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Resume Situation La sleeve gastrectomie laparoscopique (SGL) et le bypass gastrique en Y laparoscopique (BPGYL) sont couramment effectues, mais peu d’etudes ont montre la superiorite d’une strategie par rapport a l’autre. Objectif Comparer simultanement la SGL et le BPGYL en termes de perte de poids et de morbi-mortalite sur une periode de suivi de 36 mois. Methodes Etude prospective et comparative entre la SGL et le BPGYL. L’objectif principal de cette etude etait une hypothese conjointe testee au cours d’un suivi de 36 mois : le premier critere principal concernait la frequence de patients presentant une perte d’exces de poids (PEP) superieure a 50 % (% PEP > 50 %) apres SGL et BPGYL ; le deuxieme critere principal etait un critere composite defini comme la survenue d’au moins une complication majeure. Les objectifs secondaires devaient rapporter la regression des comorbidites et l’amelioration de la qualite de vie. Resultats Deux cent soixante dix-sept patients ont participe a l’etude (91 BPGYL, 186 SGL). L’âge moyen etait de 41,1 ± 11,1 ans, et l’indice de masse corporelle preoperatoire moyen de 45,3 ± 5,5 kg/m2. Apres 36 mois, le % PEP > 50 % n’etait pas inferieur dans le groupe SGL (82,2 %) par rapport au groupe BPGYL (82,1 %) ; pendant que le taux de complications majeurs etait significativement plus eleves apres BPGYL (15,4 %) qu’apres SGL (5,4 %, p = 0,005). Apres 36 mois, les objectifs secondaires etaient comparables entre les groupes alors que le reflux gastro-œsophagien (RGO) a augmente dans le groupe SGL et a diminue dans le groupe BPGYL. Conclusions La SGL a ete non inferieure au BPGYL pour ce qui concerne la perte de poids et etait associee a un taux plus faible de complications majeures au cours d’un suivi de 3 ans. Mais le RGO a augmente dans le groupe SGL et a diminue dans le groupe BPGYL.

Resume Face a l’emergence de la pandemie a COVID 19, l’activite de chirurgie bariatrique/metabolique a ete arretee. Le confinement et l’arret de cette chirurgie ont eu un impact sous-estime sur la population obese avec prise de poids, et aggravation des comorbidites. Un certain nombre de candidats a cette chirurgie sont exposes a un risque important de mortalite liee a la pandemie. En effet, l’obesite et le diabete sont deux facteurs de risque majeurs de forme grave d’infection a COVID-19. Le seul traitement efficace actuel de l’obesite est la chirurgie metabolique avec un benefice rapide et durable. Il parait donc necessaire de reprendre une activite de chirurgie metabolique. Le but de ce travail est de hierarchiser la reprise chirurgicale afin qu’elle soit progressive et coherente. Les organigrammes proposes aideront les centres a determiner les patients prioritaires selon la balance benefice-risque. Le diabete a une place centrale dans l’arbre decisionnel. Les modalites de reprise seront variables d’un centre a l’autre selon les ressources humaines, materielles et medicamenteuses, et seront a adapter a l’evolution epidemique. Un consentement eclaire specifique sera necessaire. Un depistage chez les patients obeses est a envisager dont les modalites de depistage sont elaborees sur la base des connaissances disponibles. En cas de suspicion de COVID, la chirurgie doit etre differee. Il faut insister sur les mesures et gestes barrieres afin de proteger le patient et le personnel soignant. Un confinement est fortement suggere pour le patient durant le premier mois postoperatoire. Le suivi des patients sera effectue de preference par teleconsultation.

