Chirurgie最新文献

Selective use of vascular occlusions in major hepatectomies.

Objective: To report the results of a selective use of vascular occlusions in major hepatectomies according to the size and location of the hepatic lesion.

Background: Total vascular exclusion (TVE) and portal triad clamping (PTC) ensure efficient hemostatic effect but lead to warm ischemia of the liver. Lobar vascular occlusion (LVO) avoids warm ischemia of the remnant liver but could result in increased blood loss.

Patients and methods: Sixty consecutive major hepatectomies were studied. TVE was applied in 22 patients with large lesions (=10 cm) or lesions with connections to the major hepatic veins or inferior vena cava. PTC (n=15) and LVO (n=23) were applied in remaining cases.

Results: Clamping method was efficient in 87%, 93% and 100% for LVO, PTC and TVE, respectively. Median blood transfusions were 0,3 and 2 units for LVO, PTC and TVE, respectively. Postoperative aminotransferase peak value was significantly lower after LVO than after PTC or TVE, while those peaks were not statistically different with these latter two methods. Postoperative prothrombin time fall value was identical in the three groups. Mortality was 3.3% (2/60) and was not influenced by the type of clamping, but both deaths and most complications occurred in patients with abnormal underlying liver parenchyma.

Conclusion: Provided that adequate techniques are used, the need for blood transfusions is more dependent on the characteristics of the resected tumor than on the type of clamping used. Total vascular exclusion does not create more ischemic injury to the liver than portal triad clamping and it should be recommended for the resection of large or strategically located tumors. Other tumors can be resected in more than 80% of the cases with LVO, thus avoiding ischemia to the remnant liver. With the control of hemorrhage, pathology of underlying liver parenchyma has emerged as the main prognostic factor in major liver resections.

Surgical treatment of hemorrhoids disease using Longo's procedure. Preliminary results of a prospective study (94 cases).

Aim of study: The aim of this multicenter prospective study was to report the early results of Longo procedure for the surgical treatment of hemorrhoids disease.

Patients and method: From April 1998 to July 1998, 94 patients (60 men and 34 women with a mean age of 47 years) were treated according to Longo procedure for a mucosal prolapse (12 grade II, 63 grade III, and 19 grade IV). All patients were evaluated at 2 and 6 postoperative months. The technique consisted in the reduction of mucosal and hemorrhoidal prolapses with a circular suturing device.

Results: Postoperative morbidity rate was 6.3% (n=6). A rectal bleeding occurred within 12 hours after surgery in five patients.The mean postoperative length of hospital stay was 36 hours (range: 24–72 hours). The only antalgic prescribed was paracetamol. Local care was not necessary in any patient. After 6 months, 89 patients (94.7%) were very satisfied, three patients (3.2%) were satisfied (rectal sub-mucosal abscess in one case, functional troubles in two cases) and two patients (2.1%) were not satisfied (persistence of mucosal prolapse).

Conclusion: These preliminary results are satisfactory but need to be confirmed by a prospective randomized trial, comparing Milligan Morgan procedure and Longo procedure.

Liver resection for hepatolithiasis.

Study aim: The aim of this study was to report the immediate results of a series of 65 hepatic resections for hepatolithiasis performed in Vietnam.

Patients and method: From 1986 to 1998, 44 men and 21 women (mean age: 40 years) underwent hepatic resection for hepatolithiasis. Fourty patients had previously undergone one or several operations for hepatolithiasis. The procedure was performed on emergency in 25 patients. Indications for hepatic resection were: angiocholitis and liver abscess in 22 cases, stones closely inserted in the biliary duct in 20 cases, hemobilia in 12 cases, stones located above a biliary stricture in 8 cases and stones associated with a postoperative biliary fistula in 3 cases. Liver resections (minor in 61 patients, including 55 left lobectomies, and major in 4 patients) were performed through transhepatic approach according to the Ton That Tung technique and followed by an external biliary drainage with a Kehr tube.

Results: There were 6 postoperative deaths (9%), 3 due to septic shock, 2 to cachexia, and 1 to liver failure. The 15 patients with complications recovered with conservative therapy. Bile infection was present in 93%, mostly with Escherichia coli and Enterobacter. Pigmented stones were usually found.

Conclusion: Vietnam is a country with high incidence of hepatolithiasis. Hepatic resection is an adequate treatment for localized intrahepatic bile duct stones when the involved segment including biliary strictures and calculi can be completely removed. The procedure may be performed on emergency for liver abscess, or hemobilia.

Intra-arterial chemotherapy after curative resection of colorectal liver metastases. Results of a pilot study in thirty patients.

