Sigmoid diverticulitis. Longitudinal analysis of 222 patients with a minimal follow up of 5 years.

OBJECTIVE: The surgical treatment of severe attacks of sigmoid diverticulitis and the indications for prophylactic surgery are currently matters of debate. We have analysed our experience in a university hospital, bringing new information into the discussion. METHOD: All patients admitted to our department between 1995 and 2002 for an attack of sigmoid diverticulitis were reviewed. There were 222 who had had a first attack and these formed the basis of the study. Analysis of short- and long-term outcomes was made. RESULTS: Of the 222 patients, 66 underwent an operation during the first admission (mainly Hartmann's operation) with no death. Twenty-five patients were operated during a subsequent admission, either for a deterioration of their symptoms or prophylaxis. One hundred and twenty-eight patients were managed conservatively, and were followed up for 5-12 years. Recurrence was observed in 43% of the patients with a trend to a higher incidence in patients under 50 years. Recurrent exacerbating diverticulitis were severe in 13% of cases. CONCLUSION: Complicated diverticulitis can be managed with a low mortality. Hartmann's operation was proven safe in our experience. The risk of recurrence was higher than observed in many recent studies but few recurrences were severe.

[Financial analysis of a department of general surgery in a French hospital. The new "fee-for-service" reimbursement system results in a high deficit for emergency care]. / Analyse comptable de l'activité d'un service de chirurgie digestive : l'activité d'urgence est fortement déficitaire. Quelles conséquences pour les patients ?

GOAL: The aim of this study was to perform a detailed analysis of income and expense in a department of general surgery in a French hospital under the new system of funding based on a "fee-for-service" principle. METHODS: All hospital stays of year 2006 were analysed retrospectively. The conditions of admission (elective vs. emergency), the principal diagnosis, and surgical procedures were examined. We determined hospital costs and the reimbursement for every admission. RESULTS: One thousand nine hundred and eighty-five hospitalizations generated an income of 8Meuros with a deficit of 1.3Meuros. The 775 elective admissions generated 50% of the income and 13% of the deficit (178,562euros). Seven hundred and forty-nine emergency admissions generated 45% of the income and 82% of deficit (1.1Meuros). Four hundred and sixty-one admissions for endoscopy generated 5% of the income and 5% of the deficit (67,249euros). Hospital stays of less than two days (the minimum duration of stay for total reimbursement) caused a loss of 122,624euros. Length of hospital stay below the lower limit caused a loss of 42,850euros. CONCLUSION: Elective surgical activity in digestive surgery can generate a balanced budget provided the length of hospital stay is reduced to the minimum, sometimes to the detriment of patient comfort. Emergency admissions result in a large deficit between cost and reimbursement; this fact may lead hospitals to avoid emergency activity in the future unless appropriate remedial measures are taken.

[Analysis of the drainage fluid after cephalic duodenopancreatectomy: a reliable clinical criterion]. / Analyse du liquide de drainage après duodénopancréatectomie céphalique: un critère de surveillance fiable.

The authors have retrospectively analysed the drainage fluid of 39 patients undergoing Whipple's operation over a 18-year period. The aim of the study was to assess whether the volume and amylase concentration of the drainage fluid were good criteria of healing of the pancreatico-jejunal anastomosis. The patients have been divided into two groups: Group I (30 patients) with no complications at the pancreatico-jejunostomy--Group II (9 patients) with a pancreatic leak. The analysis of the volume, amylase concentration and amylase index (Log of the amylase concentration x volume) showed that the groups had clearly different profiles: in group I all three criteria were rapidly decreasing, while they remained abnormally high in group II. Those criteria may help the clinician in the monitoring of individual patients; they also may prove useful in prospective studies evaluating new means of prevention of this anastomosis.

[Ischemic colitis. A surgical series of 88 cases]. / Colites ischémiques. Une série chirurgicale de 88 cas.

We report our experience in 88 cases of ischemic colitis including 76 cases of gangrene with 17 perforations, 6 cases with stenosis and 6 cases which regressed. The left colon was involved in 59 cases with extension to the transverse colon in 20 the right colon in 10 and global involvement in 18. Abdominal pain, diarrhea, and meteorism occurred in 81, 62 and 78% of the cases respectively. Coloscopy was performed in 61 cases, a barium study in 27. A colectomy was required in 77 patients: 50 left colectomies with 16 extensions to the transverse colon, 17 total colectomies and 10 right colectomies. Morbidity was 53% in cases with perforated gangrene and 28% without perforation. There was no morbidity in stenosis and regressive forms. Normal tube flow was conserved or reestablished in 51 of the 62 survivors. The 88 patients were referred from cardiovascular units (36%), intensive care (28.5%), or internal medicine (22%). All had intramural ischemia due to local or general lesions which progressed to parietal gangrene in 76 cases. The diagnosis was based on clinical signs and confirmed by coloscopy which determined the stage and extension. Stage II ischemia required rapid colectomy adapted to the endoscopic lesions and not the exterior aspect of the colon; immediate anastomosis is usually not used.