Introduction et but de l’etude La sleeve gastrectomie (SG) est une intervention de plus en plus pratiquee en chirurgie bariatrique. Neanmoins, les donnees restent rares concernant l’etat nutritionnel de ces patients, incluant leur statut en vitamines et micronutriments. L’etude portait sur le statut biologique des patients dans l’annee avant et dans les deux ans apres la SG. Materiel et methodes Les dossiers biologiques de 46 patients ayant eu une SG etaient suivis durant trois ans. Les patients etaient âges lors de la SG de 40,4 ± 11,5 ans, leur poids etait de 121,0 ± 19,5 kg, leur IMC de 44,2 ± 6,6. Des prelevements sanguins etaient faits 201,2 ± 114,8 jours avant l’intervention, et etaient renouveles jusqu’a 538,4 ± 184,7 jours apres la SG. Le test de Mann–Whitney comparait les taux des elements doses entre la periode preoperatoire et la periode postoperatoire, avec p Resultats et analyse statistique En preoperatoire, les deficits en vitamines portaient surtout sur les vitamines D, B6, C et B9. Les prevalences respectives de deficit etaient de 86,2, 69,7, 36,7 et 27,6 %, puis de 67,5, 34,1, 20,5 et 31,4 % en postoperatoire. Les taux de vitamines B6 et C etaient plus elevees en postoperatoire (p = 0,007 et 0,008 respectivement). Les mineraux le plus souvent deficients en preoperatoire etaient le phosphore, le magnesium et le zinc. Les prevalences respectives des deficits etaient de 46,7, 34,4 et 15,6 %, puis de 19,9, 30,4, 20,5 et 8,3 % en postoperatoire. La phosphoremie etait plus elevee en postoperatoire (p = 0,02). On relevait la presence d’une hypoalbuminemie dans 21,9 % des cas en preoperatoire, versus 26,9 % en postoperatoire, avec une CRP moins souvent elevee en postoperatoire (14,7 % des cas) versus en preoperatoire (44,4 % des cas) et une baisse du taux de CRP en postoperatoire (p Conclusion Les deficits etaient frequents chez les personnes obeses en pre SG. Il serait souhaitable de realiser des bilans proches de l’intervention, par exemple dans le mois precedent, afin d’optimiser les supplementations. De nombreuses carences persistaient en postoperatoire, pouvant causer des troubles graves, par exemple en cas de deficit en vitamine C (scorbut) ou B9 (deficit de fermeture du tube neural). La frequence des hypoalbuminemies suggerait que de nombreux patients pouvaient etre a la fois obeses et denutris. L’interet des supplementations et d’un bon apport proteique avant et apres SG est souligne.

Summary Background Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en Y gastric bypass (LRYGB) are commonly performed, but few studies have shown superiority of one strategy over the other. Objective Simultaneously compare LSG and LRYGB in terms of weight loss and morbimortality over a 36-month follow-up period. Setting University hospital and bariatric surgery centers, France. Methods Prospective, comparative study between LSG and RYGBP. The primary endpoint of this study was a joint hypothesis during the 36-month follow-up: the first primary outcome pertained to the frequency of patients with an excess weight loss (EWL) greater than 50% (% EWL > 50%) after LSG or RYGB; the second primary outcome was defined as a composite endpoint of at least one major complication. Secondary objectives were regression of comorbidities and improvement in quality of life. Results Two hundred and seventy-seven patients were included (91 RYGBP, 186 LSG). The mean age was 41.1 ± 11.1 years, and average preoperative body mass index of 45.3 ± 5.5 kg/m2. After 36 months, the %EWL > 50% was not inferior in the case of LSG (82.2%) relative to LRYGB (82.1%); while major complications rates were significantly higher in LRYGB (15.4%) vs. LSG (5.4%, P = 0.005). After 36 months, all secondary objectives were comparable between groups while only gastroesophageal reflux disease (GERD) increased in LSG group and decreased in LRYGB group. Conclusions LSG was found non-inferior to LRYGB with respect to weight loss and was associated with lower risk of major complications during a 3-year follow-up. But GERD increased in LSG group and decreased in LRYGB group.

