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Tailored neoadjuvant treatment of locally advanced rectal cancer (LARC) may improve outcomes. The aim of this study was to determine early MRI prognostic parameters with which to stratify neoadjuvant treatment in patients with LARC.All patients from a prospective, phase II, multicentre randomized study (GRECCAR4; NCT01333709) were included, and underwent rectal MRI before treatment, 4 weeks after induction chemotherapy and after completion of chemoradiotherapy (CRT). Tumour volumetry, MRI tumour regression grade (mrTRG), T and N categories, circumferential resection margin (CRM) status and extramural vascular invasion identified by MRI (mrEMVI) were evaluated.A total of 133 randomized patients were analysed. Median follow-up was 41·4 (95 per cent c.i. 36·6 to 45·2) months. Thirty-one patients (23·3 per cent) developed tumour recurrence. In univariable analysis, mrEMVI at baseline was the only prognostic factor associated with poorer outcome (P = 0·015). After induction chemotherapy, a larger tumour volume on MRI (P = 0·019), tumour volume regression of 60 per cent or less (P = 0·002), involvement of the CRM (P = 0·037), mrEMVI (P = 0·026) and a poor mrTRG (P = 0·023) were associated with poor outcome. After completion of CRT, the absence of complete response on MRI (P = 0·004), mrEMVI (P = 0·038) and a poor mrTRG (P = 0·005) were associated with shorter disease-free survival. A final multivariable model including all significant variables (baseline, after induction, after CRT) revealed that Eastern Cooperative Oncology Group performance status (P = 0·011), sphincter involvement (P = 0·009), mrEMVI at baseline (P = 0·002) and early tumour volume regression of 60 per cent or less after induction (P = 0·007) were associated with relapse.Baseline and early post-treatment MRI parameters are associated with prognosis in LARC. Future preoperative treatment should stratify treatment according to baseline mrEMVI status and early tumour volume regression.El tratamiento neoadyuvante personalizado del cáncer de recto localmente avanzado (locally advanced rectal cancer, LARC) puede mejorar los resultados. El objetivo de este estudio fue determinar factores pronósticos precoces mediante RMN para estratificar el tratamiento neoadyuvante en pacientes con LARC. MÉTODOS: Todos los pacientes de un eensayo prospectivo de fase II, multicéntrico y aleatorizado (GRECCAR4-NCT01333709) se incluyeron en este estudio y se les realizó una RMN antes del tratamiento, 4 semanas después de la quimioterapia de inducción y después de completar la quimiorradioterapia (chemoradiation, CRT). Se evaluó la volumetría tumoral, el grado de regresión tumoral mediante RMN (MRI Tumor Regression Grade, mrTRG), la estadificación T, la estadificación N, el estado del margen de resección circunferencial (circumferential resection margin, CRM) y la presencia de invasión extramural vascular en la RMN (extramural vascular invasion, mrEMVI).Se analizaron 133 pacientes aleatorizados. La mediana de seguimiento fue de 41,4 meses (i.c. del 95%: 36,6-45,2). En 31 pacientes (23%) se diagnosticó una recidiva. En el análisis univariado de la situación basal, mrEMVI fue el único factor pronóstico asociado con un peor resultado (P = 0,0152). Después de la quimioterapia de inducción, un volumen tumoral más alto en la RMN (P = 0,019), una regresión del volumen tumoral ≤ 60% (P = 0,002), la afectación del CRM (P = 0,037), mrEMVI (P = 0,026) y un grado escaso mrTRG (P = 0,023) se asociaron con un mal resultado. Después de completar la CRT, la ausencia de respuesta completa en la RMN (P = 0,004), la presencia de mrEMVI (P = 0,04) y una insuficiente mrTRG (P = 0,005) se asociaron con una supervivencia libre de enfermedad más corta. En el modelo multivariable final en el que se incluyeron todas las variables significativas (basales, postinducción, post-CRT), el estado de ECOG (P = 0,011), la afectación esfinteriana (P = 0,009), la presencia de EMVI al inicio (P = 0,002) y una regresión precoz del volumen tumoral ≤ 60% después de la inducción (P = 0,007) se asociaron con una recidiva. CONCLUSIÓN: Los parámetros basales y post-tratamiento precoces de la RMN se asocian con el pronóstico en el LARC. La estrategia terapéutica preoperatoria futura deberá estratificar el tratamiento de acuerdo con la presencia de EMVI al inicio y la regresión precoz del volumen tumoral.

