Hepatic arterial infusion of floxuridine in patients with liver metastases from colorectal carcinoma: long-term results of a prospective randomized trial.

PURPOSE: A multicentric randomized study that compared patients who received intrahepatic arterial infusion (HAI) to a group of patients who did not receive HAI (control group) was performed for unresectable hepatic metastases from primary colorectal carcinoma. PATIENTS AND METHODS: One hundred sixty-six patients were assigned randomly to HAI of floxuridine (5 fluoro-2'deoxyuridine [FUDR]) 0.3 mg/kg/d for 14 days every 4 weeks or to the control group; this latter group, depending on the investigator's choice, was either under observation or received systemic fluorouracil (5-FU). The same regimen of systemic 5-FU also was administered to the HAI group in the event of extrahepatic progression. No crossover from the control group to the HAI group was permitted. The mean duration of follow-up was 54 months (range, 31 to 72), and 163 patients were analyzed. RESULTS: A significant improvement was observed in the survival rate for the 81 patients assigned to HAI group (P less than .02) with a 1-year survival rate of 64% versus 44% in the control group (82 patients). The 2-year survival rate was 23% versus 13%. The median survival was 15 months versus 11 months for the HAI group and the control group, respectively. Survival was better for patients with a less than 30% liver involvement, and for those treated in more specialized centers. The hepatotoxic effects of HAI were observed in 47 patients (chemical hepatitis [n = 28], and biliary sclerosis [n = 19]). The 1-year rate of sclerosing cholangitis was equal to 25%. Gastrointestinal toxicity was infrequent and consisted of gastritis or diarrhea. CONCLUSIONS: Therapy with HAI of FUDR improves the survival of patients with liver metastases over colorectal carcinoma. However, the methods that are used to diminish the toxicity of HAI and efficient systemic chemotherapy, such as a combination of 5-FU and leucovorin, are required to prevent extrahepatic metastases.

Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. French Associations for Surgical Research.

OBJECTIVE: To compare surgical treatment (ST) with endoscopic management (EM) in patients with suspected common bile duct stones. PATIENTS: Two hundred twenty eligible patients originating from 18 surgery units. Patients enrolled in this multicenter randomized study had clinical symptoms that included jaundice, mild pancreatitis (Ranson score < or = 2), or mild acute cholangitis; biliary colic (with increased alkaline phosphatase levels); and common bile duct stones or a common bile duct diameter of 1 cm or larger on ultrasonography. METHODS: Two hundred two patients were randomly assigned to either ST (n=105) or EM (n=97) during a 5-year period. Both groups were comparable with respect to age, sex, American Society of Anesthesiologists score, and clinical presentation. MAIN OUTCOME MEASURES: The rates of early postoperative additional procedures necessary to deal with the impossibility to perform the initial procedure, complications, and retained stones after ST or EM. Subsidiary endpoints were intention-to-treat analyses of mortality and of major complications and the duration of hospital stay. RESULTS: Surgical treatment was associated with a significantly (P<.001) lower rate of 1 or 2 additional procedures (8% vs 29%) due to a significantly lower rate of the impossibility to perform the initial procedure (0% vs 5%) (P<.05), major complications (4% vs 13%) (P<.05), and retained stones (6% vs 16%) (P<.04). Minor complications occurred more often in patients having ST (4%) than in those having EM (0%) (P<.01). Cholecystectomy was performed routinely in 102 patients having ST and electively in 36 patients having EM. There was 1 death in each group initially. On an intention-to-treat analysis, 3 deaths (3.1%) occurred after EM and 1 (0.9%) after ST; this difference was not statistically significant (P=.56). Major complications occurred in 4% of patients having ST compared with 1 1% of patients having EM (P<.002). The median duration of hospital stay was 16 days in patients having ST and 12 days in those having EM; this difference was not statistically significant (P=.09). CONCLUSION: Whether an additional cholecystectomy is performed routinely or electively, the high risk of additional procedures after EM precludes its use as the optimal therapy in patients with symptomatic common bile duct stones, except in those with severe cholangitis.

Technetium-99m tetrofosmin scintigraphy to evaluate breast lesions.