Nous avons poursuivi en region limousin une experimentation de suivi des patients operes par chirurgie bariatrique, faisant appel au telephone mobile et au SMS, avec le support de l’Agence Regionale de Sante. Une serie de patients consecutifs a ete operee de juillet a octobre 2010 et recrutee pour un suivi postoperatoire du poids par SMS hebdomadaire. 33 patients (5 H, 28 F) ont eu une perte de poids moyenne de 28,7 kg, avec une duree moyenne de suivi de 70 semaines, et un nombre moyen de reponses SMS par mois de suivi et par patient de 3,5. Le taux final de reponses exploitables transmises par les patients a ete de 96 %. Notre proposition de suivi par SMS initie et renforce le suivi postoperatoire. Le telephone mobile devient un moyen simple, peu onereux et efficace dans ce suivi. La densite du suivi lors des premiers mois contribue a de meilleurs resultats de la chirurgie, notre proposition pourrait trouver un prolongement dans la creation d’un « Bariatric Call Center ».

Le syndrome de Prader-Willi (SPW) est une maladie genetique caracterisee par une hypotonie neonatale, une petite taille, un hypogonadisme, un retard mental et une hyperphagie compulsive expliquee, en partie, par un taux de ghreline plasmatique elevee. L’obesite est une cause majeure de morbidite et de la mortalite chez ces patients. La prise en charge dietetique avec restriction alimentaire est incapable d’induire une perte de poids stable. La chirurgie bariatrique restrictive s’est averee impuissante a obtenir une perte de poids stable. Pour un nombre limite de patients, il a ete rapporte des resultats favorables apres derivation biliopancreatique (BPD). Nous rapportons un cas de SPW ayant beneficie d’un BPD laparoscopique, suivi pendant quatre ans. Il s’agissait d’une patiente de 28 ans avec un SPW et une obesite de 123 kg, IMC = 58 kg/m2. Il n’y a pas eu de complication perioperatoire. Quatre ans apres l’intervention, le poids etait de 101 kg et l’IMC de 47 kg/m2. Le diabete initialement insulinodependant etait devenu controlable par antidiabetique oral. Il n’y a pas eu d’hypoproteinemie, ni de deficit en vitamines.

Resume Le syndrome de Chilaiditi est l'association d'une semiologie clinique et radiologique de l'interposition du colon ou du grele entre la face inferieure du diaphragme et le foie. Nous rapportons le cas d'une femme de 32 ans, primigeste, cesarisee a 39 semaines d'amenorrhee pour un tableau de douleurs abdominales persistantes, et une cytolyse hepatique debutante. La patiente a presente au premier jour postoperatoire un syndrome occlusif du grele. L'etiologie de l'occlusion du grele en post-partum etait un syndrome de Chilaiditi avec incarceration inter hepato-diaphragmatique du grele decouverte a l'examen tomodensitometrique. Une laparotomie exploratrice a confirme et permis de traiter ce syndrome de Chilaiditi complique d'une occlusion.

Le bypass gastrique (BP) est considere comme la chirurgie de reference avec d’excellents resultats ponderaux a long terme et de remarquables ameliorations des comorbidites associees. Nous voulions demontrer que la gastrectomie longitudinale (SG) est non inferieure au BP pour la perte de poids et les complications avec un suivi de 36 mois. Cette etude etait initialement prospective randomisee, controlee, multicentrique, avec une analyse de donnees en intention de traiter. Apres les 40 premiers patients, nous avons ete contraints de passer a une etude non randomisee prospective en soins courants. L’etude a teste deux hypotheses : une hypothese sur la difference de frequence de la morbi-mortalite et la non-inferiorite sur la reduction de l’exces de poids > 50 %. Deux cent soixante-dix-sept patients ont ete inclus entre fevrier 2008 et mars 2012 (91 BP vs. 186 SG). L’âge moyen etait de 41,1 ans, avec 85,9 % de femmes et un IMC moyen de 45,25 kg/m2. La perte d’un exces poids > 50 % a 36 mois etait non inferieure : 79,12 % et 79,46 % pour le BP et la SG respectivement. A 36 mois, il y avait une difference significative pour le critere composite de morbi-mortalite 15,4 % (BP) vs. 5,9 % (SG) (p = 0,0098). L’amelioration des comorbidites etait similaire dans les deux groupes. Il s’agit de la premiere etude de cette taille prospective francaise demontrant que la SG est non inferieure dans la perte de poids et moins risquee que le BP. Cela conforte le choix des patients, des chirurgiens et des autorites administratives pour preferer la SG.

