Cancer of the gallbladder associated with pancreaticobiliary maljunction without bile duct dilatation in a european patient.

A rare case of pancreaticobiliary maljunction (PBM) without dilatation of the biliary tract (DBT) associated with gallbladder carcinoma is described herein. A 62-year-old European woman with a long history of right upper abdominal pain was diagnosed as having PBM without DBT by endoscopic retrograde cholangiopancreatography and other examinations. Excision of the gallbladder and biliary duct with a Roux-en-Y hepaticojejunostomy was performed, and subsequent pathological examination of the surgical specimen showed a well differentiated adenocarcinoma of the gallbladder. She had no clinical symptoms for 58 months postoperatively. PBM allows reflux of pancreatic juice into the biliary tract. Recent findings support the idea that epithelial hyperplasia plays an important role in gallbladder carcinogenesis with PBM, and also support the concept that gene mutations are involved in the carcinogenesis of biliary epithelium in patients with PBM. For these reasons, we advocate that resection of the extrahepatic biliary tract in PBM patients without bile duct dilatation, rather than cholecystectomy alone, is the treatment of choice for preventing bile duct carcinoma.

[Nuclear magnetic resonance cholangiography in biliary disease. Prospective study in 60 patients]. / La cholangiographie par résonance magnétique nucléaire en pathologie biliaire. Etude prospective chez 60 patients.

PURPOSE: The aim of this prospective study was to evaluate a new MR cholangiography sequence, with thick slices, single shot fast spin echo (SSFSE) in biliary obstructive diseases. PATIENTS AND METHODS: This study included 60 patients (36 males and 24 females, mean age: 69 years) with cholestatic syndrome and suspected bile duct obstruction. All patients were prospectively investigated with MR cholangiography using SSFSE sequence with thick slices. The gold standard was ERCP (n = 47), per cutaneous cholangiography (n = 1), and surgical intervention (n = 12). According to this gold standard, 22 patients had obstructive gallstones, 23 had neoplastic obstruction, eight had inflammatory or postoperative stenosis and 7 had normal bile ducts. RESULTS: The sensitivity and specificity of MR cholangiography were 100 and 94% in the diagnosis of obstructive gallstones, and 95 and 97% in the diagnosis of neoplastic obstruction, respectively. A good agreement was observed between MR cholangiography and the gold standard, regardless of the site of obstruction (range of kappa value: 0.79-1). CONCLUSION: MR cholangiography with SSFSE sequence is an effective and easy technique. Acquisition of thick slices in a very short time (< 2 sec) limits cardiorespiratory artefacts and eliminates the need for post-processing.

Late recurrence of a hepatic angiomyolipoma.

Angiomyolipomas are benign mesenchymal tumours, mostly of renal origin. Hepatic angiomyolipomas are rare, and radiological and pathological diagnoses may be difficult We report on the first case of hepatic angiomyolipoma recurrence known to us, 6 years after surgical treatment of the initial tumour. Moreover, this hepatic recurrence was associated with renal angiomyolipoma without any stigmata of tuberous sclerosis.

Re-establish pneumoperitoneum in laparoscopic-assisted sigmoid resection? Randomized trial.

PURPOSE: Operating room time and anastomosis-related morbidity of laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision or laparoscopically after re-establishing pneumoperitoneum were compared. METHODS: A randomized trial was performed on patients with recurrent uncomplicated diverticulitis of the sigmoid colon during a 14-month period. Inclusion criteria were persistence of symptoms despite medical treatment and two previous admissions. Exclusion criteria included complicated diverticulitis, suspected cancer, and previous extensive abdominal surgery. Because skin incisions were similar and patients were randomly assigned in the operating room, the trial was performed as double blind. RESULTS: There were no deaths. Two patients were excluded before randomization. Three patients were not treated as allocated because of conversion to open surgery. Aside from previous abdominal-surgery rates, 16 patients with laparoscopic-assisted sigmoid resections after re-establishing pneumoperitoneum and 15 patients with laparoscopic-assisted sigmoid resections with anastomosis performed in an open fashion through a horizontal suprapubic incision were well-matched for age, gender, weight, American Society of Anesthesiology class, previous admissions, skin-incision length, size of circular stapler, and mobilization of splenic flexure. There were no significant differences in morbidity rates (3/16 vs. 3/15), complete doughnuts (16/16 vs. 15/15), blood loss (300 vs. 200 ml), flatus (4 vs. 4 days), solid-food resumption (5 vs. 6 days), stay (8.5 vs. 9 days) in laparoscopic-assisted sigmoid resection after re-establishing pneumoperitoneum and laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision groups, respectively. Patients with laparoscopic-assisted sigmoid resection after re-establishing pneumoperitoneum had statistically longer operating room time (295 vs. 190 minutes; P < 0.01). Median follow-up was 12 and 10 months in 10 patients with laparoscopic-assisted sigmoid resection after re-establishing pneumoperitoneum and 11 patients with laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision, respectively. One patient with laparoscopic-assisted sigmoid resection with anastomosis performed in an open fashion through a horizontal suprapubic incision had an anastomotic stenosis endoscopically dilated. CONCLUSIONS: Nonrestoration of pneumoperitoneum after laparoscopic-assisted sigmoid resection allows a decrease in operating room time and a similar outcome.

