[Late results of Warren's distal splenorenal shunt]. / Résultats éloignés du shunt spléno-rénal distal de Warren.

To assess the long term results of the Warren distal splenorenal shunt, 53 patients suffering from chronic liver disease and managed with such a procedure from 1975 to 1981 for bleeding esophageal varices were evaluated. No rebleeding occurred after the immediate postoperative period. Five-year survival was 62 +/- 13 p. 100. No difference in survival was found between alcoholic cirrhotics and patients without any history of alcohol abuse. Of the 28 six-year survivors, 24 accepted endoscopy, which confirmed the absence of esophageal varices. Thirteen patients accepted mesenteric angiography; all had a patent shunt and significant hepatofugal collateral flow. Although reduced portal perfusion was maintained in 10 patients. Severe chronic encephalopathy occurred in 3 patients who had important hepatofugal collateral flow. At 5 years, operation resulted in a significant increase of the mean leucocyte and platelet counts in patients who had preoperative hypersplenism (p less than 0.001). In conclusion our data confirm the long term efficiency of the Warren distal splenorenal shunt in decompression of esophageal varices. Despite the development of hepatofugal collateral veins, portal perfusion is preserved in most cases, and disabling encephalopathy is rare.

Adenocarcinoma in columnar-lined Barrett's esophagus. Analysis of 13 esophagectomies.

From 1977 to 1982, 13 patients with adenocarcinoma arising in the distal esophagus lined by columnar epithelium underwent esophagectomy with detailed analysis of the pathologic specimen. In three patients, microinvasive carcinoma was detected before dysplasia occurred. In five patients, the ectopic mucosa was discontinuous, prolonged cranially by islands of columnar epithelium scattered in the squamous mucosa. Variable degrees of dysplasia were found in the columnar epithelium in seven specimens in areas of intestinal metaplasia. In four patients with high-grade dysplasia, several foci of intramucosal carcinoma were identified. They were scattered over the whole length of the ectopic mucosa. These data strongly suggest that adenocarcinoma develops from dysplasia, the real premalignant lesion. Careful periodic screening must be carried out in patients identified as having Barrett's esophagus. Dysplasia may be detected and located by endoscopy with dye spraying with directed biopsies. Patients with high-grade dysplasia should undergo esophagectomy with resection of the whole ectopic mucosa because they are at high risk for development of carcinoma.

Prophylactic use of cefotaxime in colonic and rectal surgery.

Two hundred and seventeen patients, undergoing abdominal colonic and rectal surgery, received after randomization, the following regimen: group A (74 patients): cefotaxime 1 g intravenous at the induction of anaesthesia, the beginning of the resection, 4 and 8 h later; group B (72 patients): cefotaxime in the same regimen associated with ornidazole or metronidazole 0.5 g intravenous at the induction of anaesthesia and 0.5 g intravenous with the last injection of cefotaxime; group C (71 patients):cefotaxime following the same regimen as groups A and B and metronidazole orally 0.5 tds 3 days before surgery. All wounds were assessed daily, until discharge from hospital. Severe sepsis included: septicaemia, peritonitis, intra-abdominal abscess and extra-abdominal infections with death. Non-severe sepsis included all others. All the patients having a history of allergy to beta-lactam antibiotics and those with pre-operative infection were excluded. Mean age of the population was: 64.5 years. Seventy-seven patients had rectal cancer and 82 patients cancer of the colon; Twenty-five patients had inflammatory bowel disease, and in 33 others disease such as polyposis was present. Risk factors of post-operative infection were present in 115 cases (A, 36 patients; B, 37 patients; C, 42 patients). All three groups were very well matched for age, sex, type of intervention and diagnosis. Non-infectious complications appeared in 56 patients. Sepsis developed in 76 patients (A, 27 patients; B, 27 patients; C, 22 patients, no significant difference). Severe sepsis occurred in 14 patients (A, 6 patients; B, 4 patients; C, 4 patients, no significant difference) and in 62 patients non severe sepsis (A, 21 patients; B, 23 patients; C, 18 patients, no significant difference). Post-operative peritonitis was not seen. This study suggests that cefotaxime alone 4 g peri-operatively is useful in prophylaxis during rectal and colonic surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reoperation for primary hyperparathyroidism]. / Les réinterventions pour hyperparathyroïdie primitive.