Resume But de l’etude : La chirurgie laparoscopique du foie en est encore a ses debuts. Le but de cette etude etait de rapporter une serie de tumeurs solides et kystiques du foie traitees par voie laparoscopique. Patients et methodes : Entre avril 1991 et decembre 1999, 32 patients porteurs de lesions hepatiques ont ete operes par voie cœlioscopique. Il s’agissait de 15 patients ayant des lesions kystiques non parasitaires (kystes biliaires volumineux [ n = 11], polykystoses [ n = 4]), et de 17 patients ayant 18 tumeurs solides : hyperplasie nodulaire focale ( n = 8), angiome ( n = 6), adenome ( n = 2), metastase d’un cancer colique gauche ( n = 1) et carcinome hepatocellulaire ( n = 1). Quinze fenestrations simples ou multiples et 18 exereses hepatiques ont ete realisees par laparoscopie : une hepatectomie droite, cinq lobectomies gauches, deux sous-segmentectomies IVb, une segmentectomie III et neuf tumorectomies. Resultats : Une conversion a ete necessaire (3 %) en fin d’intervention (lobectomie gauche pour carcinome hepatocellulaire) pour confirmer la marge de securite au niveau de la tranche de section. Le diametre moyen des tumeurs solides etait de 6,5 cm et celui des lesions kystiques solitaires de 15,7 cm. La duree operatoire moyenne des exereses hepatiques a ete de 232 minutes. La mortalite postoperatoire a ete nulle. La morbidite a comporte dans chaque groupe un cas d’occlusion de l’intestin grele par hernie interne au niveau d’un orifice de trocart survenue a j5 et a j7, ayant necessite dans les deux cas une resection intestinale segmentaire. La duree moyenne de sejour postoperatoire a ete de 5,6 jours dans les tumeurs solides et de 7,5 jours dans les lesions kystiques. Dans le groupe des lesions kystiques, le taux de recidive etait de 50 % apres un suivi moyen de 5,5 mois. Conclusion : La chirurgie laparoscopique du foie semble realisable en toute securite mais necessite au prealable une experience de la chirurgie hepatique classique et une parfaite maitrise de la chirurgie cœlioscopique. Seules les lesions de siege anterieur, qu’il s’agisse de tumeurs benignes symptomatiques ou atypiques, de kystes, ou de polykystoses de type I, peuvent etre traitees par l’abord laparoscopique. Pour les lesions malignes, les indications restent a preciser.

Resume But de l'etude : La rupture spontanee d'un carcinome hepatocellulaire (CHC) est un accident grave entrainant un hemoperitoine abondant mettant en jeu le pronostic vital. Le but de ce travail etait de rapporter une serie retrospective de 22 cas observes dans le meme centre. Patients et methodes : De 1978 a 1998, 22 patients (18 hommes et quatre femmes, âge moyen : 63 ans, extremes : 18–83 ans) ont ete traites pour un CHC rompu sur foie cirrhotique dans 17 cas, et sur foie sain dans cinq cas. Dans 14 cas, le diagnostic d'hemoperitoine aigu a conduit a une laparotomie en urgence. Le siege de la rupture predominait au niveau du lobe gauche (huit cas). L'operation realisee a consiste en une lobectomie gauche ( n = 7), une hepatectomie droite ( n = 2), une exerese tumorale ( n = 4), une ligature de l'artere hepatique ( n = 5), et une hemostase directe ( n = 4). Resultats : La mortalite postoperatoire globale a ete de 45,4 % ( n = 10). Sur les 12 survivants, neuf sont decedes dans un delai de 6 a 29 mois. Trois patients etaient vivants au moment de la realisation de ce travail avec un recul de 32, 40 et 66 mois. Conclusion : La rupture aigue d'un CHC impose le plus souvent une intervention en urgence avec une mortalite elevee. La resection tumorale est le procede le plus efficace mais n'est pas toujours realisable en urgence. La fissuration permet de realiser des examens complementaires et une eventuelle embolisation arterielle preoperatoire avec des resultats immediats meilleurs.