Objective: Five-year survival after simple resection of liver metastases from colorectal carcinoma ranges from 20 to 40%. The aim was to study the reliability and long term results of adjuvant intra-arterial chemotherapy after resection of colorectal liver metastases.

Patients and method: From 1991 to 1997, 30 patients after a complete resection of liver metastases from colorectal cancer were included (16 men, 14 women, mean age: 62 years). There were 2 stage I, 19 stages II, 2 stages III, 5 stages IV and 2 stages V according to Gayowski staging system. During laparotomy, a catheter was placed in the gastroduodenal artery in order to perfuse the proper hepatic artery. Chemotherapy included 5 Fluorouracil (12 mg/m²) and Leucovorin (200 mg/m²) and was administered once a week during six months. Mean follow-up was 52 months.

Results: Adjuvant intra-arterial chemotherapy had to be interrupted before six months in 9 patients because leukopenia (n=2), infection or obstruction of the catheter (n=5), duodenal migration of the catheter (n=1) and occurrence of multiple extrahepatic metastases (n=1). No death was in relation with the method. Five-year survival rate was 41,8% for the global series. Five-year disease free survival rate was 21,4 %. Causes of death were: hepatic recurrence only (n=3), extrahepatic + hepatic recurrence (n=4), extrahepatic recurrence (n=2). Two patients died of another carcinoma (esophagus, ovary), without evidence of recurrence of the colorectal carcinoma. At the present, there is a recurrence in 4 living patients.

Conclusion: Although the benefit on survival is not significant, these results suggest a longest time of remission in patients with adjuvant intra-arterial chemotherapy. Trials comparing and / or combining this method to intravenous chemotherapy should be proposed in patients after resection of colorectal liver metastases.

Pulmonary aspergilloma: results of surgical treatment. Report of 206 cases.

Study aim: The aim of this retrospective study was to report the results of the surgical treatment in 188 patients operated on for pulmonary aspergilloma in a series of 206 patients observed in Morocco.

Patients and method : From 1982 to 1998, 206 patients were treated for pulmonary aspergilloma in the same hospital ; 188 were operated on and surgery was contraindicated in the other patients with general or respiratory failure. Hemoptysis was the main symptom, present in 190 patients (92%). Surgery was performed on principle with 108 lobectomies, 38 segmentectomies, 18 lobectomies and segmentectomies, 21 pleuropneumonectomies and 3 thoracoplasties.

Results : Postoperative complications occurred in 36% of the patients including: pyothorax (n=15), hemothorax (n=10), rehabitation defects (n=17) and respiratory failure (n=10). Reoperation was necessary in 6 patients. Postoperative mortality rate was 6,4% (12 patients including 5 treated by pleuro-pneumonectomy).

Conclusion: The surgical treatment, in spite of its high morbidity, has to be proposed to all patients with pulmonary aspergilloma, even in asymptomatic patients when there is no surgical contraindication. Pleuro-pneumonectomy is a very high risk procedure and its indications must be restricted. Thoracoscopy was rarely performed in this series.

Study aim

The aim of this multicenter retrospective study was to evaluate the immediate and 2-year results of the laparoscopic fundoplication for gastroesophageal reflux disease (GERD).

Patients and methods

From 1992 to 1996, 1,470 laparoscopic fundoplications were performed for symptomatic GERD. Preoperative workup included upper Gl tract endoscopy in 1,437 patients (97.7%), 24-hour pHmetry in 799 patients (54.3%) and esophageal manometry in 934 patients (63.5%). Four procedures were performed: Nissen, Nissen-Rossetti, Toupet and Toupet with cardiopexy. The results were estimated at 1 month and 3 months. The patients were examined or called 2 years after surgery in order to evaluate the functional results with Visick classification.

Results

Mean length of hospital stay was 4.6 days (range 2–48 days). Morbidity and mortality rates were 3.2% (47 patients) and 0.07% (1 patient) respectively. Conversion rate into laparotomy was 6.5% (96 patients). After 3 months, 87 patients (5.9%) had severe dysphagia and 91.9% of the patients were satisfied. At 2 years, 78 patients (5.6%) had a clinical recurrence. Five patients (0.35%) had a persistent dysphagia, 90 patients (6.5%) had secondary side effects ; 38 patients had been reoperated ; 92.7% of the patients were satisfied. There was no significant difference between the results of the four procedures, 3 months and 2 years after surgery.

Conclusions

Laparoscopic fundoplication for treatment of GERD is a safe and effective procedure ; 92.7% of the patients were satisfied 2 years after surgery.

Study aim

Biliary lithiasis in the main bile duct (particularly retained stones) may be treated percutaneously obviating reoperation or endoscopie sphincterotomy. The aim of this study was to determine risks and pitfalls of this approach.

