Analytical study and long-term results of 230 highly selective vagotomies for chronic duodenal ulcer.

230 highly selective vagotomies (H.S.V.) for chronic duodenal ulcer are carefully studied. Per and postoperative complications are reviewed and compared with the most important reported statistics. A 10-year follow-up gives an indication of the late functional results and evaluation of the percentage of recurrences which lies at around 6%, on first estimation. A complete study of pre- and postoperative gastric secretion tests in duodenal ulcers which did not respond to treatment with Cimetidine and also in patients with very severe hyperacidity is reported, showing that, even in these cases, H.S.V. notably decreases acidity levels and gives satisfactory results. H.S.V. has practically no mortality, a very low morbidity and is followed by excellent functional results. The only factor which remains is the relatively high rate of recurrence which increases with time.

[Total duodenal diversion by fundo-jejunostomy with Roux-Y-loop in the treatment of severe postoperative recurrent reflux esophagitis]. / Die "totale duodenale Diversion" durch Fundo-Jejunostomie mit Roux-Y-Schlinge zur Behandlung der postoperativen rezidivierenden schweren Reflux-Oesophagitis.

Fundo-jejunostomy with a 60 cm long Roux-en-Y loop removes almost all symptoms in severe postoperative recurrent reflux esophagitis. We analysed 12 own cases and compared them with those published in literature. 90% of most satisfactory results were obtained. Nevertheless indication for fundo-jejunostomy must be discussed and limited to those cases, which do not respond to medical treatment.

[The "left-open abdomen". Technic, indication and results]. / Das "offengelassene Abdomen". Technik, Indikation und Resultate.

Critical evaluation of 22 cases with serious diffuse purulent or fecal peritonitis treated by open abdomen following surgical intervention. Seven (32%) patients died, three because of continuing sepsis and one because of acute haemorrhagic necrotizing pancreatitis. The three other died of general complications (1 coma hepaticum, 2 massive embolisms; at autopsy their abdominal cavity was entirely cleaned. The therapeutic principle of "open abdomen" in cases of severe purulent and fecal peritonitis will be recommendable.

[Agenesia of the gallbladder. Report of two new cases (author's transl)]. / L'agénésie de la vésicule biliaire. A propos de 2 nouvelles observations.

A propos 2 personal cases of a rare malformation, agenesia of the gallbladder, the authors reappraise the anomaly, of which the precise diagnosis is essentially surgical. They stress the frequency of associated malformation and the usefulness of operative exploration with cholangiography. There is no specific treatment for this condition. Draining the principle bile duct is warranted in case of choledocotomy.

[Indications and long term results after surgical treatment for necrotic acute pancreatitis (author's transl)]. / Indications opératoires et résultats à court et moyen termes de traitement chirurgical des pancréatites aiguês Nécrotico-hémorragiques.

A series of 50 patients with acute pancreatitis, all complicated by necrosis and hemorrhage, is presented. Cases are broken down into 3 main categories depending on clinical and laboratory data. Thirty-nine partial pancreatectomies and 11 excisions of necrotic tissue were performed. Operative mortality is 36%. Causes of death and morbidity were analysed. Are discussed modalities of surgery from clinical and intraoperative findings. Surgical procedure is completed by generous washings of the abdominal cavity followed by continuous drainage. External biliary diversion is assumed by mews of choledocostomy. Surgical procedure is to be adapted to local conditions because a too systemic attitude is dangerous and possibly responsible of over treatment complications. Postoperative clinical behavior is of great importance when one know that reoperatives in such difficult situation are frequent.

Appendicular mucocele and peritoneal pseudo-myxoma. / Mucoeéle appendiculaire et pseudo-myxome péritonéal

From 2 personal cases the authors present a pathological appraisal of appendicular mucoceles. They distinguish between a benign kind with an atrophic mucous membrane and a malignant type with a hyperplasic epithelium arranged in papillary and vegetating structures; this is a neoplasm with local malignancy. This variety remains the most liable to become a peritoneal pseudo-myxoma representing the most serious complication of the appendicular mucecele. Treatment of the mucocele, which consists in an appenicectomy or a right bemi-colectomy, usually yields good results provided operative rupture can be avoided. Contrarily the peritoneal pseudo-myxoma remains a serious disease with a disappointing treatment.