A patient underwent at his birth, an ureterosigmoidostomy for exstrophic bladder. Fifty-six years later, she presented a carcinoma on the right ureterosigmoidostomy associated with chronic urinary infection. She underwent a right ureteronephrectomy and sigmoidectomy. Chronic alterations of the colic mucin by urines lead to carcinoma.

Resume Les auteurs rapportent une observation d’agenesie du foie droit. Cette anomalie rare a ete suspectee en postoperatoire sur des anomalies du cholangiogramme peroperatoire au decours d’une cholecystectomie et diagnostiquee par une tomodensitometrie abdominale. Cette anomalie congenitale peut etre associee a une pathologie des voies biliaires, une hypertension portale et d’autres anomalies congenitales.

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.

Two cases of mesenteric serous cysts were reported. The first was a 65 years old woman who underwent laparotomy for abdominal pain associated with a mass initially thought to be ovarian. The second cyst was also an incidental discovery in a 59 years old female during abdominal computed tomography for thrombocytopenia. After surgical resection the first woman was well, 7 months and the second lady 4 years later, without recurrence. The two were unilocular serous cysts. By reporting these two observations, the authors aimed to show the rarity of the mesenteric serous cysts in a succint clarification on the disease.

Chilaïditi's syndrome is the association of a radiological and clinical semiology of the interposition of large colon or small intestine between the lower side of diaphragm and liver. We report the case of a 32-year-old woman, primigravida, who undergone a caesarean section at 39 weeks of amenorrhoea, for a clinical picture of persistent abdominal pain and a beginning hepatic cytolysis. The patient presented one day after the ceasarean section an occlusive syndrome of the small intestine. The etiology of the occlusion of the small intestine in post-partum was a Chilaïditi's syndrome with inter hepatodiaphragmatic incarceration of the small intestine discovered at the computed tomography. An exploratory laparotomy confirmed and permitted to treat Chilaïditi's syndrome complicated by an occlusion.

The authors report a case of right liver atrophy. This rare anomaly was suspected during post-operative period on abnormalities of cholangiogram. This biliary tract anomaly was diagnosed by CT scan. This congenital abnormality may be associated with biliary tract abnormalities, portal hypertension and other congenital abnormalities.

A patient underwent at his birth, an ureterosigmoidostomy for exstrophic bladder. Fifty-six years later, she presented a carcinoma on the right ureterosigmoidostomy associated with chronic urinary infection. She underwent a right ureteronephrectomy and sigmoidectomy. Chronic alterations of the colic mucin by urines lead to carcinoma.

Background/Purpose. Portal triad clamping and total or intermittent hepatic vascular exclusion are usually used to reduce blood loss during major liver resections. We report, in this retrospective study, the results of right hepatectomy without vascular clamping. Methods. From January 1986 to July 2001, 87 right hepatectomies, including 14 extended right hepatectomies, were performed without vascular clamping. There was 53 men and 34 women, with a mean age of 60.2 ± 12.5 years. Indications were 58 metastases, 16 hepatocellular carcinomas, 5 cholangiocarcinomas, 4 adenomas, 3 angiomas, and 1 carcinoid tumor. All the procedures were carried out using an ultrasonic dissector and intraoperative ultrasonography with only vascular control (looping of the hepatic pedicle and supra; and infrahepatic vena cava). Results. There were four postoperative deaths and 23 complications (26%), including hepatocellular failure (6), pulmonary complications (6), transient bile leakage (5), digestive bleeding (2), subphrenic abscess (1), inferior vena cava (IVC) thrombosis (1), disseminated intravascular coagulation (DIC; 1), and evisceration (1). Forty-two patients (48%) had no blood transfusion. The mean blood transfusion requirement was 1.5 ± 2.7 units. The mean operative length was 280 ± 60 min and the mean hospital stay was 12.8 ± 8.1 days. Liver function test results were similar to those in other studies on days 1, 4, and 7 postoperatively, with a return to normal values after 1 week. Conclusions. In our experience with major liver resections, vascular clamping is not necessary.

