Bertrand Millat

Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery.

Background Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient. Methods Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores. Results Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24%vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups. Conclusion After major abdominal surgery in the elderly patient, patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective. The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity.

Laparoscopic versus Open Appendectomy: Time to Decide

Although widely practiced, laparoscopic appendectomy (LA) has not met with universal approval. Several controlled trials have been conducted, some in favor, others not. The goal of this review was to ascertain (1) if laparoscopy was capable of improving the diagnostic and therapeutic difficulties encountered during open appendectomy (OA) and (2) if the introduction of laparoscopy in the overall management of acute appendicitis has changed anything in practice. Analysis and criticism of 17 controlled studies (nearly 1800 patients) on laparoscopic appendectomy and 2 randomized studies dealing with diagnostic laparoscopy are reported. Because of the questionable quality of randomized controlled trials (number of patients, exclusions, withdrawals, blinding, intention-to-treat analysis), publication biases, local practice variations (hospital stay, rate of enrollment), results regarding analgesia requirements, return to activity and work, duration of hospital stay, outcome, follow-up, and antibiotic prophylaxis the studies must be interpreted with caution. The real world of appendicitis probably differs greatly from the atmosphere under which controlled trials comparing LA and OA have been performed. Statistical significance is contrary to the clinical significance of the results. Consistently longer operating times [the difference ranging from 8 minutes (NS) to 29 minutes (p < 0.0001)], a minimal reduction in hospital stay [0.1 day (NS) to 2.1 days (p < 0.007)], and, somewhat more controversial, an earlier return to normal activity were reported for LA. Data on analgesic requirements were confusing, but wound complications were more frequent after OA [pooled odds ratio for 10 studies: 2.6 (95% CI 1.3–5.2)]. Unsolved problems include national behavioral problems, age and experience of operating surgeons (LA or OA), and emergency conditions (availability of staff, instruments). Results of cost analysis vary according to the standpoint of disease, the patient, the surgeon, the treatment center, industry, and society. Three questions remain: Because of the competition of LA versus OA, OA has improved greatly. Can it be improved any more? Is there a place or need for further randomized controlled trials? Should we not conclude once and for all that LA is out?

Laparoscopic Splenectomy for Benign and Malignant Hematologic Diseases: 35 Consecutive Cases

Abstract. The feasibility and safety of laparoscopic splenectomy (LS) has been shown for a variety of diseases with small or moderately enlarged spleens. Immune thrombocytopenic purpura thus has become the typical indication for LS, although few data are available to demonstrate any superiority of the laparoscopic approach over conventional surgery for this indication. We retrospectively analyzed 35 cases of LS for benign (22 patients) or malignant (13 patients) hematologic disorders. LS was attempted irrespective of the volume of the spleen. The overall operative mortality rate was 2.9%, and complications occurred in 23% of all patients. The conversion rate was 9%, and accessory spleens were found in 17% of patients. Although the patients with malignant disease were significantly older, were higher operative risks (ASA score), had much larger spleens, and required longer operative times, more conversions to laparotomy, and more blood transfusions than patients with benign disease, their mortality and complication rates and the duration of their hospital stays were not significantly different from those with benign disease. They also compare favorably with the results of conventional surgery for the same indications. Patient selection, operative technique, and outcome of laparoscopic and conventional splenectomy are discussed with regard to the literature. Although the experience with LS for these indications is still limited, the reported results indicate that LS may be as beneficial for patients with malignant as for those with benign hematologic conditions.

Surgical treatment of complicated duodenal ulcers: controlled trials.