[Eugene Koebèrlé (1828-1915), founder of modern surgery]. / Eugène Koeberlé (1828-1915), père de la chirurgie moderne.

Eugène Koeberlé, surgeon and anatomist gained international renown due to his outstanding ability in resection of ovary cysts and in hysterectomy. He was one of the first to perform these operations successfully. He was a pioneer in asepsis and pre- and postoperative care. He also invented many surgical instruments, among them an efficient hemostatic forceps.

[Effect of surgery on the level of total and free thyroid hormones, reverse T3 and TSH]. / Effet de la chirurgie sur le taux des hormones thyroïdiennes totales et libres, la T3 inverse et la TSH.

Changes in total and free thyroid hormones, reverse triiodothyronine (rT3) and TSH were followed in 64 patients undergoing surgery and divided into three groups according to nature of surgery. Group I patients underwent extraperitoneal surgery, group II mild and group III heavy intraperitoneal surgery. A significant fall in total and free triiodothyronine (T3), a rise in rT3, free thyroxine (FT4) and in TSH were noted in each group after surgery, while total T4 levels remained unchanged. There was no correlation between the change in thyroid hormones and TSH. These changes are more marked in groups II and III than in group I. The rT3/T3 ratio was more elevated after surgery in group III than in group II. Thus the severity of the stress induced by surgery may interact with the mechanism of peripheral T4 conversion. The rise in FT4 may be interpreted as a consequence of the presence of an inhibitor of thyroid-hormonal binding to serum proteins. The slight increase in TSH levels seems rather due to stress than to a feed-back adaptation. The ratio rT3/T3 appears as an index of severity and prognosis.

[Value of blood lipase determination in pancreatic diseases. Comparison with blood amylase assay]. / Intérêt de la détermination de la lipasémie au cours des affections pancréatiques. Comparaison avec le dosage de l'amylasémie.

The comparative diagnostic value of plasma lipase and amylase levels was evaluated in 90 patients with various symptoms of pancreatic disease. Comparison with healthy subjects showed that the lipase assay was more sensitive than the amylase assay in patients with acute pancreatitis or post-traumatic pancreatic injury, but not in patients with chronic pancreatitis. On the other hand, acute pancreatitis can be detected earlier by measuring plasma amylase levels, owing to the rapid release of this enzyme. The relative importance of these two laboratory tests is discussed.

[Complicated colonic diverticulosis. Changes in treatment and results over 22 years]. / Diverticulose colique compliquée. Evolution du traitement et des résultats en 22 ans.

OBJECTIVES: The aim of this study was to analyse the clinical course, surgical strategy and results in patients with complicated colonic diverticular disease. METHODS: We retrospectively compared two groups of patients who underwent surgery for complicated colonic diverticulosis from 1970 to 1984 (Group A, n = 94, mean age 60 years, 49 males, 45 females) and from 1985 to 1992 (Group B, n = 76, mean age 63.5, 32 males, 44 females). RESULTS: Patients in the two groups were comparable; only the rate of peritonitis (20 vs 8%) was different (p < 0.05). The most frequent operations in Group A were colostomy-drainage (43%) and Hartman's procedure (26%) in emergency situations and resection with immediate anastomosis (63%) or resection-anastomosis with diverting stomy (19%) in elective cases. In Group B, surgical strategy led to a different pattern of operations, 4 and 56% in emergency, and 94 and 2% in elective surgery, respectively. Overall mortality was 11%, with 17% and 4% in Groups A and B respectively (p < 0.01). This major drop in mortality was particularly important in emergency cases (31 vs 4%; p < 0.02). Morbidity in emergency surgery fell from 21 to 4% (P < 0.0006). Interrupting the use of colostomy-drainage was a major factor in reducing mortality followed by a sharp fall in mortality after Hartmann's procedure (28.5 vs 0%). CONCLUSION: The marked improvement in results between the two groups was mainly due to preferring resections of pathological colonic segments over colostomy-drainage.

[Outpatient surgery. Why? How?]. / La chirurgie ambulatoire. Pourquoi? Comment?

