Multicentre, randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis.

BACKGROUND: The best way to manage generalized peritonitis complicating sigmoid diverticulitis is controversial. This randomized clinical trial involved a comparison of primary resection and suture, drainage with proximal colostomy followed by secondary resection. METHODS: From January 1989 to December 1996, 105 patients of mean(s.d.) age 66(14) (range 32-91) years were randomized to undergo primary or secondary resection. The main endpoint was occurrence of generalized or localized postoperative peritonitis. The Mannheim Peritonitis Index score was calculated for each patient to check for comparability of groups. RESULTS: Postoperative peritonitis occurred less often after primary than secondary resection whether considering the first procedure only (one of 55 patients versus ten of 48; P < 0.01) or all procedures (one of 55 versus 12 of 48; P < 0.001). Likewise, early reoperation was performed less often following primary resection than secondary resection (two of 55 versus nine of 48 (P < 0.02) and two versus 11 (P < 0.01)), leading to a shorter median first hospital stay for patients having primary resection (15 days) than for those undergoing secondary resection (24 days) (P < 0.05). The mortality rate did not differ significantly with regard to operative policy (primary resection 24 per cent versus secondary resection 19 per cent) or type of peritonitis (faeculent 27 per cent versus purulent 19 per cent). No patient died following a second or third procedure. CONCLUSION: Primary resection is superior to secondary resection in the treatment of generalized peritonitis complicating sigmoid diverticulitis because of significantly less postoperative peritonitis, fewer reoperations and shorter hospital stay.

[Hand-sewn intra-abdominal anastomosis performed via video laparoscopy during colorectal surgery]. / Anastomose manuelle intracorporelle sous vidéolaparoscopie au cours de la chirurgie colorectale.

STUDY OBJECTIVE: Laparoscopic colectomies have been recently shown to be feasible and safe, with the use of stapling devices to fashion the anastomosis. The aim of this study was to evaluate the feasibility and safety of laparoscopic intra-abdominal hand-sewn anastomosis. PATIENTS AND METHODS: Seven patients (four males and three females, mean age 48 years) were included. There were two ileocolic resections for recurrence of Crohn's disease, two right colectomies (one for Crohn's disease and one for carcinoid tumor of the appendix), two left colectomies for diverticulitis and one segmental colectomy for sigmoid volvulus. There were: four side-to-side anastomoses, two side-to-end anastomoses and one end-to-end anastomosis. Anastomoses were fashioned with interrupted single layer sutures in four cases (two ileo-colic and two colorectal anastomoses) and with single layer running sutures in three cases (two ileo-colic and one colo-colic anastomoses). The specimens were retrieved by means of a plastic bag through a 3 to 5 cm long minilaparotomy in five cases and through the rectum in two cases. RESULTS: Mean additional time to perform hand-sewn intra-corporeal anastomosis was 90 +/- 15 min. There was no operative mortality and no intraoperative complications. Postoperative course was uneventful in six patients. Patients were started on an oral fluid diet on day 2 and discharged on day 5, except for one patient with Crohn's disease who had a severe anastomotic bleeding on postoperative day 2 and who required laparotomy for hemostasis through a service colotomy with a single suture. He was discharged on day 8. CONCLUSION: Intra-abdominal hand-sewn anastomoses are feasible and seem reliable. This represents a new step making laparoscopic procedures even closer to conventional techniques. This technique must be evaluated in larger series.

Prevention of deep abdominal complications with omentoplasty on the raw surface after hepatic resection. The French Associations for Surgical Research.