BackgroundThe prognostic value of the primary neoplasm responsible for pseudomyxoma peritonei (PMP) remains poorly studied. The aim of this study was to determine the prognosis for patients with extra-appendicular PMP (EA-PMP) treated optimally with complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsAll patients treated for PMP with CCRS and HIPEC between 1994 and 2016 were selected retrospectively from a French multicentre database. Patients with EA-PMP had pathologically confirmed non-neoplastic appendices and were matched in a 1 : 4 ratio with patients treated for appendicular PMP (A-PMP), based on a propensity score.ResultsSome 726 patients were identified, of which 61 (EA-PMP group) were matched with 244 patients (A-PMP group). The origins of primary tumours in the EA-PMP group included the ovary (45 patients), colon (4), urachus (4), small bowel (1), pancreas (1) and unknown (6). The median peritoneal carcinomatosis index was comparable in EA-PMP and A-PMP groups (15·5 versus 18 respectively; P = 0·315). In-hospital mortality (3 versus 2·9 per cent; P = 1·000) and major morbidity 26 versus 25·0 per cent; P = 0·869) were also similar between the two groups. Median follow-up was 66·9 months. The 5-year overall survival rate was 87·8 (95 per cent c.i. 83·2 to 92·5) per cent in the A-PMP group and 87 (77 to 96) per cent in the EA-PMP group. The 5-year disease-free survival rate was 66·0 (58·7 to 73·4) per cent and 70 (53 to 83) per cent respectively.ConclusionOverall and disease-free survival following treatment with CCRS and HIPEC is similar in patients with pseudomyxoma peritonei of appendicular or extra-appendicular origin.

Background Peritoneal metastasis from biliary carcinoma (PMC) is associated with poor prognosis when treated with chemotherapy. Objective To evaluate the impact on survival of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), and compare with conventional palliative chemotherapy for patients with PMC. Material and methods A prospective multicenter international database was retrospectively searched to identify all patients with PMC treated with a potentially curative CRS/HIPEC (CRS/HIPEC group). The overall survival (OS) was compared to patients with PMC treated with palliative chemotherapy (systemic chemotherapy group). Survival was analyzed using Kaplan-Meier method and compared with Log-Rank test. Results Between 1995 and 2015, 34 patients were included in the surgical group, and compared to 21 in the systemic chemotherapy group. In the surgical group, median peritoneal cancer index was 9 (range 3–26), macroscopically complete resection was obtained for 25 patients (73%). There was more gallbladder localization in the surgical group compared to the chemotherapy group (35% vs. 18%, p = 0.001). Median OS was 21.4 and 9.3 months for surgical and chemotherapy group, respectively (p=0.007). Three-year overall survival was 30% and 10% for surgical and chemotherapy group, respectively. Conclusion Treatment with CRS and HIPEC for biliary carcinoma with peritoneal metastasis is feasible and may provide survival benefit when compared to palliative chemotherapy.

Rectal hypercontractility can lead to faecal incontinence (FI). Botulinum toxin (BT) has been used successfully for the treatment of bladder overactivity. This study aimed to evaluate the therapeutic value of intrarectal injections of BT in inhibiting colorectal contractions and relieving FI in patients suffering from FI as a result of overactive rectal contractions.A prospective open study was carried out in Rouen University Hospital. Six patients (four men and two women) with severe FI related to overactive rectal contractions underwent intrarectal submucosal injections of BT placed in three rows of 10, 1-ml injections (50 U/1 ml; Dysport(®)) starting 1 cm above the dentate line and repeated twice, at intervals of 5 cm proximally. The end-points included improvement in the FI score, in faecal incontinence quality of life (FIQL) and of manometric abnormality.All patients reported improvement in the FI score [18.2±1.1 at baseline vs 9.0±1.7 at 3 months (P=0.04)] and in FIQL. Rectal contractile activity was reduced. The frequency of contractions remained unaffected (28.1±6.6/h; P=0.46 vs baseline). High-amplitude contractions of50 cmH(2)O were significantly decreased in all patients (16.6±3.9 vs 6.6±4.1/h; P=0.03).Patients with an 'overactive rectum' are a heterogeneous group, with varying causes of dysfunction. The dose of BT used was arbitrarily selected. Nevertheless, the study introduces a further therapeutic option in the treatment of FI caused by rectal overactivity.

