Biliary pleural fistula as a complication of radiofrequency ablation for liver metastasis.

Radiofrequency ablation (RFA) recently emerged as an efficient and safe local ablative method to treat unresecable liver tumours. Currently however, the full spectrum of potential complications of RFA remains undetermined. We report a case of severe biliary complication, associating main bile duct stricture and biliary pleural fistula, arising after extensive RFA for unresectable liver metastasis of central location. Treatment consisted of external drainage of the pleural effusion and internal endoscopic drainage via a biliary stenting. This description of a life-threatening complication emphazises the need to better knowledge of the contraindications of RFA, particularly for the treatment of large tumours at proximity of main bile ducts.

Laparoscopic gastric reduction surgery. Preliminary results of a randomized, prospective trial of laparoscopic vs open vertical banded gastroplasty.

BACKGROUND: The purpose of the current study was to present the preliminary results of a randomized prospective trial comparing laparoscopic and open vertical banded gastroplasty (Mason's procedure). METHODS: From April 1995 to April 1996, 68 patients (9 men and 59 women, mean age, 36 years; ranges, 17-60 years) affected from morbid obesity (mean body weight, 123 kg; range, 89-188 kg; mean body mass index (BMI), 43 kg/m2; range, 37-66 kg/m2) were enrolled in a prospective trial and randomly assigned to a laparoscopic (group A) or open (group B) Mason's gastroplasty. There was no statistically significant difference between the two groups in terms of patient epidemiologic data. The significance level among the data was assessed by means of Fisher's exact test. RESULTS: The success of laparoscopic gastroplasty was 88.2% (30/34). The intervention was significantly longer in the laparoscopic group (150 min vs. 60 min; p = 0.001). No mortality was recorded in the overall population. Intraoperative complications included only one case of gastric bleeding in group A (2.9% vs. 0%; p value not significant [NS]). Early major complications ranged as high as 6.6% and 7.8%, respectively, in groups A and B (p = NS), and included one case of peritonitis and one case of pneumonia in group A, and two cases of peritonitis and one pulmonary embolism in group B. Early minor postoperative complications consisted of wound infections only, observed in one group A patient (3.3%) and four group B patients (10. 8%, p = 0.04). At longer follow-up, incisional hernias occurred in 15.8% (6/38) of patients surgically treated with a conventional approach compared with none among those successfully surgically treated with laparoscopic access (p = 0.04). No statistically significant difference was observed between the two groups regarding the efficacy of the procedure, in terms of decrease in percentage of excess body weight, mean body weight, or mean BMI. CONCLUSIONS: The preliminary results of current study show that the laparoscopic Mason procedure is a time-consuming and technically demanding operation, as effective as its traditional counterpart, but carrying a statistically significant decrease in the incidence of wound infections and incisional hernias.

[Case report of an adrenal hemorrhagic pseudocyst. Literature review]. / Observation d'un pseudokyste hémorragique surrénalien. Revue de la littérature.

Cysts and pseudocysts of the adrenal gland are usually discovered fortuitously, either on clinical examination or on the occasion of a radiological check-up for a non specific symptomatology. Their diagnosis rests on several examinations such as intravenous pyelography, ultrasounds, computerized tomography or arteriography. The final diagnosis relies on the histological examination of removed material. Surgery is systematically advocated as the actual nature of the tumor cannot be established preoperatively.

[Esophageal perforation caused by a foreign body. Apropos of a case report]. / Perforations oesophagiennes par un corps étranger. A propos d'une observation.

This report describes an esophageal foreign body perforation treated with T-tube drainage. The clinical diagnosis was delayed erroneously and by the absence of extravasation of water--soluble contrast material. The diagnosis has finally been made by a fiberoptic oesophagogastroscopy and a mediastinal computed tomography. As the external drainage by pleural drainage was inefficient, the authors opted for a surgical treatment, and the perforation was closed on a T-tube. Considering this case as well as the review of the different reports, urgent surgery seems to be only recommended for large esophageal perforations and for small non-cervical perforations where external drainage is inefficient.

[2 cases of duodenal duplication]. / A propos de 2 cas de duplication duodénale.

Two cases of duodenal duplication are reported. It is a rare disease and is found commonly during infancy. Symptoms of partial duodenal obstruction are dominating the clinical picture. Upper gastrointestinal contrast radiography seems to be the best paraclinical examination. The surgical treatment is governed by the relationship of the cyst to the biliary and pancreatic ducts and the presence of ectopic gastric mucosa. If total resection of the cyst implicates a danger of injury to the common bile duct and the head of the pancreas and when one is tempted to perform a cystoenterostomy, the authors insist on the necessity to detect the presence of ectopic gastric mucosa by fluid pH determination and frozen section biopsy of the cyst wall. The presence of ectopic gastric mucosa requires a total resection of the cyst.

Endoscopic management of a post-traumatic biliary fistula.

