Role of laparoscopy in blunt perforations of the small bowel.

BACKGROUND: The purpose of this study was to determine whether laparoscopy could improve our ability to diagnose and treat perforations of the small bowel. METHODS: From 1985 to 2001, among 250 patients admitted for a blunt abdominal trauma, 195 surgical explorations were performed, comprising 42 laparoscopies. On admission, 108 patients underwent an abdominal ultrasonography (US) and 104 a computed tomography (CT). Thirty-nine patients had a blunt small bowel trauma (BSBT) that was explored and/or treated by laparoscopy (n = 15) or celiotomy (n = 24). We compared the patients who underwent emergency surgery (23) and those who were operated on after a mean delay of 51 h. RESULTS: On admission, for detecting free intraperitoneal fluid with a BSBT, the sensitivity of CT was 93.3% and specificity was 13.6%. Regarding the 23 patients who underwent emergency surgery, 8/20 had positive US and 10/15 had positive CT, whereas the 15 celiotomies and 8 laparoscopies indicated BSBT. Regarding the 16 patients who underwent delayed surgery, 9 patients underwent a celiotomy and 7 a laparoscopy; all BSBTs were diagnosed. In searching for BSBT, the sensitivity and specificity of laparoscopy were both 100%, whereas the sensitivity of CT was 83.3% and specificity was 22.2%. Twenty of 23 patients undergoing emergency surgery had bowel suture repair compared to 3/16 after delayed surgery. In contrast, a resection was necessary in 10/12 patients treated after a delay compared to 2/17 operated in emergency. Five BSBTs were sutured by laparoscopy, whereas 10 required conversion. Laparoscopy avoided celiotomy in 15 cases. There were no deaths and no enterostomy. CONCLUSION: In hemodynamically stable patients with blunt abdominal trauma, laparoscopy safely and effectively identifies small bowel injuries. Early recognition of these injuries and timely surgical treatment offer the best prognosis.

[Spontaneous cholecystocutaneous fistula: natural history of biliary cholecystitis]. / Fistule cholécysto-cutanée spontanée: histoire naturelle de la cholécystite lithiasique.

Spontaneous cholecystocutaneous fistula is a rare complication of gallbladder empyema without treatment. The incidence has further decreased with the advent of resuscitation and surgical treatment. These fistulas are like a cholecystostomy. The diagnostic is confirmed with a fistulogram which allows visualization of the fistula tract. Traditional treatment has consisted of broad-spectrum antibiotics administration, cholecystectomy and fistula drainage. One-stage treatment is the preferred option. Laparoscopic approach appears feasible even the conversion rate is high.

[The avian peripheral olfactory system: model for study of apoptosis and cellular regeneration]. / Le système olfactif périphérique aviaire: modèle d'étude de l'apoptose et de la régénération cellulaire.

UNLABELLED: A reliable model, usable in vitro and in vivo, is necessary for analysis of processes engaged during cell death, regeneration and differentiation. The peripheral olfactory system is an attractive model for studying these processes through its dynamic neurogenesis that occurs continually throughout the lifetime. STUDY AIM: The aim of this study was the analysis of these processes on an animal model. MATERIAL AND METHODS: We performed axotomy of the nerve olfactory on young animals and chicken embryos E17. Then we infused IGF-I (insulin-like growth factor-I) in the lesioned site. Death, regeneration and differentiation of cells were studied by immunocytology. RESULTS: After hatching, the section of the olfactory nerve induced a rapid neuronal apoptosis at the 24th hour followed by a wave of mitosis 24 hours later. In prenatal stages, the response to the axotomy was rather similar to a dedifferentiation. In postnatal stages, the IGF-I infusion at the lesioned site had a triple function: survival of mature neurons, maintenance of differentiation and stimulation of mitosis. The neoneurogenesis, which occurred from neuronal stem cells would depend on the maturation and environment of the olfactory neurons protected from apoptosis by IGF-I. CONCLUSION: The avian olfactory epithelium is a good model for analysis of cell death, regeneration and differentiation. The capacity of these neuronal stem cells to dedifferentiate makes then more primitive than the pluripotent cells, closer to totipotent embryonic stem cells.

[Prosthetic treatment of bilateral inguinal hernias via laparoscopic approach or Stoppa procedure]. / Traitement prothétique des hernies inguinales bilatérales par voie laparoscopique ou par opération de Stoppa.

