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

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

A population-based study of the incidence, management and prognosis of hepatic metastases from colorectal cancer.

BACKGROUND: The aim of this population-based study was to evaluate the incidence, management and prognosis of patients with hepatic metastases related to colorectal cancer using data from the Digestive Cancer Registry of Calvados, France. METHODS: Of 1325 patients with colorectal cancer registered between January 1994 and December 1999, 358 developed hepatic metastases. Logistic regression was used to analyse prognostic factors. Survival analysis was carried out with Cox's proportional hazards model. RESULTS: Some 18.8 per cent of patients had synchronous metastases, while 29.3 per cent developed metastases at 3 years. Of patients with hepatic metastases, 17.3 per cent had a surgical resection, 40.2 per cent were treated with palliative chemotherapy and 42.5 per cent had symptomatic treatment. Factors associated with receiving symptomatic treatment only were age over 75 years and more than one metastasis, but not place of treatment. Median survival after a diagnosis of hepatic metastases was 10.7 (range 4.6-23.1) months. Significant adverse prognostic factors were: age over 75 years (P = 0.001), lymph node invasion of primary tumour (P = 0.024), bilateral distribution of metastases (P = 0.001), other metastases (P = 0.004) and symptomatic treatment only (P = 0.041). CONCLUSION: Despite improvement in treatment for hepatic metastases, age and extent of disease remain limiting factors for surgical resection and palliative chemotherapy.

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

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

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

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

Liver adenomatosis: reappraisal, diagnosis, and surgical management: eight new cases and review of the literature.

OBJECTIVE: Liver adenomatosis (LA) is a rare disease originally defined by Flejou et al in 1985 from a series of 13 cases. In 1998, 38 cases were available for analysis, including eight personal cases. The aim of this study was to review and reappraise the characteristics of this rare liver disease and to discuss diagnosis and therapeutic options. BACKGROUND: LA was defined as the presence of >10 adenomas in an otherwise normal parenchyma. Neither female predominance nor a relation with estrogen/progesterone intake has been noted. Natural progression is poorly known. METHODS: The clinical presentation, evolution, histologic characteristics, and therapeutic options and results were analyzed based on a personal series of eight new cases and an updated review of the literature. RESULTS: From a diagnostic standpoint, two forms of liver adenomatosis with different presentations and evolution can be defined: a massive form and a multifocal form. The role of estrogen and progesterone is reevaluated. The risks of hemorrhage and malignant transformation are of major concern. In the authors' series, liver transplantation was indicated in two young women with the massive, aggressive form, and good results were obtained. CONCLUSION: Liver adenomatosis is a rare disease, more common in women, where outcome and evolution vary and are exacerbated by estrogen intake. Most often, conservative surgery is indicated. Liver transplantation is indicated only in highly symptomatic and aggressive forms of the disease.

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

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

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

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

Bile duct cysts in adults: a multi-institutional retrospective study. French Associations for Surgical Research.