UNLABELLED: The aim of this study is to characterise benign from malignant breast lesions by using 99mTc-Tetrofosmin. MATERIALS: Fifteen female patients with suspected breast lesions and ten normal controls underwent breast scintigraphy with 99mTc-Tetrofosmin. All patients had conventional mammography. Breast imaging begun 20 minutes after i.v. injection of 740 MBq 99mTc-Tetrofosmin. Patients were imaged in supine and prone position. Results of the 15 patients with suspected breast lesions, 13 showed breast uptake, and 6 of them had suspicious lesions on mammography. Surgery confirmed 10 carcinomas and 3 benign lesions. Two patients demonstrated no abnormal accumulation or suspicious findings in mammography. None of the normal controls had breast uptake or mammographic abnormalities. Our study has a sensibility of 100% and 60%, and a specificity of 80% and 100% in scintigraphy and mammography respectively. CONCLUSION: Our findings suggest that 99m Tc-Tetrofosmin may play a role in evaluating breast masses and that can differentiate benign from malignant lesions.

Choledochoscopy in surgery for choledocholithiasis. Six year experience in 380 consecutive patients.

Choledochoscopy is a definite advance in biliary surgery as it simplifies the operative procedure and decreases the retained stone rate. Easy to perform without special training, its use is cost-effective. Therefore, we agree with Kappes et al [10] recommendation that routine intraoperative biliary endoscopy be performed in all patients undergoing common bile duct exploration.

Choledochoscopy in common bile duct surgery for choledocholithiasis: A must: Eight years experience in 441 consecutive patients.

Between 1975 and 1983, 441 choledochoscopy were performed in a series of 451 consecutive patients undergoing surgical common biliary duct exploration for choledocholithiasis. In 127 patients (27.8%), no stones were found. Forty-five cases (10%) of choledocholithiasis missed by surgical and radiologic exploration methods were found by choledochoscopy. Therefore the retained stone rate decreased from 10 per cent to 2 per cent. Fourteen patients (3%) died at surgery, ten of whom (2%) were over 70. Postoperative biliary tract was drained in 98 patients (8%) using external drainage. Biliary tract patency was checked on the tenth postoperative day by the tube cholangiography. When retained stones were not found, T-tube was removed on the 20th day after surgery. When retained stones were found (11 patients, 2%) an endoscopic papillotomy was performed. Choledochoscopy is a significant addition in biliary surgery. It reduces operative mortality and morbidity, decreases retained stone rate, diminishes indications for biliary anastomosis and sphincterotomy, and is easy to perform without specific training. Its extensive and systematic use is advocated when- ever common bile duct patency has to be surgically demonstrated in choledocholithiasis.

[Ulcerative jejunitis: a complication of celiac disease]. / Yeyunitis ulcerativa: una complicación de la enfermedad celiaca.

We report the case of a 57-year-old woman with celiac disease of long standing, who developed episodes of intestinal obstruction during two months. They were misdiagnosed as intestinal obstructions caused by adhesions. The barium meal and follow-through examination disclosed several jejunal stenoses. Therefore, the patient underwent early surgery where an intestinal resection was carried out. The histological examination showed the presence of benign ulcers at the stenoses. After surgery, the patient began to gain weight and her nutritional state improved remarkably.

[Argument for choledochostomy, intraoperative endoscopy and external biliary drainage in the treatment of lithiasis of the common bile duct. A 15-year experience]. / Plaidoyer pour la cholédocotomie, l'endoscopie per-opératoire et le drainage biliaire externe dans le traitement de la lithiase de la voie biliaire principale. Une expérience de 15 ans.

The treatment of common bile duct stones is controversial. The objective of our study was to report the results of choledochotomy, rigid choledochoscopy and systematic external biliary drainage in the treatment of stones of the common bile duct. Over a 15-year period, 555 patients were operated in our department according to a precise surgical protocol. 14% of these patients were operated as an emergency and 11.8% were operated immediately after endoscopic sphincterotomy. One third of patients suffered from cholangitis. The endoscopic investigation of the common bile duct was positive in 81.5% of patients. The investigation was negative in 18.5% and negative choledochotomy was significantly more frequent in patients operated for acute pancreatitis (p < 0.05). External biliary drainage was performed in 95.7% of patients. When necessary, a bilioenteric anastomosis (3%) or a surgical sphincterotomy (1.9%) was also performed. The postoperative mortality rate was 4.8% significantly higher in patients over the age of 70, in patients operated as an emergency and in patients operated immediately after endoscopic sphincterotomy (p < 0.05). The morbidity rate was 8.4%. Residual stones were diagnosed in 4.4% of the patients. The presence of residual stones was significantly more frequent in patients with multiple stones of the common bile duct (p < 0.05). Long-term follow-up was available for 89% of patients, 95% of whom were asymptomatic. These results, based on a homogeneous therapeutic protocol, can be used as a reference for the evaluation of other techniques, especially endoscopic and laparoscopic techniques.