Patients and methods

Forty-two cases of biliary stones treated percutaneously between 1980 and 1998 were reported. Among them, 28 patients had already a biliary drainage and in 14, a drain was placed into the bile duct by transhepatic way or by punction of the intestinal loop of a bilio-jejunal anastomosis. The means to clear the bile ducts included percutaneous endoscopy and contact lithotripsy. Thirty patients had residual lithiasis (after a surgical intervention), 11 a new lithiasis above a bile duct stenosis and in 1 a bile duct lithiasis with a gallbladder lithiasis.

Results

Morbidity included four complications (9,5% - one severe) and no mortality. After 2.3 ± 1 courses, desobstruction was complete in 33 cases (78,5%) and partial in one case (2,5%) allowing to optimize the patient for endoscopie sphincterotomy. Desobstruction failed in eight cases (19%), six patients were successfully treated by surgery and 2 by endoscopic sphincterotomy.

Conclusions

Percutaneous desobstruction of the bile ducts may be proposed as a priority in patients with a biliary drain in place and when endoscopie sphincterotomy is impossible or contraindicated. These manoeuvres have a definitive place in hepato-biliary surgery.

Aim of the study

Gastric stromal tumours are not perfectly known. The aim of this retrospective multicenter study (29 centers) was to improve knowledge of these tumours.

Patients and methods

From 1986 to 1994, 159 patients were operated on for leiomyomas (50), leiomyosarcomas (24), malignant / benign schwann cell tumours (10/29), automatic nerve tumours (4), leiomyoblastomas (28), spindle cell tumours (14). The mean duration of follow-up was 5 years. Presenting symptoms, diagnostic procedures, operative and pathological findings, evolution (recurrence, death) were recorded for each patient.

Results

Gastrointestinal bleeding and epigastric pain were the most common presenting symptoms (54% and 50% of patients, respectively). Endosonography was the most sensitive examination (97%). Malignant tumours size was greater than benign tumours size (12,6 cm versus 5,2 cm). Extension to contiguous organs or metastases were frequent (33% and 26% of patients, respectively). In 16 patients, pathological examination could not differenciate between malignant and benign tumour. Seven patients who had been operated on for a benign tumour (6%) developped a local (n = 4) or a metastatic (n = 3) recurrence. The 5-year survival rate was 40% for leiomyosarcomas, 28% for schwannosarcomas and 90% for malignant leiomyoblastomas.

Conclusion

The main feature of stromal gastric tumours is the frequent difficulty to differenciate between malignant and benign tumours. The prognosis of malignant tumours depends on pathological types. The prognosis of benign tumours is uncertain since recurrences may develop.

Study aim

The aim of this prospective study was to compare the results of cholecystectomy for acute cholecystitis through laparoscopic and open approach and to assess factors responsible for conversion into laparotomy.

Patients and methods

From January 1991 to October 1997, 200 patients with calculous acute cholecystitis were operated on in the same center, 100 through laparoscopy and 100 through laparotomy. Choice between these two procedures was only dependent on the disponibility of videolaparoscopic material. Comparison between laparoscopy and laparotomy groups concerned postoperative mortality and morbidity rates, hospital stay duration and late results. Intraoperative conversion into laparotomy occurred in 24 patients and factors responsible for conversion were assessed with univaried and multivaried analysis.

Results

Both groups were comparable with regard to sex ratio, age, ASA score but associated diseases incidence, plastron, fever above 38 ° C and leucocytosis were significantly more frequent in the laparotomy group and delay between diagnosis and surgery was significantly longer in the laparoscopic group. There were two postoperative deaths in the laparotomy group, 0 in the laparoscopic group (NS). Morbidity rate was higher (32% versus 10%) (p=0.0002) and hospital stay longer (12 ± 10 days, versus 5 ± 3) in the laparotomy group (p=0.00005). Late results were similar in both groups. Conversion rate into laparotomy was 24%. Factors predisposing significantly to conversion were in univaried analysis : plastron, fever above 38 ° C, leucocytosis, delay between diagnosis and surgery above 4 days, presence on ultrasonography of pericholecystic liquid and gallbladder wall edema, presence of ≪Klebsiella≫ in gallbladder bile. With multivaried analysis, leucocytosis and delay between diagnosis and surgery were the only independent factors.

Conclusion

Videolaparoscopic cholecystectomy is a safe and efficient technique in the treatment of acute cholecystitis, with a lower postoperative morbidity rate and a shorter hospital stay. Conversion rate into laparotomy is significantly dependant on leucocytosis and delay between diagnosis and surgery. Laparoscopic cholecystectomy should be performed as soon as possible in acute cholecystitis.