[Pancreatico-jejunal anastomosis with invagination on isolated loop after cephalic pancreatoduodenectomy]. / L'anastomosi pancreatico-digiunale con invaginazione su ansa esclusa dopo duodenopancreatectomia cefalica.

The most frequent and most dangerous complication of the duodenopancreatectomy is pancreatic fistula due to dehiscence of the pancreatic anastomosis. A technique that uses a separate Roux en Y loop for pancreatic anastomosis, to reduce the fatal risks of the pancreatic fistula, has been initially reported more than 50 years ago. With the development of the pancreaticogastrostomy, it seems interesting to present a procedure using an isolated loop for the pancreas; this technique is derived from those previously published, allowing a good intussuception of the pancreas in the intestinal loop. This method has been performed in 35 duodenopancreatectomy (malignant pancreatic disease: 32 patients, benign pancreatic disease: 3 patients). The mean age of the patients was 64 years (range 34-74). There were four operative deaths unrelated to the pancreaticojejunal anastomosis and two pancreatic fistulas with spontaneous healing. The pancreatico-jejunostomy using a separate Roux en Y loop represented in this short experience a safe procedure to prevent pancreatic fistula.

[Complicated colonic diverticulosis. Changes in treatment and results over 22 years]. / Diverticulose colique compliquée. Evolution du traitement et des résultats en 22 ans.

OBJECTIVES: The aim of this study was to analyse the clinical course, surgical strategy and results in patients with complicated colonic diverticular disease. METHODS: We retrospectively compared two groups of patients who underwent surgery for complicated colonic diverticulosis from 1970 to 1984 (Group A, n = 94, mean age 60 years, 49 males, 45 females) and from 1985 to 1992 (Group B, n = 76, mean age 63.5, 32 males, 44 females). RESULTS: Patients in the two groups were comparable; only the rate of peritonitis (20 vs 8%) was different (p < 0.05). The most frequent operations in Group A were colostomy-drainage (43%) and Hartman's procedure (26%) in emergency situations and resection with immediate anastomosis (63%) or resection-anastomosis with diverting stomy (19%) in elective cases. In Group B, surgical strategy led to a different pattern of operations, 4 and 56% in emergency, and 94 and 2% in elective surgery, respectively. Overall mortality was 11%, with 17% and 4% in Groups A and B respectively (p < 0.01). This major drop in mortality was particularly important in emergency cases (31 vs 4%; p < 0.02). Morbidity in emergency surgery fell from 21 to 4% (P < 0.0006). Interrupting the use of colostomy-drainage was a major factor in reducing mortality followed by a sharp fall in mortality after Hartmann's procedure (28.5 vs 0%). CONCLUSION: The marked improvement in results between the two groups was mainly due to preferring resections of pathological colonic segments over colostomy-drainage.

[Laparoscopic treatment of gastroesophageal reflux. Cardiopexia with the round ligament versus Nissen's type fundoplication]. / Traitement laparoscopique du reflux gastro-oesophagien. Cardiopexie par le ligament rond versus fundoplicature de type Nissen.

Thirty nine patients with a symptomatic gastrooesophageal reflux (RGO), resistant to or relapsing after medical treatment, were prospectively studied and operated on with a laparoscopic approach: 8 which a ligamentum teres cardiopexy, 31 with a 360 degrees fundoplicature. Both groups were comparable concerning clinical, endoscopic, mano- and pHmetric features (Anova test at 95% for all comparison in the study). There was no operative mortality. Conversion and morbidity rate were significantly higher (p = 0.04) in the "cardiopexy" group, even if data suggest a responsibility of the learning curve only. During follow-up patients were interviewed at 1, 3 and 12 months and proposed for mano- and pHmetry at 3 and 12 months. Late results at 12 months showed a relapse of RGO in 5 out of 8 patients of the "cardiopexy" group, with no relapse in "fundoplicature" group (p = 0.01). Mano- and pHmetric records showed at 3 months a persistent hypotony of the lower oesophageal sphincter and a persistent acid reflux in the "cardiopexy" group, with a significant (p = 0.01 and = 0.03) difference with "fundoplicature" group, in which lower oesophageal sphincter was hypercorrected and no reflux appeared at pHmetry. Despite some rare evidence in literature, cardiopexy do not give good late results, and laparoscopic 360 degrees fundoplicature seems to be the better procedure for surgical treatment of symptomatic RGO.

[Pancreaticojejunal anastomosis by intussusception of an isolated loop in pancreaticoduodenectomy]. / L'anastomose pancréatico-jéjunale par invagination sur anse isolée dans la duodénopancréatectomie céphalique.

