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Summary Introduction Primary epiploic appendagitis (PEA) is characterized by the association of localized abdominal pain with guarding. Depending on its localization, it may simulate acute appendicitis or diverticular sigmoiditis. Symptoms correspond to necrosis of the epiploic appendix due the torsion and vascular occlusion of the main epiploic pedicle. Observation A 34-year-old man (BMI = 29.38) was examined for persistent localized abdominal pain of the left lower quadrant three days after receiving systemic antibiotic therapy for what was diagnosed as mild diverticular sigmoiditis. Abdominal examination showed localized guarding in the left lower quadrant, with no fever, vomiting or diarrhea. Laboratory results showed no inflammatory response. Abdominal ultrasound showed no evidence of left hydronephrosis. Helical CT showed a localized zone of necrosis of the epiploic appendix of the sigmoid colon and thus confirmed the diagnosis without surgical exploration. Symptoms regressed after a week of analgesic treatment. Discussion PEA is a rare disease. It often occurs in mildly overweight adult men (around 35 years of age). The combination of acute abdomen with localized abdominal guarding and no evidence of fever or inflammation is the typical presentation. Surgical exploration (laparoscopy) can be avoided for diagnosis if helical CT shows a localized fatty zone situated outside the colon wall with a high attenuating dot point that corresponds to central necrosis of the epiploic appendix.

Identification of subgroups of patients at high and low risk for global infectious complications (GIC) after inguinal hernia repair without mesh.A database of 1254 patients who underwent inguinal hernia repair without mesh, issued from 3 prospective multicenter randomized trials, has been established (group A). After multivariate analysis, a score for GIC was calculated and tested using data from a similar prospective randomized multicenter study (group B).A risk score for GIC was constructed: -4.7 + (0.95 x ageor =75 years) + (1.1 obesity) + (2.1 x urinary catheter). In case of score less than -4.2 (low-risk group), the GIC rate was 2.7%; therefore, in case of score more than -4.2 (high-risk score), the GIC rate was 14.3% (P.001). In the low-risk group, the administration of antibiotic prophylaxis did not reduce the infectious complication rate, while in high-risk group the administration of antibiotic prophylaxis significantly reduced the rates of surgical site infection, GIC, and urinary infection by 72%, 67%, and 76.8%, respectively.This study demonstrates the efficacy of antibiotic prophylaxis in inguinal hernia surgery in the subgroup of high-risk patients.

PURPOSE: The aim of this article was to investigate the safety, outcome, length of stay, and cost of hospital admission in patients with Crohn's disease who underwent laparoscopy compared with open surgery. METHODS: Among 51 consecutive patients with inflammatory bowel disease (1996–2000), 46 with Crohn's disease were included in this nonrandomized prospective study. Of these, 20 patients underwent laparoscopic surgery and 26 underwent open surgery. Data collected included the following information: age, gender, body mass index, diagnosis, duration of disease, preoperative medical treatment, previous abdominal surgery, present indication for surgery, and procedure performed (comparability measures), as well as conversion to open surgery, operating time, time to resolution of ileus, morbidity, duration of hospital stay, and cost of hospital admission (outcome measures). RESULTS: There was no significant difference with respect to comparability measures between the laparoscopic and the open-surgery groups. There was no mortality. There was no intraoperative complication in either group and no conversion in the laparoscopic group. Operating time was significantly longer in the laparoscopic group (302 minutes)vs. the open group (244.7 minutes) (P

Objective: We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula). Methods: Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 ± 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality. Results: After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups. Conclusion: Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications. (Surgery 1999;125:529-35.)

Objective: To evaluate the impact of randomised clinical trials (RCT) on decision-making and therapeutic policies among general and gastrointestinal surgeons in France.Design: Telephone questionnaire.Setting Multicentre study, France.Subjects: A random sample of 152 surgeons, mean (SD) age 50 (8) years.Interventions and Main outcome measure: Surgeons were asked 12 questions about their knowledge of RCT and how trials were conducted; influence of RCT on their treatment policies; means of obtaining information about treatments; how they evaluated their own results; whether they were willing to take part in RCT; and personal details including age, speciality, and type of practice. Surgeons were stratified according to age and type of practice.Results: 148 questionnaires were suitable for analysis. 83 surgeons (56%) were under 50 years old, 38 (26%) were exclusively gastrointestinal surgeons, 82 (56%) worked in private practice, and 36 (24%) worked in teaching and university hospitals. The rest undertook mixe...

