Multicentre, randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis.

BACKGROUND: The best way to manage generalized peritonitis complicating sigmoid diverticulitis is controversial. This randomized clinical trial involved a comparison of primary resection and suture, drainage with proximal colostomy followed by secondary resection. METHODS: From January 1989 to December 1996, 105 patients of mean(s.d.) age 66(14) (range 32-91) years were randomized to undergo primary or secondary resection. The main endpoint was occurrence of generalized or localized postoperative peritonitis. The Mannheim Peritonitis Index score was calculated for each patient to check for comparability of groups. RESULTS: Postoperative peritonitis occurred less often after primary than secondary resection whether considering the first procedure only (one of 55 patients versus ten of 48; P < 0.01) or all procedures (one of 55 versus 12 of 48; P < 0.001). Likewise, early reoperation was performed less often following primary resection than secondary resection (two of 55 versus nine of 48 (P < 0.02) and two versus 11 (P < 0.01)), leading to a shorter median first hospital stay for patients having primary resection (15 days) than for those undergoing secondary resection (24 days) (P < 0.05). The mortality rate did not differ significantly with regard to operative policy (primary resection 24 per cent versus secondary resection 19 per cent) or type of peritonitis (faeculent 27 per cent versus purulent 19 per cent). No patient died following a second or third procedure. CONCLUSION: Primary resection is superior to secondary resection in the treatment of generalized peritonitis complicating sigmoid diverticulitis because of significantly less postoperative peritonitis, fewer reoperations and shorter hospital stay.

[Electrical injuries during laparoscopy]. / Les accidents électriques en coelioscopie.

Electrical injury is uncommon during surgical laparoscopy, but may be serious. Following a comprehensive literature review, we describe five mechanisms of burn injuries: direct contact, electric arc, insulation failure, direct or capacitive coupling. We discuss these mechanisms and suggest simple preventive measures designed to ensure optimal safety.

[Hemobilia after laparoscopic cystectomy. Apropos of a case. Review of the literature]. / Hémobilie après cholécystectomie laparoscopique. A propos d'un cas. Revue de la littérature.

Laparoscopic cholecystectomy is now the most widely performed operative procedure with an unmatched success. An unusual complication developed in our practice. We report a case of haemobilia secondary to an arterio-biliary fistula due to a monopolar diathermy burn. This unusual observation emphasises the high risk of thermal injuries which are serious, difficult to diagnose or manage and often unrecognised at the time of the operation. A comprehensive review of the literature, up to December 1995, revealed 6 other cases of haemobilia of various aetiologies, occurring after laparoscopic cholecystectomy.

Curative resection for left colonic carcinoma: hemicolectomy vs. segmental colectomy. A prospective, controlled, multicenter trial. French Association for Surgical Research.

PURPOSE: This study was developed to compare median and actuarial survival after left hemicolectomy vs. left segmental colectomy. METHODS: Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64 +/- 12 (range, 18-91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmental colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested. RESULTS: After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survival curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.

[Extend of colonic excision in the curative treatment of cancers of the left colon. Left or segmental hemicolectomy? A controlled prospective multicenter study]. / Etendue de l'exérèse colique dans le traitement curatif des cancers du colon gauche. Hémicolectomie gauche ou colectomie segmentaire? Essai prospectif multicentrique contrôlé.

The ideal extent of colic excision in the curative treatment of left colic cancers has not yet been defined. The aim of this study is to compare the survival rates following left hemicolectomy and segmental colectomy. Over a period of 5 years from 1980 to 1985, 270 consecutive patients with cancer of the left colon without visceral metastases nor invasion of neighboring organs were included in the study. Survival at 5 years was the main criterion of assessment, with mortality and morbidity being the secondary criteria. 10 patients were excluded a posteriori. Out of the remaining 260 patients, 131 were operated with left hemicolectomy and 129 with segmental colectomy. Both groups were comparable as regards age; sex, risk factors (diabetes, renal failure), radiation therapy, antimitotics, procedure of anastomosis (hand or machine), protective colostomy, size of the tumor, and Dukes' stage. Only the length of the colon resected proximel to the tumor was greater in left hemicolectomy. 16% of the patients had a Dukes A adenocarcinoma. Postoperative mortality was higher after left hemicolectomy (6.1%) than after segmental colectomy (2.3%), but not significantly. Morbidity was similar. The survival rate at 5 years, including immediate deaths, was 64.8% after left hemicolectomy and 65.8% after segmental colectomy. Both survival charts could be strictly superimposed without significant differences. Left hemicolectomy therefore produced results that were comparable to those of segmental colectomy.