Laparoscopic cholecystectomy in acute cholecystitis. A prospective comparative study in patients with acute vs. chronic cholecystitis.

BACKGROUND: The aim of this prospective study was to compare the outcome of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis versus those with chronic cholecystitis and to determine the optimal timing for LC in patients with acute cholecystitis. METHODS: From January 1991 to July 1998, 796 patients (542 women and 254 men) underwent LC. In 132 patients (67 women and 65 men), acute cholecystitis was confirmed via histopathological examination. These patients were divided into two groups. Group 1 (n = 85) had an LC prior to 3 days after the onset of the symptoms of acute cholecystitis, and group 2 (n = 47) had an LC after 3 days. RESULTS: There were no mortalities. The conversion rates were 38.6% in acute cholecystitis and 9.6% in chronic cholecystitis (p<10(-8)). Length of surgery (150.3 min vs. 107.8 min; p<10(-9)), postoperative morbidity (15% vs. 6.6%; p = 0.001), and postoperative length of stay (7.9 days vs. 5 days; p< 10(-9)) were significantly different between LC for acute cholecystitis and elective LC. For acute cholecystitis, we found a statistical difference between the successful group and the conversion group in terms of length of surgery and postoperative stay. The conversion rates in patients operated on before and after 3 days following the onset of symptoms were 27% and 59.5%, respectively (p = 0.0002). There was no statistical difference between early and delayed surgery in terms of operative time and postoperative complications. However, total hospital stay was significantly shorter for group 1. CONCLUSIONS: LC for acute cholecystitis is a safe procedure with a shorter postoperative stay, lower morbidity, and less mortality than open surgery. LC should be carried out as soon as the diagnosis of acute cholecystitis is established and preferably before 3 days following the onset of symptoms. Early laparoscopic cholecystectomy can reduce both the conversion rate and the total hospital stay as medical and economic benefits.

[Surgical treatment of pancreatic enzyme serous effusions]. / Le traitement chirurgical des épanchements séreux enzymatiques d'origine pancréatique.

UNLABELLED: Enzymatic seritis is a rare complication of chronic pancreatitis. Thirty-four cases are analyzed from a series of 200 cases of operated chronic pancreatitis: 22 pleural effusions, 5 ascites and 7 combined effusions. The pancreatic leak was demonstrated preoperatively in 40% of cases. The leak originated from erosion of a pancreatic duct in 7 cases and leaking pseudocyst in 27 cases. All patients were operated: internal drainage (22 cases), left splenopancreatectomy (7 cases) and external drainage (5 cases). Postoperative mortality was 9% (n = 3); postoperative morbidity was 15% (n = 5). The effusion did not recur in any of the survivors, but repeat surgery for chronic pancreatitis complications was necessary in 7 patients (20.5%). CONCLUSION: after failure of medical treatment, the treatment of large serous effusions is surgical: internal drainage or pancreatic resection when the lesion is located in the tail of the pancreas.

Pancreaticogastrostomy compared with pancreaticojejunostomy after pancreaticoduodenectomy.

OBJECTIVE: To assess the safety of the pancreatic anastomosis after pancreatico-duodenectomy (PD). DESIGN: Non-randomized prospective trial in consecutive patients. SETTING: University hospital. SUBJECTS: 171 consecutive patients with resectable periampullary cancer (80%) or intractable pain due to chronic pancreatitis (20%) undergoing PD. INTERVENTIONS: Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG). MAIN OUTCOME MEASURES: Mortality and morbidity rates due to anastomotic leak following PJ and PG. RESULTS: 91 PJ and 80 PG patients were comparable for age, gender, total bilirubin, ASA grading, indication for PD, operating time, pancreas texture, blood loss and replacement. The rate of pancreatic fistula was significantly higher in PJ patients (13%) than in PG patients (3.7%) (12 vs. 3, p = 0.029). Overall death rate was significantly higher after PJ (12%) than after PG (3.7%) (11 vs. 3, p = 0.047). Fatal outcome due to pancreatic leak (3 vs. 1, p = 0.83) and other death rates (8 vs. 2, p = 0.14) were not significantly different in PJ and PG groups, respectively. CONCLUSION: PJ was associated with significantly higher pancreatic leak rate than PG. However, there was no statistically significant difference in mortality rates directly related to pancreatic leak.