AIM OF THE STUDY: The aim of this prospective non-randomized study was to compare Stoppa's technique to laparoscopic approach in totally extraperitoneal repair of bilateral inguinal hernia. PATIENTS AND METHOD: From December 1996 to December 1998, 117 consecutive patients with 234 hernias underwent either Stoppa's technique (74 patients) or a totally extraperitoneal laparoscopic approach (43 patients). Patients were randomized in two groups according to the surgeon to whom they were referred. All patients were reviewed in December 1999. RESULTS: There was no mortality. Complications occurred in 3% of patients after Stoppa's technique (group S) and in 4% of patients in the laparoscopic group (group L). The conversion rate was 7% (3 cases). Postoperative analgesia use, hospital stay, and duration of disability were significantly shorter in group L, the cost was lower, but the operating time was significantly longer than in group S. Recurrence rates were similar in the two groups: 2% in group S, 1.1% in group L. CONCLUSION: The laparoscopic approach appears to be preferable to Stoppa's technique in the treatment of bilateral inguinal hernia.

Radical surgery for gallbladder cancer. Results of the French Surgical Association Survey.

BACKGROUND/AIMS: Gallbladder carcinoma is a highly lethal disease. The advantages of radical surgery remain controversial. The authors' objective was to evaluate the effectiveness of an aggressive approach to gallbladder carcinoma on long-term survival. METHODOLOGY: A questionnaire was sent to 73 institutions in France, Europe, and overseas. Data, from 724 patients treated between 1980 and 1989, were analyzed for patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports and survival. Seventy-eight percent of the patients were women, and 22% were men. Gallstones were present in 86% of the cases. Four percent of the patients had Tis lesions, 11% had T1 to T2 lesions, and 85% had T3 to T4 lesions. RESULTS: Twenty-three percent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (>70 years) had a higher operative risk. The overall median survival was 3 months, and long-term survival correlated with cancer stage: Tis >60 months, T1 to T2 >22 months, and T3 to T4 2 to 8 months. Projected five-year survival for cancers limited to the gallbladder and treated by simple cholecystectomy was 93%, 18% and 10% for Tis, T1 and T2 respectively. For T3 to T4, no difference was observed among the different surgical procedures adopted--hepatic resection, trans-tumoral stenting or biliary-enteric anastomosis. CONCLUSIONS: In conclusion, a simple cholecystectomy is effective only for Tis cancer. An extended cholecystectomy for invasive cancer should be performed, but only if there is limited involvement of the immediately adjacent hepatic parenchyma. There is now a need to evaluate more effective adjuvant therapy in the form of radiotherapy or newer chemotherapeutic agents.

[Postoperative incisional hernias: intra- or extraperitoneal prosthesis implantation?]. / Eventrations postopératoires: prothèse intra- ou extrapéritonéale?

STUDY AIM: The aim of this retrospective study concerning the repair of postoperative incisional hernia using Dacron mesh was to compare results according to the extra- or intraperitoneal mesh position in order to assess the respective indications of each option. MATERIALS AND METHODS: From January 1985 to December 1996, 172 patients (mean age: 61.3 years) were operated on using Dacron mesh extraperitoneally (n = 99) or intraperitoneally located (n = 73). For statistical analysis, both groups were compared using Chi square test or Fisher's test. RESULTS: There were no postoperative deaths in the group with extraperitoneal mesh and two postoperative deaths in the group with intraperitoneal mesh. There were no significant differences when results comparing parietal complications (sepsis: 2% vs 2.7%, pain: 9.1% vs 16.9%), secondary intestinal disorders (2% vs 4.2%) and recurrence rate (4% vs 5.6%) were assessed between extraperitoneal and intraperitoneal mesh. Recurrences were related to pareital infection treated by partial removal of the mesh (n = 2) or to the lateral detachment of the mesh (n = 6). CONCLUSIONS: In the group of patients receiving extraperitoneal mesh there were no postoperative deaths and morbidity was low (this technique is generally used in the treatment of large incisional hernia). In the group of patients receiving intraperitoneal mesh, similar parietal and general complications were observed. But the risk of serious complications and postoperative death is higher; this technique must be limited to the most serious incisional hernia and to high risk patients.

Surgical treatment of 724 carcinomas of the gallbladder. Results of the French Surgical Association Survey.

OBJECTIVE: The objective of this study was to evaluate the benefit of an aggressive approach to gallbladder carcinoma on long-term survival. SUMMARY BACKGROUND DATA: Recent studies have shown that an aggressive surgical treatment of bile duct carcinoma can be associated with a surprising long-term survival. However, recent data on gallbladder carcinoma are not available. METHODS: Data were obtained from a questionnaire sent to 73 institutions in France, Europe, and overseas, and they were analyzed retrospectively. The review included an analysis of patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports, and survival. RESULTS: Seventy-eight per cent of the patients were women, and 22% were men (p < 0.001). Gallstones were present in 86% of the cases. Four per cent of the patients had Tis stage lesions, 11% had T1 to T2 stage lesions, and 85% had T3 to T4 stage lesions (p < 0.001). Pain was the most frequent symptom (77%). Twenty-three per cent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (> 70 years) had a higher operative risk (p < 0.04). The overall median survival was 3 months, and long-term survival correlated with the cancer stage (Tis, > 60 months; T1 to T2, > 22 months, and T3 to T4, 2 to 8 months). No differences were observed among the different surgical procedures adopted. CONCLUSIONS: No progress has been made in the last 10 years in the treatment of gallbladder malignancies.

