The effect of metabolic syndrome on postoperative outcomes following laparoscopic colectomy.

BACKGROUND: Among the criteria used to diagnose metabolic syndrome (MS), obesity and diabetes mellitus (DM) are associated with poor postoperative outcomes following colectomy. MS is also associated with colorectal cancer (CRC) and diverticulosis, both of which may be treated with colectomy. However, the effect of MS on postoperative outcomes following laparoscopic colectomy has yet to be clarified. METHODS: In an academic tertiary hospital, data from all consecutive patients undergoing laparoscopic colectomy from 2005 to 2014 were prospectively recorded and analysed. Patients presenting with MS [defined by the presence of three or more of the following criteria: elevated blood pressure, body mass index > 28 kg/m2, dyslipidemia (decreased serum HDL cholesterol, increased serum triglycerides) and increased fasting glucose/DM] were compared with patients without MS regarding peri-operative outcome [mainly anastomotic leaks, severe postoperative complications (Clavien-Dindo III and IV)] and mortality. RESULTS: Overall, 1236 patients were included: 508 (41.1%) right colectomies and 728 (58.9%) left colectomies. Seven hundred seventy-two (62.4%) of these procedures were performed for CRC. MS was diagnosed in 85 (6.9%) patients, who were significantly older than the others (70 vs. 64.2 years, p < 0.001), and presented with more cardiac comorbidities (p < 0.001). MS was associated with increased blood loss (122.5 vs. 79.9 mL p = 0.001) and blood transfusion requirement (5.9 vs. 1.7%, p = 0.021). The anastomotic leak rate was 6.6% (with 2.2% of anastomotic leaks requiring surgical treatment), and the overall reoperation rate was 6.9%. The incidence of severe postoperative complications was 11.5%, and the overall mortality rate 0.6%. No differences were found between the groups in overall postoperative morbidity and mortality. Median length of stay was similar in both groups (7 days). CONCLUSIONS: MS does not jeopardize postoperative outcomes following laparoscopic colectomy.

Comparison between open and laparoscopic gastrectomy for gastric cancer: A monocentric retrospective study from a western country.

BACKGROUND: The majority of laparoscopic gastrectomy (LG) reports arise from Asia and the benefit of this approach in western countries remains unclear. The objective of this study was to compare the postoperative outcomes between LG and open gastrectomy (OG) for gastric cancer in a western center. METHODS: Between 2005 and 2015, all consecutive patients with gastric cancer who underwent either LG or OG were enrolled. Postoperative morbimortality was evaluated according to Dindo-Clavien classification. RESULTS: Over 164 patients, 60 had LG and 104 OG with a mean age of 62 and 65 years, respectively. Total gastrectomy represented 58% of LG and 54% of OG (P=0.749). Operative time was not different in the two groups (160.8 vs. 174.2min, P=0.780) so as intraoperative blood loss (111 vs. 173mL, P=0.057). The rate of severe complications (including postoperative bleeding) was significantly higher in the LG group (40% vs. 23%, P=0.012) so as reoperation rate (27% vs. 6%, P<0.001). There was no statistical difference in terms of postoperative mortality (0 vs. 3%, P=0.252) or length of hospital stay (20 vs. 16 days, P=0.116). CONCLUSION: Laparoscopic gastrectomy for the treatment of gastric cancer in western countries appears to be feasible but with a higher rate of severe complications compared to open gastrectomy.

Accuracy of staging laparoscopy in detecting peritoneal dissemination in patients with gastroesophageal adenocarcinoma.