[Liver transplantation in the presence of a non-functional portal vein: an original technique]. / Transplantation hépatique en présence d'une veine porte non fonctionnelle: une technique originale.

STUDY AIM: The aim of this retrospective study was to report an original technique for heterotopic liver transplantation with the graft in the left hypochondrium, and to discuss the indications and limitations of this technique. PATIENTS AND METHOD: Over the past ten years, four patients were treated by this technique; this constitutes 2% of all liver transplantations carried out during this period. RESULTS: No immediate per- or postoperative mortality related to the surgical procedure was noted. Moreover, no severe hemodynamic complications occurred during the per- or postoperative period. In three out of four cases, hepatic function was fully restored within 48 hours. Long-term survival (50 and 97 months) was observed in two patients. CONCLUSION: Heterotopic liver transplantation in the left hypochondrium is an alternative to orthotopic liver transplantation; it is a technique that is easy, non-aggressive, and with good long-term results. It is indicated in cases where the main portal vein is non-functional (following total thrombosis or porto-caval shunt), and orthotopic liver transplantation is therefore not possible.

[3606 cholecystectomies under celioscopy. The Register of the French Society of Digestive Surgery]. / 3,606 cholécystectomies sous coelioscopie. Registre de la Société Française de Chirurgie Digestive.

Early results of laparoscopic cholecystectomy must be evaluated. In this way, the "Société Française de Chirurgie Digestive" started to collect records of laparoscopic cholecystectomies from December 1989. 119 surgeons from 67 departments of surgery have been included in this study. By February 1992, 3,606 procedures were collected. The mean age of these patients was 51 years. Sex ratio was 0.29. 21.5% of patients had a history of acute cholecystitis. An operative cholangiogram was performed in 6.4% of cases. The mean operating time was 80 minutes. An immediate laparotomy was required in 7.1% of cases including 12 common bile duct injuries. Postoperative complications were detected in 4.3% of patients. Among these, 51 patients needed a second operative procedure including 13 common bile duct injuries. Two patients died in the postoperative period (mortality: 0.056%). The mean hospital stay was 4.8 days. History of acute cholecystitis increased significantly the immediate laparotomy required (p less than 0.01) and the incidence of postoperative complications (p less than 0.01). The mortality of laparoscopic cholecystectomy seems to be equivalent to that of open cholecystectomy. On the other hand, the incidence of common bile duct injury seems to be increased. However, the absence of controlled study prevents us from comparing the results with the open cholecystectomy. Furthermore, the incomplete nature of this register prevents us from concluding whether it reflects the real dangers of laparoscopic cholecystectomy. A more rigorous evaluating method should be considered in the future.

[Radio-guided resection of residual metastatic lymph node from a previously resected neuroendocrine tumor]. / Exérèse radioguidée d'une adénopathie résiduelle métastatique d'une tumeur neuroendocrine antérieurement réséquée.

Neuroendocrine tumors are slowly growing and carry a high risk of recurrence. Somatostatin receptor scintigraphy is considered as the gold standard for preoperative evaluation and postoperative follow-up. The use of an intraoperative detection probe makes easier a complete resection of abdominal residual or recurrent tumor. These resections may be incomplete because of the small size of the tumor and the postoperative adhesions. Radio-guided surgery is recommended in order to reduce the need for reoperation.

[Post-traumatic hemobilia. Is selective hepatic artery ligation dangerous?]. / Hémobilie post-traumatique. La ligature sélective de l'artère hépatique est-elle dangereuse?

Selective hepatic artery ligation has traditionally been considered dangerous by some authors in the treatment of traumatic haemobilia. Having observed one case in which this technique was successful in controlling liver haemorrhage, the authors have reviewed the literature. Conditions in which selective hepatic artery ligation can be dangerous are discussed. The safety and effectiveness of this treatment of traumatic haemobilia in normovolemic patients is emphasized.

[Horizontal laparotomy in biliary tract surgery]. / La laparotomie horizontale en chirurgie biliaire.

For operations on the biliary tract the transverse horizontal incision has the same advantages as the subcostal approach: strong abdominal wall, little influence on ventilation and wide access to the subhepatic region. But in addition, the abdominal wall nerves are preserved as much as possible, post-operative evisceration, it is occurs, can easily be repaired and subsequent surgery can be performed using the same route.

[Effects of cholecystectomy on functional signs associated with cholelithiasis]. / Effets de la cholécystectomie sur les signes fonctionnels associés à la lithiase vésiculaire.

