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Objective To determine whether early postoperative administration of erythromycin accelerates the spontaneous motor recovery process after elevation of the denervated whole stomach up to the neck. Summary Background Data Spontaneous motor recovery after gastric denervation is a slow process that progressively takes place over years. Methods Erythromycin was administered as follows: continuous intravenous (IV) perfusion until postoperative day 10 in ten whole stomach (WS) patients ai a dose of either 1 g (n = 5) or 2 g (n = 5) per day; oral intake at a dose of 1 g/day during 1.5 to 8 months after surgery in 11 WS patients, followed in 7 of them by discontinuation of the drug during 2 to 4 weeks. Gastric motility was assessed with intraluminal perfused catheters in these 21 patients, in 23 WS patients not receiving erythromycin, and in ii healthy volunteers. A motility index was established by dividing the sum of the areas under the curves or >9 mmHg contractions by the lime of recording. Results The motility index after IV or oral administration of erythromycin at and after surgery was significantly higher than that without erythromycin (IV, 1 g: p = 0.0090; IV, 2 g: p = 0.0090; oral, 1 g: p = 0.0017). It was similar to that in healthy volunteers (IV, 1 g: p = 0.2818; oral, 1 g: p = 0.7179) and to that in WS patients with >3 years of follow-up who never received erythromycin UV, 1 g: p = 0.2206; oral, 1 g: p = 0.8326). The motility index after discontinuation of the drug was similar or superior to that recorded under medication in four patients who did not experience any modification of their alimentary comfort, whereas it dropped dramatically parallel to deterioration of the alimentary comfort in three patients. Conclusions Early postoperative contractility of the denervated whole stomach pulled up to the neck under either IV or oral erythromycin is similar to that recovered spontaneously beyond 3 years of follow-up. in some patients, this booster effect persists af

Background. The classic manual end-to-side technique of esophagogastrostomy after gastric pull-up to the neck carries a rather high risk of fistula and stricture. Methods. A terminalized semimechanical side-to-side technique of cervical esophagogastrostomy was performed in 16 patients by the application of an Endo-GPA stapler across the gastric and esophageal walls placed side by side, so as to create a V-shaped posterior opening between the two lumina. The anterior aspect of the anastomosis was hand-sewn using a classic running suture. The cross-sectional area of the semimechanical anastomoses was estimated by barium swallow study 2 months after operation and compared with that of 24 manual end-to-side esophagogastrostomies. Results. The cross-sectional area was 225 +/- 15.7 mm(2) (mean a standard error of the mean) or the 16 semimechanical anastomoses versus 136 +/- 15 mm(2) for the 24 manual anastomoses (p = 0.0001). The anastomotic area decreased from 206.6 +/- 13.5 mm(2) in 29 patients without dysphagia to 107.5 +/- 4.7 mm(2) in 7 patients with moderate dysphagia for solids that did not require endoscopic dilation and to 55.7 +/- 16 mm(2) in 4 patients with severe dysphagia that required dilation (p = 0). The anastomotic area in 6 of the 7 patients with initial moderate dysphagia for solids increased spontaneously with time from 107.3 +/- 5.5 mm(2) to 174.6 +/- 8.1 mm(2), with concomitant symptomatic relief (p = 0.0277). Conclusions. The terminalized semimechanical side-to-side suture technique produces a larger anastomosis than the classic end-to-side esophagogastrostomy technique. inflammatory changes related to the operation may cause transient narrowing of a cervical esophagogastrostomy. (C) 1998 by The Society of Thoracic Surgeons.

Objective To determine whether the denervated stomach as an esophageal substitute is an inert conduit or a contractile organ. Summary Background Data The motor response of gastric transplants to deglutition suggests that the stomach pulled up to the neck acts as an inert organ. Methods The gastric motility of ii healthy volunteers and 33 patients having either a gastric tube (G.T) (n = 10) or their whole stomach (WS) (n = 23) as esophageal replacement was studied with perfused catheters during the fasting state, after a meal, and after intravenous administration of erythromycin lactobionate. A motility index:: was established for each period of recording by dividing the sum of the areas under the curves of all contractions of >9 mmHg by the time of recording. Results Over years, the denervated stomach recovers more and more motor activity, even displaying a real phase 3 motor pattern in 6 of the 10 WS patients and 1 of the 7 GT patients with >3 years of follow-up. Erythromycin lactobionate generates a phase 3-like motor pattern regardless of the length of follow-up. Extrinsic denervation of the whole stomach does not significantly modify the fasting motility index established >3 years after surgery (+17% on average, p > 0.05), but it reduces that in the led period by an average of 62% (p = 0.0016). Tubulization of the denervated whole stomach lowers the fasting motility index by an average of 60% (p = 0.0248) and further impairs that in the fed period by an average of 67% (p = 0.0388). Conclusions The denervated stomach as an esophageal substitute is a contractile organ that may even generate complete migrating motor complexes. Motor recovery is better in the fasting than in the fed period, and it is more marked in WS patients than in G.T patients.