Despite staging laparoscopy (SL) with peritoneal lavage is recommended in US Guidelines in patients with potentially resectable gastroesophageal adenocarcinoma, this procedure is not systematically proposed in French Guidelines. Therefore, we decided to analyze the results of systematic SL in patients considered for preoperative chemotherapy. From 2005 to 2011, 116 consecutive patients with distal esophagus, esogastric junction, and gastric adenocarcinoma ≥T3 or N+ without detectable metastatic dissemination by computed tomography (CT) scan imaging underwent SL before neoadjuvant chemotherapy. Positive and negative SLs were compared according to tumor characteristics. SL was positive in 15 cases (12.9%) including 14 with peritoneal seeding (localized in five, diffuse in nine). SL was positive in 7 (24.1%) of 29 patients with poorly differentiated tumor, in 9 (32.1%) of 28 patients with signet ring cells, in 7 (50%) of 14 patients with gastric linitis tumor, and in 15 (16.3%) of 92 patients with T3 or T4 tumor. All the lesions of distal esophagus extending to the cardia had a negative SL. Among the 14 patients with peritoneal carcinomatosis at SL, nine (65%) had signs of peritoneal seeding on initial CT scan. One (0.8%) patient had a small bowel perforation closed laparoscopically. If systematic SL before preoperative chemotherapy does not seem justified because of its low accuracy, it should be performed in patients with poorly differentiated tumor, signet ring cell, and gastric linitis plastica components on biopsy and when CT scan is suggestive of T4 tumor, ascites, or peritoneal nodule.

Ambulatory groin and ventral hernia repair.

OBJECTIVE: Ambulatory surgery is not commonly practiced in France today. The aim of this study was to prospectively evaluate the feasibility of ambulatory hernia repair in a consecutive series of unselected patients. PATIENTS AND METHODS: From June 2008 to October 2009, 257 patients (238 men and 19 women, median age 65 years) were treated in a same-day surgery unit for 270 hernias (244 groin hernias, 25 ventral hernias and one Spiegelian hernia). RESULTS: For groin hernia, the techniques included the totally extraperitoneal repair (TEP) in 108 cases, the transinguinal preperitoneal (TIPP) approach in 106 cases and other alternative techniques in 30 cases; for ventral hernias, the technique was an open suture in 20 cases, an open prosthetic repair in four cases and laparoscopic repair in one case. Anesthesia was general in 145 cases, local in 121 cases and spinal in four cases. Repair was completed in a same-day surgery setting in 242 (89.6%) cases; hospital stay greater than 23 hours was planned for 21 (7.8%) patients while non-programmed hospitalizations were necessary for seven (2.6%) patients. There were two (0.7%) readmissions and nine (3.3%) benign postoperative complications. CONCLUSION: These results suggest that groin and ventral hernia repair can be performed in an outpatient setting in nearly 90% of unselected patients.

Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients.

BACKGROUND: Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores. METHODS: From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration. RESULTS: The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively). CONCLUSION: The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

Laparoscopic resorbable mesh fixation. Assessment of an innovative disposable instrument delivering resorbable fixation devices: I-Clip(TM). Final results of a prospective multicentre clinical trial.

BACKGROUND: The aim of this study was to assess the performance and tolerance of an innovative disposable instrument delivering resorbable clips (I-Clip, Sofradim, France) intended for mesh fixation in inguinal, incisional and umbilical hernias of the abdominal wall. The fixation device was designed to be resorbable in 1 year, with reduced trauma to the underlying tissues or the mesh, and with initial mechanical properties equivalent to those of conventional metal staples. METHODS: The study involved 105 patients with inguinal, umbilical or incisional hernias enrolled from 11 centres. Inguinal totally extra peritoneal (TEP) or trans abdomino pre-peritoneal (TAPP) repair was performed with Parietex mesh, incisional or umbilical hernias were treated via the intraperitoneal route with Parietex composite. I-Clips were used for mesh fixation in both indications according to the surgeon's habits. Efficacy was the principal assessment criteria evaluated by two parameters: quality of fixation evaluated subjectively at the time of procedure and recurrence rate according to the follow up at 1, 6 and 12 months. Pain evaluated by the patients using a visual analogue scale (VAS) was the principal secondary assessment criteria. Other tolerance criteria were also evaluated during surgery and follow up. RESULTS: The surgeons' evaluation of the fixation quality was assessed as good to very good in 100% of ventral hernias and good to very good in 85-92% of inguinal hernias. At 1 month, 90% of patients (94/104) were totally pain-free (VAS score: 0) and only ten patients reported low pain (VAS scores: 0.3-3.1). At 1 year, the pain described by those ten patients finally disappeared, 98% of patients (102/104) were totally pain-free. The rate of minor complications not related to the device concerned 5% of the patients at 1 month, which was reduced to 2% at one year and no recurrence or mesh sepsis was observed. CONCLUSIONS: The ease of use of this device, combined with the absence of recurrence related to the investigated device and the good pain-free outcome in this group of patients confirmed the effectiveness and tolerance of the resorbable fixation concept of I-Clip(TM).

