[Idiopathic constrictive péricarditis revealed by a massive left pleural effusion]. / Epanchement pleural gauche massif révélateur d'une péricardite constrictive idiopathique.

INTRODUCTION: We report a case of constrictive péricarditis initially revealed by a massive left sided pleural effusion. CASE REPORT: The patient was dyspnoeic without any associated clinical signs. Only cardiac catheterization gave the diagnosis with a characteristic dip-plateau of the right ventricle. After full assessment, no aetiology was found. CONCLUSION: After a treatment with corticosteroids, the progress has been favourable to date.

[Thymic carcinoid tumor revealed by a Cushing's syndrome: usefulness of positron emission tomography]. / Tumeur carcinoïde du thymus révélée par un syndrome de Cushing: intérêt de la tomographie par émission de positons.

Ectopic adrenocorticotropic (ACTH) syndrome is a rare condition, generally due to lung or carcinoid tumors. 18-fluorodeoxy-glucose positron emission tomography ((18)FDG-PET) can be useful where conventional localization techniques often fail. A 50-year-old man presented with sudden diffuse oedema, hypokaliemic alkalosis, Diabetes mellitus and high serum levels of ACTH and cortisol. Ectopic ACTH syndrome was confirmed leading to ketoconazole treatment. Chest-computed tomography only revealed an aspecific anterior mediastinal nodule that was hypermetabolic on the whole body-(18)FDG-PET. A thymic tumor was suspected and the patient had a thymectomy that revealed an atypical carcinoid tumor with pleural carcinosis. The postoperative course was favorable with clinical and biochemical remission of neoplastic Cushing's syndrome.

[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.

[Reinterventions for complication and defect of coloesophagoplasty]. / Réinterventions pour complications et séquelles d'oesophagoplastie colique.

AIM OF THE STUDY: To report a series of 17 patients operated for a complication oesophagocoloplasty, with evaluation of therapeutic modalities, and both early and distant results. MATERIALS AND METHOD: From 1985 to 2003, 17 patients with a mean age of 50 years (range: 23-76) were reoperated after coloplasty pediculated on left superior colic vessels. Initial diseases were caustic ingestion (N=7), cancer (N=6), oesophageal perforation (N=2), gastric lymphoma (N=1) and oesotracheal fistula (N=1). Coloplasty has been performed as a first-intent procedure in 13 cases and as a second-intent procedure after failure of a previous operation in 4 cases. Nine patients were initially operated in another center and were subsequently referred in our unit. Complications needing reoperation were graft necrosis in 8 cases (47%) and stricture in 9 cases (53%). All patients with necrosis were reoperated within the 10 first postoperative days. RESULTS: Necroses were treated by complete (N=5) or partial (N=3) resection of the coloplasty. Strictures were treated by resection-reanastomosis (N=3), right ileocoloplasty (N=2), colic stricturoplasty (N=2), a free antebrachial flap (N=1) and a tubulized latissimus dorsi myocutaneous pedicled flap (N=1). The 30-day mortality rate was 12% (N=2) and the overall morbidity rate was 66%. All deaths occurred after reoperation for necrosis. Eleven patients (65%) kept or recovered digestive continuity (including the 9 with stenosis) and 8 (73%) eat normally. Four patients with transplant necrosis died before reestablishment. Four patients operated for necrosis died before restoration of digestive continuity and 2 patients are still awaiting restoration. CONCLUSION: Use of colon as an oesophageal substitute is risky. Reoperations for stenosis allows satisfactory oral feeding, while reoperation for necrosis is associated with both high early mortality and a low rate of restoration or digestive continuity. This later requires a range of complex surgical procedures.

[Laparoscopic pancreatic resections]. / Résections pancréatiques par laparoscopie.

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.

[ARDS as an unusual presentation of bronchiolitis obliterans organizing pneumonia]. / Le SDRA expression clinique inhabituelle de la bronchiolite oblitérante avec pneumonie organisée.

