no lymph node involvement had 1- and 3-year survival rates of 38 and 12 per cent respectively after pancreatic resection. Only patients with a small tumour (< or = 4 cm), no lymph node involvement and no metastases achieved a significantly better survival after resection (P = 0.049). Curative resection should be reserved for a small tumour confined to the pancreas. Fewer than 10 per cent of patients will be suitable for surgery. For the other cases, resection must be considered as a palliative procedure without a significant improvement in survival. It seems justified to limit palliative surgery to candidates for digestive bypass and to use non-surgical palliation for the remainder.

Cancer of the exocrine pancreas. A plea for resection.

BACKGROUND/AIMS: The aim of this retrospective multicentric study was to compare the results of resections with those of surgical palliative procedures. MATERIAL AND METHODS: The 3231 patients included had histologically proven adenocarcinoma of the pancreas and were operated on between 1982 and 1988. Seven hundred eighty-seven underwent surgical resection, and 2444 a palliative procedure. Step by step logistic regression was used to determine variables having the greatest impact on post operative mortality. Survivals were compared with the logRank test. A semi parametric Cox model was applied to estimate adjusted relative risk of death. RESULTS: After resection and bypass, postoperative mortality was 10% and 15% (P < 0.001), morbidity 35% and 27% (P < 0.001), and mean survival times 19.5 months (SE = 1.1), and 8.8 months (SE = 0.3) (P < 0.001) respectively. In patients without metastases, survival was better after resection than after bypass, even in patients with involvement of lymph nodes adjacent to or distant from the tumor (P = 0.001). CONCLUSIONS: In spite of the retrospective nature of such comparisons, these results acredit the idea that in patients with pancreatic cancer without metastases, resection should be attempted whenever possible.

[Colonic irrigation for colostomies. Results of a national survey among 795 colostomized patients]. / L'irrigation colique pour colostomies. Résultats d'une enquête nationale auprès de 795 colostomisés.

Colonic irrigation (CI) represents the procedure of choice for patients with a colostomy. Recent technical advances (irrigation kit) have provided patients with simple, safe and effective material, allowing a new expansion of this old concept. A total of 795 colostomates (from association's data base) were assessed by questionnaires 386 (49%) of them used CI: 43.5% of patients operated before 1980 and 50% after 1980 (p < 0.005). Two thirds of patients performed Cl every two days, in the morning, with one liter or less of water, for 45 to 60 minutes. No morbidity was reported. Some patients (18%) stopped the procedure deliberately, but none due to a complication. Total continence during 48 H was observed in 48.4% of patients. Wearing a classical stomabag after CI must be considered to be a precaution rather than a failure. However one half of patients wore a simplified material (minibag, obturator, sticking plaster). The vast majority of patients (86%) claimed to be entirely satisfied with CI and 96% wanted to continue the procedure as long as possible.

Various features and surgical approach of solitary pancreatic metastasis from renal cell carcinoma.

In this paper we report three cases of solitary pancreatic metastasis from renal cell carcinoma (RCC), treated surgically. Various features and the surgical approach of these metastases are discussed with references to the 33 previous published cases collected in the literature. Having eliminated widespread distant metastases, it is reasonable to restrict surgical resection of the pancreas to selected patients having a single synchronous or metachronous metastasis, or those having several unilateral metastatic foci. At any rate a careful long-term follow-up for patients with a past history of RCC is mandatory.

Prospective study of prognostic factors in patients with unresected hepatic metastases from colorectal cancer. Fondation Française de Cancérologie Digestive.

Prognostic factors of unresected liver metastases in patients with colorectal cancer are not well established. A total of 544 patients with unresected liver metastases from colorectal cancer were registered in a national survey over a 1-year period and followed until death. Twenty factors were studied in a univariate analysis (log rank test) and 16 influenced survival (P < 0.01). These 16 factors were entered in a multivariate analysis (Cox model) and eight, ranging from the most significant (relative risk of death 1.9) to the less significant (relative risk of death 1.2), independently influenced survival: performance status, alkaline phosphatase level, number of involved liver segments, administration of chemotherapy, presence of extrahepatic metastases, site of the primary tumour, prothrombin time and resection of the primary lesion. Two simple classifications are proposed, taking into account the performance status and the alkaline phosphatase level, or the performance status and the number of involved liver segments.