To evaluate the use of computed tomography-based virtual colonoscopy in the preoperative assessment of colorectal endometriosis.We included in the study consecutive women undergoing surgical management of deep infiltrating endometriosis from August 2009 to April 2010, whose colorectal involvement had been assessed by magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES). Prior to surgical procedure, a computed tomography-based virtual coloscopy was performed. Computed tomography was performed by insufflating air into the distal rectum, along with an intravenous injection of contrast agent. Then, 3D reconstruction of pictures was carried out, to allow visualization of the lumen of the rectum and the colon. Data provided by virtual colonoscopy were compared to those given by other imaging techniques and surgical exploration.Twenty-seven patients were included in the study: 7 women underwent colorectal segmental resection, 2 full thickness excision, 15 shaving, while in 3 of them no digestive surgical step was performed. Virtual colonoscopy provided the measurement of the length and the diameter of colorectal stenosis due to infiltrating nodule through rectal and sigmoid wall, which was presenting as an endoluminal indentation. The number of patients presenting with endometriotic nodules arising on the rectum, sigmoid colon, or both of them, were respectively 13, 7 and 7. Ovarian endometriomas were responsible for extrinsic compression leading to digestive tract stenosis in nine cases. The number of lesions and their height reported to the anus were accurately assessed in 24 women out of 27 (sensitivity of 88%). The origin of the digestive tract stenosis, i.e. either infiltrating endometriotic nodules or extrinsic compression due to ovarian endometriomas, was accurately assessed in all cases, by combining information provided by virtual colonoscopy, IRM, RES and transvaginal ultrasonography.Computed tomography-based virtual colonoscopy provides useful information about the degree and the height of digestive tract stenosis due to colorectal endometriosis. In our opinion, this information is of major interest to argue the choice of shaving or full thickness excision of nodules in a majority of women presenting with colorectal endometriosis.

Stapled transanal rectal resection is a new alternative for the treatment of outlet obstruction syndrome. The aim of this study was to assess its feasibility and safety in a multicenter context.The study had a retrospective design and included 102 patients who were operated in 5 centers. All patients complained of symptomatic outlet obstruction. Surgical technique involved a double hemi-circumferential rectal stapling according to the technique described by Longo. Mean follow-up was 17.2 months.The STARR procedure was done in 100 patients (2 patients had a non relaxing sphincter preventing anal dilatation). Immediate postoperative morbidity included bleeding in 4 cases (4%) and rectal stenosis in 3 cases (3%). The main postoperative medium-term complaints were urge to defecate (34%) which was regressive in most patients and de novo incontinence to flatus (9%). Nevertheless, results were considered favorable in 85% of patients.This multicenter study, reporting the results of the largest published series, suggests that the STARR technique is feasible and safe in the medium term for the treatment of rectocele. Occurrence of adverse events such as incontinence to flatus should be better evaluated by future studies with longer follow up in order to assess the actual place of STARR in the treatment of rectocele or outlet obstruction.

To assess the characteristics, the diagnosis and the treatment of intrathyroid metastasis.The authors report a case of a locally advanced intrathyroid metastasis of a bronchial cancer.A 60-year-old woman, treated seven years before for a well-differentiated bronchial adenocarcinoma, developed enlargement of the thyroid gland. Metastatic disease was confirmed by a surgical biopsy. Following incomplete radiochemotherapy, a palliative surgical debulking was performed, associating an isthmolobectomy with a large skin excision and closure with a pectoralis major myocutaneous flap.Intrathyroid metastases are rare and usually treated by surgery. Surgical management is decided taking into account the type and the kinetics of the primary tumor, the location of the thyroid metastasis, and the extension of the metastatic disease. Except for isolated intrathyroid metastasis of kidney cancer, prognosis remains poor.

Intraperitoneal (IP) ventral hernia repair is advantageous because of reduced dissection, shorter operative time and less postoperative pain. However, the IP positioning of the mesh is suspected to increase the risk of visceral adhesion and induce complications. To overcome these drawbacks, an innovative mesh: Parietex Composite (RC) was developed with one side protected by a hydrophilic resorbable film. The purpose of this study was to compare using ultrasonography the rate of visceral adhesions after IP placement of a conventional mesh (RP) versus RC mesh.Twenty-six patients who received a Parietex Composite were prospectively compared to a retrospective series of 26 consecutive asymptomatic patients who received a non protected polyester mesh (RP). In order to objectively assess visceral adhesion toward the abdominal wall, an ultrasound specific examination was used after previous validation by comparison of preoperative ultrasonographic data with peroperative gross appearance in both groups.With a mean follow up of 33 months, both groups were equivalent in term of inclusion criteria excepted for age which was older the RP group. US validation data were: sensitivity 72%, accuracy 69%, negative predictive value 67%. Using this procedure, 81% of the patients exhibit visceral adhesion to the mesh in the RP group, versus 27% in the PC group (P =0.0002, chi2).US examination represents a suitable tool to evaluate postoperative adhesions to the abdominal wall. A significant reduction of visceral adhesion in the RC group was shown.