Protective transverse loop colostomy associated with low colo-rectal anastomoses.

A transverse loop colostomy to protect a low colorectal anastomosis should be carried out with minimal morbidity and mortality related to its creation and closure. A modification of the conventional technique is described.

[37 so-called biliary cysts of the liver in adults]. / 37 kystes dits biliaires du foie chez l'adulte (KBF).

Clinical manifestations, clinical course and therapeutic schemes were studied in 37 patients with a surgical indication for biliary cysts of the liver observed in a surgery unit over 25 years. Cyst size varied from 2 to 30 cm and was greater than 10 cm in 12 cases. Yellowish-clear contents were observed in 23 cases and purulent or hemorrhagic contents in 3 each. Twenty-three patients were asymptomatic, 14 had pain and/or complications (hemorrhage 3, infection 3, compression 3, rupture 1). Therapy was abstention in 7 cases, puncture in 5, resection of the protruding dome in 17, complete exeresis in 5, and hepatectomy in 3. There were no deaths and morbidity reached 7%. Biliary cysts of the liver can be discovered fortuitously at surgery or imagery or in patients with abdominal pain, an abdominal mass or complications including compression, intraperitoneal rupture, intracystic hemorrhage, hemobilia, acute infection, torsion, cancerization. Diagnosis requires sonography and computed tomography. Therapeutic indications are: abstention for small asymptomatic cysts. For voluminous cysts, with complications or confirmed during a supramesocolic operation, the risk of recurrence or aggravation of the complications excludes puncture or injection of a sclerosing agent. Wide resection of the protruding part of the cyst with histology resection can be performed although prospective assessment is needed. Cystectomy is not indicated if there is a diagnostic doubt. Hepatectomy is an exceptional indication retained for patients with uncontrolable hemorrhage, intra-cystic tumors or voluminous cysts destroying the lobe.

[Ogilvie's syndrome or colonic pseudo-obstruction. Apropos of 26 cases]. / Syndrome d'Ogilvie ou de pseudo-obstruction colique. A propos de 26 observations.

From twenty six personal cases, the authors make a review of the literature. 92% of their cases are met in a post operative (28%), neurological (28%), general (24%) context, or in intensive care with assisted ventilation (36%). The major symptom is the meteorism (100%) with in one out of three cases, abdominal pain, vomiting, right iliac defense, absence of bowel sounds. Radiological distension involves mostly the right colon and the coecum (28%), right and transverse colon (40), sometimes the whole colon (32%). The mean diameter of the coecum reached 12 cm (9 to 25 cm). Early coloscopy was mandatory in 20 patients, of which 14 were cured, 13 patients were operated on, for suspicion of ischemia or perforation, because incertain diagnosis, or failure of colonoscopy. Ceocostomy or right hemicolectomy (55%) were performed rather than transverse colostomy. The surgical approach must be adapted to the anatomical lesions. Total mortality was 4% in this series. Early diagnosis of pseudo obstruction, early colonoscopy with intubation must allow to avoid surgery.

[Evolution of Hartmann's procedure. 249 interventions]. / Evolution de l'intervention de Hartmann. 249 interventions.

A retrospective study of 249 patients undergoing Hartmann's procedure over twenty-five years was undertaken to analyse the evolution of indications and results. Patients were divided into three time period groups: from 1969 to 1978, 1979 to 1990 and 1991 to 1994. Mean age was 68 years old. Major indications were complicated diverticular disease (42.9%), colo-rectal malignancies (35.7%) and ischemic colitis (14%). Operative mortality is 10.8%, higher in ischemic colitis (20%) than in complicated diverticulitis (6.5%) and cancer (13.4%). Overall morbidity has significantly reduced, from 65.51% to 17.24%. General complications have changed a little, while local and/or inherent operative complications have reduced from 22.4% to 1.72. Restoration of colorectal continuity was done in 59.54% of patients, increasing from 36% to 71% during the three periods. This is variable depending on initial disease: 92% in diverticular disease, 69% in ischemic colitis but remains stable for carcinoma at 33%. Overall mortality since 1981 is 2.5% and morbidity is 19.13%. Mean Hospital stay was 20 days for the initial operation and 15 days for secondary restoration of colorectal continuity. Hartmann's procedure is well indicated as emergency surgery in colonic perforations, abscessus and ischemia. Progressive improvement of its results is essentially due to persistent attention to indications and technical details.

[Stenosis caused by mechanical colorectal anastomosis. Technique of plasty]. / Sténose d'anastomose colorectale mécanique. Technique de plastie.

