Results of pancreatogastrostomy after pancreatoduodenectomy in 160 consecutive patients.

BACKGROUND: The advantages of pancreatogastrostomy over pancreatojejunostomy after pancreaticoduodenectomy are still debated. This study analyses the results of pancreatogastrostomy to identify factors that could influence immediate outcome. METHODS: During a 10-year period, 160 consecutive patients underwent a pancreatogastrostomy. There were 109 men (68 per cent) and 51 women (32 per cent) with a mean(s.d.) age of 59(10) (range 22-82) years; 27 patients were older than 70 years. The following parameters were assessed: mortality rate, morbidity, reasons for reoperation, length of hospital stay, duration of nasogastric tube and drainage. RESULTS: Hospital mortality rate was 3 per cent; overall morbidity rate was 30 per cent. The reoperation rate was 12 per cent, mainly because of bleeding at the pancreatic margin. Delayed gastric emptying occurred in 36 patients. The overall rate of pancreatic fistula was 2.5 per cent. Age, sex, indications for pancreatoduodenectomy, and the texture of the pancreatic remnant did not influence the occurrence of pancreatic fistula or delayed gastric emptying. CONCLUSION: This study confirmed that pancreatogastrostomy is a safe procedure with low mortality and morbidity rates.

Laparoscopic treatment for choledocholithiasis: a prospective evaluation in 247 consecutive unselected patients.

BACKGROUND/AIMS: Evaluation of the feasibility and results of the one-stage treatment combining routine intraoperative cholangiography and laparoscopic common bile duct exploration for choledocholithiasis. PATIENTS AND METHODS: Multicentric (5 centers-9 surgeons) prospective study in 247 consecutive patients (mean age 68 years; range 21-92) during a 50-month period (November 1991-December 1995). Laparoscopic treatment of choledocholithiasis was attempted irrespective of the circumstances leading to the diagnosis of biliary lithiasis or the preoperative suspicion of choledocholithiasis. RESULTS: One out of four patients (n = 61) had unsuspected choledocholithiasis disclosed by routine intraoperative cholangiography. A laparoscopic complete clearance of choledocholithiasis was achieved in 208 of 236 attempted cases (88%), with either transcystic duct extraction (n = 116) or choledochotomy (n = 92). Open surgery was required in 20 patients for failure of laparoscopic treatment and in 3 patients despite successful extraction. Twenty-one of 25 patients (84%) referred for failure of retrograde endoscopic stone extraction had successful laparoscopic choledocholithiasis clearance. The mean duration for the laparoscopic transcystic approach and choledochotomy were 108 min (range 50-300) and 173 min (range 70-480), respectively. Eleven patients had retained stones (4.4%). Minor and major complications were recorded in 9 and 22 patients respectively. The operative mortality was 0.4% (95% confidence interval: 0-1.2%). CONCLUSION: Intraoperative cholangiography during laparoscopic cholecystectomy and laparoscopic common bile duct exploration when required should be considered as the simplest and most efficient treatment for choledocholithiasis. The multicenter character of this study including consecutive patients from public and private practices, strengthens our conclusions and is consistent with a wide diffusion of this diagnostic and therapeutic strategy.

[Treatment of common bile duct lithiasis under laparoscopy. A prospective multicenter study in 189 patients]. / Traitement de la lithiase de la voie biliaire principale sous laparoscopie.

