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Purpose: In the literature, up to 20% of patients present a failure of weight loss after primary Roux-en-Y gastric bypass (RYGBP) or other restrictive procedures. Our aim is to describe the midterm results of our novel technique of distal Roux-en-Y gastric bypass (DRYGBP) as a revisional procedure., Materials and Methods: We performed our DRYGBP in 21 patients. The length of the common channel was 100 cm, whereas the lengths of the alimentary and the biliopancreatic limbs were 2/3 and 1/3 of the remaining bowel, respectively. We created 2 subgroups, a "revisional" group after failed restrictive procedures and a "distalization" group after failed RYGBP., Results: The mean excess weight loss at 12 months in the "revisional" group (10 patients) was 67.8% and in the "distalization" group (11 patients) 57.1%. We did not experience any mortality nor severe morbidity rates., Conclusions: In our experience, our DRYGBP differentiated procedure seems to be effective at 12 months.

Aims: To compare the perioperative parameters and excess weight loss between patients operated by laporoscopic Roux-en-Y gastric bypass (LRYGB), as a primary operation or a revisional, for insufficient weight loss after vertical banded gastroplasty (VBG) or adjustable gastric banding (AGB)., Methods: A retrospective analysis of all patients who underwent a LRYGB was performed for the period 2004-2011. Demographics, preoperative body mass index (BMI), co-morbidities, operation time, conversion rate, perioperative complications, hospitalization period, and % of excess BMI loss (%EBMIL) were investigated and compared between groups., Results: Three hundred forty-two laparoscopic gastric bypass operations were performed, 245 were primary, and 97 revisional. Median follow-up was 30 months (range 0-108 months). Mean BMI (kg/m 2 ) before bypass was 45.2 for primary laparoscopic Roux-en-Y gastric bypass (pLRYGB) and 41.1 for revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB). Median operative time and length of stay were longer for rLRYGB 157.5 versus 235 min (p < 0.001) and 6 versus 6.5 days (p = 0.05). Conversion to laparotomy was performed in eight patients, 0.4% of primary and 7.2% of revisional. Morbidity rate was 6.5% in pLRYGB versus 10% in rLRYGB (NS). There was one death in the primary group. Percentage of EBMIL was significantly lower in the revisional group at 12, 18, and 24 months of follow-up., Conclusions: Revisional and primary gastric bypass have no statistical differences in terms of morbidity. The % of excess BMI loss is lower after revisional gastric bypass during the first 2 years of follow-up. The trend of weight loss or weight regain was similar in both groups.

Background: Laparoscopic sleeve gastrectomy (LSG) has become during the last few years the most frequent procedure in bariatric surgery. However, complications related to the gastric staple line can be even more serious. The incidence of gastric fistula after LSG varies from 1 to 7%. Its management can be very challenging and long. In case of chronic fistula and failure of the previous treatment, total gastrectomy or Roux-en-Y fistulo-jejunostomy (RYFJ) might be considered. RYFJ has been described very rarely as a salvage procedure of gastric leaks after LSG., Methods: Between January 2015 and December 2015, we have performed a RYFJ in two patients, with chronic and persisting gastric fistulas, one after LSG and one after duodenal switch, respectively. In the two patients, the RYFJ procedure was attempted laparoscopically but in one case (patient after duodenal switch), conversion into laparotomy was necessary because of severe intra-abdominal inflammatory adhesions. In our video, we are presenting the case of this particular patient treated laparoscopically with a late and persisting leak 1 year after LSG., Results: In this multimedia high-definition video, we described the steps of our technique of laparoscopic RYFJ. There was neither mortality nor severe postoperative complications. The fistula control after a minimum of 6 months follow-up was 100% for both of patients., Conclusions: RYFJ in our particular case was efficient. However, larger series and longer follow-up are needed to confirm the efficiency of the RYFJ as a salvage procedure.