[Laparoscopic incisional hernia repair: prospective non randomized trial in 51 cases]. / Traitement coelioscopique des éventrations. Etude prospective non randomisée de 51 éventrations.

AIM OF THE STUDY: Insertion of a mesh in treatment of incisional hernias reduces the risk of recurrence. A single prospective randomized trial have compared laparoscopic and open approach: there were less postoperative complications and fewer recurrences in the laparoscopic group. Aim of this prospective trial was to control these results. PATIENTS AND METHODS: From January 2000 to May 2005, 51 consecutive incisional hernias were operated on by a laparoscopic approach. Incisional hernia was single in 41 and double in 5. It was median in 41 and lateral in 10. Previous hernia repair was noticed in 33.3%. Main criteria was recurrence. We have considered whether one of the following criteria was associated with the risk of recurrence: sex, obesity, previous repair, pre and preoperative sizes of the hernia, uni or multi orificial aspect of the hernia, median or lateral location, mesh size, ratio mesh surface/hernia surface. Others were postoperative mortality and morbidity, duration of hospitalisation and occurrence of late events. RESULTS: At 2 years all patients were followed. Follow up achieved 3 years in 23 cases and 4 years in 9. Recurrence was observed in 7 (13.7%). None predictive factor was disclosed. No death occurred. Median postoperative pain score at D1, D2 and D3 was respectively 3.1+/-1.9, 2.9+/-2.3 and 2.3+/-2.1. Mean postoperative stay was 4.1+/-1.9 days. Seven postoperative complications occurred, al benign. During follow-up 18 events were noticed and of these 8 were chronic abdominal pain. CONCLUSION: This technique could be employed for every type of incisional hernia but peristomial hernias (not assessed in this study) and every patient. Technical improvements ought to be find to reduce recurrence rate.

Laparoscopic liver resection.

BACKGROUND: This paper describes a 10-year experience of laparoscopic liver surgery, including several major hepatectomies for malignant tumours. METHODS: Of 243 hepatectomies carried out between January 1995 and December 2004, 113 (46.5 per cent) were performed by laparoscopy and 89 were included in this retrospective study. RESULTS: Twenty-four laparoscopic hepatectomies (27 per cent) were for benign disease and 65 (73 per cent) for malignant tumours, including hepatocellular carcinoma (HCC) in 16 patients and colorectal metastasis (CRM) in 41. Minor hepatectomy was performed in 51 patients and major hepatectomy (three or more Couinaud segments) in 38. Conversion to laparotomy was necessary in 12 patients and perioperative blood transfusion in eight. One patient with cirrhosis who underwent right hepatectomy for HCC with conversion to open surgery died 8 days after surgery. Major morbidity occurred in eight patients (16 per cent) having minor hepatectomy and in 11 (29 per cent) of those having a major resection. The 3-year overall and disease-free survival rates for patients with CRM (mean follow-up 30 months) were 87 (11 patients at risk) and 51 (6 patients at risk) per cent respectively. Corresponding values for patients with HCC (mean follow-up 40 months) were 85 (10 patients at risk) and 68 (5 patients at risk) per cent. CONCLUSION: In experienced hands, the results of laparoscopic liver surgery are similar to those for laparotomy.

Laparoscopic treatment of acute small bowel obstruction: a multicentre retrospective study.

