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Background. Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care. Methods. A retrospective multicenter study was conducted in 4 European surgical centers concerning, their experiment with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof Of the MBC (defined as being BDC with MBC involvement subgroup). Results. From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02). Conclusion. BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.

Background. The prognostic relevance of a Japanese-like lymphadenectomy for gastric adenocarcinoma in Caucasian patients is not well established. Methods. Skeletonizing en-bloc gastrectomy (SEBG) (including removal of the stomach, excision of the potentially involved lymph nodes, and skeletonization of the main anatomic structures in the upper abdominal floor) was attempted in 216 consecutive patients with adenocarcinoma of the stomach. Gastrectomy was total in 143 patients, and subtotal in 72. One debilitated patient had a wedge resection of the gastric wall. Results. SEBG was performed in 160 patients (74%), whereas 56 patients (26%) had a palliative gastrectomy (PG) without lymph node dissection. The feasibility rate of SEBG was influenced significantly (P < 0.001) by the depth of wall penetration, so that it dropped from 97% in T1 tumors to 91%, 65%, and 17% in those classified T2, T3, and T4, respectively. The 5-year survival rate, including postoperative mortality (0.9%) was 48% for the whole series, 66% after SEBG, and 0% after PG. The 5-year survival rate after SEBG was related significantly to the lymph node involvement (NO, 75% vs N+, 54%; P = 0.008) and to its magnitude (N+, <5 metastatic lymph nodes, 62% versus N+, ≥5 metastatic lymph nodes, 39%; P = 0.018). Considering the fact that 9 patients died of an unrelated cause before the postoperative term of 5 years, the cancer-related survival rate 5 years after SEBG was 71% in the whole group of 160 patients. This survival rate was 82% in patients with normal lymph nodes, versus 56% in those with metastatic nodes (P < 0.001). Conclusion. SEBG was feasible in three-quarters of a population of Caucasian patients operated on for gastric adenocarcinoma. SEBG provided a chance for a longterm favorable outcome in three-quarters of patients with normal lymph nodes and in more than half of those with metastatic lymph nodes. These results are similar to those achieved after radical gastrectomy in Japanese p

Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited disease that affects about 1 in 8000 individuals. Patients with FAP typically develop hundreds to thousands of adenomas or adenomatous polyps during their second and third decades of life. Although these benign tumours are not individually life-threatening, their large number virtually guarantees that some will progress to invasive carcinomas. Additionally, FAP patients often carry congenital retinal lesions and later develop other extracolonic manifestations, including osteomas, desmoids tumours, cysts of the skin, brain tumours and some other, rarer neoplastic formations. Throughout our different studies, the purpose was the prevention of colorectal cancer in aptients with FAP. In Part I, we emphasised the importance of including the patients and their families in a national register. The principal aim of a polyposis register is to imrpov the prognosis of FAP through family tracing, and through appropriate information, education and counselling of familu memebers at risk. This has a beneficial effect on the incidence of established colorectal cancer at diagnosis of FAP. Moreover, a register will ensure a regular follow-up of patients after surgery. A secondary aim is to provide a database for research and for national or international collaborative studies. To date, surgery is still the only effective prophylactic treatment of FAP to prevent cancerous degeneration, but the choice of a surgical procedure is controversial. In Part II, we showed that ileal pouch-anal anastomosis (IPAA) with endoanal mucosectomy offers the best prevention by removing all the diseased epithelium. In order to avoid urinary and sexual dysfunction in the often young and healthy patients with FAP, we advocate a dissection close to the rectal wall when performing the protectomy, to avoid injury of the pelvic autonomic nerves. Compared to ileorectal anastomosis (IRA), IPAA is a rather complex, technicall, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1997

