[Pancreaticoduodenectomy for cancer of the head of the pancreas]. / Duodénopancréatectomie céphalique pour cancer.

Many modifications of the original technique have been proposed to try to improve the results of the pancreaticoduodenectomy described by Whipple. To evaluate these modifications, we have reviewed randomized controlled trials, meta-analyses, and well-conducted retrospective series. Neither total pancreatectomy nor extended lymph node dissections have shown an improve of survival in retrospective studies. Preoperative evidence of mesenteric or portal vein involvement does not contraindicate pancreatic resection and survival rates are similar to those of patients with no venous involvement. Prospective trials and one meta-analysis have shown neither advantage nor disadvantage of pylorus-preserving pancreaticoduodenectomy or of pancreatico-gastric anastomosis. Three trials and one meta-analysis of pancreatico-gastric anastomosis have failed to demonstrate a decrease in the risk of pancreatic fistula. Two trials suggest that the risk of fistula formation is decreased by implantation of the pancreatic remnant into the jejunum or by trans-jejunal stenting of the pancreatico-jejunal anastomosis with external drainage; but these findings are not supported by a third trial. The results of the antisecretory use of somatostatin are contradictory. Leak and fistula formation were decreased when the criteria for leakage was based on laboratory findings; but in 4 out of 5 trials, somatostatin did not decrease the incidence of clinical fistula. The use of fibrin glue to occlude the pancreatic duct or seal the cut surface of the pancreas did not decrease the rate of intra-abdominal complications. In conclusion, the pancreaticoduodenal resection described by Whipple may still be considered the gold standard for resection of pancreatic cancer. The technical experience of surgeons and their institutional support staff resulted in lower perioperative morbidity and mortality and in higher survival rates.

[Inguinal hernia repair: time interval between surgical repair and recurrence]. / Hernies inguinales: délais d'apparition des récidives.

This study seeks to evaluate the time interval between initial inguinal hernia repair and the appearance of recurrent hernia in patients undergoing re-operation. Recurrent hernia was identified in 94 (6.4%) of 1,474 patients having undergone initial hernia repair at our institution. Recurrence appeared within two years in 40 patients (42%). Recurrences were noted beyond five years in 32 patients (34%), and after 20 years in 18 patients (19%). 75% of recurrences had occurred within 15 years. We conclude that almost two-thirds of recurrences occur later than five years after the initial intervention and a quarter occur at an interval of more than fifteen years. Most studies underestimate hernia recurrence due to an insufficient period of post-operative observation.

[Acute intestinal tuberculosis]. / Tuberculoses compliquées du tube digestif.

AIM OF STUDY: To report cases from Vietnam of intestinal tuberculosis disease, which is uncommon but did not disappear in occidental countries. MATERIALS AND METHODS: Seventy-six patients were included in this retrospective study. Mean age was 40 years and sex ratio M/F was 6. Diagnosis was established on pathological examination of resected specimen or on presence of Mycobacterium tuberculosis or by polymerase chain reaction. RESULTS: Intestinal obstruction or subobstruction was the most usual symptom (68%), and thereafter peritoneal symptoms with pain and tenderness (17%). Five patients had intractable digestive haemorrhage. Thirty-six patients had no past history or active pulmonary tuberculosis (47%). Lesions of stenosis on barium enema and thickness of intestinal wall on CT-scan were not specific. Sixty-two patients were operated on (82%) and 14 were not. Surgical techniques differed according symptoms, site and type of lesions. Intestinal resections were performed in half of the patients, others undergoing stomies or enterolysis. There were eight postoperative deaths (13% of patients operated on), seven out of these deaths were attributable to cachexy. In the postoperative period, all the patients were medically treated and follow-up in the antituberculosis centre of Hanoi. CONCLUSION: Symptomatology and operative findings of intestinal tuberculosis are similar to those observed in Crohn's disease, and sometimes in amoeboma or lymphoma. In face of stenosis and intestinal wall thickness, probability of intestinal tuberculosis is high in endemic area, but diagnosis must be suspected in occidental countries, mainly in patients immigrated coming from these areas, patients with immuno-deficiency even if they did not have past or present pulmonary tuberculosis.

Hepatic arterial infusion of floxuridine in patients with liver metastases from colorectal carcinoma: long-term results of a prospective randomized trial.

