[Complications of laparoscopic cholecystectomy: evaluation study]. / Les complications de la cholecystectomie laparoscopique: essai d'évaluation.

Laparoscopic cholecystectomy has been considered as a safe and effective procedure without randomised prospective trial. Two physician insurers associations (in France and in USA) have shown an important increase of the lawsuits after laparoscopic cholecystectomy, especially concerning common bile duct injuries. An exhaustive study of the literature demonstrates that in the rare prospective studies collecting all of the laparoscopic cholecystectomies realised in one country or one state, the percentage of biliary tract injuries is form twice to five times as big as with open surgery, and bigger in case of acute cholecystitis. It seems that diffusion of the monopolar current can explain a good number of them. These injuries are difficult for repairing because of their high localisation and the associated tissular burn. Their long term morbidity is important and their cost is huge. Three recent prospective studies comparing laparoscopic versus minilaparotomy approach demonstrate that the advantages of laparoscopic approach according to the cost and the recovery's speed are, except for the obese patients, less evident than one could believe.

[Long-term results of Beger's operation in chronic pancreatitis of cephalic predominance]. / Résultats à long terme de l'opération de Beger dans les pancréatites chroniques à prédominance céphalique.

Long-term survival (2 to 11 years) in 5 patients who underwent the Beger operation for severe, predominantly cephalic chronic pancreatitis showed that total pain relief has been achieved in all cases, together with weight gain (2 to 18 kg) and return to former occupation. In 3 of the 4 patients who did not have a concomitant biliary derivation, jaundice (2 cases treated by bile duct-duodenum anastomosis) or angiocholitis (1 case) was observed 7, 2 and 3 years after the initial operation. These results are better than with classical exeresis or derivation. The disadvantage of the procedure is that it is technically difficult. In case of a voluminous cystic cavity, the Frey operation should be preferred.

Inguinal hernia repair: totally preperitoneal laparoscopic approach versus Stoppa operation: randomized trial of 100 cases.

In a prospective randomized trial comparing the totally preperitoneal (TPP) laparoscopic approach and the Stoppa procedure (open), 100 patients with inguinal hernias (Nyhus IIIA, IIIB, IV) were followed over a 3-year period. Both groups were epidemiologically comparable. In the laparoscopic group, operating time was significantly longer (p = 0.01), but hospital stay (3.2 vs. 7.3 days) and delay in return to work (17 vs. 35 days) were significantly reduced (p = 0.01). Postoperative comfort (less pain) was better (p = 0.001) after laparoscopy. In this group, morbidity was also reduced (4 vs. 20%; p = 0.02). The mean follow-up was 605 days, and 93% of the patients were reviewed at 3 years. There were three (6%) recurrences after TPP, especially at the beginning of the surgeon's learning curve, versus one for the Stoppa procedure (NS). For bilateral hernias, the authors suggest the use of a large prosthesis rather than two small ones to minimize the likelihood of recurrence. In the conditions described, the laparoscopic (TPP) approach to inguinal hernia treatment appears to have the same long-term recurrence rate as the open (Stoppa) procedure but a real advantage in the early postoperative period.

Gastroesophageal reflux: conventional surgical treatment versus laparoscopy. A prospective study of 61 cases.

Sixty-one patients with gastroesophageal reflux who did not respond to conventional medical treatment were treated in a prospective study, 29 by conventional surgery and 32 by laparoscopic methods. All underwent manometry and pH measurement preoperatively and at a follow-up of four months. There was no mortality, and the morbidity of the two groups was not significantly different at 3% and 5%. Hospital stay was significantly reduced (5.4 versus 8.9 days; p = 0.02) following laparoscopic treatment, and time off from work was 21.3 days versus 38.2 days (p = 0.02). The satisfaction index expressed by the patients was 65% at 1 month and 95% at 3 months. Dysphagia was observed in 30% of the patients at 1 month and in 3% at 4 months in both groups. The results of manometry and pH measurements at 4 months are comparable between open surgery and laparoscopy. There was one failure (3%) in the laparoscopic group caused by disruption of the valve. The mean pressure in the esophageal segment (expressed in mm Hg) changed in the two groups from 3.6 to 18.1 (p = 0.001). The results of this series show laparoscopic management of gastroesophageal reflux to be justified.

[Inguinal hernia. Pre-peritoneal laparoscopic surgery vs. the Stoppa procedure. A prospective randomized trial: 100 cases]. / Hernies de l'aine. Traitement laparoscopique pré-péritonéal versus opération de Stoppa. Etude randomisée: 100 cas.

In a prospective randomized trial between totally pre peritoneal (TPP) laparoscopic surgery ant Stoppa procedure (open), 100 patients with groin hernia 'Nyhus IIIA, IIIB, IV) were included and followed during 3 years. Both groups were comparable. In the "laparoscopic" group, operating time was significatelly longer (p = 0.01) but hospital stay (3.2 vs 7.3 days) and delay to return to work (17 vs 35 days) were significantely reduced (p = 0.01 =. Post operative comfort (less pain) was better (p = 0.001) after laparoscopy. In this group, morbidity was also reduced (4% vs 20% p = 0.02). The mean follow up was 605 days and 93 per cent of the patients were reviewed at three years. There was 3 (6%) recurrence after TTP, specially in the beginning of the surgeon experience (learning curve) versus for the Stoppa (ns). In case of bilateral hernia, the authors suggest to use a large prosthesis than two little one to prevent recurrences. In these conditions, laparoscopics (TPP) approach of groin hernia treatment will have the same recurrence rate as open (Stoppa) procedure, but a real advantages in the early post operative period.

