Emergency management of acute colonic cancer obstruction.

Emergency management of obstructing colonic cancer depends on both tumor location and stage, general condition of the patient and surgeon's experience. Right sided or transverse colon obstructing cancers are usually treated by right hemicolectomy-extended if necessary to the transverse colon-with primary anastomosis. For left-sided obstructing cancer, in patients with low surgical risk, primary resection and anastomosis associated with on-table irrigation or manual decompression can be performed. It prevents the confection of a loop colostomy but presents the risk of anastomotic leakage. Subtotal or total colectomy allows the surgeon to encompass distended and fecal-loaded colon, and to perform one-stage resection and anastomosis. Its disadvantage is an increased daily frequency of stools. It must be performed only in cases of diastatic colon perforation or synchronous right colonic cancer. In patients with high surgical risk, Hartmann procedure must be preferred. It allows the treatment of both obstruction and cancer, and prevents anastomotic leakage but needs a second operation to reverse the colostomy. Colonic stenting is clinically successful in up to 90% in specialized groups. It is used as palliation in patients with disseminated disease or bridge to surgery in the others. If stent insertion is not possible, loop colostomy is still indicated in patients at high surgical risk.

[Should all asymptomatic inguinal hernias be surgically corrected?]. / Faut-il opérer toutes les hernies de l'aine asymptomatiques?

Femoral hernias present a high risk of strangulation and should be treated with surgery as soon as the diagnosis is made. Inguinal hernias present a low risk of strangulation, an argument for surgery only in patients who do not have rapid access to a surgical center. In the other cases, delaying hernia treatment seems to have few advantages in that patients are operated in the end and that during the waiting period, their health is generally poorer than operated patients' health. Other than patients presenting serious co-morbidities or with a short life expectancy, asymptomatic inguinal hernias should be repaired in all patients who so desire. This decision is made in agreement with the patient after he or she has been clearly informed on the risks, the sequelae, and the results of surgery. With bilateral hernias, one of which is symptomatic, it seems preferable to treat both hernias in the same anesthetic time frame. In case of a hernia occurring simultaneously with another intervention, it should be treated only after the patient has given consent.

[Causes of complications and failures of hernia repair: how to avoid them]. / Causes des complications et échecs des cures de hernies: comment les éviter.

Prevention of complications of inguinal hernia repair is first of all based on precisely dissecting the hernial sac and respecting the components of the spermatic cord and the blood vessels of the region. Resecting the sac is not necessary if it can easily be reintegrated into the abdominal cavity. Muscle reinforcement with synthetic mesh is the method that provides the most reliable repair. Systematic antibiotic therapy with prosthetic repair does not seem necessary if there is no risk factor for infection. During laparoscopy, the mesh must be a minimum of 10 x 15 cm; it is preferable not to attach it to prevent any nerve lesion. If necessary, fixation should be minimal and avoid nerve passage zones. During recurrence surgery, using an approach different from the preceding procedure is preferred so as to prevent dissection within the scar tissue.

[Perforation of the sigmoid colon secondary to acetabular fracture]. / Perforation sigmoïdienne consécutive à une fracture de l'acétabulum.

Traumatic lesions of the colon associated with fracture of the acetabulum occurs in less than 2% of the cases. Direct perforation of the colon by a bony spike, which occurred in our patient, is even more exceptional. We were unable to find any other case reported in the literature. This case illustrates the importance of looking for intestinal lesions in all patients with pelvic injury presenting an unexplained infectious syndrome. Imaging provides clear evidence for avoiding late diagnosis and life-threatening situations.

[Where does laparoscopy fit in the treatment of inguinal hernia in 2003?]. / Quelle est la place du traitement laparoscopique des hernies de l'aine en 2003?

Meta-analysis of randomized studies has clearly shown that prosthetic repair of inguinal hernias decreases the risk of hernia recurrence when compared with herniorraphy without prosthesis; but the optimal route for insertion of the prosthetic patch (laparoscopic versus open inguinal approach) remains in dispute. Meta-analysis of randomized studies comparing laparoscopic with open prosthetic hernia repair suggest that laparoscopy is associated with less post-operative pain (both early and late), a quicker recovery, and earlier return to work. Yet this is at the price of longer operative time and an incidence of rare but potentially severe complications. On the basis of these randomized studies, the ANAES in France and the NICE in England have put forth recommendations which accept the indication for laparoscopic repair in recurrent and bilateral hernias, if done by surgeons experienced in laparoscopic technique. For unilateral hernia in adults, laparoscopic repair has shown no proof of superiority over open prosthetic repair in terms of mortality, morbidity, or recurrence rate. The principal advantage of the laparoscopic approach seems to be improved patient comfort; its disadvantage is higher cost and technical difficulty with a prolonged learning curve. The excess costs of the laparoscopic approach may be compensated by an earlier return to work. At present, the laparoscopic repair of hernias finds its clinical niche in patients with bilateral or recurrent hernias or in patients with unilateral hernia who desire a minimal period of postoperative disability.

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.

Elective laparoscopic colonic resection for diverticular disease: results of a multicenter study in 179 patients.