Because some investigators have reported the systematic occurrence of exocrine pancreatic insufficiency after pancreaticoduodenectomy with pancreaticogastric anastomosis (PGA), we assessed PGA patency after pancreaticoduodenectomy.Nineteen patients underwent pancreaticoduodenectomy, and their PGAs were studied prospectively with secretin magnetic resonance cholangiopancreatography (MRCP). After administration of negative bowel contrast agent, single-shot fast spin-echo T2-weighted dynamic MR pancreatograms were obtained before and every minute for 12 min after secretin injection. Morphologic features of the pancreatic parenchymal and pancreatic duct were monitored (diameter and winding aspect of the pancreatic duct, pancreatic thickness, direct visualization of the anastomotic site). PGA permeability was classified into four grades, from 0 (obstruction) to 3 (good permeability). Pancreatic function was assessed by fecal-1 elastase concentration, fasting blood glucose, and fasting serum insulin level.MRCP grades were 0 in two patients, 1 in four, 2 in five, and 3 in eight. The anastomotic site was visualized in 10 patients. Pancreatic parenchymal atrophy was discovered in four patients. There were statistically significant relations between secretin MRCP permeability grade and fecal-1 elastase concentration (p0.03) and between secretin MRCP permeability grade and pancreatic atrophy (p0.005). In contrast, fecal-1 elastase concentration was lower than the normal value in all but one case. There was no statistically significant relation between fecal-1 elastase concentration and other morphologic data.Secretin MRCP may indicate PGA stenosis or dysfunction, but it is not the only factor suggesting exocrine pancreatic insufficiency. Thus the major role of PGA may be the preservation of long-term endocrine function.

The ideal treatment for complicated diverticulitis is still controversial. The Hartmann's procedure remains the favored option in patients with acute complicated sigmoid disease but there has been increasing interest in primary resection and anastomosis with intraoperative colonic lavage. A prospective study was carried out on 71 patients with peritonitis, comparing primary resection with intraoperative colonic lavage, and Hartmann's procedure.Between January 1994 and September 1999, 71 patients underwent emergency laparotomy for diverticular peritonitis. Primary resection and anastomosis with intraoperative colonic lavage was performed in 29 patients (group I) and Hartmann's procedure in 42 patients (group II). All data were collected on standardized forms.There were no differences between the two groups according to clinical features, biology, severity of disease and operative delay. The mortality rate in group I and group II was, respectively, 7 and 10% (P = 0.6). The incidence of postoperative complication was higher after Hartmann's procedure (P0.05). The mean hospital stay was significantly longer for the Hartmann's procedure compared to primary resection with intraoperative colonic lavage.Primary resection with intraoperative colonic lavage compares favorably with Hartmann's procedure for local or diffuse purulent peritonitis in complicated diverticulitis. It should be an alternative to the Hartmann's procedure in stercoral peritonitis.

The aim of this retrospective study was to report and quantify the immediate and 3-year complications after laparoscopic anti-reflux surgery in order to understand the mechanism.From 1992 to 1996, 1470 laparoscopic fundoplications were performed for symptomatic gastroesophageal reflux disease. Preoperative checkup included upper gastrointestinal tract endoscopy in 1437 patients (97.7%), esophageal manometry in 934 patients (63.5%), and 24-hour pHmetry in 799 patients (54.3%). Three procedures were performed: Nissen (n = 655), Nissen-Rossetti (n = 423), and Toupet (n = 392). The results were estimated at 1 and 3 months; thereafter they were evaluated at 3 years. Patients unable to return to the hospital center were contacted by telephone.Mean length of hospital stay was 4.6 days (range: 2-48 days). The preoperative complication rate was 2.1% (n = 31). The postoperative morbidity and mortality rates were 2.9% (43 patients) and 0.07% (1 patient), respectively. Conversion rate to laparotomy was 6.5% (96 patients). At 3 months, 87 patients (5.9%) had invalid dysphagia but there was no difference between the 3 procedures. Twelve patients have been reoperated (0.8%). At 3 years, 78 patients (5.6%) presented a clinical recurrence. The rate of dysphagia was 0.35%, and 38 patients were reoperated.Laparoscopic fundoplication is safe and effective with a low morbidity and mortality rate if junior surgeons commenced this procedure under the direct supervision of an experienced surgeon. Despite the advantage of this technique, we believe that indications for surgical management remain unchanged in the laparoscopic era.

