Chirurgie最新文献

Study aim

Klatskin tumors are rare. Prognosis is still poor, and long term survival can be expected only after surgery, which is the treatment of choice. The aim of this study is to report the results of 15 resected cases and, by analysis of the literature, to emphasize the progress of the surgical treatment in hilar cholangiocarcinoma.

Patients and methods

Between 1990 and 1998, 27 patients affected by Klatskin tumor were observed. Eight women and seven men underwent surgical resection. The mean age was 59 years. Thirteen patients (48%) had curative resection (7 hilar resection (HR), 5 HR combined with partial hepatectomy (PH) and 1 HR+PH with portal vein resection). Two patients had palliative resection and surgical drainage.

Results

One in-hospital death occurred right after hepatectomy with portal vein resection (6.6%). Postoperative morbidity was 40%. Patients were regularly followed. Ten patients died and 5 were alive at the time of this study. The 1, 2 and 3-year survival after a curative resection was 84%, 54% and 34%. The median survival was 28.5 months. Lymph node involvement did not show a statistically significant difference on median survival between the positive group and the negative group (26.2 vs 29.8 months) because of the small number of patients. Survival after hilar resection at 1, 2, 3, and 5 years was 100%, 57.1%, 28.6% and 0%. Four out of the 6 patients who underwent hilar resection combined with partial hepatectomy were still alive 1, 23, 29, 38 months after resection. Hepatectomy increased mortality (16% vs 0%). Palliative biliary resection and surgical drainage were successfully performed in 2 patients.

Conclusion

Aggressive surgical treatment of Klatskin tumor can improve the survival of patients. Careful preoperative management has to be carried out by a multidisciplinary approach including surgeons, hepatologists, radiologists and pathologists. Hepatic resection including the caudate lobe is often performed in order to obtain microscopic tumor-free margins and curative resection (R0). Biliary drainage and treatment of cholangitis is mandatory before surgery in order to improve the surgical outcome. Surgical treatment is characterized by high technical difficulties, and better results can be achieved by hepatobiliary surgical teams.

Study aim

The aim of this retrospective study is to report five cases of laparoscopic splenorraphy with an absorbable perisplenic mesh for splenic injury.

Patients and method

From January 1996 to February 1998, three men and two women (mean age: 52 years) were included in this study. The splenic lesions were due to either a fall (n = 3), a traffic accident (n = 1 ), or pleural paracenthesis in a patient with mediastinitis after valvular replacement. Splenic injury was recognized by ultrasonography. The patients were operated as either emergency cases (n = 2), or within 24 hours (n = 3). The procedure included evacuation of the hemoperitineum, total liberation of the spleen, and splenic hemostasis with a perisplenic mesh which was used in open surgery. The mesh placed behind the spleen, covering its superior and inferior poles, was unrolled forwards and burses progressively tightened.

Results

There was no conversion, no mortality, no morbidity. In the four injured patients, the mean duration of surgery was 120 minutes (70–180), without any blood transfusion, and the patients were discharged on d4 or 5. The fifth patient, after valvular replacement, was operated on with anticoagulation. The mean duration of surgery was 270 minutes. Four blood units were necessary. He was discharged at d26.

Conclusion

This technique combines the advantages of the perisplenic mesh which is efficient and safe, with the advantages of laparoscopic surgery which simplifies the postoperative course. It can only be used in case of isolated splenic injury in patients with stable hemodynamic condition.

Aim of the study

To report three cases of neck pancreatic disruption caused by blunt abdominal trauma and to emphasize the advantages of conservative surgery with internal drainage.

Patients and results

In two cases, one with hemoperitoneum, and the other with intraperitoneal fluid collection with 1,323 U/mL of amylase, laparotomy showed a complete disruption of the neck of the pancreas. The pancreatic head side was sutured whereas the left side was anastomosed to a Roux-en-Y jejunal loop. The clinical results were good at 8 and 6 months after surgery, respectively. For the third patient, a pancreatic trauma (which was suspected on a CT. Scan), was not confirmed at laparotomy. In the postoperative course, the amount of fluid drainage was important and the endoscopic retrograde pancreatography (ERCP) showed a disruption of the neck of the pancreas. An endoprosthesis was placed into the duct of Wirsung. Three months later, the patient complained of pain, and a migration of the prosthesis was detected by X-ray examination. It was not possible to place another endoprosthesis because of a stenosis of the duct. A resection of the neck of the pancreas was performed, the cephalic side was sutured and the left side anastomosed to the posterior gastric wall. Eight months after surgery, the clinical result was good and glycemia was normal.