A patient with hepatic angiosarcoma is described. This tumour, thought rare, still generates clinical interest, because of its characteristic association with occupationnal exposure to certain chemicals such as vinyl chloride and thorotrast. That association has led to extensive screening of high risk populations. An additional case of liver angiosarcoma which probably developed following long-term treatment with cyclophosphamide. The significant aspects of this tumour are delineated and the diagnostic modalities are discussed.

Familial adenomatous polyposis (FAP) is a dominantly inherited genetic disorder predisposing to colon cancer through the early development of multiple adenomatous polyps in the large bowel. FAP is not restricted to the colon and rectum, but is a more complex disease which can potentially affect almost any organ not only with benign tumours but also with life threatening carcinomas. Desmoid tumours and gastroduodenal polyps and cancer are the two more worrying extracolonic manifestations of FAP. Recent advances in FAP knowledge, such as the report of congenital hypertrophy of the retinal pigment epithelium (CHRPE) or the APC gene identification, are very useful for screening and long-term follow-up of the patients through regional or national registries. Nutritional and pharmacological intervention trials are under way to assess potential new medical treatments of FAP. Surgery is still the only effective treatment for colorectal cancer prevention in FAP. The choice of a surgical procedure is controversial, but the introduction of total proctocolectomy with ileal pouch-anal anastomosis can be considered as a major advance in surgical treatment of FAP during the last decade.

Background. The stomach can be used either in its entirety or as a greater curvature tube for esophageal replacement. Methods. The study compares the gastric tube (group A; n = 112) to the whole stomach whose lesser curvature is denuded (group B; n = 100) in terms of technical complication and alimentary comfort. The clinical results are substantiated by assessment of the eating performance of patients and control subjects at a test meal, measurement of the gastric dimensions before and after both tailoring procedures, and intraarterial staining of the gastric wall. Results. Major differences between the two groups are cervical anastomosis stenoses (22.3% versus 6% [A versus B]; p = 0.008), fistulas (7.9% versus 1%; p = 0.0209), number of meals and snacks per day (4.6 versus 4; p = 0.0275), sensation of early fullness at meals (52.4% versus 17.8%; p < 0.0001), ratings given to the long-term alimentary comfort (presymptomatic condition = 10 points) (7.6 versus 8.8 out of 10 on average; p < 0.0001), and calories consumed in 1 minute at a test meal (59% [p < 0.05] versus 77% of those consumed by control subjects). The volume of the stomach is reduced by a range of 21.4% to 47.2% after tubulization (group A) whereas it increases by a range of 4.9% to 17.4% after denudation of the lesser curve (group B). Intraarterial staining of the gastric wall reveals the poor vascularity of the upper-most segment of the greater curve. Conclusion. Slight increase of the gastric capacity and maintenance of the submucosal vascular network account for the better results achieved with the whole stomach.

We report a new case of S.C.C. of the large bowel with multiple liver metastases. A resection of the primary tumour and liver biopsies were performed with administration of a postoperative chemotherapy (5-Fluorouracil). After a stabilization of 3 months, the metastases were rapidly progressive and the patient died a year after the diagnosis. About 70 cases of S.C.C. of the colon and rectum have been described in the literature. It is most common in the fifth decade and occurs equally in male and female. The most frequent locations are the rectum and the sigmoid. Clinical and physical features and common diagnostic methods do not differentiate the S.C.C. from adenocarcinoma. Treatment is the same but the prognosis of S.C.C. appears to be worse than that of adenocarcinoma.

