Tracheoesophagogastric anastomosis fistula: a rare complication of esophagectomy.

Fistulas between trachea and esophagogastric anastomosis after esophagectomy are uncommon. We describe 2 patients with such a lesion successfully managed with single-stage repair. The fistula was divided, the tracheal defect was closed directly or with a free pericardial graft, and the esophagogastric anastomosis was redone. A muscle or pleural flap was used to separate the tracheal and digestive suture lines. This treatment of a potentially life-threatening condition yielded excellent results without postoperative complications.

Colorectal carcinoma in patients aged 75 years and more: factors influencing short and long-term operative mortality.

A review of 238 patients aged over 75 years and operated on for colorectal cancer was undertaken to analyse factors influencing short and long-term operative mortality. Operative mortality in the first postoperative month was 13% (n = 31) and 17% (n = 35) in the first year. Four factors influenced significantly postoperative mortality in the first month: postoperative complications (p = 0.0001) related to medical complications (p = 0.0001), emergency surgery (p = 0.007), type of anesthesia (p = 0.01). Mortality during the first year (excluding patients who died in the first month) was higher in females (p = 0.05), in patients subjected to emergency operation (p = 0.004), in patients with preexisting, cerebrovascular accident (p = 0.04) and in patients with Dukes C staging (p = 0.0001). A multivariate analysis with Cox's model revealed 3 prognostic factors: Dukes staging (p = 0.0001), medical complications in the postoperative period (p = 0.0001) and type of anesthesia (p = 0.0009). Age as an isolated factor is not a contraindication to colorectal surgery in elderly patients presenting colonic or rectal carcinoma. Prognosis in elderly patients is first correlated to the control of postoperative mortality undergoing until the first year and then to the cancer itself.

[Peroperative enteroscopy in recurrent hemorrhage of the small intestine]. / L'entéroscopie per-opératoire dans les hémorragies récidivantes de l'intestin grêle.

Two cases of severe, recurrent gastrointestinal bleeding due to a small vascular lesion of the small intestine are presented. In the two patients, the diagnosis was established by intra-operative enteroscopy; in the first patient during laparotomy carried out after negative preoperative investigations; in the second, 48 hours after a right ileo-colic resection was performed for Crohn's disease of the ileum thought to be the cause of the bleeding. These two cases confirm that intra-operative enteroscopy is a very effective method to detect bleeding from small intestinal lesions, and that it should be used when pre-operative investigations and intraoperative examination are unsuccessful.

[Ileal pouch in the treatment of ulcerative rectocolitis and familial polyposis. Analysis of morbidity in a series of 30 cases]. / Réservoirs iléaux dans le traitement de la rectocolite ulcéro-hémorragique et de la polypose rectocolique familiale. Analyse de morbidité sur une série de trente cas.

Between 1984 and 1989, 30 patients underwent total coloproctectomy with J ileal pouch and ileo-anal anastomosis. They corresponded to 29 cases of ulcerative colitis and one case of familial polyposis. The authors report their own experience and the related morbidity and functional results. There were 23% fistulae, 6.6% pouchitis, 10% stenoses, 8.7% pelvic abscesses, 10% bowel obstructions, 6.6% fistulae after ileostomy closure. Only one pouch had to be removed for severe pouchitis. Functional results were partly related to post-operative complications: 50% of patients had normal continence, 57% at least 6 stools per day, 81% had one stool per night, 15% had soiling. Morbidity is discussed for the various types of complications.

[Celioscopic cholecystectomy in simple and complicated cholelithiasis. Apropos of 392 cases]. / Cholécystectomie coelioscopique dans la lithiase vésiculaire simple et compliquée.

In a study including 392 patients we compared two groups of patients according to the indication for laparoscopic cholecystectomy: group I: 293 patients treated for simple cholelithiasis (n = 291) or gallbladder polyps (n = 2). Group II: 99 patients operated for complicated cholelithiasis. For each patient, 14 pre, intra and postoperative parameters were analysed and compared. Mean operative time was 80 minutes. Primary and secondary laparotomies were necessary in 5.8% and 1.3% of cases respectively. Biliary injury was the most frequent complication (1.3%). Mean hospital stay was 4.5 days. In terms of mean age, operative time, intraoperative incidents and complications, and primary laparotomy. There was a significant difference between the two groups (p less than 0.001). There were 4 secondary laparotomies in group II and one in group I. These results suggests that laparoscopic cholecystectomy is a safe technique with a low mortality rate (0.25%). The comparative study proves that this technique, first indicated for simple cholelithiasis, is also applicable to the majority of complicated cholelithiasis.

