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Over the last 15 years, obesity surgery has developed tremendously. The two most frequently practiced procedures are the adjustable gastric ring and gastric by-pass. A new intervention has recently appeared: the sleeve gastrectomy, an essentially restrictive intervention consisting of a vertical gastrectomy including the entire greater curvature of the stomach while leaving in place an approximately 100-ml gastric tube along the lesser curvature. This intervention was initially proposed as the first part of a duodenal switch in patients whose body mass index was greater than 60 kg/m2. Since then, these indications have developed and this intervention now enjoys a certain fervor on the part of bariatric surgery teams. The objective of this mini-review is to detail the technical aspects of this procedure, its morbidity and mortality, and the long-term results, although there are currently few teams with more than 3 years of experience.

Improving the information delivered to pregnant women with adjustable gastric banding is desirable. Indeed, we report a case of peritonitis on gastric banding due to Klebsiella pneumoniae complicated with fetal death. Then, we discuss the specific risks of infection on the gastric band during pregnancy. Although, according to the literature, prophylactic fluid removal from the band in early pregnancy is not recommended, data about complications in pregnancy due to gastric banding are limited.

We report the case of an 18-year-old man, with no previous medical history, presenting with recurrent hemorrhagic duodenal ulcers revealing a Zollinger-Ellison syndrome. The initial diagnosis of sporadic gastrinoma of the antrum associated with satellite lymph nodes led to surgical treatment. The evolution of clinical and secretory tests associated with the outbreak of a primary hyperparathyroïdism demonstrated that the patient had a type I multiple endocrine neoplasia. To our knowledge, this is the first described case of primitive gastrinoma of the antrum occurring in a type I multiple endocrine neoplasia.

Objectives: The authors propose the use of a pedicle inguinal flap for reconstruction of the scrotal region after wide tissue resection following gangrene of the perineum., Material and Methods: Between 1998 and 2002, the authors treated 14 patients by surgical debridement following Fournier's perineo-perianal cellulitis. The authors used a pedicle inguinal flap in two patients with complete resection of the scrotal sac., Results: Clinical examination at 3 years showed a good functional and aesthetic result. The trophicity and sensitivity of the neo-scrotum and testes were normal., Conclusions: The inguinal flap proposed by that authors allows cover of the scrotal region with relatively thick, sensitive tissue with limited scarring and functional sequelae.

Objective: Describe a surgical technique concerning the treatment of umbilical hernias that have a diameter less than 5 cm, with a reduction of scars., Patients and Method: After analysing the different techniques of umbilical hernias repair, the authors suggest a new personal technique. The surgical treatment consists in removing the hernia sack after double M incision of the umbilical skin, repairing the abdominal wall by Quenu technique, folding the abdominal muscles and reconstructing the umbilicus., Results: The results, which are achieved on nine patients, with check up two years after, confirm the validity of the technique., Discussion and Conclusions: The scars after umbilical hernia surgical treatment are very important and visible because of their being located on the middle line of the abdominal wall. For the female patient in particular, this scar represents a great psychological annoyance. The double M technique leaves only an invisible scar with a good functional result.

Abbreviated laparotomy and planned reoperation(s) is a new concept in severely injured patients with multivisceral failure by hemorrhagic shock, coagulopathy and hypothermia. The aim of an abbreviated laparotomy is to control hemorrhage, prevent digestive contamination and close the abdominal wall without tension. After a delay for reanimation during 24 to 96 hours, discovery of unknown lesions and anatomic reconstruction will be possible through planned reoperation in better conditions. Emergency reoperation for hemorrhage and abdominal hyperpression severely worsens prognosis.

