Papillary carcinoma of the thyroglossal duct cyst: report of two cases.

AIM: To present two cases of papillary carcinoma of the thyroglossal duct cyst (TDC) and to report their management. PATIENTS AND METHODS: Two patients, a 47-year-old woman and a 60-year-old man, were operated in 2006 and 2008 in the Department of Digestive and Metabolic Surgery of the "Jean Verdier" Hospital. RESULTS: The diagnosis of papillary carcinoma was established after the pathological examination carried out on the thyroglossal duct cyst, after its complete surgical excision. A total thyroidectomy followed by a treatment by radioactive iodine and a substitutive hormonal therapy were carried out in the second time for one of the two patients. For the other patient, a total thyroidectomy followed by a substitute hormonal therapy, were achieved. The evolution was favorable, with a follow-up of four years for the first patient and two years for the second one. DISCUSSION: Total thyroidectomy after the complete excision of the cyst is currently the recommended treatment for the papillary carcinoma of the TDC. It was shown that a latent thyroid cancer could develop even 15 years after the initial excision of the thyroglossal cyst. The treatment is curative in 95% of the cases. CONCLUSIONS: Current treatment of papillary carcinoma of the thyroglossal duct cyst is well codified, allowing an excellent prognostic.

[Is bariatric surgery in adolescents appropriate?]. / La chirurgie bariatrique chez l'adolescent est-elle légitime?

Current recommendations for bariatric surgery are limited to patients older than 18 years. Two studies in 2007 showed that bariatric surgery improves survival in adults. Medical management of severe obesity in adolescents is all too often ineffective. For these reasons, early surgical intervention for adolescents with morbid obesity may be expected to prevent or avoid comorbidities, decrease mortality, and improve the quality of life. Several studies have demonstrated the feasibility of adolescent bariatric surgery with morbidity comparable to that seen in adult series. The earlier the surgery, the better the result in terms of prevention or reversal of comorbid conditions. In the USA, a consensus definition of adolescents eligible for bariatric surgery specifies attainment of Tanner Stage IV of sexual maturity and achievement of 95% of axial growth. Just as in adults, bariatric surgery in adolescents requires prolonged follow-up; it is important that such surgery be performed in centers specialized in adult bariatric surgery having the necessary multidisciplinary structure.

Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes.

BACKGROUND: The Airtraq laryngoscope is designed to allow visualization of the glottis without alignment of the oral, pharyngeal, and laryngeal axes. We hypothesized that this new airway device would facilitate tracheal intubation of morbidly obese patients. We compared tracheal intubation performance of standard Macintosh laryngoscope with the Airtraq laryngoscope in morbidly obese patients. METHODS: One hundred and six consecutive ASA I-III morbidly obese patients undergoing surgery were randomized to intubation with the Macintosh laryngoscope or the Airtraq laryngoscope. Induction of anaesthesia was standardized. If tracheal intubation failed within 120 s with the Macintosh or Airtraq , laryngoscopes were switched. Success rate, SpO2, duration of tracheal intubation, and quality of airway management were evaluated and compared between the groups. RESULTS: Preoperative characteristics of the patients were similar in both groups. In the Airtraq group, tracheal intubation was successfully carried out in all patients within 120 s. In the Macintosh laryngoscope group, six patients required intubation with the Airtraq laryngoscope. The mean (SD) time taken for tracheal intubation was 24 (16) and 56 (23) s, respectively, with the Airtraq and Macintosh laryngoscopes, (P<0.001). SpO2 was better maintained in the Airtraq group than in the Macintosh laryngoscope group with one and nine patients, respectively, demonstrating drops of SpO2 to 92% or less (P<0.05). CONCLUSIONS: In this study, the Airtraq laryngoscope shortened the duration of tracheal intubation and prevented reductions in arterial oxygen saturation in morbidly obese patients.

Randomized, controlled, blinded trial of Tissucol/Tisseel for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: rationale and study design of the TIMELI trial.