Posttraumatic pancreatic fistula cured by endoprosthesis in the pancreatic duct.

We report a case of pancreatic fistula attributable to posttraumatic rupture of the main duct that was undiagnosed before ERCP and was cured instantaneously by endoscopic placement of an endoprosthesis in the pancreatic duct after failure of conventional medical treatment.

Leiomyosarcoma of the inferior vena cava presenting as Budd-Chiari syndrome. Vena cava replacement under veno-venous bypass and liver hypothermic perfusion.

We report the first case of leiomyosarcoma of the middle and upper part of the vena cava successfully treated by surgical resection, complete vena cava replacement and disobliteration of the hepatic veins under veno-venous bypass and liver hypothermic perfusion as described in "ex situ, in vivo liver surgery".

[Palliative treatment of cancers of the head of the pancreas. Surgery versus endoscopy]. / Le traitement palliatif des cancers de la tête du pancréas. Chirurgie versus endoscopie.

Cancers of the head of the pancreas are only resectable in 10 to 25% of cases. The majority of patients are therefore candidates for a palliative treatment jaundice, pain or upper gastro-intestinal obstruction. Palliative surgical bypasses offer a durable efficiency for patients with a relatively short-term life expectancy. Endoscopic placement of biliary stents for jaundice is an alternative but leads to frequent complications and does not act on other clinical symptoms. Controlled trials did not show any statistical difference between surgical or endoscopic treatments. We only recommend endoscopic procedures for patients unfit for surgery with poor general status or distant metastases.

[Medicosocial consequences of permanent digestive stomas. A national multicenter retrospective study]. / Conséquences médico-sociales des stomies digestives définitives. Etude rétrospective multicentrique nationale.

OBJECTIVES: To evaluate the medical (sexual dysfunction, psychological adjustment, stoma care) and social (working life, family life, leisure) consequences of definitive ileostomies or colostomies. METHOD: From February 1992 to May 1992, 1082 live patients (978 colostomies and 104 ileostomies) who had undergone surgery at least 6 months earlier were assessed in a multicentre national inquiry. RESULTS: More than 20% of the patients had not been informed before surgery of the possibility of a definitive stoma. In half of the cases, the stoma was well accepted psychologically and patient's primary reactions improved with time, especially in patients with ileostomy (p < 0.01) and patients under 60 years of age (p < 0.001). Patients were satisfied with their stoma appliance in 94% of the cases. Only 31% with colostomy performed irrigations. Life style was altered in 43% of the patients, especially those with ileostomies (p < 0.001). Sexual activity was disturbed in 55% of the colostomy patients and working life in 63% of the ileostomy patients. One-fourth of the patients were often followed by an enterostomal therapist and one-third were members of ostomate associations. CONCLUSIONS: Ileostomy appears to be more disabilitating than colostomy due to patient age and, unlike colostomy, the impossibility of irrigation. These findings emphasize the contribution of enterostomal therapy and the justified role of ostomate associations.

Laparoscopic cholecystectomy in complicated cholelithiasis.

From January 1990 to December 1992, 129 patients presenting complicated cholelithiasis were included in a prospective study to assess the feasibility and efficiency of laparoscopic cholecystectomy. There were 84 females (65%) and 45 males (35%). Mean age was 60 years (range from 23 to 88). There were 90 acute cholecystitis (70%), 14 empyema (11%), 14 cholecystitis on scleroatrophic gallbladder (11%), and 11 mucocele (9%) cases. Laparoscopic cholecystectomy has been successfully performed in 106 cases (82%) (group I). In this group of patients, morbidity and mortality were 4.7% and 0.9% (n = 1), respectively. Mean hospital stay was 4.7 days after uneventful postoperative course. Two patients required reoperation for complications (1.8%). Twenty-three patients (18%) required enforced conversion to laparotomy after unsuccessful laparoscopic procedure (group II). Mean hospital stay was significantly higher in group II (10.8 days, P = 0.0001). There was no difference between the two groups according to sex, previous surgery, or indications. Laparoscopic cholecystectomy may be attempted and successfully realized in complicated cholelithiasis without morbidity increase. Main advantages of this procedure are a shorter hospital stay and a better recovery period.

Carcinosarcoma of the gallbladder. A case report and review of the literature.