The most frequent and severe complication of pancreaticoduodenectomy is pancreatic fistula due to dehiscence of the pancreas anastomosis. The technique that uses a separate Roux en Y loop for pancreas anastomosis, to reduce the fatal risks of pancreatic fistula, has been described for more than 50 years. With the development of pancreaticogastrostomy, it seems interesting to present a procedure using an isolated loop for the pancreas; this technique, derived from those previously described allows a good intussusception of the pancreatic stump into the intestinal loop. This method was performed in 22 pancreaticoduodenectomies. There were 2 operative deaths unrelated to the pancreaticojejunal anastomosis and one pancreatic fistula, which healed under medical treatment.

[1000 cases of cholecystectomy: 500 by laparotomy versus 500 by laparoscopy]. / 1.000 cas de cholécystectomie: 500 par laparotomie versus 500 par laparoscopie.

The authors report 1,000 cases of cholecystectomy for cholelithiasis, excluding all cases with associated common bile duct surgery. The aim of the study was to compare two groups of cholecystectomies, one of 500 laparotomic procedures, evaluated retrospectively, and one of 500 laparoscopic ones, evaluated prospectively. Sex ratio was the same in both groups, and mean age was higher in the second group (54 vs 60) (p < 0.05): acute cholecystitis ratio was similar in both groups (23% vs 19%; NS). During the laparoscopic period, 84 laparotomic interventions were performed (17%), with a 0% mortality and a 18% morbidity rate. Mean operating time was 69' in the first group vs 91' in the second one, with a mean hospital stay of 11 vs 4.5 days (p < 0.001). Mortality rate was 1% vs 0% (p < 0.03) for laparotomic and laparoscopic procedures, and morbidity rate was respectively 11% and 1% (p < 0.001). Conversion rate in laparoscopic surgery was 7%. Two cases (0.4%) in laparoscopic group had a common bile duct lesion diagnosed intraoperatively and 1 case (0.2%) had a residual stone in common bile duct. Laparoscopic surgery is at present the standard technique for the treatment of cholelithiasis and laparotomic cholecystectomy seems only indicated when laparoscopic procedure is contraindicated or impossible.

[The musculocutaneous flap of the latissimus dorsi in the treatment of recurrences of breast cancer]. / Le lambeau musculo-cutané du grand dorsal dans le traitement des récidives de cancer du sein.

Breast cancers local recurrence treatment usually requires a large chirurgical resection. Latissimus dorsi myocutaneous flap was used after mastectomy in 27 patients. This technique was performed in 14 patients who had a recurrence after exclusive radiotherapy treatment. The follow-up of all the patients was more than 5 years. A 42% survival rate has been quoted in this group, after a 11 years period. Latissimus dorsi myocutaneous flap seems to be a satisfactory alternative when performing reconstruction after wall excision under 300 cm2, excepted for recurrence of fast kinetic cancers.

[Parietal prosthetic mesh in the treatment of large incisional hernias]. / Le pontage prothétique pariétal dans le traitement des grandes éventrations.

The repair of abdominal wall deficiencies has been simplified by the introduction of synthetic prostheses. The aim of this work was to describe the treatment of very large incisional abdominal hernias with a technique using a prosthetic mesh anchoring to the fibro-aponeurotic layers without closure the fascia. The procedure described has been used in 32 cases between 1974 and 1991 (15 male, 17 female). The median age was 62 years. All the patients were reexamined (median time: 4 years, range: 6 months-14 years). There was no operative mortality. Six patients had a subcutaneous seroma treated by multiple punctions. Three patients presented in the postoperative time a respiratory failure which necessitated artificial ventilation during 7 to 15 day. Two patients were reoperated, 6 months and 3 years after the first incisional hernia operation (1 cutaneous fistula, 1 hernia recurrence). Extremely large incisional hernias can be closed safely and effectively using this technique, without mortality and with a low morbidity.

[The surgical therapy of liver trauma]. / La terapia chirurgica dei traumi epatici.

The different therapeutic patterns of liver trauma are presented; they should be chosen on the basis of both clinical assessment, particularly looking for hemodynamic impairment and associated bowel lesions, and CT scan data. Surgical abstention should be considered for a great number of blunt liver trauma; open or severe blunt trauma should be preferably treated by elective hemostasis and biliostasis, with only rare use of hepatic resection "à la demande", on partially sectioned or devitalized tissues. Cavo-suprahepatic wounds remain the most important technical problem and continue to worse the prognosis in liver trauma.