BACKGROUND: Complications associated with sutured mesh fixation following open groin hernia repair have prompted surgeons to evaluate methods of atraumatic fixation such as the use of human fibrin glue. Small trials with Tissucol/Tisseel fibrin glue (Baxter Healthcare, Deerfield, IL, USA) have shown promising results that warrant further investigation. METHODS: TIMELI (Tissucol/Tisseel for MEsh fixation in LIchtenstein hernia repair) is an international, controlled, randomized, patient- and evaluator-blinded study that is comparing mesh fixation with Tissucol or sutures in patients with inguinal hernia. The primary endpoint evaluates the incidence of disabling complications (chronic pain and/or numbness and/or groin discomfort) at 12 months post-surgery. RESULTS: Patient enrolment started in February 2006 and ended on 19 April 2007, with a total of 325 patients recruited. Initial results are expected in early 2008. CONCLUSIONS: TIMELI is a major international trial that will provide important information on the efficacy and safety of Tissucol, compared with sutures, for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair.

[Evaluation of stress in surgical trainees: prospective study of heart rate during laparoscopic cholecystectomy]. / Stress des chirurgiens en formation: Etude prospective de la cardio-fréquence lors de cholécystectomies laparoscopiques.

INTRODUCTION: Surgical training is stressful, particularly in the operating room setting. The purpose of the study is to evaluate and quantitate intra-operative stress in surgical trainees. MATERIAL: and methods: Cardiac rate was used as a measure of stress during surgical cases; surgical residents serving as the primary surgeon and assistant during 21 laparoscopic cholecystectomies underwent telemetry monitoring. RESULTS: Intra-operative cardiac rate increased by 4-10%, particularly in the resident serving as primary surgeon. The most stressful moments of the procedure were the draping of the surgical field, trocar placement, clip application, and extraction of the gallbladder. CONCLUSION: This study offers a measure of the stress of surgical residents in the operating room. Heart rate is not the ideal parameter of stress, yet it gives a good idea of the level of stress. The identification of stress-inducing factors may help residents to deal with difficult situations.

Inguinal hernia repair: the choice of prosthesis outweighs that of technique.

BACKGROUND: The use of prostheses in inguinal hernia repair reduces the incidence of recurrence. Quality of life and pain after hernia repair are largely correlated with the technique and type of prosthesis. AIMS OF STUDY: To evaluate the 2-year incidence of recurrence and pain for two types of hernioplasty, Lichtenstein repair and laparoscopy (totally extraperitoneal approach or TEP), and two types of mesh, polypropylene mesh and beta-D: -glucan-coated mesh (Glucamesh). PATIENTS: A total of 410 consecutive patients of mean age 54 years (18-84) underwent repair of inguinal hernias, 96 (23%) of which were bilateral and 56 (13%) recurrent. A total of 273 (66.5%) patients underwent Lichtenstein repair: 215 (78.7%) with polypropylene mesh, 58 (21.3%) with Glucamesh; 137 patients underwent laparoscopy: 80 (58.4%) with polypropylene mesh, 57 (41.6%) with Glucamesh. In each group, the populations were comparable and the techniques utilized were identical. METHODS: The patients were followed-up for at least 2 years, after which the incidence of recurrence was determined, and chronic pain was assessed by means of a visual analog scale and a validated questionnaire. RESULTS: A total of 349 patients (85.1%) were reassessed, 117 of whom had undergone laparoscopy and 232 Lichtenstein repair. There were ten recurrences (2.8%), and incidence which was independent of the technique (laparoscopy 1.7% vs. Lichtenstein 3.4%) (ns) and the type of prosthesis (Glucamesh 1.9% vs. polypropylene 2.4%) (ns). Chronic pain was noted in 69 patients (19.7%) and severe pain in 11 (3.1%). The incidence of chronic pain was the same for the two techniques: laparoscopy 17.9% vs. Lichtenstein 20.7% (ns). The same was true for severe pain: laparoscopy 3.4% vs Lichtenstein 3% (ns). The incidence of chronic pain was closely correlated with the type of prosthesis utilized: Glucamesh 4.8% vs. polypropylene 26.5% (P = 0.02), irrespective of the technique. The same was true for severe pain (0.9 vs. 4%) (P = 0.02). CONCLUSION: The utilization of beta-D: -glucan-coated mesh did not involve more recurrence and was accompanied by a significant decrease in chronic pain at 2 years, independent of the technique. After 2 years, the results of hernia repair show that the choice of prosthesis was more determinant than choice of technique.

Repair of giant incisional abdominal wall hernias using open intraperitoneal mesh.