One day surgery--defined by the fact that the patient enters the clinic in the morning and returns at home late in the afternoon--requires the observation of a whole of criteria which are absolutely necessary to guarantee the highest security as possible. At first an outstanding collaboration with the anesthetist is mandatory. Material conditions of its practice should'nt be neglected. Rooms and medical staff have to be appropriate. Indications of its performance are large but depend of the experience of the surgeon. Limits are ruled by the general status of the patient and also by his social conditions and his surroundings, not to forget an excellent collaboration with the general practitioner. Economic advantages seem obvious but have to be calculated. It is above all necessary to persuade the public hospital administrations and the social Security structures, of the interest and the advantages of one day surgery.

[The development of surgical therapeutic concepts of acute severe pancreatitis]. / Evolution des conceptions thérapeutiques chirurgicales des pancréatites aiguës graves.

The actual surgical concepts concerning the treatment of acute pancreatitis are described. Owing to sonography and above all to computed tomography, constantly compared with clinical data, the surgical decisions can be more easily conducted. In acute pancreatitis of biliary origin, endoscopic sphincterotomy is mandatory in a great number of cases, followed by complete de-obstruction of the common bile duct. That procedure has the advantage of reducing notably mortality and morbidity. In idiopathic pancreatitis, 4 therapeutic behaviours which correspond to 4 different clinical types, are to be faced: --or after 5 to 6 days, division of the left hypochondrium with performing of a meticulous cleaning, followed by a large drainage lavage, --if all reanimation measures have failed, earlier surgery, often of the last chance, consisting in necrosectomy as extended as necessary, --in right away appearing pancreatic phlegmon, a very large drainage, --or, a more expecting attitude in cases in which resorption of the necrotic spots appears to be very slow on CT-Scan, but without any clinical abnormality. Figures support these concepts and prove their warranty.

[What are the surgical indications for non-complicated duodenal and gastric ulcers?]. / Que reste-t-il des indications opératoires dans les ulcéres duodénal et gastrique non compliqués?

Taking into account recent medical progress and on the basis of their own experience, the authors define the up-to-date surgical management of non-complicated duodenal and gastric ulcers. Chronic duodenal ulcers still remain to be submitted to surgery in case of resistance to different types of medical drugs, in case of concomitant disease requiring a specific treatment contraindicated in ulcer disease, in case of patients refusing drugs or developing side-effects, and last, in posteriorly localized or bleeding ulcers. In these situations proximal gastric vagotomy (P.G.V.) still remains the best procedure owing to its low mortality (less than 0.5%) and morbidity rates, and its very satisfactory functional results. The recurrence risk, estimated between 10 to 15%, might burden the long-term results. But in a high percentage of cases it is related to technical inefficiencies. It has to be recalled that only 30% of these patients will undergo reoperation. But it should be emphasized that prepyloric ulcers are a poor indication for P.G.V. and should be submitted to truncular vagotomy with antrectomy. In gastric ulcers, the surgical treatment is mandated whenever endoscopic signs don't disappear under medical treatment or if biopsies remain suspicious. The most satisfying procedure is a gastric resection always involving the lesion and followed by a gastroduodenal anastomosis according to Péan-Billroth I.

[The surgical therapy of liver trauma]. / La terapia chirurgica dei traumi epatici.

The different therapeutic patterns of liver trauma are presented; they should be chosen on the basis of both clinical assessment, particularly looking for hemodynamic impairment and associated bowel lesions, and CT scan data. Surgical abstention should be considered for a great number of blunt liver trauma; open or severe blunt trauma should be preferably treated by elective hemostasis and biliostasis, with only rare use of hepatic resection "à la demande", on partially sectioned or devitalized tissues. Cavo-suprahepatic wounds remain the most important technical problem and continue to worse the prognosis in liver trauma.

[New vagotomy technics]. / Nouvelles techniques de vagotomies.

Various new more extensive operative procedures have been proposed with the aim of increasing efficacy of vagotomy and ensuring maximum neurotomy. Though based on the principle of neurotomy as accomplished by highly selective vagotomy, it is completed or combined with a seromyotomy along one or both sides of the lesser curvature or with one in the cardiofundal region. Technical aspects of these different methods are discussed.