OBJECTIVE: To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection. SUMMARY BACKGROUND DATA: It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this. METHODS: Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths. RESULTS: Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups. CONCLUSION: OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Background Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates. Methods. One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8±12.1years) were randomized to undergo hand-sewn (n=74) or circular stapled (n=85) supraperitoneal colorectal anastomosis after left colectomy. Results. Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n=10) and hemorrhage (n=5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p Conclusions. According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.

PURPOSE: This study was developed to compare median and actuarial survival after left hemicolectomyvs.left segmental colectomy. METHODS: Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64±12 (range, 18–91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmentai colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested. RESULTS: After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survivai curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.

Desmoplastic round small cell tumor (DRSCT) is a rare intraabdominal mesenchymal tissue neoplasm in young patients and spreads through the abdominal cavity. Its prognosis is poor despite a multimodal therapy including chemotherapy, radiotherapy, and surgical cytoreduction (CS). hyperthermic intraperitoneal chemotherapy (HIPEC) is considered as an additional strategy in the treatment of peritoneal carcinomatosis; for this reason, we planned to treat selected cases of children with DRSCT using CS and HIPEC.Peritoneal disease extension was evaluated according to Gilly classification. Surgical cytoreduction was considered as completeness of cytoreduction-0 when no macroscopic nodule was residual; HIPEC was performed according to the open technique.We described 3 cases: the 2 first cases were realized for palliative conditions and the last one was operated on with curative intent. There was no postoperative mortality. One patient was reoperated for a gallbladder perforation. There was no other complication related to HIPEC procedure.Surgical cytoreduction and HIPEC provide a local alternative approach to systemic chemotherapy in the control of microscopic peritoneal disease in DRSCT, with an acceptable morbidity, and may be considered as a potential beneficial adjuvant waiting for a more specific targeted therapy against the fusion protein.

Background Multivariable analysis best identifies independent risk factors. Study Design We conducted a prospective evaluation of 2,605 patients through univariate analysis followed by nonconditional multiple logistic regression analysis on 39 pre-, intra-, and postoperative factors, analyzed according to preoperative factors alone, preoperative and intraoperative factors together, and all 3 combined. The purpose was to identify surgeon-dependent independent risk factors for mortality after elective colorectal surgery, with immediate anastomosis for cancer and nonacute diverticular disease. Results Overall mortality was 3.5%. Through multivariable analysis, five risk factors were found when preoperative data were analyzed alone. Four remained (age between 60 and 75 years, age greater than 75 years, male gender, and heart failure) and 4 new factors (palliative resection, total colectomy, respiratory failure, and surgeon-dependent fecal soiling [the only surgeon-dependent factor]) appeared when pre- and intraoperative factors were analyzed together. Of the latter, two remained stable when all three categories of risk factors were combined and analyzed (palliative resection and total colectomy), and the two others disappeared. Of the eight pre-, intra-, and postoperative factors combined, two new factors appeared: extrasurgical site (ESS) and surgeon-dependent, organ space surgical site (O/SSS) morbidity. Conclusions Every effort must be made to collect specific, surgeon-dependent (technical and clinical) data, along with administrative data, for multivariable analysis of risk factors. Classification into three periods (pre-, pre- and intraoperative together, and pre-, intra-, and postoperative combined) enables determination of relevant, surgeon-dependent risk factors (fecal soiling and postoperative morbidity) for which there are direct preventive actions.

