Search

Several scoring systems predict risks of clinically relevant postoperative pancreatic fistula after pancreatectomy, but none have emerged as the gold standard. This study aimed to evaluate the accuracy of postoperative day 1 drain amylase and serum C-reactive protein levels in predicting clinically relevant postoperative pancreatic fistula compared with intraoperative pancreatic characteristics.Patients who underwent pancreatectomy between 2017 and 2019 were included prospectively. Cutoff values were determined using receiver operating characteristic curves, and a score combining postoperative day 1 drain amylase and serum C-reactive protein was tested in a multivariate logistic regression model to evaluate clinically relevant postoperative pancreatic fistula risk.A total of 274 pancreatic resections (182 pancreaticoduodenectomies and 92 distal pancreatectomies) were included. The pancreatic gland texture was "soft" in 47.8% (n = 131), and 55.8% (n = 153) had a small size main pancreatic duct (≤3 mm). Clinically relevant postoperative pancreatic fistula occurred in 58 patients (21.2%). Drain amylase ≥1,000 UI/L and serum C-reactive protein ≥90 mg/L were identified as the optimal cutoffs to predict clinically relevant postoperative pancreatic fistula. On multivariate analysis these cutoffs were independent predictors of clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies (drain amylase: P.001, serum C-reactive protein: P = .006) and distal pancreatectomies (drain amylase: P = .009, serum C-reactive protein: P = .001). The postoperative day 1 "90-1000" model, a 2-value score relying on these cutoffs, significantly (P.001) outperformed intraoperative pancreatic parenchymal characteristics in predicting clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies and distal pancreatectomies. A postoperative day 1 "90-1000" score = 0 had a negative predictive value of 97% and 94%, respectively, after pancreaticoduodenectomy and distal pancreatectomies.A combined score relying on postoperative day 1 values of drain amylase and serum C-reactive protein levels was accurate in predicting risks of clinically relevant postoperative pancreatic fistula after pancreatectomy.

The place of surgery and interventional radiology in the management of delayed (> 24 h) hemorrhage (DHR) complicating supramesocolic surgery is still to define. The aim of the study was to evaluate outcomes of DHR using a combined multimodal strategy. Between 2005 and 2019, 57 patients (median age 64 years) experienced 86 DHR episodes after pancreatic resection (n = 26), liver transplantation (n = 24) and other (n = 7). Hemodynamically stable patients underwent computed tomography evaluation followed by interventional radiology (IR) treatment (stenting and/or embolization) or surveillance. Hemodynamically unstable patients were offered upfront surgery. Failure to identify the leak was managed by either prophylactic stenting/embolization of the most likely bleeding source or surveillance. Mortality was 32% (n = 18). Bleeding recurrence occurred in 22 patients (39%) and was multiple in 7 (12%). Sentinel bleeding was recorded in 77 (81%) of episodes, and the bleeding source could not be identified in 26 (30%). Failure to control bleeding was recorded in 9 (28%) of 32 episodes managed by surgery and 4 (11%) of 41 episodes managed by IR (p = 0.14). Recurrence was similar after stenting and embolization (n = 4/18, 22% vs n = 8/26, 31%, p = 0.75) of the bleeding source. Recurrence was significantly lower after prophylactic IR management than surveillance of an unidentified bleeding source (n = 2/10, 20% vs. n = 11/16, 69%, p = 0.042). IR management should be favored for the treatment of DHR in hemodynamically stable patients. Prophylactic IR management of an unidentified leak decreases recurrence risks.

