Chirurgie最新文献

Giant diverticulum of the colon is a rare complication of the colonic diverticulosis. It generally involves the sigmoid colon. In the chronic form, without symptoms or with only a few non-specific symptoms, an abdominal mass is frequently palpable. A plain abdominal radiogram, showing a gas-filled cyst, can suggest the diagnosis. If needed, an abdominal CT scan is appropriate and seems to be more accurate than a barium enema. The treatment of choice is a segmental resection of the colon involving the giant diverticulum, followed by a direct anastomosis. Despite the old age of these patients, both postoperative morbidity and mortality are low and justify such a radical approach. The acute clinical presentation (about 20%) is generally due to a peritonitis by perforation of the giant diverticulum and requires an emergency colectomy.

The advent of new computer technologies can appear as a revolution in surgical teaching, as well as in the planing and realization of surgical procedures. The introduction of a camera into the body of a patient, allowing the visual display of the operative procedure through the use of a miniaturized camera, constitutes the greatest change that the surgical world has experienced at the end of this century: mini-invasive surgery is born. This revolution also predicts further changes: the development of telecommunication devices applied to medicine (tele-education, tele-training, tele-mentoring, tele-proctoring and tele-accreditation), constitutes the basis of cybersurgery or virtual reality allowing the merging of the concepts of tele-presence and telemanipulation. These new concepts were developed at the European Institute of TeleSurgery at Strasbourg. The TESUS project developed the use of surgical images and data transmission through the realization of international multi-site videoconferences between surgeons. The WEBS project created the first virtual university concept by placing surgical techniques at the surgeon's disposal through the Internet. The HESSOS project uses virtual reality as a surgical simulation system. The MASTER project allows the development of the concept of distant telemanipulation. It is now possible to face surgical teaching out-side of the restricted University framework, and to conceive teaching on a world-wide level, offering the practitioner unimaginable possibilities of formation, training and the planning of surgical procedures.

Aim of the study

The aim of this study was to assess the oncology and functional outcome after preoperative radio-therapy and delayed coloanal anastomosis for cancers of the lower third of the rectum.

Patients and methods

From January 1988 to December 1997, 35 patients received preoperative radiotherapy (45 Gy) followed by rectal resection through a combined abdominal and transanal approach. Thirty patients had preoperative tumor staging with endorectal ultrasonography: uT1 NO = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, and uT3N+ = 14. Colorectal resection was performed on average 32 days after the conclusion of radiotherapy, and the distal colon stump was pulled through the anal canal. On post-operative day 5, the colonic stump was resected and a direct coloanal anastomosis performed.

Results

Pathological examination of the specimens revealed complete tumor sterilization in two cases, pT1 N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, and pT3N+ = 9. There was no postoperative mortality and there was no leakage. One patient had a pelvic abscess, and another one had left colon necrosis which required re-operation. Median follow-up was 43 months (range 6–113). Two patients had locoregional recurrence, seven had distant metastasis, and 3 had both. Actuarial survival rate at 1, 3 and 5 years was 97%, 86%, and 72% respectively. The rate of local control at 5 years was 78%. Functional results were evaluated by a new scoring system. Function was considered good in 59 and 70% at 1 and 2 years respectively.

Conclusion

This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma. It is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results.

Study aim

Midface is situated between the occlusal plane and the transverse midorbital plane. The aim of midface reconstruction is to restore the bony and soft tissue contour of the face, to obtain a rigid support for the velum, to allow oronasal separation, and to allow support for the orbit and obliteration of the maxillary sinus in order to restore the main functions: respiration, speech, deglutition, mastication, olfaction, vision.

Patients and methods

Between 1988 and 1997, 65 patients with defects to the midface in relation with cancer (n=60), gunshot (n=3), or congenital malformation (n=2), underwent reconstruction with one or more transplants: forearm (n=21), latissimus dorsi (n=23), scapula (n=12), composed subscapula (n=10), and fibula (n=4). Fortyseven of the patients were men and 18 were women. The mean age was 56 years (12–90 years). In patients with cancer, tumoral resection was immediately followed by midface reconstruction in the last 43 cases. Free flaps were selected for reconstruction of each part of the mid-face: cheek, nose, orbit floor, maxillary and palate.