[Surgical treatment of cancer of the left colon. True left hemicolectomy or segmental colectomy?]. / Le traitement chirurgical du cancer du côlon gauche. Hémicolectomie gauche vraie ou colectomie segmentaire?

Non-metastatic cancer of the left colon is still an exclusively surgical problem in 1988. The problem is to determine which type of colectomy should be performed: either a true left hemicolectomy, a long but apparently oncologically satisfactory operation, or segmental colectomy. A recent study by A.R.C. reported the same 5-year survival for these two types of operation with essentially identical postoperative mortality and morbidity. This conclusion confirms that of many studies published on this subject.

Nontraumatic intramural hematoma of the duodenum. Report of 4 cases and review of the literature.

The authors report 4 cases of nontraumatic intramural hematoma of the duodenum (IMHD), 1 of pancreatic origin, 2 due to anticoagulant therapy while the 4th was an unusual complication of periarteritis nodosa. The principal anatomical, clinical, biological and radiological characteristics of IMHD are reviewed. Therapy is discussed, emphasizing nonaggressive surgery when possible.

[The syndrome of compression of the left iliac vein at the promontory level; a new, serious anatomo-clinical entity?]. / Le syndrome de compression veineuse iliaque gauche au niveau du promontoire: une nouvelle et grave entité anatomo-clinique?

A new case of pseudo-Cockett syndrome is reported. Both the clinical picture and the anatomic characteristics were unusual. Apparently, no similar cases have been reported in the medical literature. The relation between the cause of venous compression and it's results (thrombosis upstream and embolism downstream) could not be stated from data reviewed in the literature. No well-defined plan of management has been described. However, in the case reported here, therapeutic decisions gave satisfactory results.

[Role of surgery in the treatment of thromboembolic disease and deep phlebitis of the legs. Apropos of 12 surgical cases]. / Place de la chirurgie dans le traitement de la maladie thrombo-embolique et des phlébites profondes des membres inférieurs. A propos de douze cas opérés.

In reviewing a series of twelve cases treated surgically for deep venous thrombosis, with an admittedly short follow up (2 months to 2 years), the authors stress the beneficial effects of venous surgery. The postoperative mortality rate was zero and the morbidity rate marginal. They underline the importance of phlebographic exploration leading to earlier diagnosis, and list the therapeutic indications which vary according to the case and may include a supporting heparinotherapy and fibrinolytic treatment in a specialized center. They advocate venous surgery which has the twofold merit of preventing embolic complications and attenuating postphlebitic sequelae.

[Primary sclerosing cholangitis associated with ulcerohemorrhagic rectocolitis. Review of the literature apropos of a case disclosed by a rare manifestation: biliary peritonitis]. / Cholangite sclérosante primitive associée à la rectocolite ulcéro-hémorragique. Revue de la littérature à propos d'un cas révélé par une manifestation rare: la péritonite biliaire.

The authors present a case of biliary peritonitis due to biliary suffusion from the gall bladder. The suffusion was caused by a non lithiasic obstacle of the main biliary tree, primary sclerosing cholangitis. Aside from its unusual presentation, the authors insist on the fact that it was associated with ulcerative colitis. At this occasion they have reviewed the literature in order to aid diagnosis and treatment of these two rare diseases.

[The blood supply of the semitendinosus, gracilis and sartorius muscles and surgical applications (author's transl)]. / La vascularisation des muscles de la patte d'oie et ses applications chirurgicales.

The vascular pedicles of the semitendinosus, gracilis and sartorius muscles were identified by the authors. Although devascularisation of the tendons is of no importance in plastic operations, any technic using the fleshy part of these muscles should take care to preserve the blood supply. It is therefore important to know their anatomy.