[Pancreaticoduodenectomy for cancer of the head of the pancreas]. / Duodénopancréatectomie céphalique pour cancer.

Many modifications of the original technique have been proposed to try to improve the results of the pancreaticoduodenectomy described by Whipple. To evaluate these modifications, we have reviewed randomized controlled trials, meta-analyses, and well-conducted retrospective series. Neither total pancreatectomy nor extended lymph node dissections have shown an improve of survival in retrospective studies. Preoperative evidence of mesenteric or portal vein involvement does not contraindicate pancreatic resection and survival rates are similar to those of patients with no venous involvement. Prospective trials and one meta-analysis have shown neither advantage nor disadvantage of pylorus-preserving pancreaticoduodenectomy or of pancreatico-gastric anastomosis. Three trials and one meta-analysis of pancreatico-gastric anastomosis have failed to demonstrate a decrease in the risk of pancreatic fistula. Two trials suggest that the risk of fistula formation is decreased by implantation of the pancreatic remnant into the jejunum or by trans-jejunal stenting of the pancreatico-jejunal anastomosis with external drainage; but these findings are not supported by a third trial. The results of the antisecretory use of somatostatin are contradictory. Leak and fistula formation were decreased when the criteria for leakage was based on laboratory findings; but in 4 out of 5 trials, somatostatin did not decrease the incidence of clinical fistula. The use of fibrin glue to occlude the pancreatic duct or seal the cut surface of the pancreas did not decrease the rate of intra-abdominal complications. In conclusion, the pancreaticoduodenal resection described by Whipple may still be considered the gold standard for resection of pancreatic cancer. The technical experience of surgeons and their institutional support staff resulted in lower perioperative morbidity and mortality and in higher survival rates.

[Inguinal hernia repair: time interval between surgical repair and recurrence]. / Hernies inguinales: délais d'apparition des récidives.

This study seeks to evaluate the time interval between initial inguinal hernia repair and the appearance of recurrent hernia in patients undergoing re-operation. Recurrent hernia was identified in 94 (6.4%) of 1,474 patients having undergone initial hernia repair at our institution. Recurrence appeared within two years in 40 patients (42%). Recurrences were noted beyond five years in 32 patients (34%), and after 20 years in 18 patients (19%). 75% of recurrences had occurred within 15 years. We conclude that almost two-thirds of recurrences occur later than five years after the initial intervention and a quarter occur at an interval of more than fifteen years. Most studies underestimate hernia recurrence due to an insufficient period of post-operative observation.

[Acute intestinal tuberculosis]. / Tuberculoses compliquées du tube digestif.

AIM OF STUDY: To report cases from Vietnam of intestinal tuberculosis disease, which is uncommon but did not disappear in occidental countries. MATERIALS AND METHODS: Seventy-six patients were included in this retrospective study. Mean age was 40 years and sex ratio M/F was 6. Diagnosis was established on pathological examination of resected specimen or on presence of Mycobacterium tuberculosis or by polymerase chain reaction. RESULTS: Intestinal obstruction or subobstruction was the most usual symptom (68%), and thereafter peritoneal symptoms with pain and tenderness (17%). Five patients had intractable digestive haemorrhage. Thirty-six patients had no past history or active pulmonary tuberculosis (47%). Lesions of stenosis on barium enema and thickness of intestinal wall on CT-scan were not specific. Sixty-two patients were operated on (82%) and 14 were not. Surgical techniques differed according symptoms, site and type of lesions. Intestinal resections were performed in half of the patients, others undergoing stomies or enterolysis. There were eight postoperative deaths (13% of patients operated on), seven out of these deaths were attributable to cachexy. In the postoperative period, all the patients were medically treated and follow-up in the antituberculosis centre of Hanoi. CONCLUSION: Symptomatology and operative findings of intestinal tuberculosis are similar to those observed in Crohn's disease, and sometimes in amoeboma or lymphoma. In face of stenosis and intestinal wall thickness, probability of intestinal tuberculosis is high in endemic area, but diagnosis must be suspected in occidental countries, mainly in patients immigrated coming from these areas, patients with immuno-deficiency even if they did not have past or present pulmonary tuberculosis.

