[Results of resection for ductal adenocarcinoma of the pancreatic head]. / Résultats carcinologiques de l'exérèse chirurgicale du cancer glandulaire céphalique du pancréas.

INTRODUCTION: Pancreaticoduodenectomy (PD) is the only curative treatment for adenocarcinoma of the pancreatic head but is associated with a significant early morbidity and a poor long term survival. Therefore, its value is still debated. The aim of this study was to evaluate early and distant results of PD for pancreatic adenocarcinoma, and to identify prognostic factors. SUMMARY: Seventy-nine patients who underwent PD with curative intent for adenocarcinoma of the pancreatic head from 1982 to 2002 were studied retrospectively. The following data were evaluated: operative mortality, long-term survival, prognostic factors (through univariate and multivariate analysis), and characteristics of 5-year survivors. RESULTS: Mortality rate was 1.3%. Survival at 1, 3 and 5 years was 46%, 26% and 11%. The median survival was 12 months. The prognostic factors were the T stage (T.N.M. classification) and radicality of resection. After multivariate analysis, radicality of resection was the only independent prognostic factor. Five patients survived for more than 5 years. They did not differ of the other patients but none had positive margin or venous invasion. CONCLUSIONS: These results (low mortality, significant distant survival including some long term survivors) suggest that PD for pancreatic adenocarcinoma must be indicated in most low-risk patients. PD remains the only curative treatment allowing prolonged survival.

Contribution of cervical ultrasound and ultrasound fine-needle aspiration biopsy to the staging of thoracic oesophageal carcinoma.

This study was performed to evaluate the use of cervical ultrasonography and ultrasound-guided fine-needle aspiration for pretherapeutic staging of oesophageal cancer. 50 patients with a thoracic-oesophageal cancer (upper third = 8, middle = 36, lower = 6), previously untreated, underwent cervical ultrasonography to detect supraclavicular lymph node metastases (LN). An ultrasound fine-needle aspiration biopsy was attempted in 12 cases of suspected LN. 26 patients were operated on, of which 13 had surgical exploration of the neck. All patients were followed after treatment with special attention to the supraclavicular area. 14 patients (28%) were ultrasonography positive, 5 of 8 in the upper third, 9 of 42 in the two other thirds. Of the 12 patients where a fine-needle biopsy was attempted, 9 showed neoplastic cells (75%). 5 patients had cervical metastatic LN at surgery, and 5 other patients demonstrated supraclavicular LN metastases during the follow-up. There was one false positive and six false negatives from cervical ultrasonography and two false negatives of UGFAB (ultrasound-guided fine-needle aspiration biopsy). The sensitivity and the specificity of the cervical ultrasonography were 68 and 97%, respectively. The pretherapeutic staging was modified: 7 patients initially stage II-III were regraded to stage IV. Cervical ultrasonography is a reliable method of assessment of supraclavicular LN in thoracic oesophageal carcinoma.

Localized squamous-cell cancer of the esophagus: retrospective analysis of three treatment schedules.