Stenosis occurs in 1.2 to 4% of the cases after colorectal anastomosis, especially after stapling. Ischaemia may have been favoured in our two cases. Treatment requires endoscopic dilatation or section of a sclerous diaphragm and may entail reconstruction of the anastomosis. The Kraske plasty is a simple and rapid procedure (case n. degree 1) and can be performed via endoluminal access (case n. degree 2) using a linear suture.

[Reoperation for locoregional recurrence of cancer of the rectum]. / Les réinterventions pour récidives loco-régionales des cancers du rectum. 71 cas.

71 recurrences after rectal resections for adenocarcinoma have been operated upon. After 43 initial anterior resections (AR), the treatment of recurrence was in 19 patients a new resection and in 18 a simple colostomy. When the initial treatment was a Mile's operation (APR in 23 patients), it has been performed 10 new exerses and 5 electrocautery. In the whole series, mortality and morbidity were respectively 17.5 per cent and 8 per cent. After AR the long term survival was 40 months when the initial tumour was classified Dukes A, and only 12 months when it was classified Dukes B or C. After APR the median long term survival was only 12 months. 75 per cent of the recurrences are observed during the first two years after initial resection. The screening includes repeated clinical examination, CEA dosage, endorectal sonography, endoscopy and CT scan. The appreciation of extirpability requires clinical examination, CT scan, MRI imaging. The aim is 1. to avoid exploratory and/or palliative operations. 2. to appreciate operating difficulties and to choose an adequate approach. The indication of systematic enlarged resections has to be appreciated related to patient's comfort and survival.

Polyadenylic-polyuridylic acid as an adjuvant in resectable colorectal carcinoma: a 6 1/2 year follow-up analysis of a multicentric double blind randomized trial.

In a double blind study, patients with operable carcinoma of the colon and the upper rectum, who have undergone a macroscopically complete resection of their tumor, were randomized to receive either (i) polyadenylic-polyuridylic acid (AU), one i.v. injection of 60 mg (in 50 ml of solution) once a week for 6 weeks, or (ii) a placebo (P) one i.v. injection of 50 ml of a saline solution with the same schedule. From January 1983 to December 1986, 288 patients were enrolled: 145 in AU group and 143 in P group. The main clinical and pathological characteristics were equally distributed throughout the two groups. There was a significant difference (P < 0.02) in the overall survival (OS) between the two groups, in favor of the P group. The 5-year OS rate was 68% (SD = 4%) in the AU group versus 81% (SD = 3%) in the P group. Thus, AU as a single adjuvant, appears to be ineffective and therefore has no indication in the treatment of colorectal carcinoma.

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.

[Sixty-one cases of acute obstructions of the colon caused by cancer. Indications for emergency surgery]. / Soixante et une occlusions aiguës du côlon par cancer. Indications chirurgicales en urgence.

Sixty-one cases of acute malignant colonic obstruction were operated upon within 24 hours after the patient's admission, between 1979 and 1989: 10 for a right colon carcinoma, 51 for a left-sided lesion. Indications, for emergency operation were: complete clinical obstruction, iliac tenderness, radiologic ileal fluid levels and arrest on barium enema. The initial procedures consisted of 8 right hemicolectomies, and for the left-sided obstructions, 32 colostomies, 7 colectomies with immediate anastomosis, and 12 colectomies without anastomosis. Overall mortality was nil for the right side and 4% left-sided obstructions. The current surgical procedures of choice according to the authors are: right hemicolectomy for right-sided obstruction; elective colostomy for the left side. In case of doubt about the mechanism of obstruction or vitality of the colon, a midline approach for operative exploration, followed by colectomy without anastomosis is recommended. Colectomy with immediate anastomosis is possible in rare favourable cases. Subtotal colectomy is indicated in cases of ischemic lesions, caecal perforation or other colonic tumours. Intraoperative irrigation of the colon is rarely permitted in this particular variety of acute obstruction.

[Peroperative cholangiography during laparoscopic cholecystectomy]. / Cholangiographie per-opératoire au cours des cholécystectomies sous laparoscopie.

The aim of this study was to assess the ease and the success of a laparoscopic technique of cholangiography. Following an initial period of training to gain expertise in laparoscopic surgery, 70 patients were included in the study. Six of them had a history of suggestive choledocholithiasis. Intraoperative cholangiography was performed using an angled catheter (Judkins) and a specific tubular cannula (Olsen, Storz) designed to guide and maintain the catheter in the cystic duct. Catheterization of the cystic duct and cholangiography were achieved in 61 patients. In 3 cases, stones were found in the common bile duct. The mean duration of the examination was 11 minutes (6.21). Cholecystectomy was performed after cholangiography. No biliary injuries were observed. These results show that intraoperative laparoscopic cholangiography is easy and not time-consuming. It obviates the need for preoperative investigations looking for biliary stones and provides an excellent definition of the biliary anatomy for safety purposes.