PURPOSE: A multicentric randomized study that compared patients who received intrahepatic arterial infusion (HAI) to a group of patients who did not receive HAI (control group) was performed for unresectable hepatic metastases from primary colorectal carcinoma. PATIENTS AND METHODS: One hundred sixty-six patients were assigned randomly to HAI of floxuridine (5 fluoro-2'deoxyuridine [FUDR]) 0.3 mg/kg/d for 14 days every 4 weeks or to the control group; this latter group, depending on the investigator's choice, was either under observation or received systemic fluorouracil (5-FU). The same regimen of systemic 5-FU also was administered to the HAI group in the event of extrahepatic progression. No crossover from the control group to the HAI group was permitted. The mean duration of follow-up was 54 months (range, 31 to 72), and 163 patients were analyzed. RESULTS: A significant improvement was observed in the survival rate for the 81 patients assigned to HAI group (P less than .02) with a 1-year survival rate of 64% versus 44% in the control group (82 patients). The 2-year survival rate was 23% versus 13%. The median survival was 15 months versus 11 months for the HAI group and the control group, respectively. Survival was better for patients with a less than 30% liver involvement, and for those treated in more specialized centers. The hepatotoxic effects of HAI were observed in 47 patients (chemical hepatitis [n = 28], and biliary sclerosis [n = 19]). The 1-year rate of sclerosing cholangitis was equal to 25%. Gastrointestinal toxicity was infrequent and consisted of gastritis or diarrhea. CONCLUSIONS: Therapy with HAI of FUDR improves the survival of patients with liver metastases over colorectal carcinoma. However, the methods that are used to diminish the toxicity of HAI and efficient systemic chemotherapy, such as a combination of 5-FU and leucovorin, are required to prevent extrahepatic metastases.

Combined radiotherapy and chemotherapy (cisplatin and 5-fluorouracil) as palliative treatment for localized unresectable or adjuvant treatment for resected pancreatic adenocarcinoma: results of a feasibility study.

PURPOSE: To evaluate a cisplatin-containing chemoradiotherapy (CRT) regimen followed by chemotherapy for unresectable (locally advanced group, n = 32) and resected (adjuvant group, n = 10) pancreatic adenocarcinoma. The quality of palliation and percentage of secondary resections were also studied for unresectable disease. METHODS AND MATERIALS: The protocol comprised CRT (45 Gy over 5 weeks), combined with 5-fluorouracil and cisplatin during the first and fifth weeks, followed, 3 weeks later, by 4 cycles of the same chemotherapy plus leucovorin. RESULTS: All patients completed CRT but only 50% of each group finished the entire protocol. Gastrointestinal toxicity and weight loss were the major side effects during CRT. Enhanced hematological toxicity limited the post-CRT chemotherapy. For the locally advanced group, median survival was 9 months; 1- and 2-year survival rates were 31 and 12. 5%, respectively. The overall response rate was 16% and 50% had stable disease. A lasting palliative effect defined as improved performance status and decreased analgesic consumption, was recorded for 43% of the patients. Only three secondary resections have been performed. For the adjuvant group, median survival was 17 months. CONCLUSIONS: Although toxic in advanced disease, this regimen significantly lowered pain and analgesic consumption, but had poor impact on secondary resectability. In an adjuvant setting, although equally toxic, this series was too small to allow conclusions to be drawn.

Portal versus peripheral venous drainage in segmental pancreatic transplantation in diabetic rats.

The effect of the site of venous drainage in segmental pancreatic transplantation was investigated in diabetic rats with two surgical procedures anastomosing the superior mesenteric vein either on the vena cava (systemic drainage) or on the superior mesenteric vein (portal drainage). Both procedures corrected polyuria, glycosuria, and blood glucose concentration, and resulted in similar peripheral hyperinsulinemia. Intravenous glucose tolerance tests were performed 8 weeks after transplantation. In portal-grafted rats, glucose tolerance was strictly normalized, with a plasma insulin profile similar to that observed in normal rats. In caval-grafted rats, a delayed plasma insulin peak was observed with slight abnormalities in the plasma glucose profile, the late plasma glucose concentrations being higher than in portal-grafted animals. The extent of fibrosis was similar under both conditions. This study, performed in rats, of the influence of venous drainage on the metabolic outcome of segmental transplantation, demonstrating an abnormal plasma insulin profile during a glucose challenge in case of caval drainage, is consistent with other studies suggesting that the site of drainage might be important in case of reduced grafted mass.

Bilioportal fistula as a complication of choledochoduodenostomy.