Indications for surgery of duodenal ulcer (DU) have changed radically because of the efficacy of H2-antagonists, endoscopic procedures, and eradication of Helicobacter pylorus. The aim of this study was to analyze the current literature to determine if definitive surgery is still relevant for complicated DU (bleeding, perforation, gastric outlet obstruction). Two studies have compared early to late surgery in terms of bleeding. One recommended early surgery (significant reduction in mortality) in the elderly, but no statistically significant difference was found when analyzed with “intention to treat.” In the other, mortality with early surgery was five times higher than with expectant therapy (when it was possible). Two studies comparing different surgical techniques for bleeding favored the radical procedure. Of at least 15 studies comparing endoscopic treatments, however, none has compared endoscopic therapy to surgical intervention for bleeding DU. One trial, comparing nonoperative to surgical treatment for perforation, found similar rates of morbidity, intraabdominal abscess, and mortality; but the hospital stay was longer (p < 0.001). Nonoperative treatment failed more often (p < 0.05) in patients over age 70. In three trials, postoperative morbidity (excepting wound sepsis in one) was not significantly increased by definitive surgery, with less ulcer recurrence (p < 0.05) compared with simple closure. Laparoscopy (versus laparotomy) was shown to take longer (p < 0.001) but required less postoperative analgesics (p < 0.03); there were no statistically significant differences as concerns the duration of nasogastric aspiration, intravenous drips, hospital stay, time to resume normal diet, Visual Analogous Scale pain scores for the first 24 hours after surgery, morbidity, reoperation rate, or mortality. Of 48 laparoscopic patients, 11 (23%) underwent conversion to open surgery. Three surgical techniques [highly selective vagotomy (HSU) + gastrojejunostomy (group 1), HSV + Jaboulay gastroduodenostomy (group 2), or selective vagotomy (group 3) + antrectomy) for gastric outlet obstruction (GOO)] showed that although postoperative results were similar (except wound sepsis in one trial), long-term Visick scores were significantly (p < 0.01) better in group 1 than in group 2, but not in group 3. Further studies are needed to determine the exact prevalence of Helicobacter pylori in complicated DU and to compare (1) definitive to minimal surgery (stop the bleeding or close the perforation) combined with antisecretory drugs and eradication of H. pylori; (2) surgery to endoscopic treatment combined with eradication of H. pylori; and (3) for GOO, surgery to balloon dilatation combined with eradication of H. pylori.

Management of intraductal papillary mucinous tumours of the pancreas

OBJECTIVE To focus attention on the management and outcome of patients with intraductal papillary mucinous tumours of the pancreas. DESIGN Retrospective study and analysis of published reports. SETTING University hospital, France. SUBJECTS 111 patients (101 published cases and our own 10 cases) divided in two groups: the first including malignant tumours (n = 46), and the second group benign or in situ tumours (n = 61). In 4 patients the type of tumour was not known. MAIN OUTCOME MEASURE Resectability, mortality and recurrence. RESULTS More men had benign or in situ tumours [48/61 (79%) compared with 28/46 (61%), p = 0.054]. Pancreatitis was more common among benign than malignant tumours [34/61 (58%) compared with 21/46 (46%), p = 0.33]. In group I, 39 patients had diabetes. A total of 107 patients were operated on: pancreaticoduodenectomy (n = 54, 50%), distal pancreatectomy (n = 25, 23%), total pancreatectomy (n = 4,4%), bypass (n = 2,2%). The type of resection was not mentioned in 22 records (21%). Four patients were not operated on because of their poor general condition. The resectability rate was 98% (105/107). Eleven patients had died at the time of publication. Hospital mortality rate was 3% (n = 3), mainly because 2 of the 4 who had total pancreatectomy died. With a median follow-up of 37 months, recurrence was 5% (n = 5). CONCLUSION Intraductal papillary mucinous tumours of the pancreas are well known distinctive pancreatic tumours that are usually intraductal but may develop into invasive carcinoma. They should be resected, and have a good prognosis and low recurrence rate.