Introduction: We present a rare case of jejunal obstruction due to the migration of a laparoscopic adjustable gastric band (LAGB) that occurred 10 years after surgery and was successfully treated by laparoscopy. This report is compliant with the SCARE guidelines., Presentation of Case: A 42-year-old woman who underwent LAGB for morbid obesity 10 years ago was admitted with a small bowel obstruction due to the migration of a LAGB in the proximal small bowel. An attempt to endoscopic removal was unsuccessful and resulted in a laparoscopic extraction of the band. The post-operative course was uneventful., Discussion: Formerly, LAGB was considered the safest technique in bariatric surgery. However, the rate of complication increases in long-term studies. When the IGM of the band is diagnosed, removal is the only issue. Small bowel obstruction caused by a migrated band appears to be a rare complication following IGM, and the only therapeutic option is surgery because an endoscopic procedure is not reliable. Furthermore, LAGB appears to be a less effective technique for weight loss than the sleeve gastrectomy and the gastric bypass., Conclusion: Small bowel obstruction caused by LAGB migration is a rare but serious complication following IGM. In such cases, endoscopy has to be avoided because of the risk of jejunal disruption. The only way to treat it properly is surgery. This type of late complication reinforces the interest in the techniques currently used in bariatric surgery such as sleeve gastrectomy and gastric bypass, providing also a better weight loss than the LAGB., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Although Roux-en-Y gastric bypass (RYGBP) has proven its reliability over time in terms of weight loss and resolution of comorbidities, there continues to be a significant controversy in terms of used limb lengths. In the classical RYGBP, most surgeons have reported an alimentary limb length (ALL) of 100 to 150 cm and a bilio-pancreatic limb length (BPLL) of 50 to 75 cm. On the other hand, the common limb length (CLL) remains unknown in all the patients. As it is theoretically related to the level of malabsorption, CLL could influence weight loss after RYGBP., Materials and Methods: We performed a laparoscopic RYGBP in 90 patients with a mean preoperative body mass index (BMI) of 44.8. ALL and BPLL were respectively fixed at 150 and 75 cm. A systematic intraoperative measurement of CLL was performed., Results: As expected, we found a great variation of the jejuno-ileal length and also of the CLL. We created three subgroups of patients: one with the entire population, one excluding the super-obese patients (BMI > 50) and the third one excluding the revisions. There was no statistically significant correlation between CLL and excess BMI loss (EBMIL) at 1, 3, 6 and 12 months of follow-up in each group. We also found a linear correlation between the jejuno-ileal length and the height of individuals., Conclusion: With a fixed 150-cm ALL and a 75-cm BPLL, there is no evidence that the anatomical variations of CLL could influence weight loss after classical RYGBP.

Background: Gastric duplication is a rare malformation mostly diagnosed during childhood. Symptoms in adults are atypical, rare, or may be completely absent. The diagnosis is suggested after a morphological and histological assessment. The treatment is a complete surgical resection., Case Report: We report on a case of a 28-year-old woman referred to our unit for a surgical assessment of a gastric duplication of the antropyloric area associated with paraduodenal and pancreatic extensions, diagnosed by several image tools and histological confirmation. She had undergone a total laparoscopic resection of the duplication without violation of the gastric lumen or any other splanchnic injury. The postoperative course was uneventful and the patient was discharged on postoperative day seven without any complains., Conclusions: The present report illustrates that complete resection of a distal gastric duplication is feasible by a laparoscopic minimal invasive procedure and therefore is considered to be a safe therapeutic modality. Our case is the first distal gastric duplication cyst with pancreatic and paraduodenal extension reported in the literature completely resected by laparoscopic approach.

Background: Vertically banded gastroplasty or adjustable gastric banding often result in weight regain, complications, or side effects. Failed restrictive bariatric procedures can be converted in revisional laparoscopic Roux-en-Y gastric bypass (LRYGB). This study aimed to compare weight loss, evolution of comorbidities, and quality of life (QOL) between primary versus revisional LRYGB., Methods: Between 2004 and 2012, 374 patients underwent LRYGB as primary or revisional surgery performed by a single surgeon. Patient data were retrospectively reviewed; questionnaires of QOL were sent to all patients. Outcomes were evaluated according to Bariatric Analysis and Reporting Outcome System (BAROS) taking into account excess body mass index loss (EBMIL), correction of comorbidities, improvement in QOL, and complications., Results: Two hundred thirty-two patients (62%) responded to the questionnaire, 163 patients in the primary group and 69 in the revisional group. Median follow-up was 36 months (12-108). Median percentages of EBMIL were, respectively, 74% (26.8-126.8) and 50% (-31.6-124.2) in the primary and the revisional groups (p < 0.01). Median BAROS score reached 6.5 (-2-9) in the primary group, against 4.3 (-1.8-9) in the revisional group (p < 0.01). There were significantly less "fair" and more "excellent" scores in the primary group, considering initial BMI before gastroplasty. Arterial hypertension and sleep apnea syndrome resolved, respectively, in 51 and 56% in the primary group and only in 29 and 33% in the revisional group (p < 0.01)., Conclusions: According to BAROS score, revisional LRYGB for failed restrictive procedures provided poorer results than primary LRYGB in terms of weight loss, resolution of comorbidities and QOL.