[Ascaris-induced acute pancreatitis]. / Ascaridiose biliopancréatique.

AIM OF THE STUDY: To indicate options in a surgical university team in Vietnam for treatment of ascaris-induced acute pancreatitis. PATIENTS AND METHODS: From January 1998 to April 2001, 33 patients (mean age 46 years) were admitted with a diagnosis of acute pancreatitis based on elevated serum amylase in 29 patients (88%), and elevated urinary amylase in all patients and a compatible clinical picture. The pancreatic ultrasonography was abnormal in 79% of cases. Biliary and pancreatic ultrasonography shown ascaris in 31 patients (94%). In other two patients ascaris was detected with duodenal endoscopy. RESULTS: In 24 patients, the worms from the duodenum and/or across the ampullary orifice was trapped and withdrawn during duodenoscopy and failed in three patients. Nine patients were operated on, three after failure of endoscopic treatment, five for lithiasis of the common bile duct associated to the ascariasis, and one for necrotic pancreatitis. Seven patients operated on underwent a choledocotomy with a T-tube drainage, two patients underwent a left pancreatectomy to withdraw the ascaris, and one patient a resection of pancreatic necrosis. All patients recovered without complications except the patient with a necrotic pancreatitis who developed a pancreatic fistula for 23 days. Mean discharge times were 5.6 days after endoscopic treatment and 12.2 days after surgery. Effective antihelminthic therapy was administered in all patients. CONCLUSION: Endoscopic treatment was effective in 24 out of 33 patients. Surgery was indicated for failures of endoscopic treatment, association of ascariasis and common bile duct stones, migration of ascaris in intra pancreatic duct, and pancreatic necrosis.

[Self-expandable metallic stent for palliative treatment of colorectal malignant obstructions: risk of perforation]. / Prothèse métallique expansive dans le traitement palliatif des occlusions colorectales malignes : risque de perforation.

OBJECTIVE: The self-expandable metallic stents are a good alternative to surgery for the palliative treatment of malignant colonic obstructions. The aim of this paper was to emphasize the causes which could increase the risk of perforation. PATIENTS AND METHODS: From November 2000 to November 2001, 6 patients with malignant colonic obstruction, to whom surgery was denied due to tumor extension and/or poor general condition, have had a palliative treatment (N = 5) or an attempt (N = 1) with self-expandable metallic stents placed by endoscopy. RESULTS: Only one patient did not developed any complication and died 5 months later of cancer. Five out of the 6 patients (83%) developed a colonic perforation following stenting (N = 4) or the attempt to place the stent (N = 1), two into the first 24 h after the procedure, and three 3, 5, and 10 months later. Subsequent colostomy was done in 2 patients while the 3 others have had an external drainage of the perforation and died postoperatively. CONCLUSION: The self-expandable metallic stents seems to be a less aggressive alternative therapy to surgery for malignant colonic obstructions. Nevertheless, the high rate of colonic perforations, suggests reconsidering the indications in the definitive palliation of malignant colonic obstructions.

[Surgical treatment of gastroesophageal reflux disease in adults]. / Le traitement chirurgical du reflux gastro-oesophagien chez l'adulte.

Pathological gastroesophageal reflux is common. The aim of this review was to compare the results of different surgical techniques. Papers were selected on Medline from 1990 to April 2001. A critical analysis was performed, concerning definitions of included patients, surgical techniques, and criteria of evaluation. For comparison, the results of 23 randomized studies were mainly selected. Their heterogeneity has not allowed a meta-analysis. A few techniques had poorer results than others: simple closure of His angle, Hill operation, Belsey Mark IV technique, and Angelchik prosthesis. In most studies, results of partial fundoplication on reflux were as good as those of total Nissen fundoplication and fewer patients had postoperative dysphagia. In a double blind trial, immediate advantages of laparoscopic approach were less important than those observed in non comparative studies. Another trial was interrupted after inclusion of 103 patients because of the higher rate of side-effects in the laparoscopic group. These results may help the surgeon in the choice of a technique. Patients have to be informed of potential adverse effects of the different techniques chosen by their surgeon.