A bilioportal fistula is rare. We report the case of a patient who had a bilioportal fistula 6 years after a choledochoduodenostomy. Percutaneous transhepatic opacification showed the bilioportal fistula to be associated with a thrombosed portal vein and a cavernous formation. Treatment consisted of separate percutaneous drainage of the portal and biliary tracts. Closure of the fistula was obtained by progressive proximal intrahepatic portal thrombosis. Our case contrasts with the four other cases of bilioportal fistula published in the literature in that (1) there was an absence of biliary lithiasis and (2) we did not use surgical treatment. The most likely explanation for our case of bilioportal fistula is an infectious complication related to the choledochoduodenostomy.

Hepatic metastases in gastrointestinal cancer: diagnostic value of biochemical investigations.

The results of biochemical estimations in 116 patients with known gastrointestinal cancer but no clinically detectable metastatic hepatic disease have been analyzed statistically. The most sensitive and the most specific tests for the presence or absence of hepatic metastasis were measurements of alkaline phosphatase and gamma-glutamyl transpeptidase. The predictive value for the absence of hepatic metastasis when the test results were normal was about 90% for alkaline phosphatase, gamma-glutamyl transpeptidase, lactate dehydrogenase, and serum aspartate aminotransferase. The best predictive value for the presence of hepatic metastasis (80%) was given by abnormal results of combined estimations of gamma-glutamyl transpeptidase and lactate dehydrogenase, and of gamma-glutamyl transpeptidase and serum aspartate aminotransferase.

Choledochoduodenostomy for calculous biliary tract disease.

After the opening of the common bile duct, several controversial procedures may be used. In choledocholithiasis, our preference is to perform choledochoduodenostomy in older patients. We report the results in 77 consecutive patients with a mean age of 75 years. There were two hospital deaths (2.6%). Follow-up ranged from six months to 15 years, with an average of 6.7 years. Fifty patients are alive and well. Twenty-five patients have died. Only two patients were unavailable for follow-up. Expected mortality in the French population corresponding in age and sex was 29 deaths and the overall survival is not different, including the two postoperative deaths. Delicate technique allows anastomoses to ducts of any size, with no difference in long-term survival compared with a French population similar in age and sex.

Hepatic flow scintigraphy in evaluation of hepatic metastases in patients with gastrointestinal malignancy.

OBJECTIVE: To assess the value of hepatic flow scintigraphy for occult metastases. DESIGN: Prospective study, 2 years of follow-up. SETTING AND STUDY PARTICIPANTS: One hundred twenty-nine patients undergoing surgery for gastrointestinal cancer. INTERVENTION: Preoperative hepatic flow scintigraphy (3mCi of technetium-99m). MAIN OUTCOME MEASURE: Development of hepatic metastases. RESULTS: Hepatic flow scintigraphy had a sensitivity of 92% and a specificity of 34%. The positive and negative predictive values were 15% and 97%, respectively. CONCLUSIONS: Hepatic flow scintigraphy could therefore be useful in identifying patients who are at low risk of developing metachronous liver metastases and thus avoid unnecessary adjuvant chemotherapy following resection of the primary tumor.

Sclerosing cholangitis induced by formaldehyde solution injected into the biliary tree of rats.

Sclerosing cholangitis has been reported after surgical treatment of hydatid disease of the liver and has been hypothetically attributed to the caustic effect of the parasiticide solution injected into the cyst and diffusing into the biliary tree through a cystic-biliary fistula. In this experimental study, we showed that, in rats, injection into the biliary tract of 20% hypertonic saline solution or 2% formaldehyde solution, the most commonly used scolicidal solutions, was followed by lesions of the biliary epithelium. As compared with 20% hypertonic saline solution, the 2% formaldehyde solution caused more severe lesions of the biliary epithelium and, in addition, induced the development of sclerosis. This experimental study confirms the deleterious effect of scolicidal solutions to the biliary epithelium, shows that their effect is mainly related to the causticity of the scolicidal solution, and indicates that intracystic injection of 2% formaldehyde solution should be abandoned.

Caustic sclerosing cholangitis. A complication of the surgical treatment of hydatid disease of the liver.