Intraperitoneal (IP) ventral hernia repair has been proposed with the advantages of reducing dissection, operative time, and postoperative pain. The IP position of the mesh is suspected of increasing the risk of visceral adhesion and inducing complications. To overcome these drawbacks, a mesh protected on one side by a hydrophilic resorbable film (Parietex Composite) has been validated [1]. Using a previously described ultrasound procedure [2], the purpose of this study was to compare the rate of visceral adhesion after intraperitoneal placement of a polyester mesh versus this protected mesh. Fifty-one patients who received a Parietex Composite mesh were prospectively compared to a retrospective series of 22 consecutive asymptomatic patients who received a Mersilene mesh. To objectively assess visceral adhesion toward the abdominal wall, an ultrasound (US) specific examination was firstly validated and secondly used to evaluate the adhesion incidence in both groups. Both groups were equivalent in terms of inclusion criteria and body mass index (BMI). Pre-operative US versus perioperative macroscopical findings determined the following parameters: sensitivity 83%, accuracy 78%, negative predictive value 81%. Using this procedure, 77% of the patients exhibited visceral adhesion to the mesh in the Mersilene group, against 18% in the Parietex Composite group (P

The aim of this prospective study was to assess the outcome of laparoscopic colectomy for sigmoid diverticulitis in normal weighted, overweighted and obese patients.From January 1995 to December 2000, all patients (n = 77) undergoing an elective colectomy for sigmoid diverticulitis were included in the study. The patients were divided into three groups: group 1 (n = 29): normal weighted patients (BMI: 18-24.9); group 2 (n = 27): overweighted patients (BMI: 25.0-29.9); group 3 (n = 21): obese patients (BMI: 30.0-39.9). Comparison between these three groups was only made during the per and postoperative period.There were no differences in the three groups with regard to age, sex and ASA classification. Duration of operation did not differ between group 1 and 2 (187 vs 210 min, P = 0.6) but was shorter in group 1 than in group 3 (187 vs 247 min, P = 0.003). Conversion rate did not differ and was respectively in group 1, 2 and 3: 13.8, 14.8 and 14.3%. The postoperative period during which parenteral analgesics were required was not different for group 1 and 2 but was longer in group 3 than in group 1 (8.5 vs 5.7 days, p = 0.03). Morbidity rate was similar in group 1, 2 and 3: 15, 14 and 17%. There was no perioperative mortality. Duration of hospital stay was similar in the three groups.Data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to overweighted and obese patients.

The aim of this prospective study was to determine the feasibility and the complications or benefits of laparoscopic colectomy for sigmoid diverticulitis in patients aged 75 years or more.From January 1993 to December 1999, 85 patients underwent an elective colectomy for sigmoid diverticulitis. Twenty-two patients over 75-years old (group 1) were compared to 63 younger patients (group 2).In group 1, there were 12 women and 10 men, with a mean age of 77.2 years (range: 75-82); In group 2, there were 35 women and 28 men, with a mean age of 53.7 years (range: 38-74) (P = 1.10-14). The operative time was shorter in group 2 (183 vs. 234 min). There was no difference between the 2 groups with regard to the postoperative period during which parenteral analgesics were required (5.4 vs. 5.2 days, P = 0.48) and the postoperative morbidity (18% vs. 14%, P = 0.06). Postoperative length of hospital stay (13.1 vs. 8.8 days, P = 0.003) was shorter in group 2 than in group 1. There was no perioperative mortality. Conversion rate was 9% (group 1) and 6% (group 2) (P = 0.6).In summary, data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to older patients with fewer complications, less pain, shorter hospital stay and a rapid return to preoperative activity levels.