Randomized trial of 5-fluorouracil, leucovorin and cisplatin in advanced pancreatic cancer.

BACKGROUND/AIMS: Phase II trials of combined 5 fluorouracil, leucovorin and cisplatin have demonstrated an 18-28% response rate in advanced pancreatic carcinomas. We investigated the effect of this chemotherapy regime on patients' survival. METHODOLOGY: Patients included gave informed consent. They had an advanced and proven pancreatic adenocarcinoma. The trial was multicentric, prospective and randomized. It compared a 5-day course of leucovorin (200 mg/m2/day), 5-fluorouracil (375 mg/m2/day) and cisplatin (15 mg/m2/day) repeated every 21 days (23 patients) with a control group (22 patients). The main end points were survival time (Kaplan-Meier and log-rank methods) a[not readable: see text]side effects of chemotherapy. RESULTS: Association of leucovorin, 5-fluorouracil and cisplatin failed to demonstrate any advantage of this regimen compared with supported care alone. Median survival times were 8.6 months (SD +/- 1.8) and 7.0 months (SD +/- 0.6), respectively. The modulation of 5-fluorouracil by leucovorin and cisplatin was well tolerated with moderate toxic effects. CONCLUSIONS: This multicentric trial failed to demonstrate any advantage of the evaluated chemotherapy regime in the palliative treatment of cancer of the exocrine pancreas. Other trials including gemcitabine and/or radiotherapy are needed in advanced pancreatic adenocarcinoma.

Irradiation therapy for gallbladder carcinoma: recent advances.

PURPOSE: Gallbladder carcinomas were usually considered to be radioresistant. So far, the role of radiotherapy has not been adequately evaluated. The aim of this report is to assess the value of radiotherapy in carcinoma of the gallbladder. METHODS: We reviewed publications concerning the role of radiation therapy in gallbladder carcinoma from 1974 to 2000. External radiation therapy, intraoperative radiation therapy, and brachytherapy were evaluated in two different groups: one group of patients underwent surgery, with apparently complete resection of the tumor; and another group underwent palliative treatment. RESULTS: Local control of the tumor and reduction of tumor size were reported in several publications. Collected data suggested a slight improvement in survival after adjuvant or palliative radiotherapy. The best benefit was obtained in tumors resected with only microscopic residual tissue. If possible an intraoperative "boost" (15 Gy) is recommended on the gross lesion, residual lesion, or tumor bed. Additional postoperative external radiotherapy (45-50 Gy) must be delivered. CONCLUSION: Radiotherapy appears to be a safe procedure that slightly improves the survival time of patients treated for gallbladder carcinoma. Further trials are needed to assess the role of combined radiotherapy and chemotherapy.

Local recurrence of cancer of the rectum.

BACKGROUND: [corrected] Although radiotherapy or total mesorectal excision decreases the risk of local recurrence of rectal cancer, this risk remains around 10%. METHODS: Of 80 patients having a local recurrence, 38 (48%) underwent a re-resection combined in 10 cases with resection of mestastases. RESULTS: The incidence of asymptomatic detected recurrence was higher after anterior resection (39%) than after abdominoperineal resection (18%). Re-resection was performed more often (P <0.01) in the past 2 decades after anterior or Hartman first procedure than after abdominoperineal resection (67% versus 21%), and more often in asymptomatic patients than in symptomatic patients (71% versus 38%). The actuarial 5-year survival rate after re-resection was 20%. CONCLUSIONS: Early detection of local recurrence, with PET scan using (18)F-fluorodeoxyglucose (8 cases in the present series), leads to an improved re-resection rate. In patients who did not undergo radiotherapy (all patients but 1) re-resection can be achieved safely (no postoperative mortality). The place for radiation in the treatment of rectal cancer has to be revaluated and compared with total mesorectal excision and results of re-resection for local recurrence.