The recurrences of inguinal hernia after onlay mesh may cause technical difficulties for a new repair. The aim of our study was to assess intraoperative findings, feasibility and results of laparoscopic transpreperitoneal mesh onlay in this indication. Twenty-one repairs were performed. In all cases, direct, internal, inguinal recurrences were observed, associated in two cases with an external or femoral recurrence. In 16 cases, there were no adhesions in the peritoneal cavity. The were no conversions and peritonealisation was always completed. The mean length of hospitalization was 2.7 days. Our study suggests that technical errors during the first procedure, insufficient mesh or wrongly positioned are responsible for recurrence and allow reinsertion of a mesh laparoscopy via transpreperitoneal in this indication.

Postoperative adhesions are the first cause of small bowel occlusion in developed countries. Nevertheless no progress was done in prevention and treatment of this disease. The aim of this trial is to report results of 276 small bowel occlusions caused by adhesion recently operated and consecutive between first january 1993 and 31 december 1996. These patients had 400 previous surgical procedures, within 67.4% infra mesocolic or pelvic. 15.1% of previous surgical procedures took place less than one year before and 36% less than 5 years. Thirty five per cent of patients were operated during 24 hours following admission 23.2% of patients had a digestive resection, caused by necrosis or iatrogenic dissection. Operative mortality was 4.3% without resection and 16.6% with resection. Progress are warranted to reduce the rate of redux of occlusion and mortality and morbidity in this benign disease: more peri operative attention and place of laparoscopy should be considered.

In order to assess the influence of severe chronic obstructive pulmonary disease on the pulmonary morbidity and mortality following transhiatal oesophagectomy, the authors reviewed 136 consecutive patients who underwent oesophageal cancer resection by a transhiatal approach. Nineteen patients had a forced expiratory volume in one second (FEV) lower than 60% of the theoretical value, indicating severe chronic obstructive pulmonary disease. The other group of 117 patients had a FEV higher than 60% of the theoretical value. Pulmonary complications occurred in 36 patients: 23 (64%) were minor and 13 (36%) were major. Severe chronic obstructive pulmonary disease did not significantly increase pulmonary morbidity. However, pulmonary complications occurring in this group of patients appeared more severe with a significant increase in major pulmonary complications (21% versus 8%, p = 0.05) and respiratory mortality rates (10% versus 1.6%, p = 0.04). One factor was significantly correlated to respiratory mortality: age higher than 75 years (p = 0.006). Severe chronic obstructive pulmonary disease does not constitute a contraindication for transhiatal oesophagectomy. However, this approach should be reserved for patients under 75 years of age, in order to obtain respiratory morbidity and mortality rates comparable to those of patients with normal spirometry.

Bleeding after needle liver biopsy (NLB) is well known but surgical hemostasis in these circumstances is rarely assessed. We report 7 cases of laparotomy for hemostasis after NLB. The 7 NLB were done for 6 diffuse hepatopathies and one focal lesion. Three patients had hemostasis disorders at the time of the biopsy. None had cirrhosis. Five patients were operated few hours after the biopsy. Direct hemostasis was performed in 6 cases and in hepatectomy in one. Two patients were reoperated for three repeated hemostasis. Two died. The occurrence of hemoperitoneum after NLB is very rare but serious, occasionally occurring a few days after the biopsy. The respect of contre-indications and technical precautions are the best prevention of this kind of accident.

Among the various procedures used for surgical treatment of morbid obesity, the adjustable silicone gastric banding is in full development. It is also a gastric restrictive procedure and in addition it enables to adjust percutaneously the size of the stoma by inflating or deflating the inflatable portion of the band via an injection reservoir placed within the rectus sheath. In a small serie of 15 patients the efficacity of adjustable silicone gastric banding seems to be similar to that of the vertical banded gastroplasty, as far as weight reduction and improvement in the obesity associated comorbidity are concerned. In addition, this technique has two major advantages: absence of failure from staple line disruption, and a good food tolerance because the stoma size is adjustable to the patient's need. In contrast to other gastroplasties, the adjustable silicone gastric banding procedure is fully reversible after cutting the prothesis, and can be done under laparoscopy.