Fifty-five patients were reoperated on for an unsatisfactory outcome after antireflux surgery. Presenting symptoms were heartburn alone (27), heartburn and dysphagia (10), dysphagia alone (9), chest pain (4), left shoulder pain (1), left shoulder pain and fever (1), and signs of anemia (3). The symptom of dysphagia was usually of immediate onset whereas heartburn reoccurred after a symptom-free period (p = 0.014). The most common failed antireflux procedure was a Nissen fundoplication (37). The incompleteness of the residual wrap, its location around the stomach and the irreducibility of the gastro-oesophageal junction below the diaphragm were accurately predicted by barium swallow study in 70, 83 and 92% of the patients, respectively. Abnormal oesophageal body motility was related to oesophagitis, herniation of the residual repair into the chest or both (16/20), and it normalized in 6 of the 11 patients evaluated at follow-up. Oesophageal acid exposure and prevalence of oesophagitis were higher in patients with heartburn than in those with other symptoms (p < 0.02). Intraoperative findings were breakdown of the repair, its location around the stomach, its herniation into the chest, its too excessive tightness, a gastric fistula, or any combination. Remedial surgery consisted of a new antireflux procedure (42), a new antireflux procedure combined with closure of a gastric fistula (3), a closure of a gastric fistula alone (1), a closure of the crura (4), an oesophageal resection (3), a total gastrectomy (1), and a duodenal diversion (1). Postoperative mortality and morbidity were 5.4 and 23.4%, respectively. At follow-up (range: 3 to 160 months), clinical, radiological and pH-monitoring success rates were 89.1, 85.7 and 88.4%, respectively.

The quality of life and alimentary comfort of 17 patients with esophageal cancer who were disease free more than 3 years after an esophageal resection were evaluated by analyzing responses to a follow-up questionnaire. Fourteen patients had subtotal esophagectomy and gastric pull-up to the neck. Three patients underwent a total esophagopharyngolaryngectomy, the digestive continuity being restored by means of an isoperistaltic colon segment interposed between the base of the tongue and the stomach. Current body weight, when compared with that existing postoperatively, was increased in 13 patients and unchanged in four. The number of meats per day was an average of 2.8, but 12 patients took additional snacks between main meals (2.3 as a mean). The major long-term complaints were a sensation of early fullness during eating in 11 patients, dysphagia in three, diarrhea in two, cough-induced vomiting in two, and postprandial sweating in two. Ratings given by self-evaluation of current alimentary comfort in comparison with that predating the initial esophageal symptoms ranged from 3 of 10 to 10 of 10 (mean 7.1/10). Thirteen patients led active lives, seven at home and six employed outside the home. The present survey suggests that most disease-free patients may obtain a satisfactory quality of life after esophagectomy and gastric or colonic pull-up; long-term alimentary comfort is conditioned mainly by the small capacity of the esophageal substitute.

The authors report their experience of liver transplantation for metastatic tumor in 6 patients. Although good palliation can be offered with prolonged survival in some patients, secondaries of the liver remain the poorest indication for liver transplantation. A prospective multicentric study would be needed to evaluate the usefulness of Post-transplantation chemotherapy.

From 1984 to 1989, 175 esophageal cancer patients, 10 patients admitted for severe caustic esophagitis, and 1 patient with pyothorax due to iatrogenic perforation of the esophagus underwent an esophageal resection or bypass operation. One hundred sixty-eight esophageal resections were performed on 167 patients; 13 were total, 106 subtotal and 49 distal. Nineteen digestive transplants were pulled up to the neck to bypass the esophagus or re-establish continuity after an esophagectomy made elsewhere. Digestive continuity was restored by a long gastric transplant in 120 patients, a colon segment in 17, a jejunal loop in 35, and a short gastric transplant after limited esophago-gastrectomy in 14 patients. Thirty day mortality was 0 in the whole group. Hospital mortality was 1.2% in the resection group and 10.5% in the bypass group (p = 0.048). Nonfatal postoperative complications consisted of respiratory distress in 33 patients, recurrent nerve palsy in 10, anastomotic fistula in 10 (cervical in 8 and intrathoracic in 2) and anastomotic stenosis in 18 patients. Respiratory complications were more frequent in patients with a cancer of the thoracic esophagus (29/111) than in those operated on for a cancer located in the esophago-gastric junction (4/50) (p < 0.01). Anastomotic stenosis occurred more frequently in the neck (17/137) than in the chest (1/49) (p < 0.05). Nine patients were reoperated on for a technical complication; intraabdominal hemorrhage (1), thoracic duct injury (2), acute cholecystitis (1), tight stricture of the esophageal anastomosis (2), jejuno-duodenal anastomotic fistual (2), or stridor related to recurrent nerve palsy (1). Low postoperative mortality may be achieved after esophageal surgery, even in a nonselected Caucasian population. However, nonfatal complications indicate that an esophageal resection or bypass operation remains a major surgical procedure. The surgical principles which we have applied to minimize postoperative mortality and sever