The aim of this retrospective study was to evaluate the short and long term results of abdominoperineal resection for local recurrence following low anterior resection of a rectal adenocarcinoma and to determine the prognostic factors.From January 1978 to December 1996, 35 patients (17 women, 18 men) with a mean age of 59.4 years, underwent an abdominoperineal resection for local recurrence after low anterior resection of a rectal adenocarcinoma. The primary tumor was below the peritoneum in 29 cases, and the mean security margin was 3 cm under the tumor. Tumor staging at the time of primary surgery included 23 Dukes B, 11 Dukes C, and 1 Dukes D. The mean time elapsed between low anterior resection and local recurrence was 16.4 months. The histological diagnosis of recurrence was obtained preoperatively in 29 cases (82.8%).Resection was curative in 12 patients and palliative only in 23 patients. The recurrence was intramural in 3 cases, extramural in 10 cases, and mixed in 22 cases. Ten patients had an extended "en bloc" resection including one or several adjacent organs, and a synchronous metastasis was resected in 2 cases. The mortality rate was 2.8% (n = 1) and the morbidity rate was 23% (n = 8). The 1-year and 5-year survival rates were respectively 77 and 30.2% with the univariate analysis of prognosis factors of survival, there were four pretherapeutic factors (age, staging of the primary tumor, delay of the recurrence, CEA rate) and four therapeutic factors (curative resection, extramural recurrence, staging of the recurrence, postoperative radiotherapy). The curative or not curative type of resection was the only independent predictor of survival with multivariate analysis.The results of this study seem to justify an abdominoperineal resection for local recurrence after low anterior resection whenever possible. Long-term results may possibly be improved by using adjuvant treatment.

The aim of this prospective comparative study was to assess the outcome of laparoscopic colectomy for sigmoid diverticulitis in normal-weight, overweight, and obese patients.From January 1995 to December 2000, all patients (n = 77) undergoing an elective colectomy for sigmoid diverticulitis were enrolled in the study. The patients were divided into three groups: Group 1 (n = 29) consisted of healthy, normal-weight patients (BMI, 18-24.9); group 2 (n = 27) consisted of overweight patients (BMI, 25.0-29.9); group 3 (n = 21) consisted of obese patients (BMI, 30.0-39.9). Groups 2 and 3 were compared with group 1.Group 1 was comprised of 13 women and 16 men with a mean age of 58.4 years (range, 37-78); group 2, was comprised of 13 women and 14 men with a mean age of 55.2 years (range, 31-83); group 3, was comprised of 13 women and 14 men with a mean age of 54.1 years (range, 33-86). There was no difference among the three groups in ASA classification, postoperative length of hospital stay, or inpatient rehabilitation. The operating time did not differ for groups 1 and 2 (187 vs 210 min, p = 0.6), but it was shorter in group 1 than in group 3 (187 vs 247 min, p = 0.003). The conversion rate was similar for all three groups: 17.2% in group 1, 14.8% in group 2, and 19% in group 3. The postoperative period during which parenteral analgesics were required did not differ between groups 1 and 2 (5.7 vs 7.7 days, p = 0.1), but it was longer for group 3 (8.5 days, p = 0.03). The morbidity rate was similar for all three groups: 17.2% in group 7, 14.8% in group 2, and 19% in group 3. There were no perioperative deaths.Data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely in overweight and obese patients

The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia.From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases.Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without).Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

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.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.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).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.

To evaluate the results of laparoscopic cholecystectomy in patients with acute cholecystitis and to determine the optimal timing.From January 1993 to December 1999, 168 patients (91 women and 77 men with a mean age of 57.3 years) underwent laparoscopic cholecystectomy for acute cholecystitis confirmed by histopathological examination. Patients were divided into 2 groups (similar in age and ASA classification): group 1 (106 patients) underwent laparoscopic cholecystectomy within 3 days after the onset of symptoms of acute cholecystitis and group 2 (62 patients) underwent laparoscopic cholecystectomy after 3 days.There was no death. Conversion rates were 30.9%. Surgery lasted 141.3 min, postoperative morbidity was 12.5%, and the postoperative length of hospital stay was 6.9 days. The conversion rates in patients who underwent surgery before and 3 days after the onset of symptoms were respectively 21.7% and 46.7% (P=0.0007). There was no statistical difference between early and delayed surgery for time to surgery and postoperative complications. On the other hand, the total hospital stay was significantly shorter in group 1.Laparoscopic cholecystectomy for acute cholecystitis is safe and associated with a shorter postoperative stay, a lesser morbidity and a lesser mortality compared to "open" surgery. Laparoscopic cholecystectomy should be carried out soon as the diagnostic of acute cholecystitis is established and preferably before 3 days after the onset of the symptoms. Early laparoscopic cholecystectomy allows a reduction of the conversion rate and a reduction of total hospital stay that are medical and economic benefits.