[Lymph node involvement and prognosis in medullary cancers of the thyroid gland]. / Envahissement ganglionnaire et pronostic des cancers médullaires de la thyroïde.

Involvement of regional lymph nodes is extremely common in medullary carcinoma of the thyroid gland (MTC). The aim of the present study was to determinate the prognostic of MTC correlated with the regional lymph node involvement. From 1975 to 1994, 23 MTC patients were treated. The surgical protocol included a total thyroidectomy with bilateral dissection of the jugulocarotid chain and of the paratracheal groove. We have distinguished two groups: group N+ (histological lymph nodes involvement) and group N- (absence of histological lymph nodes involvement). In each group we have evaluated the prognostic significance of age, sex, palpable lymph nodes, histological capsular effraction and presence of distant metastasis. The data were analyzed with the exact Fisher test and comparisons by Student t test. Significance was defined as p > 0.05. Survical curves were based on the method of Kaplan Meier. In Group N+ (n = 15), 9/15 patients died: they had palpable lymph nodes, histological capsular effraction and distant synchronous or metachronous metastasis. The median survival was 8 months, when patients have distant metastasis. Six patients are alive, 2 with an elevated thyrocalcitonin level without metastasis, and 3 with resection of metastatic MCT to regional lymph nodes. In groupe N- (n = 8), all patients are alive: 2/8 patients had palpable lymph nodes, 1/8 had histological capsular effraction, but none had distant metastasis. 2 patients underwent resection of regional lymph metastasis and one of pulmonary metachronous metastasis. Gender did not appear to affect the lymph involvement. Factors significantly associated in the group N+ included the following: age (p = 0.003), palpable lymph nodes (p = 0.015), capsular effraction (p > 0.00025), distant synchronous metastasis (p < 0.013). The regional lymph node metastasis had significant influence on the 5-year survival, 48% vs 100% (p = 0.006), and on disease free survival, 16.6% vs 62.5% (p = 0.018). The median time from resection of the primary tumor to the development of metastasis disease was 37 months for patients N+ vs 169 months for patients N-. Involvement lymph node did not affect the metastasis disease, regional involvement or distant metastasis (p > 0.05).

[Digestive surgery in patients over 80 years of age. Apropos of 690 operations]. / La chirurgie digestive chez les sujets de plus de 80 ans. A propos de 690 interventions.

Between January 1981 and December 1990, 690 patients over the age of 80 years underwent gastrointestinal surgery. These operations were performed for diseases of the biliary tract in 248 cases (28%), colon or rectum in 238 cases (27%), stomach or duodenum in 130 cases (15%), small bowel in 32 cases (1.6%), oesophagus in 16 cases (1.8%), and for peritoneal carcinologic dissemination in 26 cases (3%). Emergency operation was performed in 43% of patients. Surgery was considered to be curative in 61% of patients. Overall postoperative mortality was 23%. The six following factors were associated with increased mortality: age over 85 years, ASA categories 3, 4, 5; surgery for malignant disease, peritonitis, palliative surgery, emergency surgery.

[Prognosis in surgical treatment of cancer of extra-hepatic biliary ducts]. / Pronostic du traitement chirurgical des cancers des voies biliaires extra-hépatiques.

This work reports a retrospective multicenter study of the treatment and prognosis of 746 patients with gall bladder cancers and 684 patients with extrahepatic biliary duct cancers. Gallbladder cancers: Adenocarcinoma was encountered in 92.6% of cases, 107 were limited to the gallbladder. Removal was possible in 27% of the patients. Overall operative mortality was 21%. Overall survival at one year was 14%. The projected five-year survival for cancers limited to the gall bladder treated by simple cholecystectomy was 93% for noninvasive, "in situ" cancers. The survival was 18% with mucosal involvement, and 10% with extension to the gall bladder wall. Extrahepatic biliary duct cancers: Adenocarcinoma was encountered in 99.7% of assess; 40 were limited exclusively to the biliary ducts. 384 involved the upper 1/3 segment of the biliary duct, 86 the middle 1/3, and 121 for the lower 1/3. Cancers involving two or more of these segments were encountered in 93 cases. Removal of the cancer from these four locations was possible in respectively 30%, 50%, 50% and 7% of cases. Overall operative mortality was 27.7% and after removal: 13.5% for the upper biliary duct segment, 18.1% for the middle 1/3, and 20% for the lower 1/3. The mortality was 25% for cancer that involved two or more of these segments. Analysis related to age demonstrated a postoperative mortality of 16% in patients less than 70 years of age and 59.1% after 70 years. The five-year survival after surgery was projected to be 12% for cancers of the upper 1/3 segment, 15% in middle and 30% in the lower 1/3.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early postoperative complications of resection anastomosis in colonic and colorectal surgery. An analysis of 624 cases]. / Complications postopératoires précoces des résections anastomoses en chirurgie colique ou colo-rectale. Analyse de 627 observations.