Splenectomy is the only potentially curative treatment for chronic immune thrombocytopenic purpura (ITP) in adults. However, one-third of the patients relapse without predictive factors identified. We evaluate the predictive value of the site of platelet sequestration on the response to splenectomy in patients with ITP. Eighty-two consecutive patients with ITP treated by splenectomy between 1992 and 2013 were retrospectively reviewed. Platelet sequestration site was studied by (111)Indium-oxinate-labeled platelets in 93% of patients. Response to splenectomy was defined at last follow-up as: complete response (CR) for platelet count (PC) ≥100 × 10(9)/L, response (R) for PC≥30 × 10(9)/L and <100 × 10(9)/L with absence of bleeding, no response (NR) for PC<30 × 10(3)/L or significant bleeding. Laparoscopic splenectomy was performed in 81 patients (conversion rate of 16%), and open approach in one patient. Median follow-up was 57 months (range, 1-235). Platelet sequestration study was performed in 93% of patients: 50 patients (61%) exhibited splenic sequestration, 9 (11%) hepatic sequestration and 14 patients (17%) mixed sequestration. CR was obtained in 72% of patients, R in 25% and NR in 4% (two with splenic sequestration, one with hepatic sequestration). Preoperative PC, age at diagnosis, hepatic sequestration and male gender were significant for predicting CR in univariate analysis, but only age (HR = 1.025 by one-year increase, 95% CI [1.004-1.047], p = 0.020) and pre-operative PC (HR = 0.112 for > 100 versus <=100, 95% CI [0.025-0.493], p = 0.004) were significant predictors of recurrence-free survival in multivariate analysis. Response to splenectomy was independent of the site of platelet sequestration in patients with ITP. Pre-operative platelet sequestration study in these patients cannot be recommended.

Laparoscopy has become a routine procedure in the management of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases. However, a high level of expertise in laparoscopic and emergency surgery is required. Hemodynamic instability, huge abdominal distension, fecal peritonitis and perforated cancer are relative contraindications for the laparoscopic approach. In recent years, abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis and perforated peptic ulcer, randomized controlled trials have proven that the laparoscopic approach is as safe and as effective as open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and perforated diverticular disease are under debate, indicating that more randomized controlled trials comparing laparoscopic and open surgery are still necessary., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Laparoscopic surgery is associated with reduced surgical trauma, therefore with acute-phase response of lower magnitude as compared with open surgery. We hypothesized that NOTES might induce reduced immune response as compared with laparoscopy., Objective: To compare acute-phase reactants in a controlled trial of laparoscopic peritoneoscopy and ultrasonography versus transgastric or transcolonic NOTES peritoneoscopy and intraperitoneal endoscopic US., Methods: Eighteen pigs were divided in 3 groups: laparoscopy, transgastric and transcolonic NOTES. Serum levels of IL-6 and TNF-α were determined preoperatively and at day 2. Serum levels of haptoglobin and IL-6 mRNA levels from isolated white blood cells were measured by RT-PCR at days 0, 1, 2 and 7. Necropsy was performed at sacrifice, with peritoneal fluid microbiological analysis, macroscopic and microscopic examinations on gastrotomy/colotomy or abdominal wall closure sites, liver and parietal peritoneum biopsy sites and any area suggestive of infection., Results: The groups were similar with regards to peritoneoscopy completeness, ultrasonographic examination and biopsies. The duration of NOTES procedures was significantly longer than laparoscopic procedures. Minor complications were observed in most animals by macroscopic and microscopic examination, but NOTES procedures were associated with severe complications in 3 pigs (fistula, abscess, mortality). No significant differences in acute-phase reactants levels were found between groups., Conclusions: No significant difference in the acute-phase reactants could be demonstrated between surgical and NOTES procedures. NOTES was however associated with more severe septic complications. Optimal closure remains a challenge and better devices are needed to avoid them.