In five patients, sclerosing cholangitis developed after the surgical treatment of hydatid cyst of the liver. The cyst communicated with the biliary tree, and a scolicidal solution (2% formaldehyde in two patients and 20% sodium chloride in three) was injected into the cyst. Cholangiography showed strictures affecting the intrahepatic biliary tree in two and both the intrahepatic and extrahepatic biliary tree in three. Sclerosing cholangitis in these patients was likely to result from the caustic effect of the scolicidal solution having diffused from the cyst into the biliary tree. We propose to designate this entity "caustic sclerosing cholangitis". Because of the risk of this complication, and the unproved efficacy of intracystic injection of a scolicidal solution in preventing the dissemination of the parasite, we recommend that this maneuver be abandoned in the surgical treatment of hydatid disease of the liver.

Surgical palliation for unresected cancer of the exocrine pancreas.

Opinions are still divided regarding the optimal palliative procedures in patients with cancer of the pancreas. This retrospective, multicentric study, involving 2493 patients operated on between January 1982 and December 1988 compares the results of various procedures aimed at palliation for pancreatic cancer. Cholecystoenteric bypasses (n = 237) in comparison to choledochoenteric bypasses (n = 1770) were associated with a higher post-operative mortality (20% vs 14%), a lower long-term morbidity (26% vs 35%), and a lower survival rate (means: 3.2 vs 5.2 months). Choledochoduodenostomy (n = 1159) and choledochojejunostomy (n = 611) had similar rates of post-operative mortality (14% vs 13%), morbidity (26% vs 27%), incidence of recurrent jaundice (8% vs 7%), and median survival (5.4 vs 5.0 months). Surgically placed biliary stents (n = 114) were followed by the highest post-operative mortality (27%), morbidity (46%), rate of recurrent jaundice (14%), and the shortest median survival (2.6 months). Post-operative mortality in patients undergoing a choledochoenteric bypass and a gastrojejunostomy (n = 1134) was similar to that observed in patients who had only a biliary bypass (n = 636) (16% and 12%), but among the patients who had a biliary bypass alone, 16% developed a gastric obstruction. For the relief of pancreatic pain, radiotherapy was more effective than other symptomatic treatments (P = 0.02). In conclusion, these results and other previous reports suggest the need (1) in patients with obstructive jaundice to perform a choledochoduodenostomy rather than other biliary bypasses, (2) a routine prophylactic gastrojejunostomy to prevent gastric outlet obstruction, (3) and for the relief of pancreatic pain to perform radiotherapy or splanchnicectomy.

Treatment of local recurrence of rectal cancer.

BACKGROUND: Treatment of local recurrence of rectal cancer remains a challenge. Preoperative irradiation and total mesorectal excision halve the risks of local failure, but increase morbidity and even mortality. The results of re-resection of recurrent rectal cancer suggest need to reexamine therapeutic strategies for initial treatment. METHODS: Seventy-one patients operated on for rectal carcinoma without radiotherapy developed local recurrence (29 with metastatic disease). Thirty underwent a curative re-resection (8 had combined resection of metastases). RESULTS: The incidence of asymptomatic recurrence was higher after anterior resection (38%) than after abdominoperineal resection (16%). The actuarial 5-year survival rate was 19%; 28% in asymptomatic patients and 8% in symptomatic (P = 0.04). CONCLUSIONS: Early detection of recurrence of rectal cancer leads to an improved re-resection rate and survival. In patients who did not undergo radiotherapy at the time of the original resection, re-resection can be achieved safely. The place for radiation in the treatment of rectal cancer must be redefined.

Adenocarcinoma of the appendix.

Thirty-two patients with primary adenocarcinoma of the appendix were studied in this collective review. Immediate operation was performed in 21 patients with a diagnosis of acute appendicitis. At operation, tumor of the appendix was only identified in 50 percent of the 32 patients studied. Survival was unrelated to the histologic tumor type, but significantly correlated with the extent of tumor spread. Right hemicolectomy led to a significant increase in survival compared with appendectomy alone and to a significant decrease in risk of recurrence. In Dukes' B2 and C patients, differences in the survival curves were in favor of right hemicolectomy. Long-term survival was obtained by repeat laparotomy with resection of mucinous material in patients with pseudomyxoma peritonei.

Local recurrence of cancer of the rectum.