BACKGROUND: Several methods have been suggested to treat the hepatic raw surface after resection. Among these, omentoplasty (OP) has been employed occasionally but there are no clinical studies that clearly demonstrate its usefulness. METHODS: Of 172 randomized patients undergoing hepatic resection between January 1991 and December 1994, 5 were withdrawn for protocol violation, leaving 167 who were randomly allotted to undergo OP (n = 87) on the hepatic raw surface or not (NO; n = 80). This procedure was performed for malignant tumor in 125 cases, benign tumor in 33, and for other causes in 15. Six patients had more than two types of lesions, and 32 patients had associated cirrhosis. Sixty-five major and 102 minor hepatic resections were performed. The main outcome measures studied were the number of patients with deep abdominal complications (DAC; deep bleeding or hematoma, deep infection, with or without pus discharge through drains, bile leakage), as well as repeat operations and postoperative death. Patients were divided into two strata according to the site of the lesion with respect to the diaphragm: (1) in contact (posterosuperior segments II, VII and VIII) or (2) not in contact (anterior segments III, IV, V, and VI). RESULTS: Both groups were comparable as regards patient demographics, intraoperative procedures, intraoperative search for bile leaks and intraoperative transfusion requirements. Fewer patients had DAC in OP (n = 11) than in NO (n = 15) (difference not significant). Ten patients (6%) required repeat operations: 4 in OP without immediate mortality and 6 in NO, 3 followed by death. One further patient in OP required repeat operation after discharge and died. Four patients died in OP and 7 in NO, 1 and 4 of DAC, respectively (not significant). Deep abdominal complications were significantly associated with major hepatic resection (P <0.05) whereas postoperative death was significantly correlated with cirrhosis (P <0.05). CONCLUSIONS: OP on the raw surface after hepatic resection lowers the rate of all complications related to DAC (except biliary leaks) and their severity (repeat operations and death) but not significantly so. OP is not recommended as a routine measure to complete elective hepatic resections.

Outcome of Budd-Chiari syndrome: a multivariate analysis of factors related to survival including surgical portosystemic shunting.

The aim of this study was to assess the factors, including surgical portosystemic shunts, which affect survival in adults with Budd-Chiari syndrome. Multivariate retrospective analysis was performed using characteristics recorded at the time of diagnosis in 120 patients admitted from 1970 to 1992, of whom 82 were treated with surgical portosystemic shunts and 38 received only medical therapy. The 1-, 5-, and 10-year survival rates were 77 +/- 4%, 64 +/- 5%, and 57 +/- 6%, respectively. Survival was significantly better in the subgroup of patients diagnosed after versus before 1985. In both subgroups, and in patients with, as well as in patients without surgical shunts, 4 factors were found to be inversely and independently related to survival: age, response of ascites to diuretics, Pugh score, and serum creatinine. In patients diagnosed since 1985, an index combining these 4 factors allowed to differentiate patients with a good outcome (5-year survival 95%) from those with a poor outcome (5-year survival 62%; P <.05). There was no statistically significant and independent influence of surgical portosystemic shunts on survival. In conclusion, age, severity of liver failure, and presence of refractory ascites are the main prognostic factors in Budd-Chiari syndrome. Increased survival in recent years is consistent with improved management of hypercoagulable states as well as improved general care. It is uncertain whether surgical portosystemic shunting favorably modifies survival. Therefore, we recommend that surgical shunting should be restricted to management of refractory ascites or variceal bleeding in patients with otherwise good prognostic factors.

Omentoplasty in the prevention of deep abdominal complications after surgery for hydatid disease of the liver: a multicenter, prospective, randomized trial. French Associations for Surgical Research.