Surgical gloves constitute part of the most exposed barrier material, as one half of accidental exposures to blood in the exposures to blood in the operating room involve the hands. Approximately 15% of gloves tested at the end of the operation were found to be perforated. Double gloving lowers this rate to 5% with apparently acceptable tolerance for surgeons. Although surgical glove are initially impermeable to various viruses, the porosity increases with the duration of use. This porosity is related to hydratation and deformation of latex fibres. The maintenance of a good barrier function of surgical gloves requires regular changing, at least hourly, in the current state of knowledge.

The laparoscopic approach to inguinal hernia repair remains controversial. The authors report the results of 790 repairs performed during the first four years of their experience. The complication rate requiring surgical revision was 1.39%. None of these complications was related to the transpreperitoneal approach and all but one of them occurred during the first two years of the authors' experience. The recurrence rate for patients with a follow-up of more than two years was 5.01%. With experience, the size of the meshes has gradually increased. The authors' experience suggests that all types of hernia can be treated via this approach and that the recurrence rate makes this technique competitive compared to the results of other techniques reported in the literature.

A retrospective study was conducted to evaluate the impact of laparoscopic surgery on activity in general and digestive surgery. From May 1990 to December 1994, 2256 laparoscopic procedures were performed for cholecystectomy (36%), appendicectomy (20.4%) or inguinal hernia (19.8%). 23.2% of all procedures performed in 1994 were done laparoscopically. The use of laparoscopy did not, in our experience, added any new indications from 1988 to 1994. The conversion rate was 8.15%. 24% of the conversion cases could not be predicted. Mortality was 0.18% and 1.19% of the patients had to undergo a second operation due to complications of laparsocopic surgery. The impact of laparoscopic procedures, 7 years after the first laparoscopic cholecystectomy has been great. The results of this surgical technique must be evaluated to determine its medical and economic impact.

Mesch insertion is a reliable means for repairing inguinal hernias. Results in 162 patients treated laparoscopically via an intraperitoneal approach are reviewed herein. Analgesics were not required after the first postoperative day in 71% of patients. Fourteen patients were treated on a day-care basis. There were two recurrences due to inadequate fixation of the mesch to Cooper's ligament. The two patients who developed an infection did not require removal of the patch and had a strong, completely healed wall at the follow-up evaluation after four and ten months, respectively. The number of patients and duration of follow-up are still inadequate. However, these preliminary data warrant continued use and evaluation of this technique.

Leiomyomas are the common est benign tumors of the esophagus and most of them are located in the lower third. Dysphagia and vague pain are the most frequent symptoms. However, 50% of the patients remain asymptomatic and the tumor is often discovered incidentally. Operative management by transthoracic enucleation is the procedure of choice but for asymptomatic forms, this remains controversial. In addition, gastro-esophageal reflux frequently coexists with an esophageal leiomyoma and the therapeutic indications are not well defined for such situations. We report 3 cases of esophageal leiomyoma situated in the lower third, with emphasis on the operative management by transhiatal enucleation, particularly in case of coexisting gastro-esophageal reflux. This procedure avoids thoracotomy and the surgical treatment of the associated gastro-esophageal reflux is much easier by this approach than with thoracotomy.

We describe the clinical, radiological and pathological features of 5 cases of cystadenoma, one associated with cystadenocarcinoma. In 3 of these patients, the presence of thick wall, endoluminal buds and septations at imaging investigations was suggestive of the diagnosis of cystadenoma or cystadenocarcinoma. In 2 of these patients, these imaging features were lacking. In 2 of these patients, partial surgical resection was performed and was followed by recurrence of the tumor. In all cases, the diagnosis was confirmed by pathology examination of the resection specimen. In conclusion, this study shows that diagnosis of cystadenoma or cystadenocarcinoma may be very difficult because of the absence of suggestive imaging features in some cases, and confirms that complete resection of the tumor, allowing pathology confirmation, is needed for the optimal treatment of cystadenoma or cystadenocarcinoma.