The authors take interest in the portal aneurysm about the observation of a 52 year-old woman with an echographic lesion in the head of the pancreas. Radiological examination was done with abdominal CT and MRI. Because of no accurate diagnosis, an explorative laparotomy was done and showed an aneurysm at the junction of the portal and superior mesenteric veins. These lesions are rare: they can be acquired particularly with underlying hepatocellular diseases and portal hypertension; they can be congenital due to an incomplete obliteration of the right vitelline vein. If asymptomatic, only a close surveillance must be proposed.

Fibrin sealant is widely used to achieve complete hemostasis in many fields of surgery. A retrospective review of the surgical management of 81 patients with thyroid diseases between 1992 and 1998 was undertaken to determine if drainage after thyroid surgery could be safely avoided and substituted by fibrin sealing before closure of the wound. Complications were few and resulted in one patient with hoarseness, four minor oedemas and one case of unexplained fever during 48 h. The subjective discomfort from the collar incision was unusual and aesthetic healing was obtained in most of the cases (93.8%). These results suggest that the application of fibrin sealant can be advocated in thyroid surgery as an adjunct to a good surgical procedure and perhaps that prophylactic drainage is unnecessary.

The authors report an experimental study in the rabbit with a new composite non absorbable mesh in Polyethylene Terephtalate-Polyurethane used for incisional hernia repair in intraperitoneal positioning. This new mesh has one permeable side in polyethylene terephtalate for rapid tissue fixation and another side in polyruethane, hydrophob in order to avoid cell penetration. Eighteen rabbits were operated. A wound was created in aponeurose, muscle and peritoneal abdominal wall. The mesh was placed in intraperitoneal positioning and was taken off at 4, 9 and 13 months for histologic examination and electronic microscopical examination. Tolerance, adhesion, tissular reaction and neoperitoneum formation have been studied. All the meshes were well integrated and without sepsis. In 18% of cases small and monocclusive intraperitoneal adhesions were found. This new composite mesh in intraperitoneal positioning gave good results at medium-term in the rabbit. It's an attractive alternative for incision hernias repair with intraperitoneal mesh.

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.

In this study, the authors described a new videoscopically guided approach for tunneling in esophagoplasty and insertion of an esophageal prosthesis.

Laparoscopic liver surgery is still in its early stages. The aim of this study was to report our experience in the laparoscopic management of solid and cystic liver tumours.From April 1991 to December 1999, 32 patients with various lesions of the liver underwent laparoscopic liver surgery. One group of patients presented with cysts (n = 15) (11 giant solitary cysts and 4 polycystic liver diseases) and one group of patients presented with solid tumours (n = 18): focal nodular hyperplasia (n = 8), haemangioma (n = 6), adenoma (n = 2), isolated metastasis from a colonic cancer (n = 1) and hepatocellular carcinoma (n = 1). Fifteen cyst fenestrations and eighteen liver resections were performed via a laparoscopic approach including 1 right lobectomy, 5 left lateral segmentectomies, 2 subsegmentectomies IVb, 1 segmentectomy III and 9 non-anatomical resections.Conversion to laparotomy was performed in one case (3%) at the end of the operation (patient who had successfully undergone left lateral segmentectomy for hepatocellular carcinoma) to check the resection margins and surgical transection had been performed in healthy parenchyma. Mean diameter of solid tumours was 6.5 cm and 15.7 cm for solitary cysts. The mean operating time for hepatic resections was 232 minutes. There was no postoperative mortality. Complications occurred in one case for each group and consisted in intestinal stricture through a port site requiring intestinal resection. Mean postoperative hospital stay was 5.6 days for solid tumours and 7.5 days for cystic lesions. In the group of cystic lesions, the recurrence rate was 50% with a 5.5-months follow-up.Laparoscopic liver surgery can be safely performed, but requires a good experience in open hepatic surgery and laparoscopic surgery. The laparoscopic approach is indicated in patients with symptomatic or atypical benign solid tumour, giant solitary cyst and polycystic liver disease, located anteriorly on the liver. Indications for malignant lesions have not been clearly defined and require further information.