Background: There are few reports that show that laparoscopic rectal surgery for rectal cancer had similar oncological results based on short-term benefits. The purpose of this study was to analyze our institutional short- and long-term results in laparoscopic rectal surgery and to compare these results with that reported in the literature., Methods: The records of 121 patients who underwent sphincter-saving procedure for rectal cancer were reviewed. The variables analyzed included possible factors causing morbidity, anastomotic leak, and recurrence rate in the laparoscopic and open techniques. Multivariable analyses were used to determine relationship between variables. Survival curves were determined by using the Kaplan-Meier method., Results: Laparoscopic sphincter-saving total mesorectal excision or partial mesorectal excision was performed in 97 patients (group 1). Twenty-four patients had open procedure (group 2). The conversion rate from laparoscopic to open technique was 10.3% (n=10). The overall postoperative morbidity and anastomotic leak rates were 33.4% and 14.8%, respectively. There was no statistical difference in terms of postoperative morbidity (p=0.177) and anastomotic leak (p=0.216) between the two groups. Old age was an independent predictor for postoperative morbidity, and downstaging was an independent predictor for anastomotic leak with a sixfold increased risk. Complete downstaging to stage 0 showed a lower overall 5-year survival rate compared with non-downstaged stage I patients (79% vs. 100%). The overall local recurrence rate was 6%. There was one port site metastasis (0.8%). There were two (1.7%) postoperative deaths in group 1. The overall 5-year patient and disease-free survivals were 64% and 74%, respectively, and there was no difference between groups 1 and 2 (p=0.801)., Conclusions: Laparoscopic sphincter-saving rectal resection for rectal cancer shows good long-term results. However, it has no advantage in terms of short-term benefits compared with the open procedure. Further studies are needed to validate the effect of downstaging on anastomotic leaks.

Although tomato flavor has not been a major goal for breeders, nowadays it becomes important as it is a subject of consumer complaint. A better knowledge of tomato consumer preferences, at the European level, should provide the basis for improvement of fruit quality and for market segmentation. In the framework of a large European project, 806 consumers from 3 countries, The Netherlands, France, and Italy, were presented with a set of 16 varieties representing the diversity of fresh tomato offer in order to evaluate their preferences. In parallel, sensory profiles were constructed by expert panels in each country. Preference maps were then constructed in each country revealing the structure of consumer preferences and allowing identification of the most important characteristics. Then a global analysis revealed that preferences were quite homogeneous across countries. This study identified the overall flavor and firmness as the most important traits for improving tomato fruit quality. It showed that consumer preferences from different European countries, with different cultures and food practices, are segmented following similar patterns when projected onto a common referential plan. Moreover, the results clearly showed that diversification of taste and texture is required to satisfy all consumers' expectations as some consumers preferred firm tomatoes, while others preferred melting ones and were more or less demanding in terms of sweetness and flavor intensity. Detailed comparisons also showed the importance of the fruit appearance in consumer preference., (© 2010 Institute of Food Technologists®)

Sensory properties are important elements to evaluate the qualities of vegetable products and are also determinant factors in purchasing decision. Here we report the Italian results of a preference mapping study conducted within a larger European project with the aim of describing the preferences of European consumers in regard to the diversity of traditional and modern tomato varieties, available on the market. This study has allowed the assessment of fruit quality at 3 levels: objective description of sensory properties, consumer preference tests, and physicochemical measurements. A set of 16 tomato cultivars, with different fruit sizes and shapes, was described and classified according to 18 sensory attributes including flavor, appearance, and texture characteristics. The same cultivars were evaluated by 179 consumers in a "preference mapping" experiment with the goal of identifying the preferred varieties and the reasons for the choice. The consumer data are referred to hedonic ratings (aspect liking and overall liking), familiarity for the analyzed cultivars, and individual features collected by a questionnaire. A hierarchical analysis of the clusters allowed to distinguish, within the sampled Italian consumers, 4 segments with different preferences which represented 19%, 25%, 41%, and 15% of the population, respectively. A partial least square regression model allowed the identification of the sensory attributes that best described consumer cluster preferences for tomato cultivars. Both texture and flavor descriptors were important drivers of consumer preferences, but the relevance (predictive value) of individual descriptors to model tomato liking was different for each consumer segment. Information on demographic and behavioral characteristics, usage habits, and factors relevant for purchasing were also provided on the 4 groups of consumers.