Three patients with the Zollinger-Ellison syndrome and severe oesophagitis are reported. Intractable oesophageal stricture developed, leading to oesophago-gastrectomy in two patients and iterative oesophageal dilatations in the third. The retrospective analysis of these 3 cases led us to recommend, in case of oesophagitis in patients who have or might have the Zollinger-Ellison syndrome, to quickly institute a major antisecretory treatment, by parenteral route if necessary, to precociously and repeatedly control the efficacy of the antisecretory treatment mainly by measuring basal acid output and to avoid unjustified treatment discontinuance and gastric intubations.

Congenital esophageal stenosis and bronchogenic cyst are secondary to the same dysembryoplastic disorder in spite of different clinical signs. These lesions are revealed during infancy, unusually during adult age. Dysphagia is the most common symptom. Our two cases highlight these topics. Imaging methods displayed, in case 1, a distal stenosis, associated with a proximal dilatation, in case 2, a benign independent mass, without connection with the respiratory tract. A chirurgical excision was carried out in the two cases and the post operative course was uncomplicated. Histologically the two resection specimens showed a respiratory mucosa trapping cartilaginous pieces.

A case of congenital esophageal stenosis due to tracheobronchial remnants is reported. This is a very rare condition. Only 46 previous cases have been reported in the French and English literature. The cause is thought to be esophageal sequestration of a tracheobronchial anlage before embryologic separation. Esophageal atresia is frequently associated with this rare abnormality. Symptoms generally appear early in infancy, but are sometimes very discrete and diagnosis can be made later in infancy of exceptionally in adulthood. When there is no evidence of gastric reflux and caustic ingestion, symptoms of esophageal obstruction with date back to infancy or childhood are often the only sign suggestive of congenital stenosis. However, the diagnosis can only be established by microscopic examination of the entire esophageal wall, as endoscopic biopsy will not show the heterotopic tissue lying deep under the normal mucosa. The presence of tracheobronchial remnants in the esophageal wall explains why treatment by dilatation is unsatisfactory or impossible. Definitive treatment involves excision of the stenotic segment.

After appendectomy, mechanical obstruction of the small intestine is often due to local bands. This type of obstruction is classically treated by median laparotomy. We present ten cases of such obstruction treated via the initial gridiron incision, whose advantages are discussed.

Surgical feeding gastrostomy is attended by a significant morbidity and mortality. Today, the percutaneous endoscopic route is regarded as the best method, but it is not feasible in case of pharyngo-oesophageal stenosis and has its own drawbacks. A new method using laparoscopy to perform a Depage-Janeway gastrostomy is presented here. The theoretical advantages of this method are clear: the limited parietal damage should avoid cicatricial complications, and the limited ventilatory aggression should reduce the amplitude of respiratory complications. Moreover, in surgical practice this is a simple, rapid and efficient operation.

The authors report a new case of aortoesophageal fistula caused by a giant ulcer of the esophagus. Success of the surgical treatment during the bleeding period couldn't occult the seriousness of this fistula which is almost fatal. Only an early diagnosis permitting a surgical treatment in better conditions could improve the prognosis of this condition.

From May 1st 1983 to March 1st 1991, 126 laparotomies were performed on 104 patients infected by human immunodeficiency virus (HIV). We report the operative indications, macroscopic findings, anatomopathologic and microbiological results, and hospital mortality in this population. In 12.5% of cases, infection by HIV was established after operation. Sixty-eight percent of patients presented criteria for AIDS. The population was divided into 4 groups of indications: Group I: 30 patients had an emergency exploratory laparotomy. Laparotomy provided a diagnosis in 80% of cases, with a hospital mortality in 66%. Group II: 45 patients had an emergency laparotomy with a preoperative diagnosis. Hospital mortality was 24.4%. Group III: 29 patients had a non-urgent laparotomy with no mortality. Group IV: 14 patients were reoperated (22 laparotomies). For the entire population, hospital mortality was 9.3% for seropositive patients and 38.8% for AIDS patients.