[Current ideas in the treatment of severe acute pancreatitis]. / Conception actuelle du traitement des pancréatities aiguës graves.

The aim of this study is a current review of multidisciplinary therapeutic concepts in severe acute pancreatitis, the following being envisaged in succession: --severity criteria and factors involved in surveillance, --medical methods of intensive therapy, --surgical treatment in terms of its indications and tactical implications. Remaining in overall control, the surgeon must pay careful attention to the techniques used, and results achieved, by the intensive care specialist. In the presence of concomitant lithiasis of the common bile duct, it is essential to request endoscopic sphincterotomy first. The surgeon must interpret with the radiologist CT scan films in order to be able to wait, whilst remaining alert at all times, for the appropriate moment for any possible surgery. The surgeon must above all avoid being too active too early.

[Surgery of the left colon]. / La chirurgie du côlon gauche.

Some basic technical principles make the left colon surgery as safe as possible. The authors recall the surgical anatomy and the vascularization of the left colon and describe the technic of a left hemicolectomy, of the Hartmann procedure with restoration of the intestinal continuity and the closure of a lateral colostomy. Mastering these technics should help to face and resolve any urgent or regular pathological pattern of the left colon.

[Surgery of complicated diverticular sigmoiditis. Report of 138 cases (author's transl)]. / Le traitement chirurgical des sigmoïdites diverticulaires compliquées. A propos de 138 observations.

The authors analyse a series of 138 cases of complicated diverticular sigmoiditis treated surgically. They noted 50% of pyostercoral peritonitis, 32% of persigmoid abscesses, 13% of case of intestinal obstruction, and 5% of cases of fistual or hemorrhage. The overall mortality was 28% and depended mainly more on the surgical management adopted than on the type of complication. In this respect, simple colostomy with drainage of the septic focus had a mortality of 18%. The results suggest surgical operation in two stages, in the form of colonic resection, with, depending on each case, an anastomosis straight away with transverse colostomy or segmental colectomy with bitubular colostomy (Mikulicz procedure) or, in rarer cases, simple colostomy. The authors emphasise the interest of early surgery in sigmoiditis with complications and contrast the mortality of cold surgery which is now about 5% compared with 28% in emergency cases with complications.

[restoration of duodenal passage in severe postoperative syndrome after surgery for gastro-duodenal ulcers. Experience with 40 cases (author's transl)]. / Traitement des séquelles fonctionnelles graves de la chirurgie gastro-duodénale pour ulcère par la remise en circuit du duodénum. A propos de 40 cas.

The authors analyse 40 cases of restoration of duodenal passage for severe functional sequelae after surgery for duodenal ulcer. The type of reoperation depended upon the initial operation and thus after gastric resection with gastro-jejunal anastomosis, 26 procedures involving transposition of the efferent loop to the duodenum (Soupault-Bucaille operation) were performed, 8 conversions of a gastro-jejunal anastomosis to a gastro-duodenal anastomosis and one interposition of a small intestinal loop according to the technique of Henley. After gastro-enterostomy with or without vagotomy, 3 gastric resections with gastro-duodenal anastomosis were performed, and one replacement of a gastro-enterostomy, by a pyloroplasty. Operative mortality was 3/40 cases and long term results proved to be good in 80% of the patients.

[Hartmann's operation. Results in 96 cases and present indications]. / L'opération de Hartmann. Etude de 96 cas et indications actuelles.

The results of 96 Hartmann's operations performed over a period of 10 years are analyzed. Surgery was indicated for cancer in 72 p. cent of cases, the objective being palliative treatment in one ouf of two patients, for perforating necrotizing lesions of the colon in 11 p. cent, and for complications of sigmoid diverticulitis in 7 p. cent. Emergency intervention was necessary in 41 p. cent of cases. Overall mortality was 19 p. cent, half of these being related to the original lesion and the other half to complications due to the primary peritonitis. Re-establishment of intestinal continuity was possible in 15 p. cent of patients, must of whom had been operated upon initially for benign lesions. Postoperative mortality was nil in this group. Hartmann's operation should be employed mainly when abdominoperineal and anterior rectal resections are contraindicated. It is principally indicated for palliative treatment of rectal or rectosigmoid cancers, and for benign or malignant tumors with colonic sceptical complications.