Twenty-one patients in a series of 283 treated surgically for primary hyperparathyroidism between 1960 and 1982, underwent reoperation. Eleven had been previously treated elsewhere. The initial cervicotomy was negative in fourteen cases, but had led to the ablation of one or more adenomas in seven. The reason for reoperation was recurrence or persistence of hyperparathyroidism (HPT). It was commenced by cervicotomy in the eleven patients initially treated elsewhere, and by cervicotomy and/or sternotomy for the others. Reoperation involved ablation of adenomas in thirteen cases, but was negative in the remaining eight. Three of the eight underwent a second reoperation, with success in two cases. Overall, reoperations led to ablation of sixteen adenomas in fifteen patients. Ten adenomas were ectopic, including eight located mediastinally . Ten sternotomies were performed, leading to ablation of four mediastinal adenomas. Postoperative complications included five recurrent paralyses and two severe cases of hypocalcemia. One patient with parathyroidal carcinoma died of malignant hypercalcemia. Fifteen of the twenty one patients (71%) were cured of their HPT. Basing themselves on these cases, and a review of the literature, the authors describe the indications and practical management of reoperative surgery for primary HPT.

Results of the Warren operation for portal hypertension.

The results are reported of 40 distal spleno-renal shunts as described by Warren, carried out from 1975 to 1980. Angiographically, the shunt appeared functional in 37 cases and thrombosed in 3; flow towards the liver was preserved in 28 of the operated patients, but in 12 cases there was portal thrombosis, partial (10 cases) or total (2 cases). Five of the operated cases (12.5%) died soon afterwards, 3 of these from recurrent haemorrhage associated twice with thrombosis of the shunt and once with a massive portal thrombosis. Two patients died subsequently at 4 months ans 3 1/2 years from liver failure. The 33 other patients, at a follow-up of 1 to 6 years, are leading a normal life without encephalopathy or recurrent haemorrhage.

[Surgical treatment of primary hyperparathyroidism. Evaluation of 263 cases]. / Traitement chirurgical de l'hyperparathyroïdie primaire. Bilan de 263 observations.

A retrospective study of the case-reports of 263 patients explored surgically for primary hyperparathyroidism demonstrated the cause to be: an adenoma (206 cases), a primary hyperplasia (29 cases), or a cancer (3 cases), exploration was negative in 25 cases. Presenting symptoms were mainly urinary, but 15 p. 100 of patients seen during the last two years had been asymptomatic. Nine patients required emergency surgery and 29 had a primary normocalcemic hyperparathyroidism. The two most useful laboratory examinations, apart from measurement of blood calcium and phosphorus levels, were parathormone assay (elevated levels were present in 80 p. 100 of cases) and quantitative bone biopsy (positive in over 80 p. 100 of patients). The surgical approach was mainly cervical, except for repeat operations when ten sternotomies were performed with successful results in 4 cases. Immediate postoperative mortality was quite high (3 p. 100), particularly in the acute forms or those with multiple adenomas, and in patients over 70. Morbidity (hypocalcemia, recurrent nerve palsy) was increased after repeat surgery. Analysis of long-term results, particularly with respect to urinary symptoms, showed marked differences between lesions of single glands (adenoma) and hyperplasia. The most difficult problem to resolve with this surgery is the importance to attach to excision of the parathyroids when lesions are present in several glands.

[Superficial gastric cancer. Results of surgery in 30 cases (author's transl)]. / Cancer superficiel de l'estomac. 30 cas opérés.

Gastrectomy was performed in 30 patients with superficial gastric cancer, equivalent to 12 p. cent of cases operated upon for gastric neoplasms since 1970. Presenting signs were epigastralgia in 19 cases (in 12 cases of the ulcer type), external bleeding from the digestive tract in 4 cases, dyspeptic disorders in 2 cases, and anaemia in one patient. The lesion was asymptomatic in 4 cases, while in 3 patients it was detected by endoscopy after polypectomy or for achlorhydria. In one case the lesion was discovered completely fortuitously. Cancer was suspected by the endoscopist from gross pathological findings in 7 of the 30 cases. An adenocarcinoma was diagnosed after biopsy in 26 cases, and suspected in the remaining 4 patients. Sub-total gastrectomy was employed in 27 cases, total gastrectomy in 2 cases, and extension to a total gastrectomy in one patient. Gross pathology showed cancer of type I : 8 cases, type II (IIa : 1, IIb : 0, IIc : 10) : 11 cases, type III : 6 cases, and mixed types IIc + III : 5 cases. The submucosa was invaded 17 times, the other 13 lesions involving the mucosa only. There were no immediate postoperative deaths. Three patients were not seen again, while 7 died from secondary causes : 5 for reasons unrelated to their cancer and 2 from unknown causes. By applying strict attention to surgical procedures and precise examination of histological data it should be possible to obtain postoperative survivals comparable to those of Japanese series (80 to 90 p. cent at 5 years, 70 p. cent at 10 years).