Mesenteric lengthening in ileoanal pouch anastomosis for ulcerative colitis: Is high division of the superior mesenteric pedicle a safe procedure?

PURPOSE: Lengthening of the mesentery is the technical key point of the ileoanal pouch procedure. Division of the superior mesenteric pedicle high in the mesentery is an original artifice that regularly provides sufficient descent of the pouch to reach the dentate line without any tension. A retrospective study compares two groups of patients with ulcerative colitis. METHODS: Group 1 consisted of 21 patients with superior mesenteric pedicle division (mean lengthening, 6.1 cm), and Group 2 consisted of 44 patients without superior mesenteric pedicle division. Mortality and postoperative and late morbidity were studied along with functional outcome. RESULTS: One patient died in Group 2 (postoperative pelvic sepsis); one patient died in Group 1 at six months from late liver transplant complications. Postoperative morbidity was insignificantly less important in Group 1 (P=0.02). Five patients in Group 2 had the pouch removed; none in Group 1 did. Pouchitis episodes developed in both groups, with no significant difference (P=0.5). Three patients in Group 1 developed anastomotic stenosis vs. 8 in Group 2 (P=0.5). Functional results at one-month, one-year, and two-year follow-ups are not significantly different, except that nighttime stool frequency increased in Group 2. CONCLUSIONS: On the whole, morbidity and functional outcome appear similar. This suggests that high superior mesenteric pedicle division has no adverse effect and can be proposed routinely as an effective lengthening technique.

[Tumoral rupture in the intrahepatic biliary tracts: a rare manifestation of hepatocellular carcinoma]. / Rupture tumorale dans les voies biliaires intra-hépatiques révélation rare d'un carcinome hépatocellulaire.

We report one case of unrecognized primary liver tumor revealed by intra biliary system migration of free floating debris and hemobilia. A 64-year-old man presented an isolated jaundice. Ultrasound, computed tomography and percutaneous transhepatic cholangiography are suggestive a cholangiocarcinoma. Operative intervention demonstrated hepatocellular emboli to common bile duct causing obstruction.

Percutaneous cholecystostomy for acute cholecystitis in critically ill patients.

BACKGROUND: Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity or mortality in critically ill or elderly patients. METHODS: We report a retrospective study of ultrasonography-guided percutaneous cholecystostomy (USGPC) performed between 1988 and 1994 in 41 patients (mean age, 77.8 years; range, 42-95 years) as an alternative to surgery. RESULTS: Five patients (12.2%) died in the hospital, four (9.8%) subsequently underwent operation without complications, six (15%) had a recurrence of cholecystitis between 3 and 24 months after withdrawal of drainage, and 26 patients are cured without recurrence after a mean follow-up of 33 months (range, 3-67 months). CONCLUSIONS: USGPC appears to be the treatment of choice for high-risk patients, especially those with postoperative cholecystitis, severe acute calculous pancreatitis, or total parenteral nutrition.

[Does laparoscopy increase the bacteriological risk of appendectomy? Results of a randomized prospective study]. / La coelioscopie augmente-t-elle le risque bactériologique de l'appendicectomie? Résultats d'une étude prospective randomisée.

OBJECTIVE: The authors compare the risk of bacteraemia in open and laparoscopic appendectomy in a prospective randomized study. METHODS: 35 patients with a presumptive diagnosis of acute appendicitis were randomized to have conventional open or laparoscopic surgical procedures. Before randomization, patients signed a consent form to participate in the study. Patients who were converted from laparoscopic to open appendectomy (3 cases), HIV+, allergic to Augmentin or who had contraindications to laparoscopic surgery were excluded from the study. A total of 32 patients were randomized: 17 to open (group I) and 15 to laparoscopic surgery (group II). There were no significant differences with regard to age, ASA score, symptoms or macroscopic aspect of the appendix. Two patients had a normal appendix, 12 had acute appendicitis, 14 gangrenous appendicitis and 4 ruptured or abscessed appendicitis. All patients received preoperative antibiotic prophylaxis (Augmentin) after blood cultures (H1) were drawn. Five other blood cultures were performed in standard medium and medium neutralizing Augmentin: at the time of opening the peritoneum (H2), after appendectomy (H3), after closure of the abdomen (H4), and at 6 (H5) and 12 hours (H6) after the operation. Bacterial cultures from the appendix site were performed before (P1) and after (P2) appendectomy. RESULTS: The operative mortality rate after conventional or laparoscopic appendectomy was nil. The incidence of post-operative morbidity was 4 cases in group I and 2 cases in group II. No positive bacterial culture was obtained in 17 patients. The distribution of these patients was similar in groups I and II. Samples P1 and P2 were positive in 5 cases. Nine of 27 cases with negative P1 became positive in P2 (33%). There was no significant difference between the two groups with regard to the appearance of the appendix. Only two patients had positive blood cultures at H1. One of them had blood cultures at H3, H4 positive for a second germ. CONCLUSION: A low risk of bacteraemia exists for both open and laparoscopic appendectomy. This risk did not appear to increase for laparoscopy. Conventional and laparoscopic surgical procedures led to positive peritoneal bacterial cultures after appendectomy in 33% of cases.

