Chirurgie最新文献

Mycotic aneurysms after renal transplantation.

Purpose: The study aim was to report six cases of mycotic aneurysms in renal transplant patients and to review the literature on this subject.

Patients and methods: Six patients, aged from 13 to 59 years, who had undergone renal transplantation 4 months to 16 years earlier, developed a mycotic aneurysm after bacteremia. The diagnosis was based on morphological investigations (echotomography, arteriography, spiral computed tomography) and bacteriological studies (blood culture, culture of the aneurysmal wall and content). The aneurysm was located in five cases at the anastomosis of the renal artery with the iliac axis, and in one case on the popliteal artery and tibioperoneal trunk. All patients were treated surgically: five reconstructions were performed using two arterial iliac prostheses, three hypogastric artery autografts and one saphenous vein graft (combined with an iliac prosthesis); one repair was impossible because of profuse local suppuration, and endoaneurysmorraphy with multiple ligatures of the popliteal vessels was performed. Postoperative radiological control was performed in all cases of arterial repair. All patients received antibiotic therapy during three to six months after the operation.

Results: No postoperative mortality occurred. All kidney transplants were salvaged. Anatomical results of arterial reconstructions were satisfactory in all cases and remained so during the follow-up.

Conclusions: Mycotic aneurysms after renal transplantation are rare since only six observations with a kidney transplant in place have been published in the literature with a single long-lasting kidney salvage. Surgical treatment is mandatory to prevent rupture. Survival of patients occurred exclusively in operated cases.

Learning curve and experience in laparoscopic treatment of gastroesophageal reflux disease.

Study aim: Laparoscopic treatment of gastroesophageal reflux disease (GERD) by partial (PF) or total (TF) fundoplication is the most appropriate surgical treatment after failure of medical treatment. The aim of this study was to compare the results of the same series in three consecutive periods in order to determine the effects of the learning curve and experience on the technique and outcome.

Patients and methods: From January 1993 to January 1998, 150 patients (84 men and 66 women) with a mean age of 52.2 years (18 to 78) were included. Three groups of 49, 50 and 51 patients were chronologically defined. The comparison was established on the following criteria: the operative technique; the conversion rate; the mortality and morbidity rate; the duration of surgery and hospitalization and the results with short and medium follow-up.

Results: The three groups were comparable with respect to patients and GERD characteristics. One hundred and thirty two patients had a TF and 18 had a PF. Rossetti's type TF became the reference procedure (80,3% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between group I and the two other groups (138, 100, 80min). The rate of conversion decreased from 10,2% to 4% and then 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p=0.01). There was no mortality and the morbidity rate decreased from 14,3% to 4% and then 0%. Seven cases of recurrence occurred(4.6%), 5 in group I (10,2%), 2 in group II (4%), and 0 in group III, (with a shorter follow-up).

Conclusion: The effect of the learning curve has to be taken into account in the training of surgeons (within experienced departments, with «guidance» during initial interventions) and also in the evaluation of results, in order to allow a more accurate comparison between the different treatments for GERD.

Spontaneous rupture of hepatocellular carcinoma. Report of 22 cases.

Study aim: Spontaneous rupture of hepatocellular carcinoma (HCC) causing massive hemoperitoneum is a critical and life threatening complication. The study aim was to report a retrospective series of 22 cases observed in the same centre.

Patients and methods: From 1978 to 1998, 22 patients (18 males and four females, mean age: 63 years, range: 18–83) were treated for ruptured H.C.C involving a cirrhotic liver in 17 cases and a normal liver in five cases. In 14 cases, the diagnosis of acute hemoperitoneum indicated an immediate laparotomy. The site of rupture was predominant in the left lobe (eight cases). The surgical treatment was : left lobectomy (n=7), right hepatectomy (n=2), excision (n=4), hepatic artery ligation (n=5), direct hemostasis (n=4).