[Laparoscopic cholecystectomy in obese patients: 110 cases]. / Cholécystectomies laparoscopiques chez l'obèse: 110 cas.

110 obese patients who underwent a laparoscopic cholecystectomy were compared with a group of controls, the operative time (108 mn), the conversion rate to laparotomy (4.5% vs 1.8%) and the incidence of drainage (26 vs 11%) were significantly raised in the obese patients. However there was no difference in the mortality (0), the feasibility of intraoperative cholangiography, the hospital stay, the morbidity or the time off work when compared with the controls. In particular the incidence of wound infections, thromboembolic or respiratory complications (frequent in conventional surgery on the obese) was not significantly different to the control group operated on laparoscopically. This study supports that laparoscopic approach is an elective procedure for obese patients.

[Contribution of laparoscopic echography in the staging of curative resection of cancer of the pancreatic head (26 cases)]. / Apports de l'écho-laparoscopie dans le bilan de résécabilité curative des cancers de la tête du pancréas (26 cas).

In a prospective study, 26 patients with pancreatic and peri-ampullary cancer were evaluated with ultrasound (US), computerized tomography (CT Scan), endoscopic ultra sonography (EUS) and laparoscopic ultrasound (LUS). Sensitivity of US and CT scan were comparable, although CT scan seems better to evaluate the size of the tumor and for lymph node detection. 50 per cent of patients had a criterion for noncurative resection. EUS (16 cases) had the best sensitivity (100 per cent) for the staging of small tumors (less than 20 millimeters), detection of adjacent nodes and the relation between tumor and mesenteric and portal veins. EUS was not able to detect peritoneal and/or liver micro-metastases (44 per cent of them would be missed by this examination alone). The criterion for noncurative resection was 56.6 per cent. LUS exactly assessed all tumors larger than 3 centimeters (100 per cent). The accuracy compared with endoscopic ultra-sonography was not as good for small tumors and adjacent nodes, was equal for the venous relations with tumors, but better concerning micro-peritoneal or hepatic metastasis. The criterion for noncurative resection was 80 per cent. These results suggest to use of US and CT as first-line procedures in the pre-operative staging and assessment of resectability of pancreatic cancers. When the patient does not appear to have disseminated lesions (50 per cent), endoscopic ultra-sonography gives a good estimation of the size of the tumor, node assessment and vascular relations. LES could be the first step for a curative surgical treatment LES revealed to discover 15 to 30 per cent of unknown micrometastases and avoided useless laparotomy in these patients.

[What are abdominal painful syndromes of unexplained origin? Prospective study: 99 patients followed for three years]. / Que deviennent les syndromes douloureux abdominaux d'origine inexpliquée? Etude prospective: 99 malades suivis trois ans.

99 patients, 67 of whom were female, with a mean age of 25.5 years, were admitted as emergencies between 1991 and 1992 for acute abdominal pain of unknown aetiology. The follow-up, carried out prospectively, was 100% at 1 month, 98% at 6 months, 95% at 1 year, 84% at 2 years. The patients were divided into 3 groups: group I: 42 patients only underwent investigations; group II: 31 underwent laparoscopy, and the appendix was left in place after being considered to be normal by the surgeon; group III: 26 underwent laparoscopic appendicectomy for a histologically normal appendix. For 90% of patients, the painful episode never returned. In the other cases the pain returned within one year, but there was no difference between the three groups (11.2%, 9.6%, 11.5%) (ns). The causes found at the second admission were largely genital, or rare diseases (Crohn, Spiegel hernia). 2 patients were operated for acute appendicitis, not recognized in Group I. In those who had a laparoscopy (Group II and III), the incidence of persistent pain was identical whether the appendix was considered to be normal by the operating surgeon or found to be normal histopathologically. This study suggests that: after admission for acute abdominal pain of unknown cause, the incidence of recurrence of pains is of the order of 10% within one year; the investigations carried out during the patient's admission, allowed the exclusion of serious diseases for three years; the risk of missing a true appendicitis is small (2.5%) and has no prognostic significance; the finding of a normal appendix during laparoscopy should not necessarily lead to its removal; one year follow-up is sufficient to assess the outcome of abdominal pain of unknown cause.

[Does laparoscopic treatment of abdominal infections generate bacteremias? Prospective study: 75 cases]. / Le traitement laparoscopique des infections abdominales génère-t-il les bactériémies? Etude prospective: 75 cas.

Laparoscopy is increasingly used in conditions complicated by peritonitis. A theoretical concern is that carbon dioxide pneumoperitoneum may increase bacteraemia. In a prospective study 90 patients were treated by laparoscopic appendicectomy. 30 of them had no histological abnormality; 30 had an acute appendicitis and 30 an acute peritonitis. 75 patients were eligible for the study. The treatment protocol (surgery-antibiotherapy) was the same for the 3 groups. All patients had blood cultures before, during and after insufflation of CO2 in the peritoneum, and bacterial examination of the operative site. Septic morbidity was evaluated for each patients. Positive bacterial culture from abdominal site are correlated with the pathologic findings. There were no positive blood cultures in the groups studied and no incidence in term of septic morbidity. This study suggests that laparoscopic treatment of septic abdominal diseases does not facilitate bacteriemias and does no affect septic morbidity.