[Pure 46XY gonadal dysgenesis]. / La dysgénésie gonadique pure à 46 XY.

46 XY pure gonad dysgenesia, also known as Swyer syndrome, is a disorder of sexual differentiation. The patients are phenotypic females with a 46 XY karyotype and hypoplastic gonads without germ cells. They present most often with primary amenorrhea. The study of this abnormality in testicular differentiation contributed to the identification of the gene SRY, testis determining factor. To date, 20% of 46 XY pure gonad dysgenesia are explained by a mutation or a deletion in SRY. In 80%, SRY is apparently normal. The risk of gonadal neoplasia is high, dictating early prophylactic removal of these dysgenetic gonads. Gonadoblastoma and dysgerminoma are the most frequently reported malignancies. Because of the possible inheritance of XY gonad dysgenesia all family members should undergo a thorough screening.

[Resection of hepatic metastases from non colorectal cancers. Our experience apropos of 20 cases]. / La résection des métastases hépatiques des cancers non colo-rectaux.Notre expérience à propos de 20 observations.

The authors analyse their experience of 20 hepatic resections of metastatic malignant lesion to the liver from non-colorectal primary neoplasms: tubal or ovarian adenocarcinoma (3 cases), digestive adenocarcinoma (6 cases), sarcoma (3 cases) and endocrine malignancies (8 cases). Then, they discuss the justification of such aggressive approach, the type of hepatic resection that has to be done and the date of the procedure according to the characteristics of the secondary neoplasm (synchronous or metachronous). The histological type of the primary malignancy is an important factor in this debate.

[Gastric adenocarcinomas (excluding linites). Prognostic factors apropos of a series of 101 cases]. / Adénocarcinomes gastriques (linites exclues). Facteurs pronostiques à propos d'une série de 101 cas.

The incidence of some factors on prognosis of adenocarcinoma of the stomach was evaluated in 101 cases. Linites as well as cancers of the cardia were excluded from the analysis. There were 47 total gastrectomies with more or less extensive node dissection and 54 partial gastrectomies. Overall actuarial survival was 34.5% despite the large number of advanced stage cancers (70% positive lymph nodes, 35 with invasion of neighbouring organs, 13 cases of carcinosis and 13 with liver metastasis). Univariate analysis showed that the following factors were associated with poor prognosis: invasion of the serous layer, nodal involvement, emboli, degree of differentiation. Peritumoural reactional lymphoid infiltration, the presence of a chronic gastritis and intestinal metaplasia were found to be favourable factors. Gastric resection appeared to have less impact than the quality of the nodal dissection. These findings emphasize the importance of extensive dissection of the lymph nodes (survival ranging from 31 to 78% depending on the node score). Extensive dissection, allowing better locoregional control of the disease, improved prognosis whatever the size of the tumour (14.8% survival in case extending to neighbouring organs). The only exceptions were palliative exereses and N4+ cases.

[Intestinal obstruction after Nissen's fundo-plication]. / Les occlusions intestinales après fundoplicature de Nissen.

Nissen's fundal plication is acknowledged as the most effective procedure to suppress gastroesophageal reflux. It entails some morbidity (dysphagia, gas bloat syndrome), in which obstruction is the least frequently evoked but most severe risk. We report about 6 cases (4 children and 2 adults). The 4 children had been operated 3 times during the first few months of life, and their reflux was secondary to the cure of atresia of the esophagus in 2 cases, and caused severe apneas in 1 case, a former premature infant. In three cases, the obstruction was complicated within a few hours by intestinal ischemia causing death. In one case, the emergent insertion of a gastric tube allowed the decompression of the digestive tract and second surgery; the obstruction recurred 2 months later, with no postoperative complications. Two adults (aged 64 and 66) presented with gastric perforation 7 days and 9 months after fundal pliction; one of them died. These cases show how serious these obstructions are (4 deaths/6 cases). The emergent measure in such cases consists of inserting a gastric tube, although which may be impossible (1 case). The patients and their parents must be informed of this risk of complication and of its expressions. Prevention is based on a strictly submesocolic surgical approach, without any exposure of the small bowel.