Tuberculosis involving the liver in the absence of active pulmonary or miliary tuberculosis is very rare. The inflammatory pseudo-tumoral form is an entity difficult to diagnose. We report two patients, who underwent laparoscopic segmentectomy for suspected malignant tumour. Pathology showed tuberculoid granuloma with central caseous necrosis in both patients. The diagnosis in the first patient was made retrospectively on the resection specimen, whereas an active pre-operative work-up for tuberculosis diagnosis (biopsy and Polymerase Chain Reaction) remained futile in the second patient. The management of pseudo-tumoral hepatic tuberculosis needs a multidisciplinary concertation and a surgical approach is often the best way to ensure the diagnosis.

The objective of this study was to determine the impact of lowering nitrogen supply from 12 to 6 or 4 mM NO(3)(-) on tomato fruit yield and quality during the growing season. Lowering nitrogen supply had a low impact on fruit commercial yield (-7.5%), but it reduced plant vegetative growth and increased fruit dry matter content, improving consequently fruit quality. Fruit quality was improved due to lower acid (10-16%) and increased soluble sugar content (5-17%). The content of some phenolic compounds (rutin, a caffeic acid glycoside, and a caffeic acid derivate) and total ascorbic acid tended to be higher in fruit with the lowest nitrogen supply, but differences were significant in only a few cases (trusses). With regard to carotenoids, data did not show significant and univocal differences related to different levels of nitrogen supply. Thus, reducing nitrogen fertilization limited environmental pollution, on the one hand, and may improve, on the other hand, both growers' profits, by limiting nitrogen inputs, and fruit quality for consumers, by increasing tomato sugars content. It was concluded that primary and secondary metabolites could be affected as a result of a specific response to low nitrogen, combined with a lower degree of vegetative development, increasing fruit irradiance, and therefore modifying fruit composition.

Hydatid cysts are often incidentally found and remain clinically silent. However complications can occur. We present 2 patients who developed biliary complications due to a large hydatid cyst. In the first patient compression on the intrahepatic bile ducts and cystic duct by the cyst, caused cholangitis and cholecystitis. Moreover the cyst had ruptured into the right intrahepatic bile ducts. A sphincterotomy was performed with extraction of hydatid sand. A pericystectomy was necessary because of infectious deterioration of the patient. Albendazole was continued for 8 weeks after surgery. The second case presented with jaundice and weight-loss since 1 month. A large hydatid cyst caused compression on the bile duct bifurcation with proximal bile duct dilatation. A cystectomy was performed 2 weeks after albendazole therapy initiation, which was continued for 8 weeks after surgery. Follow-up of both surgical interventions was unremarkable. Although Echinococcus granulosus in not prevalent in Belgium, we must be aware of this pathology in patients coming from high endemic regions.

Laparoscopic cholecystectomy (LC) is now widely accepted as the modality of choice for the treatment of symptomatic uncomplicated cholelithiasis. The application of the laparoscopic technique in the setting of acute cholecystitis (AC) is more controversial. The precise role as well as the potential benefits of LC in the treatment of the acutely inflamed gallbladder have not been clearly established through large clinical series. The aim of our study was to assess the feasibility, safety, benefits, and specific complications of the laparoscopic approach in patients with AC. A retrospective chart analysis involving the patients admitted to two busy emergency digestive surgical units between October 1990 and December 1997 was carried out. Six hundred and nine patients meeting our criteria for AC were identified and evaluated. Overall complication rate was 15% with 12 postoperative bile leakages (1.97%) and 4 biliary tract injuries (BTI) (0.66%). The overall mortality rate was 0.66%. Local and overall complication rates were significantly correlated with the delay between the onset of acute symptoms and the operation but not the rate of general complications nor deaths. Our results demonstrate the safety and feasibility of LC in the setting of AC. Early cholecystectomy within 4 days is strongly recommended to minimize complications and increase the chances of a successful laparoscopic approach.