Introduction The aim of this article was to evaluate the role of hyperthermic intraperitoneal chemotherapy (HIPEC), associated or not to cytoreductive surgery (CS) in the treatment of different stages of advanced gastric cancer (AGC). Patients and methods Thirty seven patients with AGC who underwent 43 HIPEC from June 1992 to February 2007 were included. HIPEC used Mitomycin-C and Cisplatin for 60–90 min at 41–43 °C intra-abdominal temperature. The main endpoints were long-term survivals, morbidity and mortality rates. Results Eleven patients had no demonstrable sign of PC and constituted the Prophylactic -group, while 26 patients had macroscopic PC ( PC -group). Five patients were Gilly 1 or 2 (nodules PC -group a complete curative CS was achieved before HIPEC in 8 ( PC-curative subgroup) and a palliative HIPEC in 18 patients ( PC-palliative subgroup). The overall 30-days mortality was 5% (2 patients). Two patients in the Prophylactic group died within 6 months after hospital discharge (overall mortality 11%). The estimated risk of death per procedure was 9%. Ten patients (27%) presented one or more complications. The median survival was 23.4 months in the Prophylactic group, and 6.6 months in the PC -group ( p PC-curative subgroup was 15 vs 3.9 months in the PC - palliative subgroup ( p = 0.007). The median survival according to Gilly classification was significantly different (Gilly 1&2 vs Gilly 3&4, 15 vs 4 months respectively, p = 0.014). The global recurrence rates between the Prophylactic group and the PC-curative subgroup at 2 years were 36% vs 50% respectively. The median delay to recurrence was 18.5 vs 9.7 months respectively. Conclusion HIPEC might be useful to improve the survival in selected patients with ACG only when a complete cytoreduction can be achieved. Despite encouraging data, prospective studies, based on larger cohorts of patients are required to assess the role of this procedure as a prophylactic treatment in patients with AGC.

The aim of this study was to evaluate the results of an aggressive strategy in patients presenting peritoneal carcinomatosis (PC) from colorectal cancer with or without liver metastases (LMs) treated with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC).The population included 43 patients who had 54 CS+HIPEC for colorectal PC from 1996 to 2006. Sixteen patients (37%) presented LMs. Eleven patients (25%) presented occlusion at the time of PC diagnosis. Ascites was present in 12 patients (28%). Seventy-seven percent of the patients were Gilly 3 (diffuse nodules, 5-20 mm) and Gilly 4 (diffuse nodules20 mm). The main endpoints were morbidity, mortality, completeness of cancer resection (CCR), and actuarial survival rates.The CS was considered as CCR-0 (no residual nodules) or CCR-1 (residual nodules5 mm) in 30 patients (70%). Iterative procedures were performed in 26% of patients. Three patients had prior to CS + HIPEC, 10 had concomitant minor liver resection, and 3 had differed liver resections (2 right hepatectomies) 2 months after CS + HIPEC. The mortality rate was 2.3% (1 patient). Seventeen patients (39%) presented one or multiple complications (per procedure morbidity = 31%). Complications included deep abscess (n = 6), wound infection (n = 5), pleural effusion (n = 5), digestive fistula (n = 4), delayed gastric emptying syndrome (n = 4), and renal failure (n = 3). Two patients (3.6%) were reoperated. The median survival was 38.4 months (CI, 32.8-43.9). Actuarial 2- and 4-year survival rates were 72% and 44%, respectively. The survival rates were not significantly different between patients who had CS + HIPEC for PC alone (including the primary resection) versus those who had associated LMs resection (median survival, 35.3 versus 36.0 months, P = 0.73).Iterative CS + HIPEC is an effective treatment in PC from colorectal cancer. The presence of resectable LMs associated with PC does not contraindicate the prospect of an oncologic treatment in these patients.

Aims To review our experience of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of malignant ascites from advanced gastric cancer in order to discuss benefits, problems and possible indications. Methods From June 2000 to May 2003 laparoscopic approach was used to perform HIPEC on five patients affected by malignant ascites secondary to unresectable peritoneal carcinomatosis of gastric origin, in order to associate the benefits of a definitive palliation of ascites with a minimal invasiveness. All patients had ascites related symptoms requiring iterative paracenteses. Intraperitoneal perfusion of mitomycin-C and cisplatin was delivered for 60–90min with an inflow temperature of 45°C. Results Complete clinical regression of ascites and related symptoms was achieved in all the five patients treated. Intraoperative course was uneventful in all cases. Mean operative time was 181min. No postoperative deaths, related to the procedure, occurred. Only a case of delayed gastric empting was recorded as a minor postoperative complication. Conclusions Laparoscopic HIPEC appears to be a safe and effective procedure to treat debilitating malignant ascites from unresectable peritoneal carcinomatosis.