BACKGROUND AND PURPOSE: A retrospective study comparing chemotherapy and radiation, esophagectomy alone versus preoperative radiochemotherapy and surgery in localized squamous-cell esophageal carcinoma. MATERIALS AND METHODS: Between 1989 and 1995, 139 patients (40 stage I, 77 stage IIA and 22 stage IIB according to the UICC 78 TNM classification) were treated in two different institutions. They were divided into three groups according to the treatment proposed: E group (treatment by esophagectomy; n = 30), RCT+E group (treatment by preoperative radiochemotherapy and esophagectomy; n = 46), RCT group (treatment by radiochemotherapy; n = 63). Factors like age, tumor localization and stage were similar in all groups. An intention to treat analysis was made. RESULTS: The E group showed no postoperative mortality, while in the RCT+E group, the surgery mortality was 12.8%. The mortality after RCT was 1.7%. After preoperative radiochemotherapy, a pathological complete response was observed in 25% of cases and the curative resection rate was higher (82% after RCT + E versus 60% after E). The 5-year survival difference between the three groups was not relevant (E group, 12.6%; RCT group, 25.8%; RCT + E group, 38.7%). The median survival was 29, 24 and 28.5 months, respectively. The event-free survival was identical for the E group and the RCT group. For patients treated by radiochemotherapy, local and/or distant relapses were significantly reduced by esophagectomy (relapses occurred in 51% of patients in the RCT + E group versus 75% in the RCT group, P = 0.017). Palliative care (dilatations, prosthesis, gastrostomy or jejunostomy) to improve dysphagia was necessary for 38% of patients treated by exclusive radiochemotherapy versus 11% of patients treated by surgery (P = 0.001). CONCLUSIONS: Treatments by esophagectomy or radiochemotherapy were not significantly different. Preoperative radiochemotherapy and surgery lead to a higher survival rate than exclusive radiochemotherapy, however, with a high postoperative mortality rate. This study suggests the relevance of a prospective randomized trial to compare RCT+E and RCT alone.

Cancer of the esophagus and associated lesions: detailed pathologic study of 100 esophagectomy specimens.

One hundred surgical specimens from patients with esophageal cancers were studied in detail. The characteristics of the cancers were similar to those described in the literature. Subserial sectioning of the specimens permitted determination of the type, number, and extent of noncancerous mucosal lesions and their exact location in relation to the carcinomas. Ninety-five per cent of the resected esophagi contained at least one focus of intraepithelial neoplasia, for the most part adjacent to the invasive carcinoma; in 14 per cent of the cases, intraepithelial carcinomas were detected at some distance from the invasive carcinomas. The invasive carcinomas involved an average of 20 per cent of the mucosal surface and the intraepithelial neoplasias, 5 per cent. The noncancerous mucosal lesions were analyzed, and their extent was evaluated. Esophagitis, parakeratosis, atrophy, dyskeratosis of the epithelium, and hyperplasia and metaplasia of the mucosal gland ducts were encountered. The exact significance of these lesions in esophageal carcinogenesis is not known. The mucosal abnormalities associated with preoperative irradiation are defined. The results of iodine and toluidine blue testing are presented.

[Esophageal cancer in Western France. Retrospective analysis of 1400 cases]. / Le cancer de l'oesophage dans l'ouest de la France. Analyse rétrospective d'une population de 1400 cas

A retrospective review was made of 1 400 cases of cancer of the esophagus treated at the Centre "Francois Baclesse" between 1964 and 1975. The disease appeared at an earlier age and more frequently in men (95%) than in women. The lesions were located predominantly in the middle third of the esophagus. There was a high frequency of local, regional and general extension of the disease due to late diagnosis. Less than one-third of the patients were eligible for surgery--which was excluded in the other cases because of age or the presence of associated pathology or secondary neoplasm--and only 10 per 100 of this group were potentially curable.

[Surgical treatment of gastroesophageal reflux: which operation to choose: Nissen, Toupet or Lortat-Jacob? A multicenter randomized trial]. / Traitement chirurgical du reflux gastro-oesophagien: quelle intervention choisir: Nissen, Toupet ou Lortat-Jacob? Essai multicentrique par tirage au sort. Association Universitaire de Recherche en Chirurgie.