BACKGROUND: [corrected] Although radiotherapy or total mesorectal excision decreases the risk of local recurrence of rectal cancer, this risk remains around 10%. METHODS: Of 80 patients having a local recurrence, 38 (48%) underwent a re-resection combined in 10 cases with resection of mestastases. RESULTS: The incidence of asymptomatic detected recurrence was higher after anterior resection (39%) than after abdominoperineal resection (18%). Re-resection was performed more often (P <0.01) in the past 2 decades after anterior or Hartman first procedure than after abdominoperineal resection (67% versus 21%), and more often in asymptomatic patients than in symptomatic patients (71% versus 38%). The actuarial 5-year survival rate after re-resection was 20%. CONCLUSIONS: Early detection of local recurrence, with PET scan using (18)F-fluorodeoxyglucose (8 cases in the present series), leads to an improved re-resection rate. In patients who did not undergo radiotherapy (all patients but 1) re-resection can be achieved safely (no postoperative mortality). The place for radiation in the treatment of rectal cancer has to be revaluated and compared with total mesorectal excision and results of re-resection for local recurrence.

Treatment of cancer of the exocrine pancreas.

BACKGROUND: The incidence of cancer of the exocrine pancreas varies among populations, being the fourth or fifth cause of cancer death in the West. Outcome remains poor and opinions remain divided over the optimal management of the condition. METHOD: A computer literature search was made of the MEDLINE database from January 1990 to December 1997 and selected other studies. RESULTS: Indications and contraindications for surgery, indications for stenting, indications for resection, the technique of palliative procedures and of resection, chemotherapy, radiotherapy, and combined treatments and other treatments are discussed and recommendations made. CONCLUSIONS: Irrespective of tumor size or spread, resection if feasible gives the best survival rates. Careful patient selection is required, however, to exclude those patients for whom surgical resection has no benefit. Nonsurgical procedures including endoscopic stenting in patients with high operative risk or short survival expectancy can significantly improve quality of life. The place of adjuvant therapies remains controversial and further controlled trials are required to demonstrate their efficacy.

Sphincter-saving resection, or not, for cancer of the midrectum.

BACKGROUND: The purpose of this study was to compare the time to pelvic recurrence and survival after sphincter-saving resection (SSR) or abdominoperineal resection (APR). METHODS: Out of the 119 patients with a cancer of the midrectum, 43 had undergone a SSR and 76 an APR for cure. To eliminate bias of a nonrandomized retrospective comparison, an adjustment for baseline prognostic covariates was used. RESULTS: Pelvic recurrence rates and survival distribution according to the type of resection did not differ significantly, with P values of 0.31 and 0.95, respectively, by the log-rank test. The Cox regression model incorporated nine binary covariates and the treatment group. Given these nine covariates, treatment did not influence either pelvic recurrence (adjusted P value = 0.62, relative risk = 0.78) or overall survival (adjusted P value = 0.89, relative risk = 1.05). CONCLUSION: These results suggest that, in patients with cancer of the midrectum treated by SSR or APR, recurrence and survival rates are similar.

Gastric carcinoma treated by chemotherapy after resection: a controlled study.

A prospective controlled study of combined chemotherapy with 5-fluorouracil, vinblastine and cyclophosphamide was conducted in 53 patients with radical resection for gastric carcinoma. The patients were divided into two groups, a control group of 26 patients and a chemotherapy group of 27 patients, that were similar in regard to age, sex, location of carcinoma, type of resection and pathologic findings. No significant differences in survival rate were observed between the control group and the chemotherapy groups.

Treatment of adenocarcinoma of the pancreas with somatostatin and gonadoliberin (luteinizing hormone-releasing hormone). The French Associations for Surgical Research.

Experimental studies have shown a significant inhibition of adenocarcinoma of the pancreas by gonadoliberin (luteinizing hormone-releasing hormone [LH-RH]) and somatostatin. The aim of this prospective randomized study was to compare the potential value of somatostatin (250 micrograms every 8 hours), LH-RH (3.75 mg monthly), or combined, to a control group. One hundred sixty-three patients with adenocarcinoma of the pancreas who did not undergo resection for cure were divided into 4 groups that did not differ in terms of clinical, biologic, or pathologic data. The mean survival times were 6 months in the LH-RH plus somatostatin group, 5.5 months in the LH-RH group, 4.3 months in the control group, and 3.8 months in the somatostatin group. However, the life-table analyses for all randomized patients, and separately according to sex, the lymph node extension, and metastatic spread were not different between groups. Improvement of patient status was observed in 20% of the patients receiving hormone therapy without any difference noted between the treatment regimens. These disappointing results may be explained by the degree of extension of pancreatic carcinoma in the patients studied. The results suggest that different hormone therapy regimens might be considered according to the age and the sex of patients, as well as to the presence or absence of hormone receptors.