[Adenocarcinoma of the duodenum. 17 cases]. / Adénocarcinome du duodénum. Dix-sept observations.

Seventeen cases of duodenal adenocarcinoma are reported and compared with cases from the literature. Ten tumours were located in the second part of the duodenum, 9 were around the hepatopancreatic ampulla, 4 were above and 4 below this ampulla. Four tumours (23 per cent) had limited intramural expansion (Dukes' stage A or B) and 6 (35 per cent) involved the lymph nodes. The major clinical signs were loss of weight (11 cases), signs of obstruction (9 cases), bleeding (6 cases) and jaundice (6 cases). The paraclinical examinations that were determinant for the diagnosis were gastroduodenal radiographic study (16 cases) and endoscopy with biopsy (9 cases). Computerized tomography was useful for preoperative evaluation. The respective values of these examinations for early diagnosis and excisability of these tumors are discussed. All 17 patients were operated upon: 11 (64.7 per cent) underwent radical excision, 5 had duodenal bypass and 1 had exploratory laparotomy. The overall operative mortality rate was 5.8 per cent, with no deaths for bypasses and excisions. Mean survival after bypass was 5 1/2 months. The one year survival was 63.5 per cent in 5 patients with excision and 83.3 per cent in 6 patients with cephalic duodenopancreatectomy, but none of these patients survived for more than 5 years.

[Anal metastases from cancer of the colon]. / Métastases anales de cancer du côlon.

Two cases of anal metastases from sigmoid carcinoma are reported. The two patients were treated by local excision. The various mechanisms of tumoral spread are discussed from a review of the literature; the most frequent mechanism is cellular exfoliation. The most commonly used therapeutic approach is local excision combined, if necessary, with reconstruction of the sphincters.

[33 cases of hematoma of the rectus abdominis muscle in a surgical department]. / 33 hématomes du muscle grand droit abdominal en milieu chirurgical.

The authors report a series of 33 hematomas of the recti-abdominis muscles from a surgery department: 15 occurred under anticoagulants 6 were spontaneous, 5 followed trauma and 6 a surgical procedure. The clinical picture was subacute in 24 cases, combining an abdominal pain (32 cases) a mass (10 cases) and an extensive ecchymosis (6 cases). The picture was acute in 6 extensive hematomas with collapse and anemia. In 3 cases an isolated mass was the first symptom. Echography has represented, since 1977, a decisive advance in the diagnosis, which was found to be accurate in 5 out of 10 cases before its introduction, and in 19 out of 20 when it was resorted to in the 23 cases recorded later. TDM is useful only in few cases. 23 patients were have been operated on: 6 for cardiovascular collapse, 3 because the diagnosis had not been made, 8 on order to confirm the diagnosis, 3 because of an increase in size of the hematoma and 3 owing to infection. In the 10 cases not submitted to surgery, the evolution was favourable. The therapeutic approach must be lanced according to the patient's condition, the size, side effect and evolution of hematoma. The aim of the operation is to evacuate the hematoma, to drain it and sometimes to tie up the bleeding vessel.

[Extracorporeal lithotripsy of gallbladder calculi. Tolerability, complications and early results]. / Lithotritie extracorporelle pour lithiase vésiculaire. Tolérance, complications et résultats précoces.

The purpose of this prospective study, conducted on 88 patients, was to assess the tolerance, efficiency and early complications due to a piezo-electric lithotriptor in the destruction of gallbladder stones. One hundred and sixty one sessions were performed in 82 patients. All patients had symptomatic, uncomplicated lithiasis, the diameter of which was less than, or equal to, 30 mm. All patients had less than 7 stones in a functional gallbladder. In 22 patients, the stones were calcified. Lithotripsies were carried out without anesthesia or premedication, except in an 8-year-old child who had to be anesthetized. In 3 cases it was impossible to visualize the gallstones and in 3 other patients, the procedure was discontinued because of abdominal pain. Following the procedure, biliary pain occurred in 20 per cent of the patients. One patient only had biliary colic with transient anicteric cholestasis. Clinical examination, sonography, biological tests were found to be normal in all other patients. Endoscopic sphincterotomy or emergency surgery was never required. Stones were found to be unaltered in 6 patients following 2 lithotripsy sessions. The 76 other patients had fragmentation of their stones. The free gallbladder rate was 15.8 per cent between 0 and 2 months, 24.6 per cent between 2 and 4 months and 51.3 per cent between 4 and 8 months. These results tend to show that the destruction of biliary stones by piezo-electric lithotriptor is efficient and well tolerated. As repeated routine examinations were always negative, the three-day hospitalisation period no longer seems necessary.