BACKGROUND: Omentoplasty (OP) is thought to fill residual cavity, to assist healing of raw surfaces, and to promote resorption of serosal fluid and macrophagic migration in septic foci. Results published to date, whether retrospective or prospective, are not controlled and are discordant. STUDY DESIGN: The authors investigated whether OP, either filling the residual cavity after unroofing, or covering the hepatic raw surface after pericystectomy, could reduce the rate or severity of deep abdominal complications (DAC) after surgical treatment of hydatid disease of the liver. Between January 1993 and December 1996, 115 consecutive patients (51 males and 64 females, mean age 42+/-16 years [range 10 to 80 years]) with previously unoperated uni- or multilocular hydatid disease of the liver, complicated or not, without other abdominal hydatid disease, were randomly allotted to OP (n = 58) or not (NO) (n = 57) after unroofing, total, or partial pericystectomy. Patients were divided into 2 strata according to the site of the cyst with respect to the diaphragm: a) posterosuperior segments II, VII, and VIII or b) anterior segments III, IV, V, and VI. Main outcomes measures included deep bleeding, hematoma, infection, or bile leakage. Subsidiary measures included wound complications, extraabdominal complications, duration of operation, and length of hospital stay. RESULTS: Both groups were comparable regarding patient demographics, cyst characteristics, intraoperative procedures, search for bile leaks, and intraoperative transfusion requirements. On the other hand, more patients (86%) in NO had associated drainage of the abdominal cavity than in OP (64%) and the duration of operation was 9 minutes longer in OP, but neither of these differences was statistically significant. Less DAC occurred in OP (10%) than in NO (23%) (a posteriori gamma risk < 0.05) and fewer deep abdominal abscesses (0 versus 11%) (p < 0.03). Median duration of hospital stay, however, was similar. CONCLUSIONS: OP decreases the rate of DAC and especially deep abdominal abscess after surgical treatment (unroofing or pericystectomy) for hydatid disease of the liver and should be recommended in this setting.

Further refinement of Pendred syndrome locus by homozygosity analysis to a 0.8 cM interval flanked by D7S496 and D7S2425.

Pendred syndrome is an autosomal recessive disease characterised by congenital sensorineural deafness and goitre. The gene responsible for Pendred syndrome has been mapped to chromosome 7q31 in a 5.5 centimorgan (cM) interval flanked by D7S501 and D7S523. This interval was recently refined a to 1.7 cM interval located between D7S501 and D7S692. In the present study, we report linkage analysis data on a large consanguineous family genotyped with eight microsatellite markers located between D7S501 and D7S523. Complete cosegregation with the disease locus was observed with the loci analysed, which further supports locus homogeneity for Pendred syndrome and close linkage to this region. Haplotype analysis placed the Pendred syndrome gene between D7S496 and D7S2425 in a 0.8 cM interval. This additional refinement of the Pendred syndrome region will facilitate the construction of a physical map of the region and will help the identification of candidate genes.

Hepatic venous outflow block caused by short-length hepatic vein stenoses.

In contrast with the well-recognized membranous obstruction of the inferior vena cava, short-length hepatic vein stenoses are not well-recognized causes of hepatic venous outflow block. The aim of this study was to ascertain the prevalence, causes, manifestations, and outcome of short-length hepatic vein stenoses. We performed a retrospective study of patients with short-length hepatic vein stenosis among 86 patients with hepatic venous outflow block who were seen between 1970 and 1992. There were 25 patients with short-length hepatic vein stenosis. A thrombogenic condition was identified in 14 patients (56%). The lesions of the accompanying hepatic veins in these patients were variable (short-length stenoses, thromboses, or nonspecific changes) and similar to that seen in patients without short-length hepatic vein stenosis. In 3 necropsied cases, the venous lesions were suggestive of fibrous sequela of prior thromboses. In patients with short-length hepatic vein stenosis, splenomegaly (28% vs. 55%, P < .05) and hypersplenism were significantly less common; serum transaminase (P < .001) and creatinine levels (P < .02) were lower, prothrombin was higher (P < .001), and 5-year survival was significantly better (Kaplan-Meier estimates: 80% vs. 50%, P < .05). In patients with hepatic venous outflow block, short-length hepatic vein stenosis is a common lesion that appears to be the sequela of localized thrombosis. Long-term anticoagulation and percutaneous angioplasty (with or without stenting) are potentially applicable in these lesions. The long-term results of these treatments merit further evaluation.

Budd-Chiari syndrome secondary to carcinoma: report of two cases.

In two patients who had Budd-Chiari syndrome secondary to carcinoma, the diagnosis was made intraoperatively at the time of emergency right atrial clearance required for severe cardiovascular distress. Curative resection was not possible and both patients died. As previously noted in the literature, it is extremely difficult to relate carcinoma to the origin of Budd-Chiari syndrome. Retro- and suprahepatic involvement of the vena cava is associated with a very poor prognosis. Complete resection of these tumors is the only potentially curative treatment. We suggest ways to obtain a simple and early histologic diagnosis before initiating appropriate and radical surgical treatment.