Five surgical centers conducted a clinical randomized prospective trial in order to objectively evaluate the two-year results of three anti-reflux procedures regularly performed in France: complete (360 degrees) fundoplication (Nissen), posterior partial (180 degrees) fundoplication (Toupet) and cardiophrenopexy (Lortat-Jacob). Fifty-two patients, mean age 53 years, range 28 to 74 yrs, with uncomplicated gastroesophageal reflux, as defined according to clinical, radiologic, endoscopic and pHmetry criteria, were included in this study. Twenty patients underwent a Nissen procedure, 18 had a Toupet procedure, while 14 had a Lortat-Jacob procedure. The main criterion of assessment was Minaire's pHmetry score evaluated at two years postoperative. All three groups were well matched for clinical, radiologic, endoscopic, manometry and pHmetry findings. At two years, the number of asymptomatic patients did not statistically differ within the three groups. Four patients, however, required reoperation for invalidating recurrences: three following Lortat-Jacob's procedure and one after Toupet's procedure. Nissen's and Toupet's procedures significantly improved pHmetry scores compared with Lortat-Jacob's procedure; pHmetry was improved, but non significantly, by Nissen's procedure, as compared with Toupet's procedure. Lower sphincter pressure was significantly increased (p less than 0.01) by Nissen's procedure as compared with the two other techniques. The lower sphincter was significantly lengthened by Nissen's and Toupet's procedures as compared with Lortat-Jacob's technique (p less than 0.01). The total length of esophagus was significantly increased (p less than 0.01) by Nissen's and Lortat-Jacob's procedures in comparison with Toupet's technique. The distance separating the lower sphincter of the esophagus and point of pressure reversal was significantly decreased (p less than 0.05) by the Nissen procedure only.(ABSTRACT TRUNCATED AT 250 WORDS)

[Orthotopic liver transplantation for metastases of bronchial carcinoid tumor]. / Transplantation orthotopique hépatique pour métastases d'une tumeur carcinoïde bronchique.

We report the case of a 42 year old man in whom orthotopic liver transplantation was performed successfully for unresectable hepatic metastases of a bronchial carcinoid tumor. Prior to transplantation, somatostatin therapy, pulmonary lobectomy, and systemic chemotherapy (streptozotocin and fluorouracil) were performed. After 9 months there were no signs of clinical or biological recurrence. Orthotopic liver transplantation might be indicated for unresectable and limited liver metastases of neuroendocrine tumor.

[Gastroesophageal 99mTc scintigraphy in gastroesophageal reflux]. / Scintigraphie gastro-oesophagienne au 99mTc dans le reflux gastro-oesophagien.

The aim of this study was to compare gastroesophageal 99mTc scintiscanning (GES), the pH reflux test (TRA) and esophageal manometry in the assessment of gastroesophageal reflux (GER). GES was performed after oral intake of sulfur colloid labeled with 99m technetium and 300 ml of water. Calculation of an index of reflux gave a semi-quantitative assessment of the GER. Sixty patients with symptoms of GER (typical in 51 cases, atypical in 9 cases) had the three tests. A GES was also performed in 17 normal volunteers and in 12 patients of the series after fundoplication. The diagnostic specificity of GES was 1.0 in GER. GES was less frequently positive than the pH reflux test in GER (68.6 p. 100 versus 80.4 p. 100) but the difference was not significant. These two tests were more sensitive than manometry. The index of reflux was higher in patients than in control subjects (p less than 0.0005) and returned to normal values after fundoplication. A correlation between the index of reflux and the stage of pH-reflux test was observed. It is suggested that GES can be used in the initial assessment of GER as an alternative to TRA and performed repeatedly during the follow-up of patients treated surgically.

[Pseudotumoral hyperplasia of Brunner's glands]. / Hyperplasie pseudo-tumorale des glandes de Brünner.

Hyperplasia of Brünner's glands is a dysembryoplastic or hyperplasic lesion with an elective location of the proximal duodenum. Symptoms are often non-specific but severe manifestations can occur (haemorrhage, duodenal obstruction). Two cases of hyperplasia of Brünner's glands were reported due to their particularly large size and a misguiding clinical appearance. Difficulties in diagnosis due to this rare benign entity were discussed.

Bile and blood ratios of cyclosporin and its metabolites in patients on continuous infusion during the first three weeks after liver transplantation.