Early gastric cancer: univariate and multivariate analysis for survival.

BACKGROUND/AIMS: The aim of this retrospective study was to analyse the characteristics, treatment and prognosis of early gastric carcinoma, based on an analysis of our surgical results. METHODOLOGY: Between 1973 and 1994, 102 patients (68 males, 34 females) with a mean age of 65 years, were operated on for an early gastric carcinoma. Mean follow-up was 7 years. Survival was calculated using the Kaplan-Meier method. Prognosis was determined with univariate and multivariate analysis according to the Cox model. RESULTS: The carcinoma was limited to the mucosa in 57 patients (56%) and extended to the submucosa in 45 (44%). There was a lymph node invasion in 17 patients (16.5%). The post-operative mortality rate was 5.8% (n = 6). Secondary deaths occurred in relation with the gastric cancer in 10.4% (n = 10). The 5- and 10-year survival rates were 84% and 68.6%, respectively. Univariate analysis of prognosis factors showed a significant survival difference according to the age (p = 0.001); submucosal extension (p = 0.03), lymph node invasion (p = 0.0005) and type of gastric resection performed (p = 0.03). With multivariate analysis of prognostic factors, advanced patient age and lymph node metastases were the only independent factors for survival (p = 0.0002 and p = 0.002, respectively). CONCLUSIONS: Prognosis of early gastric cancer is usually excellent. Patients with high risk of recurrence may be identified in relation to lymph node invasion. We propose that lymph node dissection is necessary in addition to gastric resection, at least in patients with high risk of lymph node metastasis.

[Superficial stomach cancers: surgical experience and study of prognostic factors in 102 patients]. / Les cancers superficiels de l'estomac: expérience chirurgicale et étude des facteurs de pronostic chez 102 patients.

STUDY AIM: The aim of this retrospective study was to analyze the characteristics, treatment and prognosis of early gastric carcinoma in a series of 102 patients. METHODS: Between 1973 and 1994, 102 patients (68 males, 34 females) with a mean age of 65 years, were operated on for an early gastric carcinoma. Mean follow-up was 7 years. Survival was calculated using the Kaplan-Meier method. Prognosis was determined with univariate and multivariate analysis according to Cox model. RESULTS: The carcinoma was limited to the mucosa in 57 patients (56%) and extended to the submucosa in 45 (44%). There was a lymph node invasion in 17 patients (16.5%). The postoperative mortality rate was 5.8% (n = 6). Secondary deaths occurred in relation with the gastric cancer in 10.4% (n = 10). The 5- and 10-year actuarial crude survival rates were 84% and 68.6%, respectively. Univariate analysis of prognosis factors showed a significant survival difference according to the age (P = 0.001), submucosal extension (P = 0.03), lymph node invasion (P = 0.0005) and type of gastric resection performed (P = 0.03). With multivariate analysis of prognostic factors, advanced patient age and lymph node metastases were the only statistically significant independent prognostic factors, advanced patient age and lymph node metastases were the only statistically significant independent prognostic factors (P = 0.0002 and P = 0.002, respectively). CONCLUSIONS: Prognosis of early gastric cancer is usually excellent. Patients with high risk of recurrence may be identified in relation with prognostic factors and mainly with lymph node invasion.

Results of pancreatogastrostomy after pancreatoduodenectomy in 160 consecutive patients.

BACKGROUND: The advantages of pancreatogastrostomy over pancreatojejunostomy after pancreaticoduodenectomy are still debated. This study analyses the results of pancreatogastrostomy to identify factors that could influence immediate outcome. METHODS: During a 10-year period, 160 consecutive patients underwent a pancreatogastrostomy. There were 109 men (68 per cent) and 51 women (32 per cent) with a mean(s.d.) age of 59(10) (range 22-82) years; 27 patients were older than 70 years. The following parameters were assessed: mortality rate, morbidity, reasons for reoperation, length of hospital stay, duration of nasogastric tube and drainage. RESULTS: Hospital mortality rate was 3 per cent; overall morbidity rate was 30 per cent. The reoperation rate was 12 per cent, mainly because of bleeding at the pancreatic margin. Delayed gastric emptying occurred in 36 patients. The overall rate of pancreatic fistula was 2.5 per cent. Age, sex, indications for pancreatoduodenectomy, and the texture of the pancreatic remnant did not influence the occurrence of pancreatic fistula or delayed gastric emptying. CONCLUSION: This study confirmed that pancreatogastrostomy is a safe procedure with low mortality and morbidity rates.