BACKGROUND: Laparoscopic surgery is thought to promote early recovery and quicker return to bowel function. The objective was to evaluate the rate and predictive factors of success, the causes of failure, the morbidity, and mortality during and after hospitalization, as well as to determine whether laparoscopic treatment of acute small bowel obstruction offers the same benefits as for other laparoscopic procedures. METHODS: The records of 308 patients with acute small bowel obstruction treated laparoscopically in 35 centres between 1 October 1988 and 30 September 1996 were retrospectively reviewed. RESULTS: Treatment was implemented completely by laparoscopy ('success' group) in 168 patients (54.6%). Conversion to laparotomy ('failure' group) was required in 140 patients (45.4%; during the same operation in 126 patients and after a median delay of 4 days (range: 1-12 days) in 14 patients). There were significantly more successes in patients with a history of one or two surgical interventions than in those with more than two (56% vs 37%; P < 0.05). There were significantly more successes in patients who had undergone appendectomy only (67/94; 71%) than in patients who (i) had no antecedent surgery (52%; P < 0.05), or (ii) underwent other surgery (33%; P < 0.001). The rate of success was significantly higher (P < 0.001) in patients operated on early (< 24 h) and in patients with bands (54%), than in those with adhesions (31%) or with other causes of obstruction (15%). The median duration of postoperative ileus was significantly shorter in the 'success' group than in the 'failure' group (2 days vs 4 days; P < 0.001). The median duration of postoperative hospital stay was shorter in the 'success' group than in the 'failure' group (4 days vs 10 days; P < 0.001). Fewer immediate wound complications were sustained in the 'success' group than in the 'failure' group (1.2% vs 10.7%; P < 0.001). The total number of immediate or delayed complications and particularly the number of recurrent obstructions after hospitalization as well as the number of deaths did not differ significantly between the two groups. CONCLUSIONS: Successful laparoscopic treatment of small bowel obstruction can be expected in patients who are seen early, and who have had one or two previous interventions (particularly appendectomy, especially if bands are found).

[Can common bile duct lithiasis be removed laparoscopically without external biliary drainage?]. / Le traitement laparoscopique de la lithiase de la voie biliaire principale sans drainage biliaire externe est-il possible?

AIM OF THE STUDY: To evaluate the indications, feasibility and results of laparoscopic treatment of common bile duct stones without biliary drainage. PATIENTS AND METHODS: Between 1992 and 1999, laparoscopic procedures were performed in 70 consecutive patients, mean age 60 +/- 15 years (range: 18-82). Stone removal was attempted via the cystic duct (n=25) or choledocotomy (n=45). The emptiness of the common bile duct was checked by intraoperative cholangiography or endoscopy. After choledocotomy, closure was performed by interrupted or non-interrupted suture with slowly resorbable thread. Transcystic drainage was used whenever necessary. RESULTS: Nine conversions to laparotomy were necessary (12.8%). Among the 61 patients who had an exclusively laparoscopic procedure, 21 were treated via the transcystic route and 40 through choledocotomy. Biliary endoscopy was possible in only 10 of the 21 patients (47.6%) treated via the transcystic route and in all with choledocotomy. No biliary drainage was used in 16 of the 21 patients treated via the transcystic route and in 39 of the 40 treated through choledocotomy. The 30-day mortality was 1/61 (1.6%). Morbidity was 9.8% and 2 patients underwent a second laparoscopic procedure (one fistula on a choledocotomy suture, one hemoperitoneum of unknown origin). An endoscopic sphincterotomy for residual stone was necessary in 4 patients (4/61, 6.5%), 2 after choledocotomy for an unrecognized stone without biliary drainage. CONCLUSIONS: These results confirm the feasibility of laparoscopic treatment of common bile duct stones and suggest it can be performed without biliary drainage in most cases.

[Minimally invasive surgery for diverticula of the thoracic esophagus. Results in 11 patients]. / Traitement par vidéo-chirurgie des diverticules de l'oeophage thoracique.

OBJECTIVES: Surgical treatment of diverticula of the esophagus is associated with substantial mortality and morbidity. Few data have been published concerning results of minimally invasive surgery. The aim of the study was to retrospectively assess the results of minimally invasive surgery (either thoracoscopy or laparoscopy) in a first series of patients with diverticula of the thoracic esophagus. METHODS: Eleven consecutive patients with symptomatic thoracic diverticula of the esophagus were operated on between December 1992 and March 1999. Five were operated on by right thoracoscopy, 4 by laparoscopy and 2 by thoracoscopy and laparoscopy. The procedure performed varied according to the location and the macroscopic aspect of the diverticulum, as well as of the associated disorders (gastroesophageal reflux, hiatal hernia and/or motor disorders). RESULTS: Postoperative mortality was nil. Three patients developed an esophageal fistula; one with an esophago-bronchial fistula required another operation. Postoperative pain was treated with morphine (median duration 4 days) or IV paracetamol (5 days). Long term results were excellent in 1 patient, good in 6, fair in 2 and poor in 2. These 2 latter patients were operated on another time. One of them was operated on 3 years later for aperistalsis of the esophagus and the other one was operated 4.5 years later for paraesophageal hernia; late results of these operations were fair. CONCLUSION: These results suggest that minimally invasive surgery does not confer significant benefit compared with open surgery in the treatment of diverticula thoracic esophagus.

