Failure of Conservative Treatment of Acute Diverticulitis with Extradigestive Air.

BACKGROUND: Medical management for perforated diverticulitis without abscess or peritonitis (PDwAP) has a success rate of 40-70%. Identifying patients with a risk of medical treatment failure would improve outcomes. The aim of this study was to identify the risk factors for failure of medical treatment in patients admitted with PDwAP. METHODS: This multicenter retrospective observational study included all consecutive patients admitted for PDwAP and not surgically treated over a 7-year period. Peritonitis classified on the Hinchey scale was excluded. Potential clinical, biological and radiological risk factors for medical treatment failure were collected and compared between the group of patient with a failure of medical treatment (F) and the group in which treatment did not fail. Data were collected at referral. RESULTS: Ninety-one patients were included, and 29 had a failure of treatment (31.9%). The median heart rate was different between the two groups (p < 0.001), at approximately 100/min in the F group. A blood level of C-reactive protein (CRP) ≥150 mg/mL was associated with a higher rate of failure (p = 0.021), but it was not confirmed in multivariate analysis. Pneumoperitoneum ≥5 mm and intraperitoneal liquid located in the pouch of Douglas were more likely to be present in the F group (respectively, p = 0.001 and p < 0.001). A multivariate analysis showed independent risk factors as being the highest pneumoperitoneum diameter >5 mm (OR 5.193; p = 0.015) and peritoneal fluid location in the pouch of Douglas (OR 4.103; p = 0.036). CONCLUSION: The severity of sepsis (tachycardia and CRP ≥150 mg/mL) and of imaging signs (pneumoperitoneum ≥5 mm and peritoneal fluid in the pouch of Douglas) were risk factors for medical treatment failure of PDwAP requiring special supervision so as not to lose time in undertaking surgical management.

[Mega-esophagus: treatment by celioscopic approach]. / Méga-oesophage: cure par voie coelioscopique.

Heller's procedure is widely used as the most appropriate method for treating achalasia. We performed the procedure laparoscopically in three patients with good results. Two females and one male, age 40, 60 and 68 years, presented with long-term recurrent dysphagia due to achalasia which did not respond to endoscopic dilatation. Heller's procedure was performed laparoscopically in all three with no particular difficulty. In our cases we also attached the anterior border of the greater curvature to the left side of the myotomy and fixed it to the right diaphragmatic pillar to reduce reflux. The procedure would appear to have less risks than laparotomy since visualization of the operative fields is better. Laparoscopy will undoubtedly become the preferred procedure for achalasia.

[Mesocaval anastomosis in the treatment of recurring hemorrhage caused by portal hypertension]. / L'anastomose mésentérico-cave dans le traitement des récidives hémorragiques par hypertension portale.

The ideal therapy for variceal hemorrhage would permanently eliminate this life-threatening complication of portal hypertension and have no adverse effects on hepatic physiology. Mesocaval interposition shunts preserve a hepato-pedal blood flow. 35 shunts were performed as an elective procedure from 1982 to 1992 in patients with hemorrhagic liver cirrhosis. There were 24 men and 11 women, with a median age of 51.7 years. The underlying etiology of the varices was alcoholic cirrhosis in 31 patients. The criteria of Child-Pugh were utilised to evaluate + all patients; 21 were in class A and 14 were in class B. All patients presented before the operation, two or several histories of acute variceal hemorrhage. The mean diameter of the graft was 14 mm (range 10 to 16 mm). Intra-operative portal pressure measurements showed satisfactory pressure reduction (18.7 mmHg to 11.2 mmHg). There was no death in the postoperative period. Eight patients had postoperative complications, for an overall morbidity rate of 22.8%: 2 ascites, 4 episodes of temporary encephalopathies and 2 recurrent bleeding. At the third month, angiographic (5 cases), sonographic (6 cases) or scanographic (17 cases) studies evaluated shunt patency. In one case, We observed an occluded graft. The actuarial survival rate was 82% at 2 years, 66% at 5 years. It is concluded that the interposition mesocaval shunt appears to be an effective technique for the control of variceal hemorrhage, has important hemodynamic advantages and can be applied to most patients for the control of variceal hemorrhage due to portal hypertension. Moreover, the procedure can be considered as a solution before the hepatic transplantation.

[Intraoperative colonic irrigation in the emergency treatment of occlusive lesions of the left colon]. / L'irrigation colique per-opératoire dans le traitement en urgence des lésions occlusives du côlon gauche.

This study reports the use of an intraoperative antegrade colonic irrigation in the management of left-sided large bowel obstruction requiring emergency surgery. 35 consecutive patients had primary bowel resection with immediate anastomosis (without colostomy) after intraoperative antegrade colonic irrigation. The cause of the obstruction was large bowel carcinoma in 26, diverticulitis in seven and volvulus in two cases. There were two post-operative deaths (5.7%). No digestive fistula was observed. The results of this study suggest that intraoperative colonic irrigation is an effective method, enabling the surgeon to perform a primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.