Conclusion

In blunt abdominal trauma, if a pancreas injury is suspected upon clinical presentation an ERCP, or moreover a magnetic resonance imaging, is indicated. When there is no disruption of the Wirsung duct, a simple péritonéal drainage should suffice. In cases with partial disruption, an endoprosthesis may give good results. In patients with a complete disruption, as in the three cases reported, a suture of the head side of the pancreas, and an internal drainage of the left side with a Roux-en-Y jejunal loop (or more easily with the stomach), are indicated.

Study aim

In children, living donor liver transplantation has been shown to be efficient in treating end-stage liver diseases when the left lateral segment is harvested. In adults, more liver mass is needed to provide adequate hepatic function. The aim of this study is to report 2 successful cases of living donor liver transplantation using a right hepatic lobe from adult.

Patients and methods

In 2 sons, the right hepatic lobe was harvested without the middle hepatic vein for transplantation in their fathers who were suffering from end-stage liver cirrhosis. Hepatectomy was done without vascular inflow occlusion after dissection of vascular and biliary structures, itself strictly restricted to the right side. In recipients, the graft was implanted orthotopically with preservation of the native inferior vena cava and after temporary porto-caval shunt.

Results

The duration of donors procedures was 7 h and 11 h 45 min; intra-operative transfusions comprised of 700 mL from cell-saver in the first case, and 1300 mL plus 1 autologous red blood cell unit in the second case. Graft weights were 770 g and 1100 g. None of the donors experienced liver failure and both were able to leave the hospital 9 days after the operation. In recipients, initial graft function was excellent in the first case and correct in the second case, despite the necessity to redo intraoperatlvely the hepatic vein anastomosis secondary to a twisting. Patients were discharged 20 and 40 days respectively following transplantation.

Conclusion

Adult living donor liver transplantation using a right hepatic lobe is efficient and safe. This option could contribute to reducing the mortality of patients on the waiting list.

Background

Peritoneal colonization is a crucial event in the pathogenesis of peritonitis and its local complications. Adherence to the serosal mesothelium is mediated in a number of microorganisms derived from the digestive tract (especially E. coli) by type-1 fimbriae which have an oligosaccharide specificity.

Purpose

To evaluate the effect of repeated peritoneal washes with saline solution and oligosaccharides on E. coli peritoneal adherence in a rat peritonitis model.

Methods

Sixty rats were randomized in 3 groups of 20. E. coli was inoculated at a constant concentration of 10⁸/mL per 100 g of weight. Then, peritoneal washes were achieved daily during three consecutive days (D1, D2, D3), with saline solution in Group I (control group), Methyl α-D-Mannoside (MADM) in Group II, and p-Nitrophenyl α-D-Mannoside (pNADM) in Group III. Peritoneal samples were obtained before and after lavage at D1, D2, and D3. Microbial recovery was expressed as cfu/mg of tissue, and converted into a percentage of the initial value. A 10% threshold defined efficiency of the wash (inhibition of adherence for 90% of bactéries).

Results

Compared with data from Group I, E. coli peritoneal adherence was significantly lower after washes in Group III (D1: p = 0,03; D2: p = 0,009; D3: p = 0,003). Repeated washes were more efficient in Group III than in Group II (D1: p = 0.1; D2: p = 0,5; D3: p = 0,001).

Conclusion

These results suggest that the addition of oligosaccharides, especially of pNADM, reduces the peritoneal adherence of E. coli when a péritonéal wash is performed for peritonitis.

Laparoscopic surgery for small bowel obstruction is still under evaluation. A review of the literature retrieved over 200 published cases. Technically, the open laparoscopy procedure seems mandatory to avoid bowel injuries. Grasping the enlarged bowel and using monopolar cautery should be avoided. The surgeon should also be sure that at the end of the procedure adhesiolysis was correct. Evaluation of the results must also take into account that most studies were retrospective and included few patients. The cumulative effectiveness rate of laparoscopy was 60%. Failures were mainly due to multiple adhesions, iatrogenic perforations to the intestine, and colonic cancers not recognized before the procedure. There was no prospective study comparing laparoscopy with laparotomy. Finally, it is not proved at present that laparoscopy prevents the recurrence of adhesions after digestive surgery. Owing to the results of the literature, laparoscopic surgery for acute small bowel obstruction does not appear as based on fact.