We report the case of a 46-year-old patient with liver transplantation who developed an acute respiratory distress syndrome (ARDS). The commonly associated clinical disorders, those associated with direct injury to the lung and those that cause indirect lung injury in the setting of a systemic process, were not responsible for the clinical picture. Finally, because of progressive clinical deterioration, an open-lung biopsy was performed and revealed a bronchiolitis obliterans with organizing pneumonia (BOOP). Physicians should be aware of this rare aetiology of ARDS.

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.

[Barrett's esophagus and antireflux surgery: a study of a series of 26 patients]. / Endobrachyoesophage et chirurgie antireflux: étude d'une série de 26 patients.

STUDY AIM: The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery. PATIENTS AND METHODS: From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient. RESULTS: Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma. CONCLUSION: Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.

[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.

[Long-term results of 186 patients with large incisional abdominal wall hernia treated by intraperitoneal mesh]. / Cure chirurgicale des grandes éventrations par prothèse intra-péritonéale. A propos d'une série de 186 patients avec un long recul.

Massive incisional abdominal wall hernias are frequent and difficult to repair, especially when they are large, multiply recurrent and when associated high with risk factors. We report the long-term results of 192 hernia repairs (in 186 patients) by non-resorbable mesh placed intraperitoneally and fixed by fascia stapler. We describe the details of the technique. There were no deaths. Early and late wound infections occurred in 11.7%, late occlusions in 6.3% and recurrence in 16%. Four percent of patients required removal of the mesh. The main caracteristic of this study was the long follow-up period (mean duration = 77 months). In view of the good results (70%), simplicity and quite execution of this technique, intraperitoneal mesh placement should be considered in the repair of large hernias when a prothesis is required.

[Peritoneovenous diversion using the LeVeen shunt in the treatment of refractory ascites after liver transplantation]. / Dérivation péritonéo-veineuse par shunt de leveen dans le traitement de l'ascite réfractaire après transplantation hépatique.

Intractable ascites is a rare complication after liver transplantation. In this study, the authors report 2 cases of intractable ascites after liver transplantation. The authors discuss the etiology of ascites and the place of peritoneovenous shunt as a therapeutic option. From 1985 to 1996, 354 liver transplantations were performed. In two cases, liver transplantation was performed for post-VHC liver cirrhosis and giant hemangioma. Both patients developed intractable ascites and were successfully treated by peritoneovenous shunt. The etiologies of ascites after liver transplantations are multiple: mechanical after vascular complication; lymphatic leak after surgical dissection; metabolic disorder; intrahepatic lesion of the graft. In our cases, the etiology of ascites was intrahepatic lesion of the graft due to VHC infection in the first case and acute rejection in the second. Peritoneovenous shunt is a therapeutic option for the treatment of intractable ascites after liver transplantation. Its indication should be considered only for isolated intractable ascites without portal hypertension and without liver cell failure after liver transplantation.

[Compression of the celiac trunk by the diaphragmatic arcuate ligament during supramesocolonic surgery]. / Compression du tronc coeliaque par le ligament arqué du diaphragme au cours de la chirurgie de l'étage sus-mésocolique.

Coeliac stenosis induced by arcuate ligament compression is usually asymptomatic. Current caution is advised during a supramesocolonic surgical procedure in the case of a collateral arterial system due to coeliac stenosis. 11 cases of coeliac stenosis are described. 3 patients underwent duodenopancreatic resection, 8 patients had liver transplantation. 2 patients died after complications due to celiac, stenosis. These cases are described. The authors discuss the diagnostic and therapeutic approach.

Results of orthotopic liver transplantation for liver cirrhosis in the presence of incidental and/or undetected hepatocellular carcinoma and tumour characteristics.