BACKGROUND: Very large and complex incisional hernias, especially those involving loss of abdominal wall, present a particular challenge to the surgeon. AIMS: The open intraperitoneal technique was used prospectively for the repair of incisional hernias in a selected group of patients with large defects, often those with major loss of abdominal wall, overweight patients, and previous failures of incisional repair. MATERIALS AND METHODS: Between 1 January 1999 and 31 December 2005, out of 275 patients operated on for incisional hernia repair, 61 of them, most of whom were obese with multiorificial recurrent or giant hernias and contraindicated for laparoscopy, were treated using an open intraperitoneal mesh technique. There were 50 females and 11 males, with a mean age of 61. The median ASA score of the group was 2.3, with a mean BMI of 34 kg/m(2) and a mean hernia surface of 182 cm(2). Sixty-four percent of the patients had undergone one or more previous incisional hernia repairs. RESULTS: Mean operating time was 130 min, with an average hospital stay of 13 days. None of the patients died. Postoperative complications occurred in 21% of the patients; most of which were minor, but two cases (3.3%) developed deep abscesses requiring surgery and removal of the mesh. A recurrence rate of 5% was found after a mean follow-up of 35 months (8-88). CONCLUSION: Open intraperitoneal mesh repair appears to be a good option for the treatment of complex incisional hernia (at least 10 cm in diameter or multiorificial) in obese patients contraindicated for laparoscopy.

[Diaphragmatic hernias, excluding hiatal hernias with gastroesophageal reflux]. / Les hernies diaphragmatiques á l'exception des hernies hiatales avec reflux gastro-oesophagien.

Large, mixed hiatal hernias are usually found between the ages of 60 and 70 years, with a female predominance (60%). The natural history is progression toward the appearance of symptoms, although 30%-40% of patients are initially asymptomatic. Symptoms develop quietly. The indication for surgical treatment of hiatal hernias amounts to considering the risks of leaving it in place. The literature reports a morbidity and mortality rate related to the complications of these hernias, leading to emergency interventions, which have an incidence of 1.16%.with a 27% mortality rate. Morbidity appears different depending on the approach used: laparoscopy or laparotomy (4.3% versus 16%). The debate continues on whether to monitor or treat these hernias, with a lack of consensus on the indications and the technique. However, the laparoscopic approach shows a gain in the length of the hospital stay, an easier approach to the hiatus in the diaphragm, and a lower morbidity and mortality rate. Fundoplication is advised, as well as placing prosthetic mesh if the orifice is larger than 8 cm. There is no indication for lengthening the esophagus (Collis-Nissen fundoplication).

[Comparison of quality of life in morbidly obese patients and healthy volunteers. A prospective study using the GIQLI questionnaire]. / Qualité de vie des patients obèses relevant d'un traitement chirurgical comparée à celle d'une population témoin. Etude prospective utilisant le questionnaire GIQLI.

BACKGROUND: Morbid obesity decreases the quality of life. The aims of surgical and medical treatment are weight loss, reduction of co-morbidity, and improved quality of life. AIMS: To compare the quality of life between obese patients (BMI: 40 or>35+comorbidity) and healthy volunteers using the GIQLI (Gastrointestinal Quality of Life) questionnaire. PATIENTS: Between January 2001 and December 2002, 127 morbidly obese patients (109 female, 18 male) with a mean age of 40.1 years were surgically treated with laparoscopic gastric banding. Quality of life, as measured by the GIQLI questionnaire, was systematically evaluated pre-operatively. During the same period, a control group of 125 healthy volunteers of comparable age, gender, and prior surgical history were evaluated using the same questionnaire. RESULT: The two groups, while comparable in age and gender, were significantly different in terms of weight (123 vs. 66 kg), BMI (44.3 vs. 22.2) (p<0.001), co-morbidity factors (p=0.001), and professional activity (p=0.02). The mean global GICLI score was 122 for healthy individuals and 95 for morbidly obese patients. (p=0.001), and the differences were most marked in the super obese. These differences particularly involved social dysfunction, physical status, and emotional symptoms but were not significantly different for gastrointestinal symptoms. CONCLUSION: The quality of life in morbidly obese and super obese patients is significantly diminished from that of a control population. There was good correlation between the degree of obesity (BMI) and the alteration of the GIQLI global and subscales scores. Quality of life should be systematically evaluated before and after both medical and surgical therapy.