[Immediate postoperative complications after a laparoscopic partial posterior fundoplication. Early laparoscopic reoperation]. / Complications postopératoires immédiates de la fundoplicature partielle postérieure coelioscopique. Réintervention précoce par coelioscopie.

AIM OF THE STUDY: The immediate postoperative course of laparoscopic partial posterior fundoplication can be complicated by severe dysphagia or paraesophageal hernia. The aim of this study was to describe the technical causes of these complications. PATIENTS AND METHOD: Four patients, operated for gastroesophageal reflux disease by laparoscopic partial posterior fundoplication, developed severe dysphagia (n = 2) or paraesophageal hernia (n = 2) during the immediate postoperative period. A barium swallow examination visualized the complication in both cases of dysphagia and in 1 case of paraesophageal hernia. The correct diagnosis was established by CT scan in the other case of paraesophageal hernia. Reoperations were performed by laparoscopy, 3 days (n = 2) or 6 days (n = 2) postoperatively. RESULTS: Dysphagia was due to compression of the esophagus against the hiatus by the fundoplication. A new and looser fundoplication was easily performed. Dysphagia was no longer present postoperatively. The two patients were symptom-free after 6 and 12 months of follow-up, respectively. In the cases of paraesophageal hernia, the bottoms of the crura were torn. In the patient reoperated 3 days postoperatively, the procedure was easily performed, the postoperative course was uneventful and the patient was symptom-free after a follow-up of 20 months. In the patient reoperated 6 days postoperatively, the upper part of the stomach had moved into the left pleural cavity, the procedure was difficult due to inflammation and thickening of the gastric wall, and the postoperative course was uneventful, but reflux recurred 18 months later. CONCLUSION: When severe dysphagia or paraesophageal hernia occurs during the immediate postoperative course of laparoscopic partial posterior fundoplication, reoperation, possibly by laparoscopy, identifies and cures the technical defects. Based on our experience, we suggest that surgical cure of paraesophageal hernia is easier when performed during the immediate postoperative period.

[Results of elective segmental colectomy done with laparoscopy for complicated diverticulosis]. / Résultats de la colectomie segmentaire élective faite par coelioscopie pour diverticulose compliquée.

OBJECTIVES: To analyze a unicentric series of 100 consecutive elective laparoscopic colon resections for diverticular disease and to evaluate in intention to treat the early- and middle-term postoperative results. METHODS: From February 1993 to March 1998, 100 colon resections for complicated diverticular disease were performed through laparoscopy with systematic mobilization of the splenic flexure and resection of the rectosigmoid junction. The colorectal anastomosis was stapled or manual without proximal stoma. In 53 females and 47 males (mean age 60.4 years), indications for surgery were: one or more attacks of acute diverticulitis (n = 70), abscess (n = 17), symptomatic stenosis (n = 8), colovesical fistula (n = 4) and diverticular bleeding (n = 1). RESULTS: Mortality was nil. The conversion rate was 9%, never for anesthetic reasons. The mean operating time was 226 +/- 68 min. There was no splenic or ureteral injury. The morbidity at 30 days was 19% with fistulae rate accounting for 2%, 2 patients were reoperated on. The median time for passage of flatus was 3 days and median length of hospital stay was 7 days. Late morbidity was 10%, one patient complained of retrograde ejaculation. CONCLUSION: This study demonstrates that laparoscopy is a safe alternative to laparotomy for elective one-stage colectomy for complicated diverticular disease.

[Gastric stromal tumors. Results of a multicenter study. French Associations of Surgery Research]. / Tumeurs gastriques conjonctives. Résultats d'une étude multicentrique. Associations Françaises de Recherche en Chirurgie.