Surgical resection of hepatic metastases is mainly performed for colo-rectal carcinomas. The natural history of theses metastases shows that their course is variable but death of the patients occurs within one year after discovery of obvious hepatic metastases in 50 % of these patients. Five years survival after complete surgical hepatic resection is reported to be around 20 % in most series. Prognosis is determined by the node involvement of the primary tumour, the degree of local invasion (Dukes classification) and the time of appearance of the liver-metastases (metachronous or synchronous). A better pre- and intra-operative (ultrasound) detection could improve these results.

From 1977 to 1989, 66 patients were operated on in emergency, without any bowel preparation, for acutely obstructing left-sided colon cancer. Two synchronous cancers were diagnosed and the 68 tumours were located as follows: 13 on the left transverse colon or at the splenic flexure, 7 on the descending colon, 37 on the sigmoid, and 11 at the rectosigmoid junction or below. According to Astler-Coller staging, 15 patients were classified as B, 17 as C and 25 as D. Initial treatment was a colostomy in 58 patients (88%), or a resection with or without anastomosis in 2 and 6 cases respectively. Most patients underwent a two- or more rarely a three-staged resection and 44 patients left the hospital without either tumour or stomy. Cumulative operative mortality was 12%. Five-year survival rates were 21% for the patients with a minimal potential follow-up of 5 years, and 39% for curative resections (disease-free survival of 33%). From these results, we think that two-staged resection, with close proximal colostomy followed by resection and anastomosis, remains an appropriate approach for most obstructing left-sided colon cancers; more tempting procedures such as resection with primary anastomosis or subtotal colectomy are probably indicated in selected patients.

To evaluate the benefit of arterialisation of the portal vein in conjunction with a therapeutic end-to-side portocaval shunt, a prospective randomised study, was started in december 1979 comparing these two techniques in Child A and B cirrhotic patients with a hepatopedal portal flow of at least 100 ml per min. Sixty-four patients were included in the study: 33 were submitted to portocaval shunt (NART) and 31 were arterialised (ART). The two groups of patients were similar for clinical and haemodynamic parameters. Arterialisation lowered the operative mortality for the whole group (ART: 6.5 %, NART: 12 %) and in high risk patients; Child class B patients (ART: 0 %, NART: 22 %) and emergency operation (ART: 0 %, NART: 17 %) but the difference is not statistically significant. Postoperative ascites was more frequent in arterialised patients (ART: 45 %, NART: 18 %; p = 0.02), with an increased need for reoperation (ART: 26 %, NART: 6 %; p < 0,05). The mean follow-up time was 56,9 +/- 28,1 months (SD) for the 58 surviving patients. The five-year actuarial survival rate was 68 % for ART patients and 60,6 % for NART patients (NS). In Child B patients the five-year actuarial survival rate was 75 % in ART patients and 22 % in NART patients (p < 0,05). Actuarial estimation of arterialisation patency - proved by angioscan - was 38 % at five years. There was no significant difference in postoperative and long-term encephalopathy and liver function. In conclusion, arterialisation of the portal vein in conjunction with a therapeutic end-to side portocaval shunt improved survival in high risk patients (Child class B), without increasing operative mortality, with a higher incidence of postoperative ascites and without a decrease in the incidence of long-term encephalopathy.

Durant la période 1970-1983, neuf patients présentent dix anévrismes d'une des branches du tronc coeliaque. Le dia­gnostic précis, dans cette série, est base sur le scanner abdominal avec injection de produit de contraste et sur /' artériographie viscérale sélective. Un patient présentant une néoformation pancréatique inopérable n' est pas opéré. En plus de la ligature de l' artère nourricière réalisée chez les 8 autres patients, une résection pancréatique est nécessaire chez 3 de ces malades. Le non développement d'une circulation collatérale hépatique et la présence d'une hypertension porta/e segmentaire doivent faire recourir à la revascularisation hépatique ( 1 pat.) et la splenectomie (2 pat.). La mortalité hospitalière des patients opérés est nulle, leur évolution à long terme, en moyenne de 5 ans, est excellente.