The thesis addresses two main questions of major clinical importance regarding the surgical treatment of esophageal cancer: 1. What is the potential of esophagectomy including extensive thoraco-abdominal lymph node clearance to provide oesophageal cancer patients with long-term survival and cure? 2. What are the qualities of the stomach as an esophageal substitute after total or subtotal esophagectomy regarding surgical feasibility, technical complications, and alimentary comfort? In the introduction, we reviewed the current knowledge according to the world literature concerning, vasculature, innervation and mobility of the stomach which is required for a clear understanding of the to issued presently studied. The review of a personal series of 306 esophagectomies performed for malignancy showed that resection of the esophagus en-bloc with the loco-regional lymph nodes was technically feasible in 213 patients (70%). Five-year survival rate after radical esophagectomy was 70% for the 104 patients having no lymph node involvement (T1-T2-T3-N0) and 31% for the 109 patients having metastatic lymph nodes. (T1, T2, T3, N1). Five-year survival rates improved with increasing experience on the procedures over the years. Comparison of results obtained form 1984 to 1988 with those from 1989 to 1997 showed that the 5-year survival rate increased form 63.6% to 75.5% for patients classified N0 and from 17.5% to 39% for those classified N1. Replacement of the esophagus with the stomach is governed by anatomical constraints in relation to the shape, vascularisation and innervation of the organ, the distance to bridge between the abdomen and the neck, and the need for complete lymphatic clearance of the lesser curvature. We have compared the classic technique of gastric tubulisation with stapling resection of the lesser curvature to a personal technique in which the lesser curvature of the whole stomach is denuded for the purpose of gastric lengthening and l, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1997

La transplantation hépatique est actuellement reconnue comme la thérapeutique de choix dans le traitement des enfants atteints de maladie hépatique irréversible. La survie est possible dans plus de 80% des cas. Ces résultats furent obtenus grâce aux incessantes améliorations apportées aux soins de ces enfants, qui commencent tôt après le diagnostic de l’affection et se poursuivent ensuite tout au long de la surveillance du patient. La période périopératoire bien qu’étant la plus courte est aussi celle qui s’accompagne des plus importants changements physiologiques. Cette thèse s’intéresse à certains de ces évènements et présente notre expérience dans leur approche. Les techniques anesthésiques et chirurgicales sont s’abord présentées et illustrées par les améliorations observées durant les 450 premières transplantations réalisées par notre équipe, ensuite, nous décrivons l’approche que nous avons adoptée dans le cas particulier de l’enfant cirrhotique et hypoxémique, et finalement, nous démontrons de nouvelles théories concernant les mécanismes responsables des modifications hémodynamiques du patient cirrhotique. Nous avons montré que grâce à la mise en place de nouvelles stratégies et au développement d’innovations dans les techniques chirurgicales, nous pouvions réduire considérablement les besoins transfusionnels de ces patients ainsi que la fréquence de décès peropératoires. Auparavant, vu le risque opératoire trop important, nous nous trouvions devant l’obligation de récuser les enfants souffrant d’hypoxémie secondaire à leur cirrhose hépatique. De plus, la physiopathologie de cette complication chez l’enfant était peu connue. Nous avons étudié celle-ci en utilisant la méthode des gaz inertes et avons pu ainsi montrer que cette hypoxémie était principalement due à d’importantes inégalités du rapport ventilation/perfusion causées très probablement par une vasodilatation exagérée des capillaires pulmonaires. Nous avons aussi démontré la réversibili, Liver transplantation is now widely recognized in the management of children with end-stage liver disease. Survival rates are in excess of 80%. This has been achieved by continuous improvements of the care provided throughout the whole procedure, starting very early after diagnosis and going on during all the follow-up of these patients. The perioperative period probably represents the shorter period of this challenge though it is undoubtedly accompanied by the greater physiological stresses. This thesis reviews some of the complications of pediatric liver transplantation and our experience in their management. We will first present the improvements in anesthetic management observed during the first 450 liver transplantations performed by our team. In the first part, we then describe our approach in the particular case of the hypoxemic and cirrhotic child and finally, in the second part, we give new insights on the mechanisms involved in the hemodynamic modifications induced by liver disease. We have shown that the development of new surgical techniques and appropriate intraoperative strategies enabled us to dramatically decrease the blood requirements and the intraoperative mortality. Because of its prohibitive perioperative risks, hypoxemia in children was until recently considered as contraindication for liver transplantation and the physiopathology of this complication was poorly understood. We studied it with the use of the multiple inert gas elimination technique (MIGET), and showed this hypoxemia to be due to a severe intrapulmonary ventilation/perfusion mismatch probably caused by intrapulmonary vascular dilatations. We demonstrated that theses modifications were fully reversible after liver transplantation, for which hypoxemia can therefore no longer be viewed as a contraindication. The pulmonary vasodilatation is part of the more general hyperdynamic circulation, which is a well-known complication of cirrhosis. Many vasodilators have been su, Thèse d'agrégation de l'enseignement supérieur (faculté de médecine) -- UCL, 1997