OBJECTIVE: To review the features of adult patients undergoing surgery for bile duct cysts, focusing on the anatomy of the biliary tree as well as the long-term outcome. SUMMARY BACKGROUND DATA: Bile duct cysts (BDCs) are uncommon in Western countries, and the majority of reported cases originate from Asia. Japanese authors have emphasized the frequent association of extra- and intrahepatic bile duct dilatations, but grading of patients based on Todani's classification is often hindered by the absence of an accurate definition of types IC and IVA cysts. Moreover, despite the increasing use of extrahepatic cyst excision, little is known about the long-term outcome in patients with intrahepatic bile duct involvement. METHODS: Forty-two adult patients with BDC were treated between 1980 and 1992 in 17 institutions of the French Associations for Surgical Research. Clinical presentation, radiologic presurgical evaluation, and surgical procedures were analyzed. The long-term postsurgical outcome was derived from patient charts, attending physicians, or direct patient contact. RESULTS: Twelve patients (30%) had recurrent abdominal pain or jaundice from childhood. Seven (17%) had undergone prior cystenterostomy. Twenty-one (50%) had a Todani-type IVA cyst with extra- and intrahepatic bile duct involvement. Of these, nine had segmental, exclusively left-sided intrahepatic bile duct dilatation. Biliary carcinoma was encountered in five patients (12%). Extrahepatic cyst excision with a Roux-en-Y hepaticojejunostomy was performed in 34 patients with type I or IV cysts. The overall operative mortality rate was 2.4%. Long-term results were clearly correlated with cyst type: during a mean follow-up of 8.4 years, 11 of 12 patients (92%) treated by cyst excision for type I cyst remained free of symptoms, whereas 31% of patients who underwent surgery for type IV cyst had episodic or severe cholangitis with intrahepatic stones. CONCLUSIONS: In patients with BDC, particular attention must be given to the associated intrahepatic bile duct dilatations. We propose a modification of Todani's classification to distinguish cystic, segmental, and fusiform dilatations of the intrahepatic biliary tree in type IV cysts. In patients with segmental left intrahepatic cystic dilatations, combined left liver lobectomy and extrahepatic cyst excision is suggested to decrease late postsurgical biliary complications.

Results of liver transplantation in the treatment of metastatic neuroendocrine tumors. A 31-case French multicentric report.

OBJECTIVE: The purpose of this study was to assess the value and timing of orthotopic liver transplantation (OLT) in the treatment of metastatic neuroendocrine tumors (NET). SUMMARY BACKGROUND DATA: Liver metastasis from NET seems less invasive than other secondary tumors. This observation suggests that OLT may be indicated when other therapies become ineffective. However, the potential benefit of this highly aggressive procedure is difficult to assess due to the scarcity and heterogeneity of NET. METHODS: A retrospective multicentric study was carried out, including all cases of OLT for NET performed in France between 1989 and 1994. There were 15 cases of metastatic carcinoid tumor and 16 cases of islet cell carcinomas. Hormone-related symptoms were present in 16 cases (55%). Only 5 patients (16%) had no previous surgical or medical therapy before OLT. Median delay from diagnosis of liver metastasis and OLT was 19 months (range, 2 to 120). RESULTS: The primary tumor was removed at the time of OLT in 11 cases, by upper abdominal exenteration in 7 cases and the Whipple resection in 3. Actuarial survival rate after OLT was 59% at 1 year, 47% at 3 years, and 36% at 5 years. Survival rates were significantly higher for metastatic carcinoid tumors (69% at 5 years) than for noncarcinoid apudomas (8% at 4 years), because of higher tumor- and non-tumor-related mortality rates for the latter. CONCLUSION: OLT can achieve control of hormonal symptoms and prolong survival in selected patients with liver metastasis of carcinoid tumors. It does not seem indicated for other NET.

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

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

Pathologic assessment of tumor regression after preoperative chemoradiotherapy of esophageal carcinoma. Clinicopathologic correlations.

BACKGROUND: The benefits of preoperative chemotherapy and radiation for esophageal carcinoma are under investigation. A pilot study was undertaken to determine if pathologic assessment of tumor regression correlated with disease free survival. METHODS: Ninety-three resected specimens from patients treated with cis-dichloro-diamino cisplatin and irradiation before surgery were examined on semiserial sections. Patients selected for surgery were all Status 1 according to the World Health Organization (WHO) classification. Histologic typing was based on the WHO classification. Tumor regression grade (TRG) was quantitated in five grades: TRG 1 (complete regression) showed absence of residual cancer and fibrosis extending through the different layers of the esophageal wall; TRG 2 was characterized by the presence of rare residual cancer cells scattered through the fibrosis; TRG 3 was characterized by an increase in the number of residual cancer cells, but fibrosis still predominated; TRG 4 showed residual cancer outgrowing fibrosis; and TRG 5 was characterized by absence of regressive changes. Survival curves were estimated according to the Kaplan-Meier method. A quantification of the relationship between treatment failure and confounding variables (age, tumor location, tumor size, esophageal wall involvement by residual cancer and/or regressive changes, histology, treatment, adequacy of surgery, pathologic lymph node status, and tumor regression grade) was done using Cox's proportional hazards model. RESULTS: Forty-two percent of specimens were TGR 1-2; 20%, TGR 3; and 33%, TGR 4-5. Univariate analysis found that tumor size, pathologic lymph node status, tumor regression grade, and esophageal wall involvement were highly correlated with disease free survival (P < 0.05). After multivariate analysis, only tumor regression (i.e., TRG 1-3 versus TRG 4-5) remained a significant (P < 0.001) predictor of disease free survival. CONCLUSIONS: This study highlights the importance of tumor regression in the survival of patients with esophageal carcinoma treated with preoperative chemoradiotherapy. These findings suggest that tumor regression grade should be considered when evaluating therapeutic results.