35 consecutive pancreatic trauma were operated (21 blunt trauma and 14 penetrating injuries). 30 patients were operated in emergency and diagnosis was suspected before laparotomy in only one case. 12 patients had a superficial lesion, 21 had a wirsung disruption (14 in the left pancreas, 7 in the right pancreas), 2 had a diffuse pancreatitis. For the 30 patients operated in emergency, 20 had a conservative treatment, 10 had a resection. 5 patients died (14.2%), from exsanguination (2 cases), missed diagnosis or inadequate treatment (2 cases), sepsis after adequate management (1 case). Our experience suggests that an aggressive diagnosis management in emergency, with pre or pre-operative wirsungography, could determined with precision the type of the lesion and permit an adequate management, to decrease mortality.

Between January 1, 1983 and October 1, 1990, we performed 266 surgical operations in 255 patients with human immunodeficiency virus (HIV) infection. We report the reasons for these operations and compare them with those recorded in all patients operated upon in our department between January 1, 1988 and December 31, 1989 (4,960 operations in 4,498 patients). During the 1988-89 period, 2.4 percent of these patients had HIV infection, which suggests that the proportion of patients operated upon is the same in an HIV-infected population as in the general population. The proportion of HIV-infected patients who underwent surgery for diagnostic purposes or as adjuvant treatment was 42.7 percent as compared with 37.3 percent in the general population. Among laparotomies, 37.3 percent were exploratory in the HIV group versus 7.3 percent in the control group. The emergency surgery rate was the same in both groups. In gastrointestinal surgery, proctological operations were performed in 33.5 percent of the HIV group versus 7.4 percent of the control group. Among other types of surgery, only splenectomies were more frequent in HIV-infected patients than in the general population (6.3 versus 1.7 percent).

Appendectomy is the most current digestive surgical procedure in France. Ascending prevalence of infection by HIV, invites us to report 19 documented cases of appendicular syndroma in a population infected by HIV, within 13 cases who required criteria for AIDS. In 31.5% of cases, operation discovered infection by HIV or AIDS. 10 patients had an abscess or gangrenous appendicitis. Furthermore, a tumoral, inflammatory of infectious associated disease which required a treatment was found in 5 others patients. 2 patients died. In all cases, histologic, bacteriologic, virologic and parasitologic samps are warranted to discover current associated diseases.

In sigmoid volvulus, most authors recommend an emergency detorsion with transrectal intubation and delayed resection. In 25% of cases, detorsion in unsuccessful, necessitating multi-stage laparotomy. However, this approach can be harmful in these patients who are often elderly or with multiple diseases. When detorsion is impossible, we now use a one-stage resection with staplers. Using a median laparotomy, detorsion is performed and viability of the colon is confirmed; a Faucher tube placed freely in the rectum, is pushed by the nurse into the dilated colon; the colon is then deflated by applying gentle suction. After removing the tube, we perform a side-to-side anastomosis at the lower ends of both limbs with mechanical staplers, after economic resection of the mesosigmoid. We have used this procedure in five patients with a median age of 82 years; the mean operating time was 92 minutes. There was no mortality, no fistulae, or stenosis with a median follow-up of 16 months. The patients stayed in hospital for 12 to 18 days. In volvulus cases which cannot be reduced immediately, this procedure obviates multi-stage operations, often the cause of mortality, morbidity or loss of autonomy in patients who are often elderly or with multiple disease.