MRI of Budd-Chiari syndrome.

A retrospective study was undertaken to reassess the various magnetic resonance imaging (MRI) features of Budd-Chiari syndrome (BCS). MRI examinations of 22 patients with pathologically confirmed BCS were studied. Spin-echo (SE) T1- (TR = 300-450 ms/TE = 12-15 ms), and SE T2-weighted (TR = 1600-2000 ms/TE = 30-60/90-120 ms) MRI images were obtained in all patients. Gradient-recalled-echo (GRE) images (TR = 7-60 ms/TE = 3-19 ms, flip angle = 10-40 degrees) were obtained in 14 patients. MRI showed thrombosis of three or two hepatic veins in 19 (86%) and 3 (14%) patients, respectively. Spontaneous intrahepatic anastomoses was depicted in five (23%) patients. Ascites appeared in 15 patients (68%). Thrombosis or external compression of the inferior vena cava (IVC) by an enlarged caudate lobe was depicted in six (27%) and five (23%) patients, respectively. Prominent azygos and hemiazygos veins were demonstrated in seven (32%) patients (six of whom had thrombosis of the IVC). MRI showed hepatomegaly in all patients and enlarged caudate lobe in 18 (82%) patients. SE T1- and SE T2-weighted MRI images revealed inhomogeneous signal intensity of hepatic parenchyma in 14 (64%) patients. SE T1- and SE T2-weighted MRI images showed homogeneous signal intensity of hepatic parenchyma in eight (36%) patients. Our results demonstrate that BCS displays various features on MRI images, and such information is important for diagnosis.

Detection of recurrent hepatic metastases after partial hepatectomy: value of CT combined with arterial portography.

OBJECTIVE: We did a retrospective study to evaluate the sensitivity of CT combined with arterial portography in detecting recurrent hepatic metastases after partial hepatectomy. MATERIALS AND METHODS: CT scans combined with arterial portography in 18 patients who had partial hepatectomy and suspected intrahepatic recurrence of metastases were retrospectively reviewed. Eleven of the patients had further surgery, and recurrent hepatic metastases were proved; seven patients were inoperable. The sensitivity of CT with arterial portography for detecting recurrent intrahepatic metastases was determined and correlated with intraoperative findings and findings on follow-up imaging studies in the 11 patients (with a total of 23 hepatic metastases) who had further surgery. RESULTS: Not one of the 18 CT examinations combined with arterial portography was compromised by inhomogeneous perfusion of contrast material in the portal vein. Of the 23 metastases that were found in the 11 patients who had further surgery, 21 (91%) were shown on CT with arterial portography. In two patients, CT with arterial portography showed two subcapsular hypoattenuating pseudolesions that were correctly identified as nontumorous perfusion defects, as confirmed by intraoperative findings and follow-up imaging studies. CONCLUSION: This study shows that postoperative CT with arterial portography is efficacious in the detection of intrahepatic recurrent metastases in patients who have had a partial hepatectomy. Furthermore, prior partial hepatectomy does not compromise the quality of this examination.

Focal hepatic masses: comparison of detection during arterial portography with MR imaging and CT.

PURPOSE: A prospective study was performed to compare the sensitivity and specificity of magnetic resonance (MR) imaging and computed tomography (CT) both performed during arterial portography in depicting focal hepatic masses. MATERIALS AND METHODS: Eleven patients with 31 pathologically proved focal hepatic masses were prospectively evaluated. MR arterial portography was performed with 4 mL of a 0.5 mmol/kg solution of gadolinium tetraazacyclododecanetetraacetic acid (DOTA) injected through a catheter into the superior mesenteric artery during multisection gradient-echo imaging. RESULTS: MR arterial portography depicted 29 of the 31 masses (sensitivity, 94%). CT arterial portography depicted 27 of the 31 masses (sensitivity, 87%). Two masses not depicted with either CT or MR had a diameter of 3 and 7 mm, respectively. Neither MR nor CT demonstrated a false-positive finding (specificity, 100%). The difference in sensitivity and specificity between the two techniques was not statistically significant. CONCLUSION: MR arterial portography does not enable detection of significantly more focal hepatic masses than does CT arterial portography.