OBJECTIVES: The aim of this study was to assess the feasibility and results of common bile duct laparoscopic treatment and exploration in patients with choledocholithiasis. PATIENTS AND METHODS: From November 1991 to December 1994, 189 consecutive malades (120 females; mean age 68 years, range: 21-92) with choledocholithiasis identified during routine intraoperative cholangiogram underwent surgical exploration of common bile duct in 5 surgical centers. Twenty patients were referred to surgery after unsuccessful endoscopic sphincterotomy. RESULTS: Following laparoscopic exploration and intraoperative cholangiography, common bile duct stone extraction by laparoscopy was not attempted in 11 patients (5.8%). The common bile duct was successfully cleared of all stones in 153 patients (81% of the overall population and 86% of laparoscopic attempts), either via the transcystic route (n = 97) or through choledocotomy (n = 56). Eighteen patients required conversion to open surgery, 16 for unsuccessful stone extraction and 2 despite successful stone extraction. Postoperative endoscopic sphincterotomy was required in 7 patients (4.4%) for retained stones after laparoscopic treatment. There were no postoperative deaths (95% confidence interval 0-1.6%), and follow-up, ranging from 3 to 42 months, has shown no further clinical evidence of retained stones. CONCLUSION: Diagnosis and treatment of common bile duct stones is feasible by laparoscopy, and the results in this series compare favorably with those of conventional surgical treatment. Complete treatment of biliary lithiasis, in one operation, avoids the pitfalls of patient selection for preoperative endoscopic retrograde cholangiography and the risks of endoscopic sphincterotomy.

Prospective evaluation in 121 consecutive unselected patients undergoing laparoscopic treatment of choledocholithiasis.

Laparoscopic common bile duct (CBD) exploration was attempted in 115 of 121 consecutive unselected patients with choledocholithiasis (mean age 69 (range 21-92) years) found during routine intraoperative cholangiography. The CBD was successfully cleared of all stones in 100 patients (87 per cent). Ten of 11 patients referred for surgery after failure of endoscopic sphincterotomy had complete laparoscopic choledocholithiasis. Eleven patients (10 per cent) required conversion to open CBD exploration, and laparoscopic exploration was not attempted in six (5 per cent) because of inflammation or fibrosis. Postoperative endoscopic sphincterotomy was required in four patients (4 per cent) for retained stones after laparoscopic exploration. There were no postoperative deaths (39 per cent of patients were aged 75 years or more). Routine intraoperative cholangiography, and when required laparoscopic CBD exploration, should be compared in randomized trials with preoperative endoscopic retrograde cholangiography in patients with suspected choledocholithiasis.

[Ileal pouch in the treatment of ulcerative rectocolitis and familial polyposis. Analysis of morbidity in a series of 30 cases]. / Réservoirs iléaux dans le traitement de la rectocolite ulcéro-hémorragique et de la polypose rectocolique familiale. Analyse de morbidité sur une série de trente cas.

Between 1984 and 1989, 30 patients underwent total coloproctectomy with J ileal pouch and ileo-anal anastomosis. They corresponded to 29 cases of ulcerative colitis and one case of familial polyposis. The authors report their own experience and the related morbidity and functional results. There were 23% fistulae, 6.6% pouchitis, 10% stenoses, 8.7% pelvic abscesses, 10% bowel obstructions, 6.6% fistulae after ileostomy closure. Only one pouch had to be removed for severe pouchitis. Functional results were partly related to post-operative complications: 50% of patients had normal continence, 57% at least 6 stools per day, 81% had one stool per night, 15% had soiling. Morbidity is discussed for the various types of complications.

[Pancreatic pseudo-tumor caused by bilio-pancreatic tuberculous lymphadenitis. 2 cases]. / Pseudo-tumeur du pancréas par tuberculose ganglionnaire bilio-pancréatique. Deux observations.

Peripancreatic tuberculous lymphadenitis is rare and of difficult diagnosis. The two cases described illustrate two clinical aspects according to the proximity of the biliary tract: either anterior lymph nodes responsible for obstructive jaundice, or posterior lymph nodes responsible for chronic epigastric pain. Endoscopic retrograde cholangiopancreatography is essential to exclude a pancreatic lesion and facilitate the interpretation of the CT images. Tuberculosis must then be suspected. In the absence of another tuberculous localisation, laparotomy is necessary to assert the diagnosis. Antituberculous chemotherapy alone, administered for 9 to 12 months, cures this form of tuberculous lymphadenitis.