Although the tolerance of indwelling catheters in AIDS patients has been evaluated, the complications of implanted devices in this population are unknown. This encouraged us to compare in a prospective unicenter trial, dealing with 80 consecutive implanted devices, the complications of this kind of system in 20 AIDS patients, versus a control population. The follow-up was 10,658 days. No patient was excluded or lost to follow-up. In the control population, the infection rate was 5% (0.036 per 100 catheter days). We observed 3 thromboses (5%). In the AIDS group, the infection rate was 25% (0.21 per 100 catheter days). We observed 1 thrombosis (5%). This trial shows that implanted devices are more frequently infected in AIDS patients (p less than 0.05) than in a control population; it suggests that the infection rate in AIDS patients is not superior to the indwelling catheter rate, as reported in the literature. The precision of bacteriological tests and use of antibiotic therapy adapted to the clinical context should help to determine, in the presence of suspected infection, whether the implanted device can be maintained or should be removed in this high risk population.

Only palliative treatment may be contemplated when advanced oesophageal cancers present with dysphagia. Operability depends on respiratory, hepatic and nutritional status. Resectability may be assessed on the information provided by bronchoscopy, thoracic CT scan and surgical exploration. Advanced resectable oesophageal cancers require oesophagectomy without thoracotomy and radiotherapy. We performed 93 oesophagectomies in 106 advanced oesophageal cancers with a mortality rate of less than 2%. Non resectable advanced oesophageal cancers require bypass procedures. We performed 13 in the 106 cases. Inoperable advanced oesophageal cancers require radiotherapy in the absence of a fistula, laser therapy or an endoprosthesis for dysphagia.

From 1978 to 1988, we performed 110 laparotomies for hepatic metastases. With 41 resections for colorectal metastases, the survival was 34% at 3 years. The operative mortality was 7%. With 25 resections for non colorectal liver metastases, the survival was 42% at 1 year, 12% at 3 years. The results, compared with those of literature justify, in the absence of any other potential curative treatment, to remove colorectal liver metastases. For metastases from other tumours, results of resection for endocrine tumours and few sarcomas invite us to an aggressive approach.

We report a case of necrotic collection in the head of the pancreas infected by Salmonella typhimurium. Treatment associated necrosectomy and antibiotic therapy without cholecystectomy. The course of pancreatic disease was uneventful. Complete sterilization was obtained with quinolone antibiotic therapy.

Esophagectomy can be carried out without thoracotomy by referring the anastomosis to the neck. This allows for complete excision of the thoracic esophagus, while avoiding the inconveniences connected with resections via mixed abdominal and thoracic routes. The stomach is the most commonly used transplant, but only a liberal resection of the small curvature enables the surgeon to reach unmistakably the hyoid bone. This technique was used in 82 patients who were operated on between January 1982 and January 1988. The lesion was benign in 10 of them and malignant in 72 (12 Killian's operations, 9 upper thirds, 30 medium thirds, and 19 lower thirds). Gastric grafts were utilized in 69 patients and colic grafts in 13 others. There were 8 deaths: 3 pulmonary infections, 2 myocardial infarctions, 1 subphrenic abscess, 1 peritonitis, and 1 case of partial necrosis of the gastric graft. Actually, this mortality rate was mainly due to the patients' background (2.8% below 75 years of age and 43% above) and not to the technique. Eleven patients developed non lethal complications (13%) such as pulmonary infections (5), subphrenic abscesses (3), cervical fistulas (2), evisceration (1), while 63 patients (77%) had an uncomplicated course with oral realimentation starting from the 7th day and hospital stay under 3 weeks. Transhiatal esophagectomy is a safe intervention which is well tolerated as far as benign esophageal lesions are concerned, as well as those interesting the upper and lower thirds of the thoracic esophagus.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic imaging of acute pancreatitis has been revolutionized by the introduction of computed tomography (CT). The purpose of this report is to review the different CT findings of the disease. The authors emphasize the predictive value of the contrast enhanced CT. It seems to be the most reliable method for detecting the most severe forms of acute pancreatitis and their complications. Correlation of CT findings with clinical and biological prognostic signs allows an easier surgical management.