[Value of the informed consent in digestive surgery? Prospective study 259 cases]. / Le consentement éclairé: quelle est sa valeur en chirurgie digestive? Etude prospective sur 259 cas.

SITUATION: In 1997 the Supreme Court of Justice decreed that "the doctor is responsible for giving his patient certain information and is obliged to prove that the information has been given". French surgical societies recommend using a form of informed consent signed by the patient applicable to all practices. AIMS: To evaluate a step taken systematically since 1999 in our department. PATIENTS AND METHODS: A prospective study was put into place for 259 patients candidate for elective surgery. All patients signed and returned the "informed consent" before surgery. The day of leaving the hospital, they answered a post-operative questionnaire to evaluate what they remembered of the "informed consent form" and the quality of information. RESULTS: Ninety three per cent of them remembered it. Eight per cent signed it without reading it. Eighty two per cent of the patients think that this document is useful for their medical records. Among the patients who did not read the informed consent form: 38% wished it gave more information, whereas only 16% of those who had read it, considered the given information inadequate. This difference is statistically (p=0.03) significant. CONCLUSION: The informed consent form gives a lot of information to the patients, but the surgeon is still obliged to do likewise. Patients who did not read the consent were less satisfied with the given information than those who had read it. The positive reaction of the patients in favour of the form makes it evident that the existence of the form reassures them.

Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery.

BACKGROUND: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Impact of peritoneal tears on the outcome and late results (4 years) of endoscopic totally extra-peritoneal inguinal hernioplasty.

BACKGROUND: The reported rate of intra-operative peritoneal laceration during endoscopic extra-peritoneal hernioplasty (TEP) ranges from 10 to 64%. AIMS: To evaluate in a prospective study the predictive factors of peritoneal tears, their consequences in terms of outcome and late results. PATIENTS AND METHODS: Between July 1994 and December 2000, we performed 467 endoscopic extra-peritoneal hernia repairs (TEP). In 14.8% of the cases, single or multiples recurrences after conventional open herniotomy were treated. One hundred and forty-nine patients (38%) had had previous surgery (appendectomy); 277 procedures (70.8%) were performed by experienced surgeons and 114 (29.2%) by surgical trainees. We used a diathermic hook in 26.3% of the procedures. The mean follow-up period was 68 months (48-100). RESULTS: Peritoneal tears occurred in 43 patients (10.9%). Six of them (13%) required operative closure, and six a conversion (four Lichtenstein, one Shouldice, and one TAPP). In 37 cases (86%), the tears were not closed. Peritoneal tears were significantly correlated with surgical experience, Nyhus classification, scar adhesion from previous surgery and the use of sharp instruments. Peritoneal tears interfere significantly (P=0.001) with the operating time (82 vs. 63 min) and conversion rate (13.9 vs. 1.7%). It does not affect the outcome and late results in terms of recurrences, pain, or small bowel obstruction. CONCLUSION: Our data suggest that peritoneal tears in the vast majority of cases may be safely managed without peritoneal closure. In case of peritoneal laceration, the operative time was significantly longer, and the conversion rate was increased. These situations do not affect the outcome and late complications compared with the procedures without peritoneal tears.

[Surgical training and inguinal hernia repair]. / L'enseignement de la chirurgie influence-t-il les résultats des cures de hernies de l'aine?

AIMS: To evaluate influence of surgical experience on inguinal hernia repair. PATIENTS: From 1997 to 2003, 380 patients (mean age 55 years old) with primary unilateral inguinal hernia were treated by Lichtenstein technique. METHODS: In this retrospective study, surgeons were classified in three groups: group 1: hernia repair was performed by an experimented surgeon (consultant or senior registrar) and a young surgical trainee (resident) (161 cases); group 2: surgery was performed by a junior surgeon (resident) under the control of an experimented surgeon (135 cases) and in the group 3 (84 cases), Lichtenstein technique was performed by two residents, alone, supervised by an experimented surgeon, in the operative room. Evaluation criterion were operative time, hospital stay, morbidity, time to return to normal and professional activities, recurrences and chronic pain with a follow up of, at least, 2 years. RESULTS: The three groups were comparable in term of socio economic data, hernia and follow up. The only significant (P=0.01) difference concern operative time which increased from 20% for group 2 and 3 (residents) compared to the group 1. There was also no difference between junior and senior resident. CONCLUSION: Lichtenstein hernia repair should be performed by young surgeon in training alone in condition of precise teaching organization and experimented surgeon supervision. For patient, in this condition, there is no trouble in term of surgical results.