Organ transplantation and laparoscopic surgery are clearly the two most recent revolutions in actual surgical practice. Laparoscopic surgery really started in 1987, when Philippe MOURET performed the first laparoscopic cholecystectomy (LC) in France. The concept of laparoscopic surgery is to create o working space by insufflating an inert gas (CO2) within the peritoneal cavity. The surgical procedure is performed though a variable number of “key-holes” by using special introduction tubes (trocars) and instruments. The operation is assessed on a video-screen via a camera connected to a rigid fiberoptic (the laparoscope). This procedure is performed on a “closed abdomen” in comparison to open surgery through a laparotomy, and for this reason has at times been called “Nintendo surgery”. Several advantages have been advocated, such as reduced postoperative pain and pulmonary dysfunction, lower stress response to surgery, shorter postoperative hospital stay, earlier return to normal activities and esthetic benefit (3-5). Based on the suggestion than laparoscopic surgery is “minimally-invasive surgery”, LC had a rapid wide spread diffusion among general surgeons all over the world and the approach has been applied to an increasing number of pathologies. According to MEDLINE, 256 publications were dedicated to laparoscopic surgery in 1990. This number rose to 1,064 in 1992, 1,954 in 1994, and 1,415 from January to November 1996n thereby confirming the exposure enthusiasm for the techniques. Almost all types of gastro-intestinal operations have been performed laparoscopically : appendectomy, inguinal hernia repair, antireflux procedures, cardiomyotomy for esophageal achalasia, vagotomies, Billroth II gastrectomy, gastroenterostomy, esophagectomy, treatment of perforated peptic ulcer and small bowel obstruction, gastroplasty for morbid obesity, all types of colorectal resections, small bowel resection for Crohn’s disease … etc. In urology, nephrectomy, adrenalectom, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1997

Laparoscopic splenectomy has become an attractive treatment for patients with selected hematologic disorders. Almost 200 observations have been reported. The rate of conversion to laparotomy is 10% to 15%, and the complication rate is between 0% and 30%. Adequate selection of patients, preoperative administration of intravenous immunoglobulin in patients with idiopathic thrombocytopenic purpura, meticulous surgical techniques, and careful preoperative and intraoperative search for accessory spleen are critical factors for success in these patients. The procedure should be confined to expert laparoscopic surgeons with considerable experience in the management of hematologic diseases.

A Heller-Dor procedure was performed by laparotomy (group A: n = 8) or by laparoscopy (group B: n = 12) after failure of one to 17 sessions of intraluminal dilatations (n = 13) or as a primary treatment of oesophageal achalasia (n = 7). The oesophagomyotomy was extended over the thoracic oesophagus by thoracoscopy in two patients having vigorous achalasia. Injury to the oesophageal mucosa occurred in two group A patients who had previously been dilated. At follow-up (range: 1 to 113 months), 6 patients of group A (75%) and 10 of group B (83.3%) had no residual dysphagia. The four patients (group A : n = 2; group B : n = 2) who complained of heartburn prior to the operation were asymptomatic, only one group A patient developed symptoms of reflux, and oesophageal pi-I-monitoring was normal in the 6 group B patients investigated at follow-up. The laparoscopic approach reduces the magnitude of the operation, and the magnified overview permits precise dissection of the intraparietal adhesions which may develop after numerous sessions of dilatation.

