We report the case of a 65-year-old man admitted for an upper-GI hemorrhage. A CT scan performed with vascular reconstructions demonstrated a pseudoaneurysm of the left gastric artery. Proximal vascular control of the ce...We report the case of a 65-year-old man admitted for an upper-GI hemorrhage. A CT scan performed with vascular reconstructions demonstrated a pseudoaneurysm of the left gastric artery. Proximal vascular control of the celiac axis was obtained by balloon occlusion with a Fogarty balloon inserted retrograde via the femoral artery: the pseudoaneurysm was then successfully controlled with direct suture.
GOAL: To evaluate the results of a strategy of conservative laparoscopic treatment of peritonitis due to perforated diverticulitis for all patients, without exception for intraoperative findings or general patient condit...GOAL: To evaluate the results of a strategy of conservative laparoscopic treatment of peritonitis due to perforated diverticulitis for all patients, without exception for intraoperative findings or general patient condition, and to study the feasibility of eventual second-stage laparoscopic colectomy. MATERIALS AND METHODS: Between January 2003 and May 2007, 25 consecutive patients were urgently hospitalized with acute peritonitis due to perforated diverticulitis. All patients underwent laparoscopic peritoneal lavage and debridement; when there was a large perforation (ten cases), suture closure under laparoscopic control was performed. The Hinchey classification of peritonitis was Stage I in 2, Stage IIB in 8, Stage III in 9, and Stage IV in 6. RESULTS: Postoperative morbidity occurred in 12% of cases. Mean operative time was 71 minutes. Conversion to open laparotomy was not required. Complications included residual abscess (drained percutaneously with CT guidance), urinary tract infection, and prolonged drainage via the drain tract. Mortality was zero. Mean hospital stay was 13.8 days. Sixteen patients (64%) subsequently underwent laparoscopic colectomy as a second stage procedure. CONCLUSION: Conservative laparoscopic treatment of acute peritonitis due to perforated diverticulitis is a reliable alternative to open laparotomy in many cases; eventual laparoscopic colectomy at a subsequent stage is possible in the majority of patients.
INTRODUCTION: The treatment of pseudomyxoma peritonei (PMPs) and appendiceal mucocele (AM) has changed radically. To assess the contribution of preoperative imaging to the treatment strategy and choice of approach, a sur...INTRODUCTION: The treatment of pseudomyxoma peritonei (PMPs) and appendiceal mucocele (AM) has changed radically. To assess the contribution of preoperative imaging to the treatment strategy and choice of approach, a surgeon and a radiologist different from the initial radiologist examined the files of all patients treated for PMP or AM in four facilities in one district from January 1, 1996, through December 31, 2008. PATIENTS AND METHODS: The study included 27 patients (20 men and seven women, mean age: 63+/-13 years). Eleven patients had an intact AM, seven synchronous PMP (malignant appendiceal lesion in two of seven), six metachronous PMP (five with peritoneal mucinous carcinomatosis and one with diffuse peritoneal adenomucinosis) and three a ruptured AM but not PMP. The incidence of mucin-secreting tumors observed (27 cases in 12 years in a region of 500 000 inhabitants) corresponds to a prevalence of approximately five cases per year per million inhabitants. Acute clinical pictures (7/27) were significantly more frequent for the malignant forms (5/7) (p<0,02). RESULTS AND DISCUSSION: The overall sensitivity of computed tomography (CT) for all the criteria studied was 93%. The predictive value for AM rupture of visualization of thick calcifications was 100%. On the other hand, rupture never occurred when the CT showed an AM under pressure, with thin walls and septa. The predictive value for PMP of "scalloping" was 100%. The diagnostic accuracy of the initial reading was 25/27 for the imaging overall and 25/25 for the CT. Preoperative visualization of the exact size of the intact AM or of diagnostic information about ruptured AM and PMP helped to select an appropriate approach in 25 of 27 cases.
The indications for interventional treatment (endoscopic or surgical) of chronic pancreatitis can be classified in several major groups of lesions or symptoms: pain, consequences of fibrosis on neighboring organs (biliar...The indications for interventional treatment (endoscopic or surgical) of chronic pancreatitis can be classified in several major groups of lesions or symptoms: pain, consequences of fibrosis on neighboring organs (biliary, duodenal or even colic stenosis, thrombosis of the splenic vein with segmental portal hypertension), consequences of duct rupture above the obstacle (persistent symptomatic pseudocyst, refractory pancreatic ascites), and suspected cancer. Finally, surgery is indicated for patients for whom endoscopic procedures are impossible (papillae inaccessible) or too close together. Recently, two new criteria have been suggested: the number of procedures necessary for achieving the objective set, and the duration of hospitalization.