Inguinal hernia repair with beta glucan-coated mesh: results at two-year follow up.

In a prospective study, 115 patients with a mean age of 55 years, presenting a primary or recurrent hernia were treated with a beta glucan-coated polypropylene mesh (Glucamesh). Fifty-eight underwent a Lichtenstein procedure and 57 had a laparoscopic procedure (TEP/TAPP). Oat beta glucan is an entirely natural plant product that eliminates the risk of viral or prion contamination associated with the use of collagen of animal origin. The beta glucan coated mesh is of lower weight and profile compared to a typical polypropylene implant. Preliminary results have been previously reported. With a mean follow up of 2 years, patients were evaluated by a physician and or a standardized questionnaire in order to evaluate the incidence rate of recurrence discomfort and residual chronic pain. One hundred nine (94.7%) questionnaires were returned. Of these, 104 (90.4%) were complete and analyzed. Mean follow up was 24 months (21-27). Two years after operation the recurrence rate was 1.9% (two cases: one in each group); 98 patients (94.2%) had no pain and have returned to normal activity, work and sport. Five patients (4.8%) had mild pain on moving or at rest and one (0.96%) had moderate pain at rest. There was no correlation between pain and hernia type or surgical technique. At 2 years follow up hernia repair with beta-glucan coated mesh has a low recurrence rate. Incidence of chronic pain is low. The situation is in relationship with a lightweight and smooth mesh of polypropylene and the role of oat beta glucan optimizing the healing and inclusion of the mesh into the tissues.

[Are there predictive items of successful surgery in morbid obesity treated by adjustable gastric banding: a prospective study]. / Existe-t-il des facteurs prédictifs de succès dans le traitement de l'obésité morbide par anneau périgastrique modulable? Etude prospective.

BACKGROUND: Surgical treatment of morbid obesity by perigastric adjustable banding give at mid term follow up, contrasted results which associate success, failure and intermediate situations. AIMS: The objective of this work was to prospectively validate predicting items that would predict success in the surgical treatment of morbid obesity by adjustable gastric banding. MATERIAL AND METHODS: Eighty patients with morbid obesity have been treated with adjustable gastric banding. Seventy-one women, and nine men with a mean age of 37.8 years (20-59) with a mean follow up of 17 months (12-52). They have been classified in three groups: success, failure, and intermediate results. Uni- and multivariate analysis was performed on six criteria: age, sex, professional activity, metabolic disorders, length of obesity and body mass index (BMI). RESULTS: Concerning age, sex, professional activity, metabolic disorders, and length of obesity, there was no difference between the three groups. However, a BMI more than 50 kg/m(2) has a strong predictive value. Patients called "super obese", BMI >50, has a high rate of failure (64%) even the weight loss is often important in absolute value, but the BMI at the follow up remain high and more than 40. In this situation: gastric banding does not seem a good treatment because it does not protect these patients against the lethal risk of their comorbidities. CONCLUSION: In this study, there is not a specific candidate "profile" to a successful treatment of morbid obesity by adjustable gastric banding. Meanwhile the initial BMI appear to be a predictive factor of success or failure. In the case of patients with high BMI >50 (super obese) gastric banding did not seen to be a good treatment and another technical approach (gastric bypass) must be discussed.

[Drug interactions in an elderly population. Prospective assessment of their frequency and seriousness among 56 patients]. / Interactions médicamenteuses dans une population âgée.