Orthotopic liver transplantation (OLT) for liver cirrhosis in the presence of hepatocellular carcinoma (HCC) is based on tumour number and size. The high incidence of undetected HCC before OLT has been reported previously. The object of this work to report the results of OLT for liver cirrhosis in the presence of incidental and/or undetected HCC and tumour characteristics. From 1985 to 1996, 334 patients received OLT. Two groups of patients were studied; group 1 (G1) where HCC was diagnosed on radiological examination before OLT (n = 13, mean age 53.8 +/- 8.1 years), and group 2 (G2), where HCC was diagnosed on pathological review (n = 13, mean age 53.3 +/- 6.1 years). Indications for OLT were (G1/G2) hepatitis C = 6/8, hepatitis B = 5/2, alcoholic = 2/3. There was no statistically significant difference in alpha-foetoprotein levels between both groups. Pathological review showed 26 and 30 HCC with a mean size of 1.6 +/- 0.8 and 1.6 +/- 1.2 cm (P > 0.05) in G1 and G2, respectively. Tumour stagings were (G1/G2) stage I = 6/2, stage II = 4/6, stage III = 2/3, stage IVa = 1/2. We had two (G2) hospital and three (G1) later mortalities; none had HCC recurrence. The other patients are alive and recurrence free. Reinforced immunosuppression related to acute or chronic rejection treatment was not associated with HCC recurrence. The 5-year actuarial survival rates were 76% for G1 and 85% for G2 (P > 0.05). Our study revealed that long-term survival can be achieved with liver transplantation in the presence of HCC in carefully selected patients.

Carcinoma of the oesophagus. Anastomotic leaks after manual sutures--incidence and treatment.

Progress in the development of suture materials results in a lower rate of fistulas. Modern techniques for the diagnosis of leakage (contrast study, CT-scan) allow for an early diagnosis and adequate therapy: if possible conservative therapy with drainage of the abscess, adapted antibiotic therapy and parenteral and enteral nutrition are the best methods. In the case of necrosis of the transplant, reoperation permits enables extra time for reconstruction. All the technical possibilities of reconstruction must be known. It is necessary to apply prophylactic precautions to avoid leakage of the anastomosis on the oesophagus.

[Is pancreatectomy with resection of the retro-pancreatic vessels for cancer justified?]. / La pancréatectomie pour cancer avec résection des vaisseaux rétropancréatiques est-elle justifiée?

AIM OF THE STUDY: Tumoural invasion of the retropancreatic vessels and particularly of the superior mesentericoportal vein confluence (SMPV) is often considered as a contraindication to resection of malignant tumours of the pancreas. The aim of this retrospective study is to report a series of 20 patients and to demonstrate that resection of the vessels supposed to be involved is justified when it is the only barrier to a complete tumoural resection. PATIENTS AND METHOD: Twenty patients, 11 men and nine women (mean age: 61.7 years) underwent a right (n = 14), left (n = 2) or total (n = 4) pancreatic resection for pancreatic adenocarcinoma (n = 19) or cystadenocarcinoma (n = 1) associated with partial resection of SMPV (n = 17), inferior vena cava (n = 1), right hepatic artery (n = 1) and common hepatic artery (n = 1). The veins were reconstructed in all cases by end to end anastomosis and the arteries by direct suture in one patient and venous or artery graft in two patients. RESULTS: Tumoural invasion was histologically present in the vascular wall in nine patients, in the perivascular area in six and negative in five. The in-hospital mortality was nil. One patient had an early venous thrombosis of the repaired SMPV which was reoperated and treated with success by desobstruction and venous graft. The 3-year actuarial survival rate was 16%. CONCLUSION: Segmental venous resection of the SMPV confluence can be performed safely. Localised invasion of the vascular wall, considered as the only obstacle for a complete tumoural resection, is not associated with a poor prognosis. In case of tight adhesions between tumour and SMPV (inflammatory or tumoural) the venous resection may be included in a deliberate surgical strategy. On the other hand, total obstruction of SMPV, extrapancreatic tumoural extension, tumoural invasion of superior mesenteric artery or coeliac trunk are contraindications to pancreatic resection.