Summary: Several authors have demonstrated the feasibility and efficacy of the laparoscopic approach in the acute abdomen. The aim of this study was to evaluate the diagnostic performance and safety of laparoscopy as a routine approach in the management of appendicular peritonitis. This retrospective study included 96 consecutive cases of acute appendicular peritonitis. All patients underwent a laparoscopic approach. The mean APACHE II score and Mannheim Peritonitis Index were 7.6 and 17.4, respectively. Laparoscopic diagnostic accuracy was 98%. Laparoscopy allowed the physician to correct the preoperative suspected diagnosis in 6 patients (6.5%). The results of preoperative clinical evaluation of the peritonitis severity were corrected by laparoscopic exploration in 26% (25/96) of cases. Complete laparoscopic management was achieved in 79% (76/96). Overall, the postoperative morbidity rate was 13% (13/96). Postoperative intra-abdominal abscess and wound sepsis rates in patients treated by laparoscopy were 2% and 1%, respectively. There were no deaths. The laparoscopic approach for the management of appendicular peritonitis is safe and effective and does not result in any specific complication. Advantages include the high quality of laparoscopic exploration, a very low incidence of septic complications, and a comfortable postoperative recovery.

Background/aims: Laparoscopic management of acute small bowel obstruction has potential advantages over classical laparotomy. The aims of this study were to assess the feasibility and the safety of this technique, as well as to find any predictive success factors., Methodology: A laparoscopic approach was undertaken in 68 out of 150 patients admitted between 1991 and 1997 for acute small bowel obstruction., Results: The cause of obstruction was bands or adhesions in 80% of the patients. A correct laparoscopic diagnosis was established in 66% of the cases. A laparoscopic treatment was performed successfully in 31 patients (46%), and was assisted by minilaparotomy in 4 patients (6%), and by open herniorraphy in 2 patients (3%). Thirty-one patients (46%) needed a conversion to laparotomy. There were 6 bowel injuries (9%), all recognized during laparoscopy. There were 2 deaths in converted patients and 2 early reoperations for persisting ileus in patients treated by laparoscopy alone or by assisted laparoscopy., Conclusion: Acute small bowel obstruction can be treated by laparoscopy alone, or assisted by minilaparotomy or open herniorraphy with advantages for the patient and few complications despite a high rate of conversion. There were no pre-operative predictive factors for successful laparoscopy, except for an isolated previous scar from an appendectomy. Pre-operative predictive success factors were parietal intestinal adhesions, as the only cause of obstruction. Multiple adhesions will mostly require conversion to laparotomy.

Background: The purpose of this study is to evaluate the possibility, safety and advantages of laparoscopic approach in the diagnosis and therapy of perforated peptic ulcer., Methods: This is a retrospective study including 69 cases of gastroduodenal perforation initially treated laparoscopically. The safety (morbidity and mortality) was estimated according to the two mortality rates fixed for laparotomies, APACHE II and Mannheimer Peritonitis Index (MPI). Sixty-nine patients (average age: 52 years), 23% of whom being over 70 years old, suffering from gastroduodenal perforation, were initially treated with laparoscopy., Results: The laparoscopic diagnosis was done in 91% of cases. When the perforation was localized, the laparoscopic treatment was possible in 94% of cases. In 93% of cases a simple closure of the ulcerated perforation was performed. The conversion ratio was of 16%. One-hundred minutes (55-180) was the average operating. The morbidity was of 13%. One septic shock was reported in a patient with general purulent peritonitis diagnosed with laparoscopy and, after having converted, it was treated with laparotomy. No malignant iperCO2 was relieved. The reported mortality was of 4.3%, the theoretical mortality estimated was of 6% (MPI) and of 14% (Score APACHE II). The 3 deceased (87, 87 and 93 years old) had ASA index superior to 3. The remarkable advantage of laparoscopic approach is, in addition to diagnostic contribution, the absence of wall complications when the operation is not converted., Conclusions: The laparoscopic approach is suggested in gastroduodenal perforation, since it allows an etiological diagnosis and a treatment without conversion in 84% of cases.