The aim of this 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.STC was performed in 60 consecutive 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.Postoperative mortality was 6.6% (n = 4): 3 patients over 85 years of age died postoperatively as a result of cardiopulmonary complications; an 83 year-old female died as a result of an anastomotic dehiscence. Morbidity was 10% (n = 6) including one fistula which recovered without surgery. There were 5 synchronous colon cancers. Six months after surgery, the mean daily stool frequency was 2 after STC, and 3 after TC.Emergency STC achieves 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 a possible synchronous carcinoma.

Internal hernia is an uncommon cause of acute intestinal obstruction. The aim of this study was to retrospectively evaluate the diagnosis, the management, and the follow-up of the internal hernias operated over a 10-year period in our department of visceral surgery.14 spontaneous internal hernias were observed. The patients were evaluated with respect to symptoms, radiological findings, time elapsed between the onset of symptoms and surgery, type of operation performed, postoperative morbidity and mortality, postoperative stay, and follow-up.There were 8 men and 6 women. The preoperative diagnosis was evoked in only one case. The mean time elapsed between the onset of the symptoms and surgery was 31.1 hours (range 6 to 72 hours). Two intestinal resection were performed. Mean postoperative hospital stay was 11.3 days (range 6 to 22 days). The morbidity was 21.4% with no mortality. Mean follow-up was 7 months (range 3 to 15 months); one patient developed an incisional hernia.Since preoperative diagnosis of an internal hernia is difficult because of the lack of specific signs, morbidity and mortality can be decreased with early surgical intervention. Operative risks include vascular accidents, especially to hernia neck vessels.

The aim of this prospective study was to determine the feasibility and the complications or benefits of laparoscopic cholecystectomy (LC) in the patients older than 75 years.From January 1992 to July 1998, a total of 863 patients underwent LC, of these patients, 102 patients older than 75 years (group 1) were compared with 761 younger patients (group 2).In the elderly, 35.3% were at high surgical risk (American Society of Anesthesiology [ASA] III and ASA IV). The conversion rate to open cholecystectomy (OC) was 21.6%. The mean length of hospital stay was 6.9 days for both laparoscopy and conversion. Morbidity and mortality rates were 13.7% and 1%, respectively. No patient suffered intraoperative cardiopulmonary complication, and there was no reoperation in the elderly.Elderly patients experience more complications and longer duration of hospital stay than younger patients. However, our results compare favorably with other OC studies in elderly patients.

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.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.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).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.

The aim of this prospective study was to determine the feasibility, complications and benefits of laparoscopic cholecystectomy in the patients over 75 years of age.From January 1992 to July 1998, among the 863 patients who underwent laparoscopic cholecystectomy, 102 patients over 75 years (group I) were compared to 761 younger patients (group II).The conversion rate was 22% in group I versus 13% in group II (P = 0.017). Mortality and morbidity rates were respectively 1% and 13.7% in elderly patients versus 0 and 6.6% in younger patients (P = 0.009). Mean length of hospital stay was higher in group I: 6.9 versus 4.5 d in group II (P10(-6)).Laparoscopic cholecystectomy is feasible in patients above 75 for the treatment of symptomatic gallstones and acute cholecystitis with a low morbidity rate.

Background: To assess the outcome of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy (LC) for symptomatic gallbladder and suspected duct stones. Methods: During 3 years, one or more of four criteria led to ERC: jaundice, choledocus >8 mm, cholestasis, and severe biliary pancreatitis. Endoscopic extraction (ESE) of ductal stones was attempted before LC. Results: In all, 990 patients were prospectively included. There were no exclusions. There were no deaths. A multivariate logistic regression analysis identified jaundice ( P = 0.001), pancreatitis ( P = 0.001), and cholestasis ( P = 0.001) as statistically significant predictors of ductal stones. Choledocus >8 mm was not a significant predictor ( P = 0.12). A total of 155 (16%) patients underwent ERC for suspected stones: 21 of 155 (13%) patients had no stones; and 6 of 134 (4%) patients had stone impaction cleared at open surgery. ERC clearance rate was 95% (128 of 134). LC was performed in 149 of 155 patients after a median interval of 3 days (range 1 to 7). Morbidity rates were 3% (4 of 134), 2% (3 of 149), and nil (0 of 6) after ESE, LC, or open surgery, respectively. Median hospital stay was 11 days. A total of 835 patients underwent LC with a 1.5% complication rate. Laparoscopic fluoro-cholangiography showed ≤3 mm-sized stones in 10 of 835 (1.2%) patients. No stones were reported at a median follow-up of 4 months including 990 patients. Conclusions: Ninety-five percent of patients with ductal stones can be successfully and safely managed by ERC prior to LC.