OBJECTIVE: To assess the nature and the number of potential adverse drug interactions by analysis of outpatient prescriptions for elderly patients, of medications taken during the week before hospitalization in a general surgery department. METHOD: The study of 56 patients older than 65 years was conducted from November 2002 through February 2003. The outpatient prescriptions corresponding to medications taken during the 7 days before admission were analyzed by a pharmacy resident, who used data-processing tools and databases. RESULTS: Most patients (83%) knew the reason for their prescription. Thirteen (28%) reported using over-the-counter medication. Only 89% of the patients reported complete compliance with the prescription. The average age of the patients was 72.1 +/- 6.3 years and the median was 71 years [65-91]; 43% were women and 57% men. The 257 lines of prescriptions analyzed averaged 5.7 +/- 2.6 drugs (range: 2-10) per prescription. The average number of possible interactions was 3.1 +/- 2.8 per prescription for a total of 89 listed potential interactions. The levels observed were 3 warnings (3%), 37 precautions (42%) and 49 possible adverse interactions (55%). No contraindication was noted. The drugs mentioned most often were benzodiazepines, diuretics, conversion enzyme inhibitors, angiotensin II inhibitors, and beta-blockers. The potential risks most often found were hypotension, depression of the central nervous system, hypoglycemia and acute renal failure. The drug interactions were mainly due to the accumulation of the effects of separate drug classes. Deterioration in renal function was often noted as plasma concentration of the second drug increased. DISCUSSION: This exploratory study shows the reality of the iatrogenic risk for elderly patients. This analysis of outpatient prescriptions is consistent with findings in the literature. Analysis of interactions is conducted on a pairwise basis. It is thus difficult to envisage the consequences of the association of 5 or more drugs in patients with complex illnesses and diminished physiological and metabolic capacity. Patient files kept by the pharmacist could provide information about individual combinations ofthe prescription and over-the-counter drugs.

Laparoscopic treatment of pancreatic pseudocysts.

BACKGROUND: A multicentric study was performed to evaluate the clinical results after laparoscopic treatment of pancreatic pseudocysts (PP). METHODS: We collected the data of 17 patients presenting with PP and operated on by laparoscopy between 1996 and 2001. There were nine men and eight women with a median age of 42 years (range 30-72). In 15 patients the PP developed after acute pancreatitis and the median delay between the acute onset and surgery was 7 months (range: 2-24). In two patients the PP was associated with chronic pancreatitis. All the patients had a single PP with a median diameter of 9 cm (range: 5-20). RESULTS: According to the location of the PP, a cystogastrostomy was performed in 10 patients and a cystojejunostomy in seven patients. The median operative time was 100 min (range: 80-300). Laparoscopic PP surgery was completed successfully in 16 patients and the median size of the cystoenterostomy was 3 cm (range: 2-5). Necrotic debris was present within the PP in 11 patients. The median postoperative hospital stay was 6 days (range: 4-24). No mortality and no immediate morbidity were recorded. However, two patients were readmitted within the first 3 postoperative weeks because of secondary PP infection. The first patient had an early closure of cystogastrostomy and was treated by endoscopic placement of a stent. The second represented with a right retrocolic abscess after cystojejunostomy and was treated by percutaneous drainage. One patient was lost for follow-up 2 months after surgery. The others had regular clinical and radiological controls. With a median follow-up of 12 months (range: 6-36), no recurrence of PP was observed. CONCLUSIONS: The laparoscopic treatment of PP was associated with a low postoperative complication rate and an effective permanent result. That approach avoided some difficulties, particularly bleeding that is classically linked with endoscopic internal drainage.

Laparoscopic antireflux surgery: comparative study of Nissen, Nissen-Rossetti, and Toupet fundoplication. Société Française de Chirurgie Laparoscopique.

BACKGROUND: The aim of this retrospective study was to compare the results of Nissen, Nissen-Rossetti, and Toupet laparoscopic fundoplication in terms of gastroesophageal reflux disease (GERD). METHODS: From 1992 to 1996, 1,470 laparoscopic fundoplications were performed using one of three procedures: Nissen (n = 655), Nissen-Rossetti (n = 423), and Toupet (n = 392). Preoperative checkup included esophagogastroduodenoscopy in 1,437 patients (97. 7%), esophageal manometry in 934 patients (63.5%), and 24-h pH-metry in 799 patients (54.3%). The results were estimated at 1 month, 3 months, and 2 years. Patients unable to visit the hospital center were contacted by telephone. RESULTS: The three groups were quite similar regarding demographic data such as age, gender, preoperative clinical symptoms, and duration of GERD. One death (0.07%) occurred. At 3 months, there were no differences among the three groups concerning conversion, morbidity, dysphagia, early reintervention, or postoperative length of stay. The length of surgery was more important in the Toupet procedure. In the Nissen group, there were fewer Visick grade I patients but more Visick grade III patients. At 2 years, the recurrence and reintervention rates were similar. The overall residual severe dysphagia rate was 0.35% (n = 5). In the Nissen group, there were fewer Visick grade I patients but more in Visick grade II patients. There was no difference in Visick grade III and IV among the groups. More than 90% of the patients were satisfied (Visick I + Visick II), with no significant difference among the three groups. CONCLUSIONS: The results of this study do not differ significantly from the data reported in the literature, suggesting such surgical techniques are effective and well tolerated, and that both can be properly used in the treatment of GERD.