From December 1989 to May 1995, a prospective study of laparoscopic cholecystectomy was carried out in our department, in order to assess the reliability and safety of this method in the case of acute cholecystitis. During this period, 1453 patients underwent laparoscopic cholecystectomy. Acute cholecystitis was diagnosed in 280 patients, based on clinical history and macroscopic lesions. Only 221 cases (15%) were included in the study after positive histology was obtained (M: 86; F: 135). The mean age was 62 years (20-90). Sixty-two patients (28%) were classified as ASA III and IV. The mean interval between the first symptoms and the operation was 9.9 days (1-53). The mean operating time was 130 minutes (45-420). Conversion to an open procedure was necessary in 22 cases (10%). The operative mortality was 0.9% (2 ASA IV patients) and the overall morbidity was 13.5%. A bile duct injury occurred in 0.4% of cases (1/221). In conclusion, laparoscopic cholecystectomy for acute cholecystitis is a safe procedure, when performed by operators experienced in laparoscopic surgery.

In hepatocellular carcinoma, invasion of the biliary tree usually occurs in large tumors. We report a case of a minute hepatocellular carcinoma which invaded the biliary tree and was revealed by secondary hemobilia, in a 65-old alcoholic patient with cirrhosis. The tumour was not identified by preoperative morphological examinations. Surgical exploration was performed due to unexplained hemobilia. Tumoral debris were observed in the right intrahepatic biliary tract during operative choledoscopy, justifying a right hepatectomy. A 5 mm diameter tumour was found in liver specimen. No recurrence had occurred after 22 months. In conclusion, in cirrhotic patients, unexplained hemobilia can reveal a small, potentially curable, hepatocellular carcinoma which has spread to the biliary tree.

Biliary surgery in the elderly is associated with a high morbidity and mortality rate. The aim of this prospective study is to determine the complications or benefits of laparoscopic cholecystectomy in patients over 75. From December 1989 to July 1992, 60 women and 15 men, all aged over 75, underwent laparoscopic cholecystectomy. 32 (43%) were at high surgical risk. In one half of cases, complications were present (30 cases of acute cholecystitis and 13 cases of choledocolithiasis). 10 underwent endoscopic sphincterotomy preoperatively and 4 patients with common bile duct stones were treated by laparoscopy during the same operating time. Eight conversions were necessary because of inflammatory process. The global morbidity rate was 10.6%. Local complications were: 1 wound abscess, 1 wound dehiscence, 2 biliary leaks and 2 cases of bleeding at puncture sites. The general complications concerned the respiratory tract except for one case of urinary tract infection. The mortality rate was zero. Laparoscopic cholecystectomy seems to be better tolerated than laparotomy. It allows curative treatment of gallstones, complicated or not, with a low morbidity rate.

The diagnostic and therapeutic value of laparoscopy in emergency was studied in 314 patients presenting with non-traumatic acute abdomen. Laparoscopy gave a correct and complete diagnosis of the underlying disease in 92% (290/314) of cases. An erroneous preoperative diagnosis was corrected by laparoscopy in 18% (58/314) of cases. This implied a change of the therapeutic strategy in 9% (27/314). Seventy five per cent (234/314) of patients were exclusively treated by laparoscopy, 22% (68/314) by laparotomy and 3% (11/314) by laparoscopically assisted surgery. Mortality was 2.5% (8/314) and morbidity 9% (29/314). In conclusion, laparoscopy is a valuable diagnostic tool for the surgeon in the context of acute abdomen and is an interesting therapeutic alternative in selected cases. However, it requires extensive experience in laparoscopic techniques.

We performed a laparoscopic cholecystectomy in 300 patients with gallstone disease complicated or not. The rate success was 97%, however involved the pathology might be. Indeed, 15% of the patients had an acute cholecystitis (10% catarrhalis, 5% empyema). Twenty-four patients with common bile duct stones had a complete endoscopic management of the biliary disease: endoscopic sphincterotomy and laparoscopic cholecystectomy. Operative mortality was absent and overall morbidity was 3.7%, exclusively minor.