[Strangulated hernia and eventration]. / Hernies et éventrations étranglées.

Incarcerated hernia or wound dehiscence are responsible for more than 10% of small bowel obstructions. The complication is easily recognized when hernia or wound dehiscence was previously diagnosed. Difficulties occur when mass is deeply located in a thick abdominal wall or inside the inguinal canal. Femoral hernias and direct inguinal hernias are those which strangulate the most. Strangulation in wound dehiscence is the most severe. Strangulated hernia should be routinely excluded in patient with intestinal obstruction, to avoid inappropriate surgical approach.

Surgical treatment of hepatic metastases: impact of intraoperative sonography.

OBJECTIVE: A prospective study was done to determine the influence of intraoperative sonographic findings on surgical decision making in patients with hepatic metastases. SUBJECTS AND METHODS: Thirty-seven consecutive patients with hepatic metastases who underwent surgery (for hepatic resection or intraarterial catheter placement) were prospectively evaluated. For each patient, the resectability of the metastases and the surgical approach were determined preoperatively on the basis of the combined results of sonography, bolus dynamic CT, and CT during arterial portography (CTAP). Those determinations were compared with the decisions made during surgery, which were based on the intraoperative sonographic findings. The surgical procedure that was actually performed was compared with the procedure decided on preoperatively. RESULTS: Eighty-two metastases were surgically and pathologically proved. Preoperatively, 73 (89%) of the 82 metastases were detected with a combination of sonography, bolus dynamic CT, and CTAP. Seventy-nine metastases (96%) were detected with intraoperative sonography. Six metastases in four patients were detected only with intraoperative sonography. Furthermore, in two patients, intraoperative sonography showed four additional metastases, which changed the initial surgical approach decided on preoperatively. CONCLUSION: Our study suggests that intraoperative sonography provides important data that cannot be obtained with preoperative imaging techniques and affect the surgical decision making in patients with hepatic metastases.

Mesoinnominate shunt for the treatment of Budd-Chiari syndrome: evaluation with multimodality imaging.

The construction of a mesoinnominate shunt between the superior mesenteric vein and the left innominate vein is a recent surgical procedure for the treatment of Budd-Chiari syndrome with vena caval obstruction. The purpose of this study was to determine the role of the different imaging modalities for the follow-up of mesoinnominate shunts. Doppler US (n = 32), and MR imaging examinations (n = 32) were prospectively performed in 10 patients with mesoinnominate shunts. Shunt patency or thrombosis was confirmed with angiography (n = 32) and transhepatic portography with pressure measurement (n = 6). For each follow-up evaluation, all examinations were performed within 4 days. Shunt patency was correctly demonstrated in 28/28 cases with Doppler US, CT and MR imaging. Shunt thrombosis was correctly demonstrated in 4/4 cases with Doppler US, CT and MR imaging. Since Doppler US, CT and MR imaging have the same accuracy for diagnosing mesoinnominate shunt patency and detecting thrombosis, our study suggests that redundant screening methods can be avoided. Doppler US is accurate enough and should be the preferred technique in the evaluation of mesoinnominate shunts.

[Digestive hemorrhage caused by congestive gastropathy in a patient with liver cirrhosis: emergency treatment by transjugular intrahepatic portosystemic anastomosis]. / Hémorragie digestive par gastropathie congestive chez un malade atteint de cirrhose: traitement en urgence par anastomose porto-systémique intra-hépatique transjugulaire.

A 34-year-old woman with liver cirrhosis and portal hypertension was admitted for gastric bleeding due to congestive gastropathy. Her past medical history included 4 episodes of variceal rupture within the last 5 months. As medical treatment was a failure, an emergency transjugular intrahepatic portosystemic shunt was successfully performed, resulting in a marked drop in portal pressure (from 32 to 15 mm Hg) and a subsequent arrest of acute hemorrhage. Four months later, no recurrent bleeding has been observed and the shunt has remained patent as documented by duplex Doppler sonography.