Delayed post-pancreatectomy hemorrhage (PPH) is still one of the most dreaded complications after pancreatic surgery. Its management is now focused on percutaneous endovascular treatments (PETs). Between 2013 and 2019, 307 patients underwent pancreatic resection. The first endpoint of this study was to determine predictive factors of delayed PPH. The second endpoint was to describe the management of intra-abdominal abscesses (IAA). The third endpoint was to identify risk factors of bleeding recurrence after PET. Patients were divided into two cohorts: A retrospective analysis was performed (“cohort 1,” “learning set”) to highlight predictive factors of delayed PPH. Then, we validated it on a prospective maintained cohort, analyzed retrospectively (“cohort 2,” “validation set”). Second and third endpoints studies were made on the entire cohort. In cohort 1, including 180 patients, 24 experienced delayed PPH. Multivariate analysis revealed that POPF diagnosis on postoperative day (POD) 3 (p=0.004) and IAA (p=0.001) were independent predictive factors of delayed PPH. In cohort 2, association of POPF diagnosis on POD 3 and IAA was strongly associated with delayed PPH (area under the curve [AUC] 0.80; 95% confidence interval [CI] [0.59–0.94]; p=0.003). Concerning our second endpoint, delayed PPH occurred less frequently in patients who underwent postoperative drainage procedure than in patients without IAA drainage (p=0.002). Concerning our third endpoint, a higher body mass index (BMI) (p=0.027), occurrence of postoperative IAA (p=0.030), and undrained IAA (p=0.011) were associated with bleeding recurrence after the first PET procedure. POPF diagnosis on POD 3 and intra-abdominal abscesses are independent predictive factors of delayed PPH. Therefore, patients presenting an insufficiently drained POPF leading to intra-abdominal abscess after pancreatic surgery should be considered as a high-risk situation of delayed PPH. High BMI, occurrence of postoperative IAA, and undrained IAA were associated with recurrence of bleeding after PET.

The aim of the study was to compare histological features, postoperative outcomes, and long-term prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma. From 2005 to 2017, 188 pancreaticoduodenectomies (pancreatic ductal adenocarcinoma n = 151, distal cholangiocarcinoma n = 37) were included. Postoperative outcomes were compared after matching on pancreatic gland texture and main pancreatic duct size. Matching according to tumor size, lymph node invasion and resection margin was used to compare overall and disease-free survival. Distal cholangiocarcinoma patients had more often “soft” pancreatic gland (P = 0.002) and small size main pancreatic duct (P = 0.001). Pancreatic ductal adenocarcinoma patients had larger tumors (P = 0.009), and higher lymph node ratio (P = 0.017). Severe morbidity (P = 0.023) and clinically relevant pancreatic fistula (P = 0.018) were higher in distal cholangiocarcinoma patients. After matching on gland texture and main pancreatic duct diameter, clinically relevant postoperative pancreatic fistula was still more frequent in distal cholangiocarcinoma patients (P = 0.007). Tumor size > 20 mm was predictive of impaired overall survival (P = 0.024) and disease-free survival (P = 0.003), tumor differentiation (P = 0.027) was predictive of impaired overall survival. Survival outcomes for distal cholangiocarcinoma and pancreatic ductal cholangiocarcinoma were similar after matching patients according to tumor size, lymph node invasion and resection margin. Long-term outcomes after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma patients are similar. Postoperative course is more complicated after pancreaticoduodenectomy for distal cholangiocarcinoma than pancreatic ductal adenocarcinoma. After pancreaticoduodenectomy, patients with distal cholangiocarcinoma and pancreatic ductal adenocarcinoma have similar long-term oncological outcomes.

Additional file 1: Supplemental Table 1. Participant Demographics in the Full Dataset after Local Case Control Subsampling Adjustment for the Effect of Age. Description of Data: Demographic information for the full dataset before and after adjustment for age using the LCC subsampling method.

Additional file 4: Supplemental Table 4. Phenotypic data included for analysis in this study. Description of data: Description and categorization of data included in ViSEN analyses.

Additional file 2: Supplemental Table 2. Age Adjusted and Unadjusted Female Subset Demographics. Description of data: Demographic information for female-only analyses in the age adjusted and unadjusted datasets.

Additional file 3: Supplemental Table 3. Age Adjusted and Unadjusted Male Subset Demographics. Description of data: Demographic information for male-only analyses in the age adjusted and unadjusted datasets.

