Median arcuate ligament in orthotopic liver transplantation: relevance to arterial reconstruction.

Median arcuate ligament (MAL) syndrome results from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or by fibrous bands of the celiac nervous plexus. In 10% to 50% of cases it is responsible for significant angiographic celiac trunk compression. In orthotopic liver transplantation (OLT), the presence of celiac compression by MAL is considered to be a risk factor for hepatic arterial thrombosis (HAT); it may lead to graft loss. Various surgical procedures have been proposed to overcome the impact of MAL in OLT, but their impact is still ill defined. The aim of our study was to compare standard hepatic artery reconstruction and graft reconstruction (aortohepatic bypass) in terms of HAT among patients with MAL undergoing OLT. We retrospectively reviewed 168 adult recipients of OLT performed from January 1991 to December 1998. Ten cases (5.6%) of celiac compression by MAL were identified after celiomesenteric arteriography. There was no significant difference in terms of HAT incidence when aortohepatic bypass was performed compared to a standard anastomosis; moreover, this was greater in the graft reconstruction group (25% vs 17%; P = .67). In our opinion, the presence of an arcuate ligament should not contraindicate a routine hepatic artery reconstruction.

Does laparoscopic colorectal resection for diverticular disease impair male urinary and sexual function?

BACKGROUND: Laparoscopic colorectal resection may induce bladder and sexual dysfunction secondary to injury to the autonomic nervous system. The aim of this study was to evaluate urinary and sexual function in male patients after laparoscopic colorectal resection for diverticular disease. METHODS: From January 1997 to March 2002, we performed a retrospective analysis of urinary and sexual function in 56 consecutive male patients who had undergone laparoscopic colorectal resection for diverticular disease. Preoperative and 6-month postoperative assessment was carried out using data collected via standardized postal questionnaires. RESULTS: Three patients were excluded (one had a prior prostatectomy, one had Peyronie's disease, and one was treated with neuroleptics). Fifty-three patients with a mean age of 54 A+/- 2 years were included in the study. There were no conversions. The morbidity rate was 9.4%. Mean follow-up was 27 A+/- 2 months. There was no significant difference in preoperative and postoperative urinary function. Fifty-one patients (96%) were sexually active preoperatively and were still sexually active postoperatively. Compared with the preoperative period, postoperative impairment of libido, erection, ejaculation, and orgasm were not significant. Every patient was able to achieve ejaculation after the intervention, and no retrograde ejaculations were reported. One patient was unable to have an erection after the intervention. CONCLUSION: Laparoscopic colorectal resection for diverticular disease does not significantly impair urinary and sexual function.

[Surgical treatment of pancreatic adenocarcinoma: limitations and latest developments]. / Traitement chirurgical de l'adénocarcinome pancréatique: limites et actualités.

Duodenopancreatectomy with preservation of the tail for pancreatic adenocarcinoma is not contraindicated by age except in case of comorbidity. Curative excision is contraindicated in case of metastasis to the liver, peritoneum or distal nodes or in case of arterial invasion. Inversely, isolated venous invasion is not incompatible with curative surgery if one can accept the potential overmortality due to the vascular risk. Palliative surgery may be indicated for tumors limited to the pancreas in selected patients as it appears to improve survival and quality of life over derivation surgery. Preoperative biliary drainage using an endoscopic, a percutaneous or a surgical approach increases the rate of surgical complications and mortality and should be avoided, especially when the resectability of the tumor is not formally established. Wide node dissection does not modify prognosis after excision and would not be warranted on the basis of current data. Preserving the pyloris increases the rate of postoperative gastroparesia without bringing the expected nutritional advantages. It is not warranted in this indication. The type of pancreas anastomosis (pancreatogastric or pancreatojejunal) does not modify the incidence of complications or pancreatic fistulae. The rate of pancreatic fistulae and postoperative complications is decreased by preventive administration of octreotide, particularly when the pancreas is healthy. The prevalence of postoperative gastroparesia is decreased by preventive treatment with intravenous erythromycin. Progress will undoubtedly issue from complimentary treatments combining radiotherapy and chemotherapy

[Results of laparoscopic treatment of perforated ulcers]. / Résultats du traitement coelioscopique des ulcères perforés.

STUDY AIM: The aim of this retrospective survey was to evaluate the results of laparoscopic treatment in perforated peptic ulcer. PATIENTS AND METHODS: From 1989 to 1998, 84 patients were operated on for perforated ulcer. Sixty nine patients, operated on with videolaparoscopy, were included in this study: 53 men and 12 women with a mean age of 45 +/- 16 years (19-85). Nine had a history of peptic ulcer disease and 12 received anti-inflammatory drugs. Perforation occurred in the duodenum (60 patients) and in the stomach (five patients). Laparoscopic treatment included peritoneal lavage and either a simple duodenal closure (51 patients), a closure with a highly selective vagotomy (one patient), an epiplooplasty (eight patients), or an excision-closure for the gastric ulcers (five patients). Drainage was associated in 38 patients (58%). RESULTS: A conversion into laparotomy was necessary in six patients. Among the 59 patients treated with laparoscopy, 56 were only managed laparoscopically, three had exploration and peritoneal lavage through laparoscopy, and underwent suture of the perforation through minilaparotomy. Mean operative time was 105 +/- 40 minutes (30-240). Mean postoperative hospital stay was 8.2 +/- 4 days. Reoperation was performed in three patients for leakage (n = 2) and gall bladder perforation (n = 1). Complications were medically treated in three patients. There was no in-hospital mortality. CONCLUSION: Laparoscopic management in perforated peptic ulcer is successful in 90% of the patients. Results are good. There was no postoperative death in this series.

[Hydatid cyst of the psoas]. / Kyste hydatique du psoas.

Recurrent hydatic cyst of the psoas is an exceptional disease in France but should not be missed in patients coming from endemic areas. A case report and a review of the literature on the aetiopathology, diagnosis and therapy are presented. Abdominal pelvic CT scan should give the diagnosis. Surgical treatment is indicated, with complete exeresis to avoid early relapse.

[Value of celioscopy in the diagnosis of abdominal wounds]. / Intérêt de la coelioscopie pour le diagnostic des plaies abdominales.

Gunshot or stab wounds with equivocal evidence of intraabdominal injury lead to negative laparotomy in 20% to 30% of cases. The aim of this prospective study was to evaluate, in hemodynamically stable patients, the role of laparoscopy in order to reduce the rate of unnecessary laparotomies for such wounds. This study was carried out in 21 patients. Laparoscopy revealed 15 penetrating wounds (71.4%) with two isolated diaphragmatic injuries. Eight laparotomies (38%) for visceral injuries were performed on the 15 penetrating wounds. The laparoscopic exploration was complete in 7 cases without laparotomy. Thirteen unnecessary laparotomies were avoided (62%). Laparoscopy was found to have a 100% specificity and sensitivity for the diagnosis of peritoneal effraction and diaphragmatic injury. Laparoscopy is very effective for evaluation of equivocal penetrating wounds.