Ten patients with orthotopic liver transplants were investigated during routine therapeutic monitoring to study the relationship between the concentrations of cyclosporin and its metabolites in blood, bile and urine, and whether this information can provide early signs of severe hepatic disorders post-transplantation. Cyclosporin (Sandimmun®) was administered by continuous infusion at a constant rate of 5 mg/kg/day, modified to keep the blood cyclosporin concentration within the target range (400 to 500 µg/L). The concentrations of cyclosporin and combined cyclosporin-metabolites in blood, bile and urine were assayed daily during the 3 post-transplantation weeks that the patients spent in intensive care.All patients developed cholestatis and cytolysis during the first week. The severity of these liver transplant disorders increased in 5 patients and decreased in the other 5 in the second week. The pharmacokinetics of cyclosporin differed in the 2 groups: in patients without severe hepatic disorders, the blood metabolites/cyclosporin ratio (M/C) stabilised at 1.2 ± 0.4 in week 2 and at 0.8 ± 0.2 in week 3, bile cyclosporin/blood cyclosporin (bile C/blood C) fluctuated around 13.5 (13.5 ± 9.5 in week 2 and 13.5 ± 9.0 in week 3) and the bile metabolite/blood metabolite (bile M/blood M) ratio was very high and variable (131 ± 86 in week 2 and 159 ± 116 in week 3). Metabolites significantly accumulated in the blood of patients with severe hepatic disorders (M/C = 2.8 ± 0.6 in week 2 and 3.5 ± 1.0 in week 3); bile C/blood C (2.6 ± 2.1 in week 2 and 3.4 ± 1.1 in week 3) and bile M/blood M (11.9 ± 7.8 in week 2 and 12.5 ± 7.9 in week 3) significantly decreased and showed less interindividual variability.Blood cyclosporin is usually monitored to help optimise the dosage. However, if this was extended to include the monitoring of metabolites in the blood, and cyclosporin and metabolites in the bile, it could provide an early indication of severe hepatic disorders in patients with transplanted livers.

[Perforation of esophageal cancer (author's transl)]. / Cancer de l'oesophage perforé.

Perforation of an esophageal cancer can occur spontaneously or during radiotherapy. If the perforation is the first manifestation of the cancer, the diagnosis depends on X-ray and endoscopy. During radiotherapy, the intending perforation must be carefully watched for. We have treated two perforations appearing as first manifestation of the cancer and 3 developed during evolution, 2 of them during radiotherapy. Various treatments have been applied. In 2 cases, resection was possible, curative in one, palliative in the other. In the other 3 cases, retrosternal by-pass has allowed feeding and radiotherapy. Such a complication generally condemns the patient to a gastrostomy. However, a more aggressive surgical attitude can be adopted if the general status of the patient permits. An esophageal endo-prosthesis can also be used.

[Zenker's diverticulum: diverticulopexy versus diverticulectomy]. / Diverticule de Zenker: diverticulopexie contre diverticulectomie.

STUDY AIM: The aim of this retrospective, nonrandomized study was to compare the results of diverticulectomy and diverticulopexy in the treatment of Zenker's diverticulum. Over the 10-year period between 1988 and 1998, surgery for Zenker's diverticulum was performed in 40 patients. PATIENTS AND METHOD: The study group consisted of 23 men and 17 women with a mean age of 72 years. Only 39 patients were evaluated. In 19 patients, treatment consisted of cricopharyngeal myotomy and diverticulum suspension; in the other 19 patients, treatment consisted of diverticulectomy in addition to myotomy. Only one patient had a diverticulectomy without myotomy. RESULTS: There was no mortality and the morbidity rate was low: one fistula, one pneumonia, three cases of transient dysphonia and one hematoma. The results were excellent in 36 patients, and good in 3 patients. CONCLUSION: Cricopharyngeal myotomy with diverticulopexy is particularly suitable for geriatric patients. Diverticulectomy is proposed in the case of a diverticulum larger than 6 cm and for young patients to prevent the risk of malignant transformation.

[Post-traumatic hemobilia. How to treat? Apropos of a case]. / Hémobilie post-traumatique. Quel traitement? A propos d'un cas.

Severe hemobilia after blunt hepatic trauma is one of the limits for a conservative medical treatment. Urgent percutaneous highly selective embolization of the bleeding vessel is the treatment of choice today. Failures of radiological treatment require surgery. Primary direct ligation of the bleeding vessel carries a risk of recurrence and prevents subsequent embolization. Under these conditions, when the surgeon prefers a conservative approach, preoperative embolization using permanent material can be performed as reported in our case study.