Spontaneous rupture of hepatocellular carcinoma (HCC) causing massive hemoperitoneum is a critical and life threatening complication. The study aim was to report a retrospective series of 22 cases observed in the same centre.From 1978 to 1998, 22 patients (18 males and four females, mean age: 63 years, range: 18-83) were treated for ruptured H.C.C involving a cirrhotic liver in 17 cases and a normal liver in five cases. In 14 cases, the diagnosis of acute hemoperitoneum indicated an immediate laparotomy. The site of rupture was predominant in the left lobe (eight cases). The surgical treatment was: left lobectomy (n = 7), right hepatectomy (n = 2), excision (n = 4), hepatic artery ligation (n = 5), direct hemostasis (n = 4).Postoperative mortality was 45.4%. Among the 12 survivors, nine died within a delay of 6 to 29 months. Three patients were still alive at the time of this study at 32, 40 and 66 months.Acute rupture of HCC requires emergency procedures with a high risk of mortality. Curative operation with hepatic resection is the most effective procedure but is not often feasible because of the spreading of the tumor or/and the cirrhosis. The ligation of hepatic artery seems to be an alternative procedure to obtain an immediate hemostasis. Fissuration allows performance of complementary explorations and possibly preoperative arterial embolization with better immediate results.

The authors report three cases of primary adenocarcinoma, two concerning the duodenum and the third concerning the duodenojejunal junction. These rare tumours are characterized by polymorphic and non specific clinical signs. Diagnosis is suspected by upper gastrointestinal fibroscopy and barium swallow, and confirmed by biopsies. Prognosis varies according to histological differentiation and lymph node extension. Whipples operation is the sole curative procedure in the absence of local lymph node involvement. Cases of extensive invasion are managed by bilio-digestive by-pass.

A retrospective study of 134 total gastrectomies performed between 1982 and 1992 was conducted with regular follow-up. There were 96 males and 38 women (mean age 66.66 years, range 27-82). The indication for total gastrectomy was malignant tumour (n = 115), mostly adenocarcinoma (79.1%, 91/115) with 7 cases of stump degeneration after partial gastrectomy (5.2%) and benign lesions (n = 19), mostly gastric ulcers. Gastrectomy was associated with node dissection in 53 cancer cases (47.8% 53/115) and dissection of neighbouring organs in 16 patients. Y anastomosis with circular mechanical suture was performed in 78 cases (62.9%) with pre-stapling in 30 (38.5%). Operative mortality was 8.2% (11/134). The oesophagealjejunal disunion occurred in 7/133 patients (5.3%) including two fatal cases. Early reoperation was necessary in 10.5%. Long-term follow-up for 2 to 12 years in 119 patients gave the following data. For malignant tumours: 5-year survival rate 10.1% (n = 8), recurrence an anastomosis 6.3% (n = 5), distant recurrence 28.2% (n = 21). For all patients sequellae were: reflux oesophagitis 8.1% (n = 10), stenosis of the anastomosis 7.3% (n = 9) requiring late reoperation in 2. The quality of life was considered satisfactory by 28.57% (n = 8) and good in 39.29% (n = 11). These results were compared with those reported in the literature and led to the conclusion that the general view as to the gravity of gastrectomy should be reconsidered in light of the progress in viscerostapling.

In this study, the authors described a new videoscopically guided approach for tunneling in esophagoplasty and insertion of an esophageal prosthesis.