Goni Moreno’s procedure was described 60 years ago as a solution for giant hernias repair through the creation of a progressive preoperative pneumoperitoneum (PPP). The main objective of the present study is to assess its effectiveness in terms of primary fascial closures. The secondary objectives of this study are to explore the morbidity and mortality associated with Moreno’s procedure using 40 years of data from a large cohort of patients. This is a retrospective study of all patients who underwent PPP procedures between October 1974 and January 2019 at the digestive surgery unit at Grenoble University Hospital, France. Data were reviewed to assess the preoperative demographic characteristics of the patients, procedure, postoperative course, complication following Clavien–Dindo classification and 30-day outcomes. 162 procedures were attempted. The mean age of patients was 57.8 years. 83 patients had a history of chronic respiratory disease (51.2%). The mean BMI was 33.2 kg/m2, and 52 patients were obese (32.1%) Half of the patients were classified as ASA score III. Success rate of fascial closures was 95.7%. The global rate of complication during the insufflation period and after surgical repair of the hernia was 51.8% (n = 84). Among these, only 16.7% (n = 27) were major according to the Clavien–Dindo classification. The global mortality rate was 3.1%. Goni Moreno PPP is an effective procedure that allows a high rate of fascial closure. The population of patients requiring such procedures presents a high-risk profile for complications regarding demographics and associated diseases.

Resume La prise en charge des traumatismes fermes du foie est caracterisee depuis une vingtaine d’annee par un traitement non operatoire initial (NONOP) dans tous les cas ou il est possible (80 % des cas), c’est-a-dire dans tous les cas ou l’etat hemodynamique n’impose pas la laparotomie d’urgence. La prise en charge non operatoire est marquee par l’existence d’un trio therapeutique tres efficace : la radiologie avec la TDM injectee et l’embolisation arterielle hepatique, la surveillance armee attentive, et enfin l’operation differee (OD). Cette OD ne constitue pas un echec de la prise en charge NONOP mais au contraire fait partie integrante de la strategie chirurgicale. L’option operatoire immediate imposee par l’instabilite hemodynamique a vu son efficacite transformee par le developpement du concept de laparotomie ecourtee et par l’application large du procede du tamponnement perihepatique. L’efficacite de ces deux prises en charge initialement conservatrices et prudentes est attestee par l’ensemble des experiences actuelles, mais la gestion des evenements secondaires qui menacent les grades les plus severes doit etre rapide et efficace.

For the last 20 years, nonoperative management (NOM) of blunt hepatic trauma (BHT) has been the initial policy whenever this is possible (80% of cases), i.e., in all cases where the hemodynamic status does not demand emergency laparotomy. NOM relies upon the coexistence of three highly effective treatment modalities: radiology with contrast-enhanced computerized tomography (CT) and hepatic arterial embolization, intensive care surveillance, and finally delayed surgery (DS). DS is not a failure of NOM management but rather an integral part of the surgical strategy. When imposed by hemodynamic instability, the immediate surgical option has seen its effectiveness transformed by development of the concept of abbreviated (damage control) laparotomy and wide application of the method of perihepatic packing (PHP). The effectiveness of these two conservative and cautious strategies for initial management is evidenced by current experience, but the management of secondary events that may arise with the most severe grades of injury must be both rapid and effective.

Il s'agit d'une etude retrospective, monocentrique de 186 cas de plaies abdominales ou abdomino-thoraciques prises en charge entre 2004 et 2013 dans le service de Chirurgie Digestive et de l'Urgence du CHU de Grenoble. Ont ete exclus les traumatismes fermes, les plaies non traumatiques, les plaies cervicales, de la sphere cephalique, des membres, les plaies ano-perineales et les plaies thoraciques isolees au dessus du 5e espace inter-costal. Ont ete inclus les cas presentes en revue de morbi-mortalite du dechoquage. La mortalite etait de 11 cas (5,9%). L'âge moyen etait de 36 ans (13-87). Les armes utilisees etaient majoritairement des armes blanches (145 cas - 78%). Les patients etaient stables ou stabilises a leur arrivee dans 163 cas (87,6%). Il y a eu 6 thoracotomies ressuscitatives. Pour les plaies abdominales necessitant une exploration au bloc operatoire, la laparotomie etait le geste choisi le plus souvent (78/186 - 41,9%), mais la coelioscopie a ete retenue dans 46 cas (24,7%), convertie en laparotomie dans 9 cas (20%). Il y a eu une penetration abdominale dans 103 cas (55,4%), thoracique dans 44 cas (23,7%), et a la fois thoracique et abdominale dans 29 cas (15,6%), dont 16 plaies diaphragmatiques. Les tentatives de suicide representaient 43 cas (23,1%) avec une effraction peritoneale dans 31 cas (72,1%). Deux patients (1,1%) ont ete operes devant un tableau de peritonite tardive, apres laparotomie exploratrice qualifiee de negative et apres exploration de la plaie sous anesthesie generale. La prise en charge des plaies penetrantes ou suspectes de l'etre represente un defi medico-chirurgical imposant des protocoles de prise en charge efficients.