[Indications and results of mucosal proctectomy with colo-anal anastomosis in villous disease of the rectum]. / Indications et résultats de la proctomucosectomie avec anastomose colo-anale pour maladie villeuse du rectum.

The objective of this study was to define the indication for proctectomy and colo-anal anastomosis in large rectal villous adenomas. The study population consisted of 20 patients (12 men and 8 women; mean age 63.6) who underwent rectal excision and colo-anal anastomosis from 1990 to 1997. The average size of tumors was 59.8 mm; 18 tumors were located in the lower third of the rectal ampulla; 8 patients had prior treatment (surgical or medical) before proctectomy. There were 13 straight colo-anal anastomoses and 7 constructed with colonic J pouch. Eighty percent of the anastomoses were defunctioned by a temporary stoma. The overall morbidity included one case of pelvic sepsis, two anastomotic strictures and one colonic trans-anal prolapse. One patient experienced persistent mild fecal incontinence and two others developed urogenital. The mean hospital stay was 14.4 days and 8.5 days for stoma closure. 8 tumors contained malignancy: 3 Tis, 4 T1 and 1 T2. In our opinion the extension, natural history or potential of occult malignancy of large rectal villous adenomas may requires rectal excision with colo-anal anastomosis with low morbidity and good functional results.

[Esophagectomy without thoracotomy using a stripping method: technic, results, indications in benign and malignant diseases of the esophagus]. / L'oesophagectomie sans thoracotomie par retournement: technique, résultats, indications dans les affections bénignes et malignes de l'oesophage.

A technique of esophagectomy without thoracotomy using a stripper with limited dissection of the mediastinum has been applied to 48 patients: neoplasia in 41 (squamous-cell carcinoma of the esophagus: 34, carcinoma of the gastric cardia: 5, pharyngeal carcinoma: 2) and non-malignant pathology in 7 (2 caustic necroses, 2 ruptured esophagus, 2 anastomotic leakages after gastro-esophageal resection, 1 caustic stenosis). There were 3 post-operative deaths. The best indications of this procedure are extended tumors of the lower esophagus in poor-risk patients, and perhaps superficial carcinomas of the esophagus whatever the site. The usefulness of this technique in such situations as perforations and mediastinitis is emphasized.

[Calibrated latero-lateral portacaval anastomosis in the treatment of digestive hemorrhages by portal hypertension in the cirrhotic patient]. / L'anastomose porto-cave latéro-latérale calibrée dans le traitement des hémorragies digestives par hypertension portale du cirrhotique.

The calibrated side to side portocaval shunt was described in 1979 by P. Marion. This type of shunt preserves a hepatopedal blood flow by maintaining portocaval pressure gradient superior to halve of the initial gradient. Twenty nine shunts were performed from 1981 to 1989 in patients with hemorrhagic liver cirrhosis alcoholic in 83 percent of cases). Two patients were in Child Pugh C class (7%), six procedures were performed as an emergency (21%). The operative mortality was nil. The hepatopedal blood flow assessed by direct venous angiography was maintained in 66% of cases at one year and 22% at five years. The actuarial survival rate without recurrent bleeding was 96% at two years, 88% at five years. Severe chronic encephalopathy was noted in three cases (10.3%). One patient was successfully treated by surgical anastomotic tightening with disappearance of the hepatic encephalopathy. The actuarial survival rate without encephalopathy was 82.7% at five years. The side to side calibrated shunt is a technically easy procedure with low mortality, low incidence of thrombosis and clinical results similar to the results of Warren's procedure. For these reasons, we have decided to include this procedure in our local protocol of management of hemorrhagic liver cirrhosis.

[Results and indications of lateral ileostomy functionally terminated in colorectal surgery]. / Résultats et indications de l'iléostomie latérale fonctionnellement terminalisée en chirurgie colo-rectale.