Results

One post-operative death occurred (1.5%). The morbidity rate (18.7%) included necrosis of the free flaps in four cases. Average resumption of oral intake was ten days. The mean time to discharge was 17 days. Aesthetic and functional results were rated good or excellent in 53 patients. After one year, 52 patients were alive. Oral intake was normal in 48 patients, and mixed in four. Speech was excellent or good in 49 patients. From amongst the patients, 80% were able to find a job.

Conclusion

Free flaps with micro surgery provides an optimal, functional, morphological and aesthetic outcome. Patients with advanced cancer of the midface are best managed through a multidisciplinary team approach. Microsurgical reconstruction represents the technical state of the art in case of extensive and complex midface defect.

After a brief definition of virtual endoscopy (VE), the authors, through personal experience and an analysis of the literature, present the results of this new method applied to several applications: tracheo-bronchial tree, vessels, colon, bladder, and central nervous system. Virtual endos-copy was compared to standard endoscopy; advantages and limits were studied. We underline the atraumatic feature of VE and the superiority of fibroscopy. Terminology is assessed. A comparison between the two methods is not actually justified because one of the methods is a recent development. Virtual endoscopy development is an undeniably interesting challenge for standard endoscopy. It is conceivable that in the near future, an important number of purely diagnostic exams will be carried on by virtual techniques (J.F. Rey).

Study aim

The report of a series of 20 patients with the aim of trying to specify the implications of pelvic exenteration for rectal cancer.

Patients and methods

From 1986 to 1996, 20 total pelvic exenterations were performed for rectal adenocarcinoma. This retrospective study included locally extended carcinomas (n=10), and recurrences (n=10) after anterior resection (n=7), and after abdominoperineal resection (n=3). The subjects included 13 men and seven women with a mean age of 54 years (34–74years). Complaints were major and serious: pain (n=20), rectal syndrome (n=17), recto-vesical fistula (n=5) recto-vaginal fistula (n=5), urinary infection (n=13), and hematuria (n=6). Preoperative radiotherapy was performed in 11 patients and preoperative radio chemotherapy in six. The surgical procedure included a total pelvic exenteration with perineectomy in 12 patients, and a total pelvic exenteration with preservation of levator ani and perineum in eight, associated in two cases with a partial resection of the sacrum, and in two other cases with partial hepatectomy for a single liver metastasis. Urinary diversion was a trans ileal ureterostomy in 17 patients and a direct double ureterostomy in three.

Results

The mean duration of surgery was 6 h. The mean preoperative blood loss was 1,200 L. Nine patients received blood transfusion. There was no postoperative mortality but in contrast, the morbidity rate was high with mainly urinary and digestive complications, pelvic sepsis and thromboembolic complications. After pathological examination, tumoral resections were classified R0 in 19 cases, and R1 in one. All tumors were T4 with tumoral invasion of the bladder (n=15), prostate (n=6), seminal vesicles (n=4), ureter (n=3), vagina (n=7), urethra (n=1), and sacrum (n=1). Lymph node involvement was present in four patients. The 3 and 5 year actuarial survival rate was respectively 47 and 18%. Thirteen patients died of their cancer, nine from metastases, and four from local recurrence with a mean survival of 29 and 32 months respectively. Seven patients were alive at the time of this study, six without actual recurrence.

Conclusions

In spite of its aggressive aspect, total pelvic exenteration seems justified in rectal carcinoma when extended to the urinary tract, when it causes major functional disorders, when there are no detectable metastases, and when the tumor has no posterior or lateral fixation. Local tumoral evolution can usually be controlled by pelvic exenteration but prolongation of survival is not demonstrated.

Aim of study

After removal of a perforated appendix with generalized peritonitis by a McBurney incision, peritoneal lavage may be performed by videolaparoscopic approach.

Patients and methods

This method was used in 14 children, seven boys and seven girls, aged from 2.7 to 14 years, with acute appendicitis and peritonitis.

Results

Conversion to median laparotomy was necessary in order to perform adhesiolysis in two cases in which small bowel was observed. Postoperative complications occurred in four patients involving three wound infections and one mechanical intestinal obstruction. There was no intra-abdominal abscess.

Conclusion

This procedure allows appendectomy by an open classical approach to be performed, and subsequently allows the treatment of the generalized peritonitis by videolaparoscopy, usually without median laparotomy.