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%).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.

The aim of this retrospective study was to compare pancreatico-jejunostomy vs pancreatico-gastrostomy with regard to safety of pancreatic anastomosis after pancreatico-duodenectomy.From January 1980 to June 1995, 171 patients underwent pancreatico-duodenectomy, 136 for pancreas, ampulla, distal bile duct or duodenum cancers, and 36 for chronic pancreatitis. Pancreatic anastomosis was realised by pancreatico-jejunostomy in 91 cases and by pancreatico-gastrostomy in 80 cases. There was no significant difference between the two groups (age, gender and primary disease). Comparison between the two groups concerned mainly postoperative mortality and morbidity.The overall postoperative mortality rate was significantly higher in the pancreatico-jejunostomy group (12%) than in the pancreatico-gastrostomy group (3.7%) (P = 0.05); death was directly related to necrosis of the remnant pancreas in four cases among the 14 postoperative deaths. The postoperative morbidity rate was respectively 23% after pancreatico-jejunostomy and 12.5% after pancreatico-gastrostomy; the pancreatic leakage and/or necrosis rate was higher in the pancreatico-jejunostomy group (13%) than in the pancreatico-gastrostomy group (3.75%) (P = 0.029).This study seems to demonstrate the superiority of the pancreatico-gastric anastomosis, but these results have to be confirmed or invalidated by a prospective multicentric randomised trial.

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.

The aim of this retrospective study was to analyze the characteristics, treatment and prognosis of early gastric carcinoma in a series of 102 patients.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.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).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.

The purpose of our prospective study was to evaluate the contribution of follow-up in resected colorectal cancer.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.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 (p0.001). 5-year survival after recurrence in group 1 was 11.5% versus 1% in group 2 (p0.01).These results emphasize the rational for a follow-up program in patients undergoing surgery for colorectal cancer.

The aim of this study was to assess retrograd cholangiogram findings and first-line endoscopic sphincterotomy followed by laparoscopic cholecystectomy for the treatment of main bile duct lithiasis. Clinical, biological and echographic criteria predictive of main bile duct lithiasis were observed in 125 patients (32 men, 93 women, mean age 44.2 years) who underwent retrograde cholangiography. Results suggested lithiasis of the main bile duct in 105 case (87.5%) and were confirmed at endoscopic sphincterotomy in 99. There were no deaths; four complications occurred (3 moderate cases of pancreatitis, 1 cholecystitis). Conversion was required in 11.6%, usually because of difficulties in dissecting. No residual lithiasis was observed. Mean duration of hospitalization was 11.4 days. This sequential treatment scheme for main bile duct lithiasis appears to be effective, minimally invasive and safe.

Twenty-three patients with volvulus of the caecum were operated on from 1982 to 1995. There were 17 men and 6 women, mean age 63 years. Preoperative diagnosis was obtained in 48% of the cases. A right hemicolectomy was performed in 22 cases with immediate anastomosis; in one case, a double ilial and transverse stomy was required. Necrosis was observe in 12 patients (52%). Post-operative mortality was 8.6% (n = 2) due to circulatory shock in 2 patients with necrosis of the colon. Post-operative morbidity was 21% (n = 5) including one case with fistulization of the anastomosis requiring a double stomy. On the basis of this series and a review of the literature, it appears that right hemicolectomy is the treatment of choice for volvulus of the right colon, as it avoids all risk of recurrence and mortality is lower than conservative treatment.

Lesions of the iliac arteries after blunt trauma is uncommon. We observed 5 cases in our unit from 1992 to 1995. This pathology usually is seen in young men and the diagnosis often is made late. A Doppler examination and arteriography should be made in case of clinical doubt. Treatment is exclusively surgical. We present the mechanism of the arterial lesions, the symptomatology caused by the lesions and the therapeutic modalities.

SCOPUS: ar.j, info:eu-repo/semantics/published