We report a carcinosarcoma (CS) of the gallbladder in an 83-year-old woman. Ultrasonography found an enlarged gallbladder with thickened walls, a 3-cm gallstone, and a polypoid mass in the fundus. Pathological examination revealed neoplastic tissue composed of sarcomatous and glandular components. Twelve months later, the patient is alive. We review 24 other cases in the literature to outline the characteristics of this tumor.

[Resection anastomosis of the small intestine by celioscopy in swine. Comparative experimental study between manual and mechanical anastomosis]. / Résection anastomose de l'intestin grêle par coelioscopie chez le porc. Etude expérimentale comparative entre anastomose mécanique et manuelle.

Laparoscopic intestinal anastomosis is not very reliable and needs to be evaluate in an experimental model in animals before being performed in man. The purpose of this study was to evaluate the feasibility, efficacy and safety of manual anastomosis comparatively to the standard stapling suture. Twenty female pigs weighing 20 +/- 5 kg. were used for this study. A 5 cm ileal segment resection was performed under laparoscopy. The animals were assigned to 2 groups. Group I: 10 animals underwent end-to-end hand-swen anastomosis with Polyglactin 910, dec 1.5. Group II: 10 animals underwent side-to-side anastomosis using the Endo stapler. Operating time and anastomosis time were compared using the Mann-Whitney test for statistical analysis. On the 15th postoperative day, the animals were sacrificed and the anastomoses were evaluated. There was no operating death in the 2 groups. The operative time was significantly longer in group I than in group II (p < 0.01), with 180 +/- 40 min vs 49 +/- 25 min respectively. This difference was due to the anastomosis time of 130 +/- 40 min vs 16 +/- 6 min respectively (p < 0.01). There was 1 postoperative death related to fistula and peritonitis in group I and none in group II. The post-operative follow-ing showed 5 anastomotic leakages (4 in group I and 1 in group II) and 2 relative stenoses in group I. This study shows the simplicity and rapidity of performing stapling intestinal anastomosis under laparoscopy. Hand-sewn anastomosis is technically more difficult to perform under laparoscopy and requires a greater experience.

[Surgical managements and cancer of the exocrine pancreas. Survey of the French Association of Surgery]. / Comportements chirurgicaux et cancer du pancréas exocrine. Enquête de l'Association Française de Chirurgie.

In a French national enquiry, 3761 cases of cancer of the exocrine pancreas operated between 1982 and 1989 were collected. The aim of the part of the enquiry presented in this study was to define the various surgical attitudes. Surgical techniques significantly differed from one department to an another (P < 0.001). Resections were performed in 21 per cent of cases (range 6-45 per cent). Causes of unresectability, choice of a biliary by-pass, indications for gastro-jejunostomy, and use of spanchnicectomy varied from one Surgical Department to another (P < 0.001). The magnitude of these differences can be explained only by different habits or skillfulness for a rarely curable disease. These findings would justify a consensus about the indications for various procedures in the treatment of cancer of the exocrine pancreas.

Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery.

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.

[Laparoscopic treatment of gastroesophageal reflux by the modified Toupet technique. Preliminary results apropos of 55 cases]. / Cure laparoscopique de reflux gastro-oesophagien selon la technique de Toupet modifiée. Résultats préliminaires à propos de 55 cas.

Between October 1992 and July 1994, 55 patients with gastrooesophagal reflux disease underwent laparoscopic 270 degrees posterior fundoplication. The technique used was exactly the same as for the conventional approach. There were no deaths but there were 2 peroperative complications requiring conversions to laparotomy: one oesophagal perforation and one pleural perforation. The mean operative time was 150 min, ranging from 90 to 240 min. The mean hospital stay was 2.5 days, ranging from 1 to 14 days. One patient had to be operated on the 15th postoperative day because of a dysphagia secondary to an oesophagal motility disorder. One other patient underwent a laparoscopic treatment of a bowel obstruction on 30th postoperative day. None patient had dysphagia for more than 1 month after laparoscopy. The mean postoperative follow-up was 10 months with a good clinical result in 90% of the patients at 6 months. Four of our 15 first patients complained of recurrence of reflux symptoms. These preliminary results indicate that laparoscopic Toupet procedure can be performed safely and with similar results as for the open approach if the surgeon is well trained.