STUDY AIM: The aim of this study was to compare the surgical and functional results of hand-sewn and stapled colonic J-pouch anastomoses after proctectomies for cancer. PATIENTS AND METHODS: Over a 6-year period, 120 pat...STUDY AIM: The aim of this study was to compare the surgical and functional results of hand-sewn and stapled colonic J-pouch anastomoses after proctectomies for cancer. PATIENTS AND METHODS: Over a 6-year period, 120 patients had a laparotomic conservative rectal excision with total mesorectal excision but without intersphincteric dissection, for cancer of the mid- and lower rectum: the colonic J-pouch anastomosis was hand-sewn for 49 and stapled for 71 patients. The functional results were assessed at 1 year, by a questionnaire completed by the patient. RESULTS: Morbidity was 37% in the hand-sewn group and 38% in the stapled group (ns). Mean duration of surgery in the hand-sewn group was 288 minutes and in the stapled group, 246 minutes (p<0.001). At 1 year, the rate of perfect continence was 71% for the hand-sewn group and 76% for the stapled group (ns). Significantly, more patient from the hand-sewn groups used enemas (16% versus 3%, p<0.005). On the other hand, there was no significant difference between the two groups for wearing protection, urgency, number of stools a day or gas/stool discrimination. CONCLUSIONS: There is no major difference in either the surgical or functional results between hand-sewn or stapled colonic J-pouch anastomosis by laparotomy for rectal cancer. Because it is simpler and faster to perform, a stapled pouch is preferable when the tumor site so permits.
Are presented in this issue, the main oral communications presented at the 4(th) francophone congress on digestive and hepatobiliary surgery and an overview of the symposium that was dedicated to the metastatic colorecta...Are presented in this issue, the main oral communications presented at the 4(th) francophone congress on digestive and hepatobiliary surgery and an overview of the symposium that was dedicated to the metastatic colorectal cancer treatment. Colorectal carcinoma is the second leading cause of cancer in Europe and the third cause of cancer death in the United States. Every year in France, 36,000 new cases are diagnosed, 50% of them with visceral metastases. Among these metastasis patients, 70% exhibit liver metastases exclusively at time of diagnosis. In most patients, liver metastases are non resectable, with exclusive chemotherapy offering poor survival. Surgery is the only curative treatment. Among patients with liver metastases, 10 to 20% are resectable with 40% of them surviving at 5 years. The aim of the chemotherapy intensification schedules is to allow resection in 15 to 30% of initially non resectable metastatic patients and consequently offering some long term survivals. Regarding metastatic colorectal cancer treatment, confrontation between oncologists and surgeons is essential in order to give the opportunity to a significant number of metastatic patients to access to cure.
Major abdominal surgery may be contraindicated in patients with cirrhosis because of the high risk of intraoperative bleeding and postoperative decompensation. Careful preparation of these patients is essential, aimed es...Major abdominal surgery may be contraindicated in patients with cirrhosis because of the high risk of intraoperative bleeding and postoperative decompensation. Careful preparation of these patients is essential, aimed especially at reducing portal hypertension. We report the case of a patient with cirrhosis complicated by hepatocellular carcinoma, whose portal hypertension manifested almost exclusively by reanastomosis from the umbilical vein. A transjugular intrahepatic portosystemic shunt (TIPS) was placed before surgery to prepare the patient for hepatic resection. In addition to the singularity of the presentation of portal hypertension, this case prompts us to consider neoadjuvant TIPS as a means of preparing these at-risk patients for major abdominal surgery.
Currently, regulatory agencies have serious difficulty in obtaining high-quality scientific proof that demonstrates the clinical efficacy of new medical devices. These difficulties are specific to medical devices and to...Currently, regulatory agencies have serious difficulty in obtaining high-quality scientific proof that demonstrates the clinical efficacy of new medical devices. These difficulties are specific to medical devices and to the medical environment that uses them. Schematically the clinical development of a new medical device has two stages: feasibility studies and studies to demonstrate clinical benefits. Feasibility studies are proposed immediately after the preclinical phase. The type of study that is methodologically appropriate is a noncomparative trial that responds to questions about patient selection, the development of implantation techniques, clinical efficacy, and complications. The demonstration of clinical benefits depends on the performance of a randomized control trial, although the feasibility studies are taken into account. The construction of the trial should be based on the formulation of a clear, specific, and pertinent principal objective. Eligible patients should correspond to those for whom the new device is intended in daily practice. The choice of a control group depends on the reference strategy or treatment, determined from the literature. A single principal endpoint should be proposed, consistent with the principal objective, which should be clinical (whenever possible), pertinent, and validated. The measure used to determine the endpoint must be as objective as possible. Multicenter trials are preferable to facilitate patient recruitment and minimize the inclusion period. Moreover, the results of multicenter studies can be extrapolated more readily. Nonetheless, the teams likely to participate in a multicenter trial must have stabilized their learning curve. To meet the methodological requirements of clinical trials for new medical devices, clinical research must improve its structure, especially by promoting the links between industry, clinicians, and academics.