Two hundred hospital patients with gallstones who had been cholecystectomized on account of typical biliary colics were investigated for migraine, headache, malaise, vertigo, flatulence, diarrhoea or constipation 2, 6, 12 and 24 months after the operation. The study showed that these symptoms are common in patients with biliary lithiasis, particularly women, and that their frequency increases with the duration of the disease. The beneficial effects of cholecystectomy are uncertain and appear to decrease with time ; only 30% of the patients seemed to improve after surgery. It is concluded that these symptoms betray real functional disorders, that cholecystectomy is not the appropriate treatment for them and that any improvement observed may be credited to the placebo effects of the operation.

[Efficacy of hyperselective vagotomy on duodenal ulcer. 284 cases]. / Efficacité de la vagotomie hypersélective sur la maladie ulcéreuse duodénale. 284 observations.

Two hundred and eighty-four patients who underwent highly selective vagotomy for duodenal or prepyloric ulcer were followed up for at least 1 year, and 47.9% of them for at least 5 years (mean : 58 months). The actuarial recurrence rates were 4.7% at 3 years, 9.6% at 5 years and 13.1% at 7 years. These results do not agree with the recently published figure of 20%. The authors insist on the necessity to dissect the lower oesophagus on a length of at least 5 cm. In duodenal ulcers, this technical detail should result in a cure rate of about 90% at 5 years.

[Spontaneous splenic rupture: surgical or conservative treatment?]. / Ruptura esplénica espontánea: tratamiento quirúrgico o conservador?

A case of Splenic Spontaneous Rupture (SSR) due to Infectious Mononucleosis is presented, occurring after a slight clinical course without significative abdominal pain. The SSR was recognized by ultrasonography and CT, with free intraperitoneal liquid. The evolution was successful with non operative management. The Medical literature concerning SSR is comment, enhancing the possibility of non operative management of SSR associated to infectious mononucleosis.

[Cystic pancreatic tumors]. / Les tumeurs kystiques du pancréas.

Cystic tumors of the Pancreas (CTP) are rare (less than 5% of all pancreatic tumors). We have limited our study to CTP of epithelial origin which represent 90% of all CTP. These can be divided into three subgroups: (1) Benign tumors with no risk of malignant progression (serous cystadenoma). (2) Tumors with risk of malignant degeneration (mucinous cystadenoma, intraductal papillary mucinous tumors (IPMT), and pancreatic solid-cystic papillary tumor. (3) Malignant tumors (cystadenocarcinoma, IPMT with malignant degeneration). The latter two groups of CTP require radical resection while serous cystadenoma does not require surgical intervention unless symptomatic. The ability to determine preoperatively the exact nature of a CTP is of tremendous importance; cytologic examination and biochemical assays of cyst fluid aid greatly in this determination. Better understanding of the biologic evolution of CTP has increased the indications for surgical resection but the risks of postoperative morbidity and mortality in these patients must not be underestimated.

[A case of idiopathic muscular hypertrophy of the esophagus complicated by a pulsion diverticulum]. / Un cas d'hypertrophie musculaire idiopathique de l'oesophage compliqué d'un diverticule de pulsion.

Diverticulectomy and esophagomyotomy provided a successful result in a patient with idiopathic muscular hypertrophy of the esophagus complicated by a pulsion diverticulum. The anatomical, clinical, and etiopathogenic features of this affection are described and problems concerning differential diagnosis discussed.

[Colonic occlusions. Retrospective cooperative study of 497 cases]. / Les occlusions coliques. Etude rétrospective coopérative de 497 cas.

A retrospective multicenter study involving 12 digestive surgery centers was conducted on 497 cases of colon obstruction. The most frequent cause of colon obstruction was colo-rectal cancer (71 p. cent of cases), but many other etiologies were involved, including 61 cases of torsion and 37 patients with occlusive sigmoiditis. Differential clinical and radiological features in each etiological group are discussed, the results of therapy undertaken analyzed, and a reasonable line of conduct proposed, adapted to each situation, with the objective of attempting to reduce mortality which still affects 25 p. cent of cases operated upon.

[Techniques of appendectomy]. / Techniques de l'appendicectomie.

Appendicectomy is a century old. McBurney's incision is the oldest but still most frequently used approach. This well-codified surgical procedure can be made difficult by anatomical variations in the situation of the caecum within the peritoneal cavity or by variations in winding of the appendix around the caecum. In uncomplicated appendicectomy abdominal drainage must be installed only when the base of the appendix is of poor quality. Complicated forms of appendicitis (with peritoneal abscess, appendiceal mass, appendicular peritonitis) have their own specific treatment. Laparoscopic surgery has a role to play among the appendicectomy techniques, and this role seems to be particularly interesting in appendicular peritonitis.