Hypothesis The anti-infective actions of povidone-iodine (PVI) and sodium hypochlorite enemas are different. Design Prospective, randomized, single-blind study. Setting Multicenter. Patients Five hundred seventeen consecutive patients with colorectal carcinoma or sigmoid diverticular disease undergoing elective open colorectal resection, followed by primary anastomosis. Intervention All patients received senna (1-2 packages diluted in a glass of water) at 6PMthe evening before surgery. Patients were administered two 2-L aqueous enemas of 5% PVI (n = 277) or 0.3% sodium hypochlorite (n = 240) at 9PMthe evening before surgery and at 3 hours before operation. Intravenous ceftriaxone sodium (1 g) and metronidazole (1 g) were administered at anesthetic induction. Main Outcome Measure Rate of patients with 1 infective parietoabdominal complication or more. Results The percentages of patients with 1 infective parietoabdominal complication or more did not differ between the 2 groups (13.7% in the PVI-treated group vs 15.0% in the sodium hypochlorite–treated group). Tolerance was better in the PVI-treated group than in the sodium hypochlorite–treated group (79.4% vs 67.9%), with fewer patients experiencing abdominal pain (13.0% vs 24.6%) or discontinuing their preparation (3.0% vs 9.0%) ( P =.02 for all). There were more patients with malaise in the PVI-treated group than in the sodium hypochlorite–treated group (9.1% vs 4.9%, P Conclusion When antiseptic enemas are chosen for mechanical preparation before colorectal surgery, PVI should be preferred over sodium hypochlorite because of better tolerance and avoidance of necrotic ulcerative colitis.

Primary epiploic appendagitis (PEA) is characterized by the association of localized abdominal pain with guarding. Depending on its localization, it may simulate acute appendicitis or diverticular sigmoiditis. Symptoms correspond to necrosis of the epiploic appendix due the torsion and vascular occlusion of the main epiploic pedicle.A 34-year-old man (BMI=29.38) was examined for persistent localized abdominal pain of the left lower quadrant three days after receiving systemic antibiotic therapy for what was diagnosed as mild diverticular sigmoiditis. Abdominal examination showed localized guarding in the left lower quadrant, with no fever, vomiting or diarrhea. Laboratory results showed no inflammatory response. Abdominal ultrasound showed no evidence of left hydronephrosis. Helical CT showed a localized zone of necrosis of the epiploic appendix of the sigmoid colon and thus confirmed the diagnosis without surgical exploration. Symptoms regressed after a week of analgesic treatment.PEA is a rare disease. It often occurs in mildly overweight adult men (around 35 years of age). The combination of acute abdomen with localized abdominal guarding and no evidence of fever or inflammation is the typical presentation. Surgical exploration (laparoscopy) can be avoided for diagnosis if helical CT shows a localized fatty zone situated outside the colon wall with a high attenuating dot point that corresponds to central necrosis of the epiploic appendix.

Prophylactic administration of octreotide acetate decreases the rate of postoperative intra-abdominal complications (IACs) after elective pancreatic resection.Single-blind, controlled, randomized trial.Multicenter (N = 20) trial in France.Of 230 randomized patients undergoing pancreatoduodenectomy and pancreatic enteric anastomosis or distal pancreatectomy for either malignant or benign tumor or chronic pancreatitis, 122 were allotted intraoperatively to receive octreotide; 108 served as controls.All 230 patients were analyzed. Both groups were comparable except that significantly more patients in the octreotide group had biological glue injected into the main pancreatic duct alone (P.001) or reinforcing the pancreatic enteric anastomosis (68% [83/122] vs 39% [42/108]; P =.002). Fewer patients (P =.08) in the octreotide group sustained 1 or more IACs (22% vs 32%). In subgroup analysis, octreotide significantly reduced the rate of patients sustaining 1 or more IACs when the main pancreatic duct diameter was less than 3 mm (P.02), when pancreatojejunostomy was performed (P.02), or both (P.02). No significant differences were found regarding IAC severity. Twenty-three patients (10%) died postoperatively, 16 (70% of deaths) of whom had 1 or more IACs. The only independent risk factor for IACs found on multivariate analysis was pancreatoduodenectomy compared with distal pancreatectomy (P.01) (odds ratio, 3.54 [95% confidence interval, 1.44-8.65]).Our results suggest that octreotide is not necessary for all patients undergoing pancreatic resection; it could be useful when the main pancreatic duct is less than 3 mm in diameter and when pancreatoduodenectomy is completed by pancreatojejunostomy.