AIM OF THE STUDY: Gastric stromal tumours are not perfectly known. The aim of this retrospective multicenter study (29 centers) was to improve knowledge of these tumours. PATIENTS AND METHODS: From 1986 to 1994, 159 patients were operated on for leiomyomas (50), leiomyosarcomas (24), malignant/benign schwann cell tumours (10/29), automatic nerve tumours (4), leiomyoblastomas (28), spindle cell tumours (14). The mean duration of follow-up was 5 years. Presenting symptoms, diagnostic procedures, operative and pathological findings, evolution (recurrence, death) were recorded for each patient. RESULTS: Gastrointestinal bleeding and epigastric pain were the most common presenting symptoms (54% and 50% of patients, respectively). Endosonography was the most sensitive examination (97%). Malignant tumours size was greater than benign tumours size (12.6 cm versus 5.2 cm). Extension to contiguous organs or metastases were frequent (33% and 26% of patients, respectively). In 16 patients, pathological examination could not differentiate between malignant and benign tumour. Seven patients who had been operated on for a benign tumour (6%) developed a local (n = 4) or a metastatic (n = 3) recurrence. The 5-year survival rate was 40% for leiomyosarcomas, 28% for schwannosarcomas and 90% for malignant leiomyoblastomas. CONCLUSION: The main feature of stromal gastric tumours is the frequent difficulty to differentiate between malignant and benign tumours. The prognosis of malignant tumours depends on pathological types. The prognosis of benign tumours is uncertain since recurrences may develop.

Sclerosing encapsulating peritonitis: early and late results of surgical management in 32 cases. French Associations for Surgical Research.

OBJECTIVE: To propose guidelines for treatment based on the study of early and late outcome after various surgical procedures for sclerosing encapsulating peritonitis (SEP). PRIMARY BACKGROUND DATA: SEP is rare. The main complication is intestinal obstruction. Ideal treatment is resection of the membrane, whenever possible. Mortality and morbidity, however, have not been well analyzed. METHODS: The case records and histopathological reports of 32 operated cases of SEP (18 centers during 16 years) were retrospectively studied. Patients underwent four types of procedures: group 1 (n = 5), membrane resection; group 2 (n = 12), enterolysis with partial excision of the membrane; group 3 (n = 7), intestinal resection, and group 4 (n = 8), exploratory laparotomy only. Five cases were considered as idiopathic. Medical and surgical antecedent history for the 27 other cases (6 patients had associations) included laparotomy for carcinoma (n = 14) or benign disorders (n = 5), beta-blocker treatment (n = 4), cirrhotic ascites (n = 4), generalized peritonitis (n = 3) and continuous ambulatory peritoneal dialysis (n = 3). Indications for operation included subacute (n = 22) or acute intestinal obstruction (n = 6), abdominal mass (n = 8), other clinical presentations (n = 4) and asymptomatic SEP discovered during surgery for portacaval shunt (n = 1). Seven patients had two associated clinical presentations. All cirrhotic patients with ascites and the asymptomatic patient were in group 4. None of the imaging techniques (plain radiograms, barium follow-through, sonograms and CT scans) were formally contributive to the preoperative diagnosis of SEP. RESULTS: In group 1, both complicated patients, one with an inadvertent intraoperative intestinal wound, the other with a postoperative intestinal leak, healed uneventfully. In group 2, 4 inadvertent intraoperative intestinal wounds led to 4 postoperative leaks with 3 consequent deaths. One further patient died of persistent intestinal obstruction. In group 3, 1 inadvertent intestinal intraoperative wound healed uneventfully and 2 deaths, one due to persistent intestinal obstruction associated with anastomotic leakage and the other due to ventricular fibrillation, were noted. In group 4, there were no intraoperative wounds, no postoperative morbidity or deaths. The median follow-up was 49.5 months (range 4-142 months). Seven patients (1 or 2 in each group) experienced transient episodes of subacute intestinal obstruction between 1 month and 6 years after discharge, none of which required a repeat operation. Eight patients (in all groups) died of their initial cancer between 4 and 75 months after discharge. CONCLUSIONS: Our results suggest that: (1) resection of the membrane should be attempted when feasible; (2) in case of inadvertent intestinal wound(s), the most proximal one should be brought out as a stoma, and partial resections should not be anastomosed primarily, but (3) no surgical treatment is required in ascites, asymptomatic SEP or subacute intestinal obstruction.