Introduction La prise en charge optimale des hemorragies tardives (HMT) apres chirurgie sus-mesocolique (> 3 jours) n’est pas definie. Methodes Entre 2005–2019, 56 patients (44 hommes, âge moyen 62 ans) ont presente une HMT apres transplantation hepatique (n = 24) et resection pancreatique (n = 32). Un scanner (TDM) en urgence suivi d’un traitement radiologique (TR) ou surveillance (S) etait proposee. Une chirurgie (TC) premiere etait reservee aux malades instables. Resultats La mortalite etait de 30 % (n = 17). Le taux de re-saignement etait de 38 % (n = 21) dont 10 % (n = 6) multiples ; 84 episodes de saignement etaient recenses. Les episodes de saignement ont ete traites par TC (n = 33), TR (n = 36) et S (n = 15). La recidive etait significativement plus elevee apres S (67 %) qu’apres TR (25 %, p = 0,0145) et apres TC (30 %, p = 0,04). Les deces sont survenus apres un episode traite par TC, TR et S dans 10, 6 et 1 cas respectivement. L’intervention initiale n’etait pas un facteur predictif de mortalite apres saignement (p = 0,29). Conclusion Une arteriographie systematique doit etre discutee apres HMT avec TDM normal en raison du risque eleve de re-saignement lors d’une simple surveillance. Le TR premier devrait etre privilegie afin de diminuer la mortalite des HMT.

Internal biliary stenting (IBS) was reported to decrease biliary complications after liver transplantation (LT) but data in literature is scarce. The aim of the present study was to evaluate our experience with end-to-end choledoco-choledocostomy during liver transplantation with special focus on the influence of IBS on patient and biliary outcomes. Between 2009 and 2013, 175 patients underwent deceased donor LT with end-to-end choledoco-choledocostomy and were included in the study. Supra-papillary silastic stent was inserted in 67 patients (38%) with small-size (

Diabetes & Metabolism - In Press.Proof corrected by the author Available online since mardi 21 octobre 2014

Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications. Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis. Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter

Le pancreatiti acute gravi si caratterizzano per l’esistenza di tre fasi: una fase precoce, dove la risposta sistemica infiammatoria preponderante si accompagna a insufficienze d’organo e dove le colate di necrosi si costituiscono ma sono, di solito, sterili, una fase intermedia oltre una quindicina di giorni dopo l’inizio della malattia, che comporta un rischio di infezione delle colate di necrosi, e una fase tardiva, parecchie settimane dopo l’inizio della malattia, dove possono svilupparsi delle pseudocisti. Nella fase precoce della pancreatite, sul pancreas l’astensione chirurgica e la regola, tuttavia molteplici complicanze viscerali possono richiedere una chirurgia in urgenza: necrosi intestinale, emorragia e sindrome del compartimento addominale. La seconda fase e quella del trattamento delle colate di necrosi infetta. Le necrosectomie devono essere limitate alla rimozione dei frammenti necrotici che si distaccano spontaneamente. Esse sono realizzate mediante accessi e mezzi adeguati al grado di setticita e di gravita del paziente e alla localizzazione delle lesioni. Questa seconda fase puo richiedere una gestione multidisciplinare radiologica, chirurgica e, a volte, endoscopica, se possibile con tecniche mini-invasive o, in caso contrario, convenzionali, mediante laparotomia o accesso retroperitoneale. La terza fase, quella del trattamento delle pseudocisti sintomatiche, e in prima intenzione endoscopica.