Results: Postoperative mortality was 45,4%. Among the 12 survivors, nine died within a delay of 6 to 29 months. Three patients were still alive at the time of this study at 32, 40 and 66 months.

Conclusion: Acute rupture of HCC requires emergency procedures with a high risk of mortality. Curative operation with hepatic resection is the most effective procedure but is not often feasible because of the spreading of the tumor or/and the cirrhosis. The ligation of hepatic artery seems to be an alternative procedure to obtain an immediate hemostasis. Fissuration allows performance of complementary explorations and possibly preoperative arterial embolization with better immediate results.

The use of lanreotide to prevent pancreatic fistula after pancreaticoduodenectomy. A preliminary study.

Study aim: Dehiscence of pancreatic anastomosis is the main complication after pancreatoduodenectomy. The efficacy of somatostatin analogue to prevent complications after pancreatic resections is at present well-established by several randomized trials. The aim of this preliminary prospective study was to assess the role of lanreotide (a long acting somatostatin analogue) in this field.

Patients and method: Forty patients with pancreatic head tumour have been included in a prospective study. Criteria for pancreatic fistula were : high concentration of amylase in the drainage fluid (> 3 times that in the serum), or intra-abdominal fluid collection adjacent to the pancreatic anastomosis, or reoperation (or postmortem verification) showing an anastomotic dehiscence. The patients received 12 h before the operation 30 mg of lanreotide intramuscularly.

Results: Of the 40 patients included prospectively, 34 underwent a pancreatic resection. Parenchyma of pancreatic remnant was crumbly in 28 cases. Six patients experienced a pancreatic fistula (17.6%) which healed in all cases.

Conclusion: This preliminary study shows clearly the feasibility of a long acting somatostatin analogue (lanreotide) to prevent pancreatic fistula after pancreatectomy. This agent appears simple to use and its efficacy needs obviously to be assessed by randomized trials.

Surgery for large bowel cancer in patients over 75 years of age. (240 cases).

Aim of the study: The aim of this retrospective study was to report the results of the surgical treatment for large bowel cancer in patients over 75 years of age.

Patients and method: From 1985 to 1996, 240 patients, 114 men and 126 women, aged 75 years or over (mean age: 82, range: 75 to 95 years) underwent surgical treatment for large bowel carcinoma. Tumors were located in the right colon (n=120), left colon (n=100), transverse colon (n=5), or were multiple (n=15). Clinical presentation was failure of general condition (25%), intestinal obstruction (20%), rectal bleeding (20%), abdominal pain (17%). ASA score was I (n=1), II (n=69), III (n=134), or IV (n=36). Emergency surgery was mandatory in 110 cases (43 urgent and 67 delayed procedures) and 130 patients underwent elective surgery. Surgical resection was performed in 221 cases, including 177 cases with curative intent (67%). Surgical procedures included right colectomy (n=119), left colectomy (n=59), transverse colectomy (n=9) or subtotal colectomy (n=31). Histopathological staging was Astler - Coller A (n=8), B (n=116), C (n=54) et D (n=62).

Results: The postoperative course was uneventful in 157 cases (65.4%). Medical complications occurred in 46 patients with 34 deaths; and surgical complications in 39 patients with 20 subsequent reoperations and 15 deaths. The overall postoperative mortality rate was 20.4% (n=49). Postoperative mortality rate was higher after emergency operations (32.7% vs 10%), higher with the level of ASA grading (class II: 8.6%, Class III: 17.1%, Class IV: 38.8%), higher in patients over 90 years (37.4% vs. 19.1%) and in patients wihout surgical resection (42% vs 18.5%). Disease specific 5-year survival rate was 45% and did not differ when compared to patients younger than 75 years (42%, data not reported).

Conclusions: Patients older than 75 years remain a high risk group, specially if operated on emergency. Nevertheless, age is not a limiting factor in the surgical treatment of colon cancer. Prognosis is mostly depending on ASA grading. Colectomy with curative intent has to be performed when possible.