Elective laparoscopic colonic resection for diverticular disease: results of a multicenter study in 179 patients.

BACKGROUND: We undertook a retrospective multicenter study of elective laparoscopic sigmoidectomy for diverticulitis in order to assess the safety and the results of the procedure performed by a large number of surgeons. MATERIALS AND METHODS: Between January 1998 and April 1999, the French Society of Laparoscopic Surgery recruited retrospectively 179 patients from 10 surgical units, operated on for elective laparoscopic sigmoidectomy. There were 94 men and 85 women with a mean age of 58 years (range, 30-82). The indications for surgery were acute attacks in 123 cases, complicated diverticulitis in 47 cases, and miscellaneous in 9 cases. RESULTS: The performed procedure was a successful laparoscopic assisted sigmoidectomy in 154 cases (with totally intracorporeal anastomosis in 136 cases and hand-sewn anastomosis via small incision in 18 cases). The mean operation time was 223 min +/- 79 (range, 100-480). There was no mortality and 23 complications occurred in 23 patients (14.9%). Postoperative ileus lasted 2.5 +/- 0.9 days (range, 1-6), and oral intake started after 3.3 +/- 1.3 days (range, 1-12). The mean postoperative stay was 9.3 days (range, 4-50). Conversion to laparotomy was necessary in 25 cases (13.9%). The essential causes of conversion were obesity, severe adhesions, and colonic inflammation. The mean postoperative stay for the 25 converted patients was 13 +/- 8.5 days (range, 7-42). CONCLUSION: Elective laparoscopic sigmoidectomy for diverticulitis is feasible and is safe. The complication and mortality rates are similar to those observed after open procedures. For experienced surgical teams, laparoscopic colonic resection is a good approach for selected patients suffering from symptomatic diverticulitis.

Management of recurrent inguinal hernias: a prospective study of 163 cases.

There remains debate as to how recurrent inguinal hernias should be managed. This study aimed to establish a management plan for recurrent hernias. From 1991-2000, 163 patients were operated on for recurrent inguinal hernias. The average interval from the initial surgery to recurrence was 46 months (range 10 days-13 years). The initial surgery prior to recurrence was Shouldice and other techniques without mesh in 142 cases, a Stoppa or a Lichtenstein procedure in ten and three cases, respectively, and laparoscopic repair in eight cases. The recurrent hernias were treated with a Shouldice repair in 52 cases (31.9%), the Lichtenstein technique in 48 cases (29.4%), a totally extraperitoneal laparoscopic repair in 40 cases (24.5%), and a Stoppa procedure in 23 (14.1%). The approaches to management evolved with time: the use of prostheses for recurrent hernia repair increased from 10% in 1991 (2/10) to 100% in 2000 (22/22). In contrast, the Shouldice repair decreased from 90% (18/20) in 1991 to 0% (0/22) in 2000. The Lichtenstein technique was first employed in 1993, in patients with a history of a conventional, laparoscopic, or Stoppa repair and has increased to represent 77% of cases (17/22) in 2000. The Stoppa technique has not been used since 1998. The use of a totally extraperitoneal laparoscopic approach went from 11% (2/18) in 1992 (introduction of the technique) to 23% (5/22) in 2000 and is reserved for recurrence after a Lichtenstein procedure or after conventional repair in working and/or physically active patients without any contraindications to general anesthesia. Prosthetic reinforcement has become the norm in the treatment of recurrent hernias. Given a previous conventional repair, the prosthesis can be placed by either an anterior or posterior approach. The approach is dependent on the level of activity and operability of the patient. If the recurrence follows a totally extraperitoneal or a Stoppa procedure, then the Lichtenstein intervention is recommended. A recurrence after a Lichtenstein procedure should be treated by a totally extraperitoneal approach.