BACKGROUND: We undertook a retrospective multicenter study of elective laparoscopic sigmoidectomy for diverticulitis in order to assess the safety and the results of the procedure performed by a large number of surgeons. MATERIALS AND METHODS: Between January 1998 and April 1999, the French Society of Laparoscopic Surgery recruited retrospectively 179 patients from 10 surgical units, operated on for elective laparoscopic sigmoidectomy. There were 94 men and 85 women with a mean age of 58 years (range, 30-82). The indications for surgery were acute attacks in 123 cases, complicated diverticulitis in 47 cases, and miscellaneous in 9 cases. RESULTS: The performed procedure was a successful laparoscopic assisted sigmoidectomy in 154 cases (with totally intracorporeal anastomosis in 136 cases and hand-sewn anastomosis via small incision in 18 cases). The mean operation time was 223 min +/- 79 (range, 100-480). There was no mortality and 23 complications occurred in 23 patients (14.9%). Postoperative ileus lasted 2.5 +/- 0.9 days (range, 1-6), and oral intake started after 3.3 +/- 1.3 days (range, 1-12). The mean postoperative stay was 9.3 days (range, 4-50). Conversion to laparotomy was necessary in 25 cases (13.9%). The essential causes of conversion were obesity, severe adhesions, and colonic inflammation. The mean postoperative stay for the 25 converted patients was 13 +/- 8.5 days (range, 7-42). CONCLUSION: Elective laparoscopic sigmoidectomy for diverticulitis is feasible and is safe. The complication and mortality rates are similar to those observed after open procedures. For experienced surgical teams, laparoscopic colonic resection is a good approach for selected patients suffering from symptomatic diverticulitis.

[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.

[Prevention of anastomotic dehiscence in colorectal surgery]. / Prévention des déhiscences anastomotiques en chirurgie colorectale.

Anastomotic leakage is a major cause of mortality in colorectal surgery. Some variables associated with a high-risk level for anastomotic leakage have been identified, including denutrition, obesity, smoking, level of the anastomoses, qualification of the surgeon. Several methods have been evaluated in order to prevent anastomotic leakage. Prophylactic antibiotic therapy has been recommended, but has no effect on the rate of anastomotic leakage. Optimal preoperative colonic preparation appears to be obtained with povidone iodine enemas associated with a low residue diet. Stapling gives better results than sutures only for difficult anastomoses. Colostomy does not prevent leakage but minimizes its consequences. Omentoplasty, peritoneal drainage, gastric tube, biofragmentable anastomotic ring, and Coloshield have demonstrated their efficacy.

Prevalence and mechanisms of small intestinal obstruction following laparoscopic abdominal surgery: a retrospective multicenter study. French Association for Surgical Research.

HYPOTHESIS: The prevalence and mechanisms of intestinal obstruction following laparoscopic abdominal surgery have not been studied extensively. DESIGN: Retrospective review of cases of intestinal obstruction after laparoscopic surgery. SETTING: Sixteen surgical units performing laparoscopy in France. PATIENTS: Twenty-four patients with intestinal obstruction. MAIN OUTCOME MEASURES: Prevalence values and descriptive data. RESULTS: The 3 most frequent primary procedures responsible for intestinal obstruction were cholecystectomy (10 cases), transperitoneal hernia repair (5 cases), and appendectomy (4 cases). Prevalences of early postoperative intestinal obstruction after these procedures were 0.11%, 2.5%, and 0.16%, respectively. Intestinal obstruction was due to adhesions or fibrotic bands in 12 cases and to intestinal incarceration in 11 cases. Obstruction was located at the trocar site in 13 cases (9 incarcerations and 4 adhesions), mainly at the umbilicus, and in the operative field in 10 cases (2 incarcerations in a wall defect after transperitoneal inguinal hernia repair, 4 adhesions, and 4 fibrotic bands). The small intestine was involved in 23 of 24 cases; the other was due to cecal volvulus following unrecognized intestinal malrotation. Intestinal obstruction was treated by laparoscopic adhesiolysis in 6 patients and by laparotomy in 18 patients, 6 of whom required small intestine resection. Three postoperative complications but no deaths occurred. CONCLUSION: Intestinal obstruction following laparoscopic abdominal surgery can occur irrespective of the type of operation; the prevalence is as high as (cholecystectomy and appendectomy) or even higher than (transperitoneal hernia repair) that seen in open procedures.

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.

Recurrence of biliary drug lithiasis due to dipyridamole.

The occurrence of drug-containing gallstones is not often observed. To our knowledge, three drugs have so far been incriminated-ceftriaxone, glaphenine, and dipyridamole. This report presents the case of an 85-year-old woman who developed a recurrent drug-containing gallstone caused by dipyridamole eighteen months after a previous stone had been removed endoscopically.

[Limits of laparoscopic surgery of adrenal glands. Apropos of 17 cases and a review of the literature]. / Limites de la résection coelio-chirurgicale des surrénales. Dix-sept observations et revue de la littérature.

OBJECTIVES: To review own cases of laparoscopic adrenalectomy in order to better ascertain limits therapeutic management and indications, compared with the literature data. PATIENTS-METHODS: Medical files of 15 patients after 17 laparoscopic adrenalectomies in the Dupuytren hospital of Limoges from February 1994 to November 1996, were analyzed 10 women and 5 men mean aged 59.4 years (22-77) were operated. Transperitoneal laparoscopic adrenal resection indications were: Conn adenoma (3), Cushing discase (2 bilateral resection), adrenal incidentaloma (9) and adrenal metastasis (1). RESULTS: Mean (range) of adrenal tumor size was 4 cm (0.8-7.5 cm). Operating times mean (range) was: 3 hours 40 minutes (1 h 50-6 h). Mean (range) of hospital stay was 3.4 day (3-6), marquedly reduced than open traditional adrenal surgery. Neither complication nor mortality per- or post-operative were present. But the laparoscopic operation required conversion to an open adrenal resection in 3 cases (18%). COMMENTS: Laparoscopic adrenalectomy offer real advantages: effectiveness and safety with a reduced time hospital discharge. Indications and adrenal size limits need to be precised on largest studies.