Transplantation of a vascularized allograft in a host leads to acute rejection of the graft and elimination of the foreign antigen. This rejection process can be avoided by inhibition of the immune response. There are different ways in which one can overcome the immune response to an allotransplant: matching, nonspecific immunosuppression and specific transplantation tolerance. The matching is based on the fact that allotransplants are rejected because the recipient’s immune system recognizes on donor cells histocompatible antigens that are different from his own. If there are no such disparate antigens, such as in identical twins, then no rejection response occurs. The most important histocompatibility antigens are those of the Major Histocompatibility Complex (MHC); known in human beings as the Human Leukocyte Antigen (HLA) system. However, there are numerous other antigens capable of causing rejection, termed minor histocompatibility antigens. Matching to avoid or eliminate the immune response in conceivable in kidney or bone marrow transplants, since the time necessary to carry out tissue typing is available. Matching, however, is unrealistic in case of liver, heart or lung transplants, since the admissible ischemia time does not allow the achievement of tissue typing. The use of nonspecific immunosuppressive drugs represents the most practical means to avoid rejection. This therapy is accountable for the enormous success in the field of transplantation over the past three decades. Such a drug regimen, however, can produce major complications during the early as well as long-term follow-up such as infections, malignancies or drug-induced side-effects. Long term, the immunosuppressive regimen therefore may directly cause loss of patients ad cannot prevent chronic rejection, which is the second major cause of graft loss. Therefore, induction of specific transplantation tolerance still represents a major goal of modern transplantation immunology. Specific, Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1995

Objective: Our goal was to assess the state of the portal vein in cirrhotic patients treated with a portacaval shunt associated with an arterialization of the portal vein. Materials and Methods: We reviewed the follow-up CT of 23 patients treated by portacaval shunt with arterialization of the portal vein. Results: Five patients demonstrated an aneurysm of the portal vein. Followup Studies revealed progression of the aneurysm and development of a mural thrombosis in four patients. The thrombosed portal vein was calcified in three patients. One patient demonstrated a dilatation of the saphenous vein graft in addition to the portal vein aneurysm. Only one of the five patients was symptomatic, presenting with ascites, dilatation of intrahepatic biliary ducts, and jaundice secondary to the compression of hilar structures by the huge portal vein. Conclusion: Aneurysm of the portal vein following portacaval shunt associated with arterialization of the portal vein is not a rare complication.

Two uncommon complications of en bloc resection of the oesophagus for cancer are reported: paraplegia, probably related to division of the right intercostal arteries at the thoraco-abdominal junction, and abundant weeping of lymphatic fluid originating from the retropancreatic area due to both the resection of the thoracic duct and a Kocher's manoeuvre that had been performed to facilitate gastric pull-up to the neck. The former strongly suggests that both right and left intercostal arteries should be maintained when performing an en bloc resection of the oesophagus and the latter that Kocher's manoeuvre should be avoided after ligation or resection of the thoracic duct whenever abundant retroperitoneal oedema is present at the time of the laparotomy made for the gastric mobilization.

Thoracic duct drainage (TDD) may be of value for removing toxic substances released by the inflamed pancreas and which are responsible for lung damage. We have prospectively assessed the efficacy of TDD in improving pulmonary gas exchange in 12 patients with severe acute pancreatitis (SAP) complicated by persistent respiratory failure despite standard conservative treatment including peritoneal dialysis in 8 patients. In group A were 6 patients (mean Ranson score=7.3) with adult respiratory distress syndrome (ARDS) and in group B were 6 hypoxemic patients (mean Ranson score=6.6) judged to be at risk of developing ARDS. The duration of TDD ranged from 3 to 10 days and the total amount of drained lymph (L) varied from 770 to 15 600 ml. Immunoreactive trypsin levels were significantly higher in L when compared to blood in both groups. Leukocyte myeloperoxidases in L (normal value < than 332±82 ng/ml in plasma) were increased in 5 of 5 group A patients (830±317 ng/ml) and in 3 of 6 patients in group B (671±467 ng/ml). After TDD pulmonary gas exchange as measured by median PaO2/FiO2 (mmHg) improved from 148±60 to 285±42 in group A and from 192±37 to 330±42 in group B (p<0.05). All patients were weaned after ventilation for a mean of 8 days in group A and 4 days in group B. All patients survived apart from 1 group B patient who died of sepsis on day 34. These data suggest that TDD, by allowing removal of potential mediators of lung injury is of major therapeutic value in ARDS complicating SAP. This approach may also prevent further respiratory impairment in susceptible patients.

Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1968

Thèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 1964