Las pancreatitis agudas graves se caracterizan por la existencia de tres fases: una fase precoz, en la que la respuesta sistemica inflamatoria predominante se acompana de insuficiencias organicas y donde se forman zonas de necrosis, aunque suelen permanecer esteriles; una fase intermedia, pasados 15 dias del inicio de la enfermedad, que conlleva un riesgo de infeccion de las zonas de necrosis; y una fase tardia, varias semanas despues del inicio de la enfermedad, donde se pueden desarrollar seudoquistes. En la fase precoz de la pancreatitis no se suele operar el pancreas, aunque muchas complicaciones viscerales pueden requerir una cirugia urgente: necrosis intestinal, hemorragia, sindrome compartimental abdominal. La segunda fase es la del tratamiento de las zonas de necrosis infectada. Las necrosectomias deben limitarse a la reseccion de los fragmentos necroticos que se desprenden de forma espontanea. Se realizan por accesos y metodos adaptados al grado de infeccion y de gravedad del paciente, asi como a la localizacion de las lesiones. Esta segunda fase puede requerir un tratamiento multidisciplinario radiologico, quirurgico y, en ocasiones, endoscopico mediante tecnicas minimamente invasivas si es posible o en ocasiones convencionales, por laparotomia o por un acceso retroperitoneal. La tercera fase es la del tratamiento de los seudoquistes sintomaticos y se realiza por via endoscopica como primera eleccion.

Background and study aims: Endobiliary brushing during endoscopic retrograde cholangiopancreatography (ERCP) is the main technique used to diagnose a malignant stricture, but has a poor sensitivity. This study evaluated the diagnostic performance of bile aspiration associated with biliary brushing during ERCP to diagnose a malignant stricture, compared to brushing alone. Patients and methods: Between January 2007 and December 2012, all consecutive patients undergoing ERCP to treat a biliary stricture were included. After a biliary sphincterotomy, 3 mL to 10 mL of bile was aspirated into the brush catheter and collected in a dry sterile tube before and after brushing (to yield three samples). Brushing was performed as commonly recommended. Results: One hundred eleven patients (68 males, 43 females) were included; mean age 67 ± 15.4 years. A final diagnosis of malignant stricture was established in 51 patients, including 43 cholangiocarcinomas; 60 patients had benign strictures. Specificity (Sp) and positive predictive values were 100% for all samples. The diagnostic performance of the three-sample combination of bile aspiration + brushing + bile aspiration was significantly greater than brushing alone (P = 0.004): sensitivity (Se) = 84.3 % vs. Se = 66.7 %. The three-sample combination gave a negative predictive value of 88.2 %, and a diagnostic accuracy of 92.8 %. When suspicious results were added to malignant results as positive results, the three-sample combination gave Sp = 91.7 % and Se = 94.1 %. Conclusions: In cases of biliary stricture, conducting bile aspiration before and after brushing significantly increased the ability to diagnose a malignant stricture with a sensitivity of 84.3 % (P = 0.004).

This is a single center retrospective review of abdominal or abdomino-thoracic penetrating wounds treated between 2004 and 2013 in the gastrointestinal and emergency unit of the university hospital of Grenoble, France. This study did not include patients who sustained blunt trauma or non-traumatic wounds, as well as patients with penetrating head and neck injury, limb injury, ano-perineal injury, or isolated thoracic injury above the fifth costal interspace. In addition, we also included cases that were reviewed in emergency department morbidity and mortality conferences during the same period. Mortality was 5.9% (11/186 patients). Mean age was 36 years (range: 13-87). Seventy-eight percent (145 patients) suffered stab wounds. Most patients were hemodynamically stable or stabilized upon arrival at the hospital (163 patients: 87.6%). Six resuscitative thoracotomies were performed, five for gunshot wounds, one for a stab wound. When abdominal exploration was necessary, laparotomy was chosen most often (78/186: 41.9%), while laparoscopy was performed in 46 cases (24.7%), with conversion to laparotomy in nine cases. Abdominal penetration was found in 103 cases (55.4%) and thoracic penetration in 44 patients (23.7%). Twenty-nine patients (15.6%) had both thoracic and abdominal penetration (with 16 diaphragmatic wounds). Suicide attempts were recorded in 43 patients (23.1%), 31 (72.1%) with peritoneal penetration. Two patients (1.1%) required operation for delayed peritonitis, one who had had a laparotomy qualified as "negative", and another who had undergone surgical exploration of his wound under general anesthesia. In conclusion, management of clear-cut or suspected penetrating injury represents a medico-surgical challenge and requires effective management protocols.