A number of techniques of surgical endoscopy have been used in the management of a post-traumatic biliary fistula. The endoscopic sphincterotomy with placement of a perfused nasobiliary catheter, followed by the insertion of a biliary stent allowed the fistula to dry out. A secondary stricture of the left hepatic duct was treated by endoscopic internal drainage after the insertion of a transhepatic guidewire by an epigastric route. This kind of combined transhepatic and endoscopic procedure is useful in some difficult cases.

Mesenteric vein thrombosis: early CT and US diagnosis and conservative management.

We report a case of isolated superior mesenteric vein thrombosis with acute ischemic bowel disease, diagnosed early by a screening ultrasound scan of the upper abdomen and definitively assessed by computed tomography and angiography. This report stresses the contribution of cross-sectional techniques in the early diagnosis and management of venous occlusive disease of the small bowel.

[Recurrent retroperitoneal liposarcoma, diagnostic and therapeutic problems]. / Liposarcomes rétropéritonéaux récidivants, problèmes diagnostiques et thérapeutiques.

Retroperitoneal liposarcomes are characterised by their tendency to recurrence, Eight cases are related, from which no one get out of this rule. Late diagnosis is due to their silent growth and poor symptomatology. Ancillary procedures, particularly computerised tomography, and histological examination, allow to confirm diagnosis. The main treatment is surgery, it must be as aggressive as possible, it allows to confirm histologically the nature of the tumor. Postoperative radiotherapy is helpful and chemotherapy can be associated, if it seems that complete excision has not been possible or if metastasis are detected. Histologically, these sarcomes seem to derive from a pluripotential mesenchymatous cell, it explains their polymorphic differentiation. A clinical prognosis, based on histology, seems to be illusive.

[Digestive system surgery in octogenarians]. / Chirurgie digestive chez l'octogénaire.

Between October 1, 1977 and June 30, 1983, 139 G.I. tract operations were performed in patients over 80 years-old. 45,3% were post-operatively admitted to the I.C.U.; the criteria for admission were emergency surgical interventions, the type and duration of the operation. The operative mortality was 15,8%. Contributory factors were the type of the intervention, its curative nature and the necessity for post-operative reanimation. The urgent nature of the intervention as well as the histology of the lesion had no bearing on the mortality. Local complications were noted in 34,5% of the cases and were mainly superficial and deep wound infections. General complications, mainly involving the cardio-pulmonary and urinary tract systems, occurred in 68,3% of the cases. Morbidity was mainly associated with the timing of the intervention.

Intussusception in adults--report of 3 cases.

Intussusception in the adult is rare. The cases reported here illustrate the usual clinical development of the condition: incomplete, subacute, or chronic subobstruction. Intussusception is usually associated with a localized lesion, mostly a small bowel benign tumor, and a colonic malignant tumor. Diagnosis is effected using barium enema, ultrasonography, or CT scanning. Treatment of intussusception requires surgical intervention.

[Medico-surgical attitude in the treatment of cancer of the bile ducts]. / Attitude médico-chirurgicale dans le traitement des cancers des voies biliaires.

In order to evaluate the operative possibilities in patients with obstructive carcinoma of the biliary tract a precise diagnosis of local extent of the tumor and metastasis is essential (cholangiography, US, CTscan). The treatment is preferably surgical whether the tumor be resectable or not. However some patients who, for any reason, are not surgical candidates can be helped by new endoscopic intubation techniques. Medical and surgical consultation is essential to set the criteria for the best treatment modality in all patients with this disease, especially those who are not surgical candidates.

[Acute appendicitis: the benefit of a wait-and-see attitude]. / Appendicite aiguë: bénéfice d'une attitude attentiste.

Acute appendicitis. Acute appendicitis is often suspected but in 70% of the cases the complaints to an other diagnosis. Aggressive therapy is therefore not indicated. A 12 to 24 h observation allows to avoid surgery and complications which are not exceptional.

[Complications of jejunal diverticulosis. Apropos of 2 cases]. / Complications de la diverticulose jéjunale. A propos de 2 cas.

Two cases of acute jejunal diverticulitis are presented and confronted to data found in the literature. Acquired jejunal diverticulosis is a rare disease; its complications occur in a small percentage of cases. Chronic complications (malabsorption, megaloblastic anemia) should be treated medically. Acute complications (diverticulitis, perforation, haemorrhage, obstruction) require an emergency operation. Preoperative diagnosis is rarely made. Radiological or peroperative discovering of asymptomatic jejunal diverticula does not justify surgical treatment.

[Surgery of acute cholecystitis in patients 80 years of age or older]. / Chirurgie de la cholécystite aiguë au-delà de 80 ans.

In 17 Belgian surgical centers, 324 operations have been performed for acute cholecystitis in patients 80 years of age or older. In this group of patients: 1. The incidence of acute cholecystitis is hardly higher in women than in men. 2. The patients were operated within 24 hours of admission in 38% of cases. The main bile duct was surgically explored in 1/3 of patients. Cholecystostomy or simple drainage were used in 1/10 of cases only. 3. Operative mortality was 19%. It was higher for patients operated as emergencies than for delayed operations and higher also when the cholecystectomy was associated with an exploration of the bile duct. The ideal treatment for such patients should thus be a cholecystectomy with an endoscopic sphincterotomy.