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

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

[Antibiotic prophylaxis in surgery of the esophagus]. / Antibioprophylaxie en chirurgie de l'oesophage.

Surgery of oesophagus carcinoma is a long and major procedure. Perioperative radiochemotherapy is often required. Therefore many factors favour the occurrence of local and general postoperative infection, justifying an antibiotic prophylaxis directed against oesophageal and gastric flora. In case of oesophageal stenosis, the oesophageal floral often switches to the fecal type. Antimicrobial agents diffuse to the surgical site and reach there high concentrations for the time of surgery. We recommend, just prior the induction of anaesthesia the intravenous administration of a single dose of a third generation cephalosporin (ceftriaxone 2 g) and nitroimidazole (ornidazole 1 g). The long half-life of these agents allows sufficient concentrations at surgical site to be obtained and the efficacy of this regimen has been demonstrated. Selective decontamination of the digestive tract with systemic antibiotherapy is another approach for the prevention of postoperative complications of surgery of oesophagus carcinoma.

Clinical evaluation of the CORDIS vascular access port systems: a multicenter study.

Two non-metallic vascular access port systems, the Multipurpose Access Port (MPAP) and Miniport, developed by CORDIS S.A., France, have been evaluated clinically in 78 cancer patients. During the investigational period covering a total experience of 369 treatment cycles and 1,370 infusion days, no cases of infection or septicemia were observed. Serious complications such as drug extravasation and catheter occlusion occurred, although the incidence was relatively low (+/- 1%) when compared with the number of treatment courses (cycles), but in relation to the number of patients included in this study, the procedure-related complication rate was 17.5% for the MPAP and 15.8% for the Miniport. Procedure-related complications can be avoided by proper handling and use of suitable drug combinations to minimize crystallization reactions within the port-catheter systems. The final complication rate (total minus procedure-related) in terms of termination of treatment, i.e. explantation of the port-catheter system was 12.1% for the MPAP and 12.5% for the MINIPORT, which generally confirms the results of other groups. More than 87% of both port-catheter systems were still functional at the end of evaluation.

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

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

[Adenocarcinoma on endobrachyesophagus. Results and prognostic factors apropos of 19 cases surgically-treated]. / Adénocarcinomes sur endobrachyoesophage. Résultats et facteurs pronostiques à propos de 19 cas opérés.

The authors report about a retrospective series of 19 operated patients with adenocarcinomas in a columnar lined esophagus. The resection rate was 95%, the postoperative mortality rate was 5.5%. The survival rate following curative exeresis (n = 14) was 32% (+/- 14) at 5 years. All patients with a stage III lesion died after 2 years, while 46% (+/- 19) of those with stage I or II tumors (p less than 0.001) survived at 5 years. In a multivariative analysis, the most important prognostic factor is the histological grade (p less than 0.01), then the extension to the lymph nodes (p less than 0.1). As the adenocarcinoma often reveals the columnar lined esophagus, the improvement of the prognosis certainly depends on the evaluation of the treatment, which combines pre- or postoperative radiation and chemotherapy, in multidepartmental prospective studies.