Resume La coloproctectomie totale avec anastomose ileoanale est un geste complexe comportant un taux de complications non negligeable qui compromet le reservoir dans plus de 5 % des cas. Ces complications sont essentiellement les suppurations, la stenose anastomotique, l'ischemie du reservoir et les troubles fonctionnels comme la polyexoneration et la pochite (« pouchitis » des Anglo-Saxons). Si les complications aigues menacant le pronostic vital imposent la suppression de l'anastomose et la realisation d'une ileostomie, il n'en va pas de meme pour les complications plus tardives qui autorisent, apres un bilan, une ou plusieurs reinterventions dans le but de preserver le reservoir. La plupart de ces techniques de sauvetage du reservoir ileal peuvent etre realisees par voie basse. Il s'agit de la dilatation eventuellement repetee d'une stenose anastomotique, du drainage de suppuration perineale, de l'abaissement du reservoir et de la section d'un septum residuel dans le reservoir. En cas d'echec de ces techniques, ou lorsque les lesions sur le reservoir sont diffuses et severes, il faut se resoudre a intervenir par voie mixte, abdominale et perineale. Apres viscerolyse totale, le reservoir sera repare, le plus souvent apres desinsertion, puis reanastomose a la ligne pectinee, sous couvert quasi systematique d'une ileostomie laterale.

La coloproctectomia total con anastomosis ileoanal es una intervencion compleja que se asocia a una proporcion no desdenable de complicaciones, con afectacion del reservorio en mas del 5% de los casos. Estas complicaciones son esencialmente supuraciones, estenosis de la anastomosis, isquemia del reservorio y trastornos funcionales, como defecacion frecuente y reservoritis (la «pouchitis» de los anglosajones). Cuando las complicaciones agudas ponen en peligro el pronostico vital, hay que suprimir la anastomosis y practicar una ileostomia. Sin embargo, en las complicaciones mas tardias puede optarse, tras el estudio adecuado, por una o varias reintervenciones con el fin de conservar el reservorio. La mayoria de estas tecnicas de rescate ileal pueden efectuarse por via baja. Se trata de la dilatacion, que puede repetirse, de una estenosis anastomotica, del drenaje de una supuracion perineal, del descenso del reservorio y de la seccion de un tabique residual en el reservorio. Si estas tecnicas fracasan o las lesiones del reservorio son difusas y graves, habra que decidirse a intervenir por via mixta, abdominal y perineal. Tras la viscerolisis total, se repara el reservorio, la mayoria de las veces tras su desinsercion, y se realiza una nueva anastomosis en la linea pectinea, con la proteccion, casi sistematica, de una ileostomia lateral.

Summary Aims of the study Percutaneous drainage of infected pancreatic necrosis is not always efficient and morbidity is high with open necrosectomy techniques. Minimally-invasive procedures have been developed to reduce this morbidity. We report our early experience with percutaneous video-assisted necrosectomy. Methods Among 61 patients with acute pancreatitis treated between January 2001 and February 2003, seven developed infected pancreatic necrosis. Six of these seven patients underwent percutaneous video-assisted necrosectomy after failure of radio-guided percutaneous drainage. Results One to four sessions of percutaneous video-assisted necrosectomy were required. There was no death. Sepsis control was achieved in all patients. One patient developed postoperative peritonitis due to intraoperative contamination of the peritoneal cavity. Eighteen months after the last necrosectomy, one patient developed a pseudocyst which was successfully cured by percutaneous drainage. One patient developed diabetes mellitus. Conclusion Early experience in six patients has shown that percutaneous video-assisted necrosectomy is feasible, safe and efficient, in accordance with reports in the literature. Further evaluation is necessary.