Hypothesis Infectious complications are the main causes of postoperative morbidity in abdominal surgery. Identification of risk factors, which could be avoided in the perioperative period, may reduce the rate of postoperative infectious complications. Design A database was established from 3 prospective, randomized, multicenter studies. Multivariate analysis was performed using nonconditional logistic regression expressed as an odds ratio (OR). Setting Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). Patients From June 1982 to September 1996, a database was established containing the information of 4718 patients who underwent noncolorectal abdominal surgery. Main Outcome Measures The dependent variables studied included surgical site infection (SSI) (divided into parietal and deep infectious complications with or without fistulas) and global infectious complications (SSI and extraparietal and abdominal infectious complications). Results The rate of global infectious complications was 13.3%; SSI, 4.05%; parietal infectious complications, 2.2%; deep infectious complications with fistulas, 2.18%; and deep infectious complications without fistulas, 1.38%. In multivariate analysis, the following 7 independent risk factors for global infectious complications have been identified: age (60-74 years, OR, 1.64; ≥75 years, OR, 1.45); being underweight (OR, 1.51); having cirrhosis (OR, 2.45), having a vertical abdominal incision (OR, 1.66); having a suture placed or an anastomis of the bowel (OR, 1.48) in the digestive tract; having a prolonged operative time (61-120 minutes, OR, 1.66; 121 minutes, OR, 2.72); and being categorized as having a class 4 surgical site (ie, obese patients or having a risk factor of a healing defect) (OR, 1.66). Ceftriaxone sodium therapy was identified as a protective factor (OR, 0.43). In multivariate analysis, the following 5 independent risk factors for SSI have been identified: the existence of a preoperative cutaneous abscess or cutaneous necrosis (OR, 4.75), having a suture placed or an anastomosis of the bowel (OR, 1.82) in the digestive tract, having postoperative abdominal drainage (OR, 2.15), undergoing a surgicial procedure for the treatment of cancer (OR, 1.74), and receiving curative anticoagulant therapy (OR, 3.33) postoperatively. Conclusions Our data show that risk factors for SSI and for global infectious complications are disparate. Indeed, only the placement of a suture or having an anastomosis of the bowel in the digestive tract is a risk factor for both SSI and global infections. Some of these factors may be modifiable before or during the surgical procedure to reduce the infection rate or to prevent postoperative complications.

PURPOSE: With advances in laparoscopy, various hemostatic procedures have been advocated with variable results. Using currently available tools, some steps in laparoscopic colorectal surgery still represent technical challenges. Our aim was to investigate the feasibility and reliability of the Harmonic Scalpel™ in laparoscopic colorectal surgery. METHODS: In this nonrandomized prospective study, 34 consecutive patients (15 males; mean age, 46 (range, 24–80) years) underwent laparoscopic colorectal surgery for benign disease (27 patients) and colorectal cancer (7 patients). Dissection, hemostasis, coagulation, and division of several types of vascular pedicles were performed exclusively with the Harmonic Scalpel™. The 10-mm-blade Harmonic Scalpel™ device was used at full power mode for all purposes through a 10-mm port. Coagulation of vascular pedicles was always achieved with the blades in the flat position. The large pedicles (inferior mesenteric, right and left colic, and ileocolic) were coagulated for 20 seconds in several locations along the length (1 cm) before final division. Smaller vascular pedicles were coagulated for ten seconds before division. When the vein and the artery of major pedicles were divided at their origin, either for malignancy or for technical reasons, they were dissected and coagulated separately. For more limited resection of the mesentery, as in the case of benign disease, vascular pedicles were coagulated together as a single bundle. Operative time, minor or major intraoperative or postoperative hemorrhage, need for conversion to laparotomy, bowel injury, and trocar complications were recorded. All anastomoses were checked on Day 8 by a diatrizoate sodium enema. RESULTS: There was no mortality. Mean operative time was 276 (range, 200–520) minutes. Neither minor nor uncontrollable hemorrhage occurred; no conversion to laparotomy and no vascular or bowel injury were recorded. There was one port-site hematoma. Neither hemoperitoneum, intraperitoneal hematoma, fistula, nor intra-abdominal abscess was observed. CONCLUSION: Coagulation and division of minor as well as major vascular pedicles in laparoscopic colorectal surgery with the Harmonic Scalpel™ are technically easy, feasible, and reliable.