Dropped gallstones after laparoscopic cholecystectomy mimicking appendicitis: CT features.

We present a case in which clinical and ultrasonographic features of dropped gallstones after laparoscopic cholecystectomy mimicked appendicitis.

[Ganglioneuroblastoma of the head of the pancreas. Report of a case in a 2-year-old boy]. / Ganglioneuroblastome de la tête du pancréas. Présentation d'un cas chez un garlcon de 2 ans.

This is a case report of a two years old young boy whose abdominal tumor was discovered by a routine examination. The mass was a huge, solid and painless one, located anteriorly in the right upper quadrant of the abdomen. Abdominal X-ray, IVP and ultrasonography showed a calcified mass with a normal right kidney. Urinary catecholamine excretion was significantly increased and the diagnosis of extrasurrenal prerenal sympathoblastoma was preoperatively suspected. Transverse laparotomy founded an encapsulated solid tumor, widening the duodenal loop and developing in the head of the pancreas. A cephalic duodenopancreatectomy was performed with an un eventful post-operative course. Histopathological examination confirmed it was a ganglioneuroblastoma of the head of the pancreas with lymphatic metastasis and local invasion of the neighbouring pancreas with immature tissues. The child was then treated with radiotherapy (35 Grays) and chemotherapy (Oncovin-Endoxan alternated with Oncovin-Adriamycine). The boy is now in good health with a two years follow up. Malignant pancreatic tumors are exceedingly rare in the pediatric age group (about 40 cases in the literature). Most of them are carcinoma and sympathoblastoma is quite exceptional (Research has yielded only one case : Bienaymé, 1976). The presence of a nervous tumor in such an unusual position explains the lack of precision in the preoperative location and brings up the difficult question of prognosis. It leads to pathogenic hypothesis.

Evaluation of the laparoscopic cholecystectomy on patients with simple and complicated cholecystolithiasis.

Laparoscopic cholecystectomy is now a well described method for the treatment of cholelithiasis. The purpose of this paper is to define its implementation, limits, risks and indications. Following a prospective method, the results of this treatment were compared in 187 patients with simple cholelithiasis and 75 patients with complicated cholelithiasis. Cholecystectomy was performed with a straight optic introduced through the paraumbilical region, and coupled with video camera. Two, 3, or 4 other trocars were inserted and placed as required by anatomic conditions. In the group with simple cholelithiasis, laparoscopic cholecystectomy was performed in 99% of the patients while in the group with complicated cholelithiasis the procedure was achieved in 75% of the patients. Immediate laparotomy was done in 1% and 25% of cases respectively in both groups. No interventional mortality occurred. Postoperative complications have been acceptable (1.6% and 2.7%), with no late complications reported. Our study shows that laparoscopic cholecystectomy is feasible in the majority of cases of complicated cholelithiasis and that the main advantages of this method were retained.

Laparoscopic cholecystectomy in complicated cholelithiasis.

From January 1990 to December 1992, 129 patients presenting complicated cholelithiasis were included in a prospective study to assess the feasibility and efficiency of laparoscopic cholecystectomy. There were 84 females (65%) and 45 males (35%). Mean age was 60 years (range from 23 to 88). There were 90 acute cholecystitis (70%), 14 empyema (11%), 14 cholecystitis on scleroatrophic gallbladder (11%), and 11 mucocele (9%) cases. Laparoscopic cholecystectomy has been successfully performed in 106 cases (82%) (group I). In this group of patients, morbidity and mortality were 4.7% and 0.9% (n = 1), respectively. Mean hospital stay was 4.7 days after uneventful postoperative course. Two patients required reoperation for complications (1.8%). Twenty-three patients (18%) required enforced conversion to laparotomy after unsuccessful laparoscopic procedure (group II). Mean hospital stay was significantly higher in group II (10.8 days, P = 0.0001). There was no difference between the two groups according to sex, previous surgery, or indications. Laparoscopic cholecystectomy may be attempted and successfully realized in complicated cholelithiasis without morbidity increase. Main advantages of this procedure are a shorter hospital stay and a better recovery period.