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the surgical treatment of ulcerative colitis. Fistulas originating from the ileal pouch are uncommon but serious complications, sometimes leading to failure of the operation. We describe a technique to treat and salvage a pouch involved in a chronic fistulating ileal J-pouch-anal anastomosis by disconnecting the pouch, turning it inside out after repair, and reanastomosing it to the dentate line.

Resume But de l’etude : La destruction des tumeurs hepatiques malignes par application d’un courant de frequence offre de nouvelles possibilites therapeutiques. Nous rapportons ici notre premiere experience realisee entre 1998 et 2000. Patients et methode : Vingt-cinq patients ont ete traites, 11 pour un carcinome hepatocellulaire (CHC), 14 pour des metastases. Trente tumeurs sur 63 au total ont ete detruites par radiofrequence (RF) dont 13 CHC (diametre moyen 32 mm) et 17 metastases (diametre moyen 26 mm), six fois par voie percutanee, 19 fois par laparotomie. Onze patients ont eu une hepatectomie associee : cinq hepatectomies droites dont une elargie au segment IV, six sous-segmentectomies. Resultats : Deux patients cirrhotiques ont eu une thrombose porte postoperatoire, dont une letale et cinq patients ont eu une complication postoperatoire autre. Le recul moyen etait de 14 mois (extremes : 2–28 mois). Deux patients sont decedes deux et quatre mois apres la RF (carcinose, decompensation ascitique). Quatre CHC et deux metastases ont recidive sur le site de la radiofrequence. Trois patients atteints de CHC et quatre autres atteints de metastases ont developpe de nouvelles lesions hepatiques ou extra-hepatiques. Conclusion : La radiofrequence est particulierement interessante pour le traitement des metastases bilobaires. Elle semble aussi efficace que les autres traitements locaux pour les CHC de petite taille. Des ameliorations techniques restent necessaires pour accroitre le rayon de destruction. Un recul plus important est indispensable pour apprecier la place reelle de cette technique.

Nonoperative management (NOM) is considered standard treatment for 80% of blunt hepatic trauma (BHT). NOM is associated with some events that may require delayed operation (DO), usually considered a criterion of failure of NOM. A retrospective case note review was performed on 257 consecutive patients with BHT, with a median age of 32.7 years, admitted from 1994 to 2005. We considered the 186 patients (72%) who had an initial indication of NOM, and focused on the 28 patients who were secondarily operated (DO), mainly on the 22 patients operated on for liver-related indications. Celioscopy was used in five cases. The severity grade of these 22 patients was: zero grade I, seven grade II, ten grade III, four grade IV, one grade V. The timing of DO varied from day 0 to day 11. Ten patients were operated on for a peritoneal inflammatory syndrome. Death occurred in three patients at days 2, 10, and 125. One was attributed to underestimation of hepatic necrosis, another to a nondiagnosed peritoneal inflammatory syndrome; 27, 3% of the patients had liver-related complications. Our data suggest that BHT treated by NOM must be frequently reevaluated and that DO is an actual part of the so-called nonoperative treatment. The use of laparoscopic washing has to be proposed as soon as day 3 or 5 in patients with large hemoperitoneum and any sign of inflammatory response (fever, leukocytosis, discomfort, tachycardia).

We describe the rates and potential risk factors of complications of radiofrequency ablation of hepatic tumors. SUBJECTS AND METHODS. Over a 5-year period, 312 patients underwent 350 sessions of radiofrequency ablation (124 intraoperative and 226 percutaneous) for treatment of 582 liver tumors including 115 hepatocellular carcinomas and 467 metastatic tumors. The chi-square test was used for a group-to-group comparison of the occurrence of adverse events.Thirty-seven (10.6%) adverse events and five (1.4%) deaths were related to radiofrequency treatment. The deaths were caused by liver insufficiency (n = 1), colon perforation (n = 1), and portal vein thrombosis (n = 3). Portal vein thrombosis was significantly (p0.00001) more frequent in cirrhotic livers (2/5) than in noncirrhotic livers (0/54) after intraoperative radiofrequency ablation performed during a Pringle maneuver. Liver abscess (n = 7) was the most common complication. Abscess occurred significantly (p0.00001) more frequently in patients bearing a bilioenteric anastomosis (3/3) than in other patients (4/223). We encountered five pleural effusions, five skin burns, four hypoxemias, three pneumothoraces, two small subcapsular hematomas, one acute renal insufficiency, one hemoperitoneum, and one needle-tract seeding. The 6.3% of minor complications did not require specific treatment or a prolonged hospital stay. Among the 5.7% major complications, 3.7% required less than 5 days of hospitalization for treatment or surveillance and 2% required more than 5 days for treatment.Radiofrequency ablation of liver tumors is a well-tolerated technique, but caution should be exercised when treating patients with a bilioenteric anastomosis, and radiofrequency ablation during vascular occlusion in cirrhotic livers should be avoided.