BACKGROUND: Hernia repair is the second most frequently performed operation in France and in the United States, the prevalence being 36 for every 1000 males. Lowering the recurrence rate by 1% would mean 1000 fewer operations for hernia repair per year in France. METHODS: Between 1983 and 1989, 1578 adult males with a total of 1706 nonrecurrent inguinal hernias were prospectively and randomly allotted to undergo either a Bassini's repair, Cooper's ligament, or Shouldice repair with polypropylene or a Shouldice repair with stainless steel for determination of which technique was associated with the lowest recurrence rate. Fifty-nine hernia repairs were withdrawn after inclusion. Of the 1647 remaining hernias, 52.2% were indirect, 25.6% were direct, and 23.2% were combined. Patients were seen every 6 months for 3 years and then every year. Median follow-up was 5 years 8 months (range, 3 months-8.5 years). RESULTS: At 8.5 years, 5.6% of hernias were lost to follow-up. Ninety-seven hernia repairs failed, 50% during the first 2 years. The actuarial recurrence rate was 7.94% at 8.5 years. The Shouldice repair (stainless steel or polypropylene) was associated with fewer recurrences (6.1%) than either the Bassini's (8.6%) or Cooper's ligament repair (11.2%) technique (p < 0.001). This difference remained significant even when the maximal bias test was used. Fewer recurrences (5.9%) were observed with the stainless steel wire Shouldice repair than with polypropylene version (6.5%), but the difference was not significant. CONCLUSIONS: Shouldice hernia repair provides the patient with the best chances of nonrecurrence regardless of the anatomical type of hernia. The Shouldice hernia repair should be the gold standard for inguinal hernia repair in men and serves as the basis for comparison with all other techniques, be they prosthetic or laparoscopic.

A 61-year-old man presented with ascites in the course of agnogenic myeloid metaplasia (AMM). Ascitic fluid was exudative and contained mature and immature leukocytes, erythroid cells, and megakaryocytes as observed on a bone marrow smear. Peritoneal biopsy showed myeloid metaplasia, and liver biopsy revealed intrasinusoidal myeloid metaplasia and peliosis. Ascites cleared after abdominal radiotherapy but treatment resulted in transient aplasia. Subsequently, portal hypertension was demonstrated by hepatic transjugular catheterization. Complications of splenomegaly led to splenectomy and splenorenal shunt followed by fatal acute hepatitis and septic shock. A review of the literature and an analysis of mechanisms of ascites occurring in AMM, especially peritoneal implants of myeloid tissue and occurrence of peliosis in myeloproliferative disorders, are presented.

Hypothesis Senna is more efficient than polyethylene glycol as mechanical preparation before elective colorectal surgery. Design Prospective, randomized, single-blind study. Setting Multicenter study (18 centers). Patients Five hundred twenty-three consecutive patients with colonic or rectal carcinoma or sigmoid diverticular disease, undergoing elective colonic or rectal resection followed by immediate anastomosis. Intervention Two hundred sixty-two patients were randomly allotted to receive senna (1 package diluted in a glass of water) and 261 to receive polyethylene glycol (2 packages diluted in 2-3 L of water), administered the evening before surgery. All patients received 5% povidone iodine antiseptic enemas (2 L) the evening and the morning before surgery. Ceftriaxone sodium and metronidazole were given intravenously at anesthetic induction. Main Outcome Measures Degree of colonic and rectal cleanliness. Results Colonic cleanliness was better ( P =.006), fecal matter in the colonic lumen was less fluid ( P =.001), and the risk for moderate or large intraoperative fecal soiling was lower ( P= .11) with senna. Overall, clinical tolerance did not differ significantly between groups, but 20 patients receiving polyethylene glycol (vs 16 with senna) had to interrupt their preparation, and 15 patients (vs 8 with senna) complained of abdominal distension. Senna, however, was better tolerated ( P =.03) in the presence of stenosis. There was no statistically significant difference found in the number of patients with postoperative infective complications (14.7% vs 17.7%) or anastomotic leakage (5.3% vs 5.7%) with senna and polyethylene glycol, respectively. Conclusion Mechanical preparation before colonic or rectal resection with senna is better and easier than with polyethylene glycol and should be proposed in patients undergoing colonic or rectal resection, especially patients with stenosis.

The study by the time of flight method of the 15 MeV neutrons scattered by carbon, permit us to separate the four first groups of neutrons elastically and inelastically scattered by carbon 12 and the neutrons group of the αn decay of excited state of carbon 13 .

In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.