[Value of oncologic follow-up of patients operated for colorectal cancer. A prospective study of 1000 patients]. / Intérêt d'un suivi carcinologique chez les patients opérés d'un cancer colo-rectal. Etude prospective portant sur 1,000 patients.

OBJECTIVE: The purpose of our prospective study was to evaluate the contribution of follow-up in resected colorectal cancer. METHODS: One-thousand patients with colorectal adenocarcinoma who underwent radial resection from January 1975 to January 1990 were prospectively divided into two groups: the first group (n = 442, 42%) entered a 5-year follow-up protocol and the second group (n = 558, 56%) was free to make unscheduled visits in case of symptoms. RESULTS: Recurrence was found in 31.5% of the patients in the first group compared with 33% in the second group. Chorioembryonic antigen was the most accurate test detecting recurrence: 77% of the cases (97% for hepatic metastasis). Surgical resection of recurrent tumors was performed in 37% of the group 1 patients (curative resection in 15%) and in 9% (curative resection in 1.5%) of the group 2 patients (p < 0.001). 5-year survival after recurrence in group 1 was 11.5% versus 1% in group 2 (p < 0.01). CONCLUSION: These results emphasize the rational for a follow-up program in patients undergoing surgery for colorectal cancer.

[The role of subtotal/total colectomy in the urgent treatment of obstructive cancer of the left colon]. / Place de la colectomie subtotale/totale dans le traitement en urgence des cancers occlusifs du côlon gauche.

PURPOSE: The aim of the study was to evaluate the results of management of acutely obstructed carcinoma of the left colon by emergency subtotal/total colectomy (STC) with immediate anastomosis without diversion. METHODS: STC was performed in 48 patients (mean age 72 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively-distended colon of dubious viability, signs of impending cecal perforation. RESULTS: Postoperative mortality was 6.2% (n = 3): 2 patients over 85 years of age died postoperatively as a result of cardiopulmonary complications: an 83 year-old female dies as a result of an anastomotic dehiscence. Morbidity was 12.4% (n = 6) including one fistula which recovered without surgery. There were 4 synchronous colon cancers. Six months after surgery, the mean daily stool frequency was 2 after STC, and 3 after TC. CONCLUSION: Emergency STC achieves in one stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions, ensures restoration of gut continuity via a "safe" anastomosis and removes occasional synchronous carcinoma.

[The role of pancreatojejunostomy in the treatment of chronic pancreatitis]. / Place de la pancréatico-jéjunostomie dans le traitement des pancréatites chroniques.

From 1978 to 1995, 120 patients (105 males, 15 females, mean age: 46 years) underwent pancreatico jejunostomy (PJ) for chronic pancreatitis (CP). Alcohol abuse was presented in 105 cases (87.5%). PJ was the unique procedure in 67 cases; it was associated with a biliary or a duodenal diversion in respectively 38 cases and 5 cases. In ten cases, three diversions were performed. Postoperative mortality was 1.6% (n = 2), postoperative morbidity was 10% (n = 12). Mean hospital stay was 16 days. Fifteen patients (13%) required a second operation some years subsequent to the PJ, due to the progress of the CP or alcohol abuse. In the late postoperative course 22 deaths occurred (18.5%), 8 of them were directly related to alcohol abuse. Mean follow-up was 7 years. Good and medium results for pain were evaluated to 92%, but the progression of exocrine or endocrine pancreatic insufficiency indicates that wirsung decompression was insufficient to stop the progressive sclerosis. In conclusion, PJ was our preferred surgical procedure in CP treatment, when the wirsung was dilated.

[Splanchnicectomy using thoracoscopy]. / Splanchnicectomie sous thoracoscopie.

A technique of thoracic splanchnicectomy under video thoracoscopic control is reported. This simple and non aggressive procedure is indicated for very painful forms of pancreatic cancer and for some cases of chronic pancreatitis. It should relieve pain for a longer period than splanchnic nerve injection or radiotherapy.

[Neurosarcoma of the Treitz fossa. Apropos of a case]. / Neurosarcome de l'angle de Treitz. A propos d'une observation.

A unique neurosarcoma was observed located in the Treitz' fossa. Such tumours are usually occur in Rechlinghausent's disease and are exception in isolated situations. Diagnosis is difficult and requires a small bowel study. Surgical exeresis is the only treatment.