Damage control laparotomy is a new approach to the more severe abdominal traumas. It stems from a better understanding of the physiopathology of the haemorragic shock.A national retrospective study from 27 centers about 109 trauma patients who underwent a damage control procedure between January 1990 and December 2001, is analysed. Surgical procedures included 97 hepatic packing, 10 abdominal packing, 4 exclusive skin closure, 1 open laparotomy technique and 3 digestive stapplings.The mortality rate is 42%. Eleven abdominal compartment syndromes have occurred with 7 decompressive laparomy (4 deaths).This study is based on the largest series of damage control laparotomy published in France. Results in terms of mortality and morbidity are similar to those of published studies from the USA.

Radiofrequency (RF) ablation of malignant hepatic tumors is an interesting and recent technique which offers new treatment possibilities. In this study, the preliminary findings have been reported on 25 patients with hepatic tumors who received RF treatment between January 1998 and February 2000.Twenty-five patients (11 cases of hepatocellular carcinoma, HCC; and 14 cases of liver metastases, LM) underwent RF treatment. Thirty tumors (range: 10 to 54 mm in diameter) out of a total of 63 were destroyed by RF: 13 HCC (average diameter: 32 mm) and 17 LM (average diameter: 26 mm). Treatment consisted of six percutaneous and 19 surgical RF procedures. In the surgical group, there were 11 cases of hepatectomy: right hepatectomy in five patients with segment IV enlargement in one case, and sub-segmentectomy in six other patients. In all cases, hepatic tomodensitometry was performed at one month post-treatment and then every three months.Postoperative portal thrombosis occurred in two patients, one of whom died. Other postoperative complications were observed in five patients. During the mean follow-up period of 14 months (range: 2 to 28 months), two patients died (carcinosis, ascitic decompensation), two and four months respectively after RF treatment. In situ recurrence occurred in four HCC and two LM patients. Three HCC and four LM patients developed new hepatic or extra-hepatic lesions.RF is a particularly interesting technique for the treatment of bilobar or unresectable metastases. It appears to be equally as efficient as other local treatments for small-sized HCC. However, technical improvements remain necessary to increase the destructive field covered by RF. A more important follow-up is needed so that the long-term efficacy and specific role of this new therapy can be accurately assessed.

To report our preliminary experience with self-expandable metal stent in the treatment of acute malignant obstruction of the left colon and to review the literature on this specific subject.From March to September 1999, 8 consecutive patients with a mean age 71 were admitted as an emergency for acute malignant obstruction of the left colon. A self-expandable metal stent was inserted under radioscopic and, in 4 cases, endoscopic guidance. The patients then underwent bowel preparation before operation, if required.There was no mortality. Bowel preparation was satisfactory in 6 cases. Complications occurred in 1 patient, who was operated on day one for peritonitis due to perforation of the tumour by the prosthesis inserted after dilatation. Another six patients were operated: 2 had resection followed by anastomosis; 3 had resection and anastomosis protected by ileostomy; 2 had Hartmann's procedure. The last patient retained the prosthesis as palliation. In the literature, self-expandable metal stent application in obstructed carcinoma of the left colon gives satisfactory results.Based on our experience and a review of the literature, we provide practical recommendations when inserting self-expandable metal stents for acute malignant left colonic obstruction.

Die Zersetzung von H2O2 und K2S2O8 wird im Wellenlangenbereich 0,19 bis 1,54 A untersucht und die erforderliche Strahlungsenergie bestimmt.