UNLABELLED: Loop ileostomy (LI) ensures fecal diversion to protect an anastomosis or anatomic colorectal or ano-perineal damage. The aim of this retrospective study was to evaluate loop ileostomy morbidity in emergency and planned colorectal surgery. PATIENTS AND METHODS: From 1991 to 1996, 145 loop ileostomies were performed in 139 patients, 77 men and 62 women with a mean age of 48.7 years (15-82). The etiology was a rectal tumor (cancer or large villous tumor n = 47), inflammatory bowel disease (n = 47, ulcerative colitis = 37 and Crohn's disease = 10) Familial Adenomatous Polyposis (n = 13) and other diseases (n = 32). 80% LI (n = 116) protected ileo-anal anastomoses (n = 46) colo-anal anastomoses (n = 45, 26 with colonic pouch), ileo-rectal anastomoses (n = 11) and other anastomoses (n = 15). 20% LI (n = 29) dysfunctional ano-perineal lesions (n = 8), anastomosis leak (n = 4) or distal bowel without intestinal resection (n = 17). RESULTS: 7 deaths were not stoma-related. 91% LI were closed after a mean diversion time of 3.6 months. LI closure was performed by a parastomal (n = 128) or laparotomy procedure (n = 4). Morbidity during LI diversion was observed in 24 patients (16.5%) 12 of whom (8.3%) were operated for small bowel obstruction (n = 6; 4.2%) stoma revision (n = 5; 3.5%) and prolapse (n = 1; 0.7%). 2 patients had peristomal skin excoriations, and 5 patients required readmission for dehydration due to high LI output. Morbidity after LI closure was observed in 12 patients (8.6%) 5 of whom were operated for anastomotic leak (n = 4) or small bowel obstruction (n = 1). Low morbidity and defunctioning efficiency confirm the indications for LI. LI is our first-line stoma in planned or emergency colorectal surgery.

[Spontaneous and instrumental perforations of the thoracic esophagus (non-neoplastic, non-caustic). Apropos of 20 cases]. / Les perforations spontanées et instrumentales de l'oesophage thoracique (non néoplasiques, non caustiques). A propos de vingt cas.

The authors present twenty cases of spontaneous or instrumental perforation of the thoracic esophagus (neoplastic and caustic perforations excluded). The delay before treatment was less than 24 hours in only one case. Mortality rate was 15%, concerning three patients (three cases of Boerhaave's syndrome) treated by T tube drainage. The contribution of exclusion using stapling technique should increase the indications of direct suture, which remains elective treatment. Esophagectomy retains its indications for perforations with pathologic esophagus or late diagnosis.

[Adjuvant radiochemotherapy in operable cancers of the thoracic esophagus. Preliminary results of a multicenter study. A study of 119 cases]. / Radio-chimiothérapie adjuvante dans les cancers opérables de l'oesophage thoracique. Résultats préliminaires d'une étude multicentrique. Etude portant sur 119 cas.

119 operable patients with an oesophageal squamous cell carcinoma were treated preoperatively by a combination of radiotherapy (37 Gy in two courses) and chemotherapy by cisplatin (delivered before each course of radiation). The response was evaluated on the resected specimen. 111 patients underwent operation and 101 tumours were resected. The toxicity was acceptable by reducing the Cisplatin dosage from 100 mg/m2 to 80 mg/m2 for the last 67 patients. A complete response was observed in 24 patients and a partial response in 46. The preliminary results show a 57% eighteen-month survival in the group of resected patients. A controlled study is needed to compare this combined regimen versus surgery alone in curatively resectable patients.

[Chemoembolization of hepatic metastases. Preliminary study]. / Chimio-embolisation des métastases hépatiques. Etude préliminaire.

Twenty-one patients with hepatic metastases were treated by chemoembolization over a 2-year period, the technique consisting of selective injection of a mixture of Spongel powder and Adriamycin plus 5-FU into the hepatic artery. Indications and results are discussed as a function of clinical, biologic and radiologic criteria.