Six hundred twenty seven patients have been studied retrospectively to evaluate early complications after sewn or staples colonic anastomosis. Seventy four per cent of the patients underwent surgery because of malignant lesions and seventy seven per cent had an elective operation. Fourty seven per cent of the patients had a sewn anastomosis, 53% a stapled anastomosis. In elective surgery, most of the right hemicolectomies and partial proctocolectomies have been performed using stapler devices (p < 0.05). In emergency surgery, most of the anastomosis after partial and total colectomy have been hand sewn (p < 0.05). Operative mortality was 5.6%. It was significantly higher in older patients (> 80 years old) (p < 0.01) and after emergency operations (p < 0.0001). The rate of anastomotic leak was 3.7% and it was significantly higher after right hemicolectomy and partial proctocolectomies when anastomosis has been hand sewn compared to stapled anastomosis (p < 0.05). With regard to postoperative mortality, intra-abdominal abscess, intestinal obstruction, evisceration, pulmonary embolism and anastomotic stenosis 1.4% (global: after a 6 months follow-up) no significant differences have been observed between sewn and stapled anastomosis.

[Hartmann's procedure. Indications, results. Apropos of 105 cases]. / Intervention de Hartmann. Indications, résultats. A propos d'une série de 105 cas.

The authors report in this retrospective study, 105 cases of patients operated with Hartmann's technic since 1979 to 1990. There were 55 men and 50 women with average age of 70 years (34-90 years old), 71 patients were strucked down by malign disease, 34 by benign disease. 42 surgical operations were performed immediately, 63 were delayed, 26 operations were immediately performed for serious sepsis, 11 for occlusives syndromes. Delayed surgical operations were performed for malignant diseases in 50 cases, elsewhere, there were 6 sigmoiditis with malignant aspect. The upper half rectum was resected at a rate of 38%, the original technic was performed at a rate of 65%. Post operatory mortality was at a rate of 13% (14 died) concerning 25% of immediately operated patients and 6% of delayed operations. Post operatory mortality was at a rate of 15.4% for malignant disease and 8.8% for benign disease. Post operatory results were complicated with 4 occlusives syndromes, 3 fistula from the rectum, 1 cholecystis, 1 small intestine perforation. There were 10 parietal complications and 10 general complications with 7 urinary infections, 4 lung infections and 2 venous thrombosis. The colon anastomosis was performed in a manual way in 23.4% of cases, in a mechanical way in 23% of cases (with EEA or PCEA forceps) with a 8 month average interval between the 2 surgical operations. The mortality rate of this surgical operation is high because patients are old and have heavy deficiencies and are immediately operated for serious diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Villous tumors of the rectum. 50 cases treated surgically]. / Les tumeurs villeuses du rectum. 50 cas traités chirurgicalement.

The authors report a study of 50 patients who underwent surgery for a villous adenoma between 1978 and 1988 (29 men and 21 women). Mean age was 70 years old. 84% of the lesions were sessile. They ranged from 1 to 15 centimeters in size. They were associated 12 times with colon adenomas and 3 times with adenocarcinomas. All these lesions were biopsied preoperatively. Removal was performed: in 38% of cases vie a transanal approach in 38% of cases by colorectal resection vie an abdominal approach in 12% of cases by rectal amputation vie both an abdominal and perineal approach, in 12% of cases by Kraske's procedure. 22 adenocarcinomas and 28 benign lesions were discovered. 2 patients died in the early post-operative course after colorectal resection performed vie an abdominal approach. At long term (minimum of 2 years) there were 5 complications and 9 recurrences, the later occurring after tumorectomies. It is essential to know the lesions histologic characteristics in order to administer appropriate therapy, but this is not only possible to determine precisely before excision. Even biopsy specimens may miss the malignant portion of a lesion. Only complete pathological examination of the tumor can establish the diagnosis of a malignancy. Surgery remains the principal method of treatment of these lesions because it permits complete histologie examination and properly adapted management: simple removal for benign tumors or those with malignant degeneration in situ, wide excision for invasive tumors.