MRI of liver metastases from colorectal cancer vs. CT during arterial portography.

A prospective study was performed to compare, with a lesion-by-lesion analysis, the sensitivities of high field strength MRI and CT during arterial portography (CTAP) in detecting hepatic metastases from colorectal cancer. Twenty-one patients with liver metastases from colorectal cancer were prospectively investigated by high field strength MRI (1.5 or 2 T) and CTAP. High field strength MRI was performed with pre and post gadopentetate dimeglumine enhanced T1-weighted SE sequences and T2-weighted SE sequences. All patients underwent partial hepatectomy and 37 metastases were surgically and pathologically proved. The metastasis detection rate (sensitivity) was 94% (35 of 37) for CTAP and 78% (29 of 37) for high field strength MRI. The 16% (95% confidence interval: 1-31%) difference in sensitivity between CTAP and high field strength MRI was statistically significant (p < 0.05, McNemar test). The use of gadopentetate dimeglumine did not improve the sensitivity of T1-weighted SE sequences. Since our study demonstrated significant difference in sensitivities between high field strength MRI and CTAP in our group of patients, we can conclude that high field strength MRI cannot replace CTAP in the preoperative evaluation of patients with liver metastases from colorectal cancer. Computed tomography during arterial portography must be considered as the preoperative gold standard.

[The role of embolization and chemo-embolization in the emergency treatment of hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma]. / Apport de l'embolisation et de la chimio-embolisation au traitement en urgence des hémopéritoines par rupture spontanée de carcinome hépatocellulaire.

Twelve caucasian patients with intraperitoneal hemorrhage due to spontaneous rupture of hepatocellular carcinoma were treated by emergency transcatheter arterial embolization (n = 9) or chemoembolization (n = 3). Pretreatment angiography showed active bleeding (extravasation of contrast medium) in two patients only. Successful hemostasis was initially achieved in all patients. Early recurrence of hemorrhage was noted in 3 patients with large tumors; two were successfully treated by a second embolization and one died immediately after the first embolization. Of the 12 patients, two underwent subsequent chemoembolization while two had surgical resection of their tumors. The mean length of survival was 7 months from the time of rupture. No serious complications related to embolization or chemoembolization were noted. Our data suggest that emergency embolization or chemoembolization is an effective treatment in caucasian patients with intraperitoneal hemorrhage from hepatocellular carcinoma. Prognosis of ruptured hepatocellular carcinoma in those patients, however, remains poor.

Preoperative assessment of resectability of hepatic metastases from colonic carcinoma: CT portography vs sonography and dynamic CT.

OBJECTIVE: A retrospective study was performed to determine the influence of CT portography vs sonography and dynamic CT on the preoperative assessment of the resectability of hepatic metastases from colorectal cancer. MATERIALS AND METHODS: Results of sonography, bolus dynamic CT, and CT portography in 28 patients who underwent surgical exploration (resection or intraarterial catheter placement) for hepatic metastases from colorectal cancer were retrospectively reviewed by two abdominal radiologists and one hepatic surgeon. For each patient, the resectability and surgical approach were decided on the basis of the results of combined sonography-bolus dynamic CT and compared with the decision made from the CT portographic results alone. The final approach suggested was compared retrospectively with the surgical procedure actually performed. RESULTS: Sixty-nine metastases were identified at surgery and pathologically proved. Combined sonography-bolus dynamic CT and CT portography showed 52 (75%) and 64 (93%) metastases, respectively. Twelve metastases in five patients were seen only with CT portography. In four patients, CT portography depicted additional metastases, which changed the surgical approach that had been chosen on the basis of results of sonography and bolus dynamic CT. In one patient, CT portography showed four additional metastases, precluding hepatic resection. CONCLUSION: Findings from CT portography provide vital data unattainable with sonography and bolus dynamic CT that improve the preoperative assessment of the resectability of liver metastases from colonic carcinoma.