Cost and effectiveness of follow-up examinations in patients with colorectal cancer resected for cure in a french population-based study

The cost of follow-up examinations for patients having undergone potentially curative surgery for colorectal cancer is considerable. The aim of this study was to provide a thorough assessment of the cost and effectiveness of the follow-up tests used during the 5 years after surgical resection for colorectal cancer and its recurrences. We studied medical and economic data from the records of 256 patients registered in the Herault Tumor Registry who underwent potentially curative surgical resection in 1992. Recurrence, curative recurrence, survival, and the cost of follow-up tests were assessed respectively for at least 5 years. We analyzed the cost and effectiveness of follow-up tests in patients who received either follow-up with carcinoembryonic antigen (CEA) monitoring as advocated by the 1998 French consensus conference recommendations (standard follow-up) or a more minimal follow-up schedule. Nine patients died in the postoperative period. The 5-year survival rates in the standard and minimal follow-up groups were 85% and 79%, respectively (p = 0.25). Cost-effectiveness ratios were 2123 in Dukes’ stage A patients, 4306 in Dukes’ stage B patients, and 9600 in Dukes’ stage C patients. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the standard follow-up group were 1238 and 2261.5, respectively. Cost-effectiveness ratios for CEA monitoring and abdominal ultrasonography per patient alive in the minimal follow-up group were 1478 and 573, respectively. There were no survivors 5 years after a recurrence when the recurrence was detected by physical examination, chest X-ray, and colonoscopy in either follow-up group. Dukes’ classification is a poor indicator of patient selection. The follow-up tests should only include CEA monitoring and abdominal ultrasonography for the diagnosis of recurrence.

Treatment and prognosis of early multiple gastric cancer

AIM Early gastric cancer (EGC) may have a 5-year survival rate of over 90% following surgery. Early multifocal gastric cancer (EMGC) accounts for between 8.3 and 17% of all EGCs. A multicenter retrospective study is reported of prevalence, characteristics, prognosis and type of resection for EMGC patients. METHOD 333 patients with EGC were operated on, between January 1979 and December 1988, and followed to June 1996. RESULTS 33 EGC patients had EMGC. There was no significant difference in clinico-pathological features between EGC and EMGC. 21 cases of EMGC underwent a subtotal gastrectomy and 12 underwent a total gastrectomy. Recurrences after subtotal gastrectomy were, respectively, 10 and 18% for EGC and EMGC patients (p=0.2). The cumulative 5 years specific survival rate for 298 EGC and 34 EMGC were 94 and 90%, respectively (p=0.9). Five-year survival rates after subtotal gastrectomy were 92 and 90% for EGC and EMGC patients, respectively (p=0.8). CONCLUSION EGC and EMGC had the same clinico-pathological features and prognosis. A careful follow up of the stomach remnant is essential.

Predictability of clinicobiochemical scoring systems for early identification of severe gallstone-associated pancreatitis

Early identification of severe gallstone-associated acute pancreatitis (GAAP) is a prerequisite for treatment with urgent endoscopic sphincterotomy. This study assesses the value of two clinicobiochemical scoring systems to this end. Over the 7-year period from 1983 to 1989, 100 consecutive patients with acute pancreatitis (45 related to gallstones, 36 to alcohol, and 19 of undetermined etiologies) had clinicobiochemical analysis within 48 hours of admission. The final diagnosis and outcome were retrospectively compared with the prediction achieved by the scoring systems. With regard to Blameys criteria for early identification of gallstones, significant differences were found between the biliary and nonbiliary groups with respect to female sex, serum amylase concentration greater than or equal to 4,000 IU/L, alkaline phosphatase level greater than or equal to 300 IU/L, and alanine aminotransferase level greater than or equal to 100 IU/L (all p values less than 0.001). Age greater than or equal to 50 years was found to be significant (p less than 0.02) only in differentiating gallstone- versus alcohol-associated acute pancreatitis. When three or more positive factors were present, the sensitivity and specificity for predicting gallstones were 60% and 87%, respectively; the predictive value of a positive result was 79%, of a negative result 74%, and the overall accuracy was 75%. At a cutoff level of five, rather than three or more prognostic factors, the modified Ransons criteria for patients known as having GAAP allowed a suitable discrimination of patients with an expected high risk of complications and mortality. When the two scoring systems (Blamey greater than or equal to 3 and Ranson greater than or equal to 3) were combined, 17 patients were predicted as having severe GAAP: 6 of these 17 patients were misdiagnosed as having biliary pancreatitis, whereas 9 patients with definite severe GAAP were not selected because of a Blamey score less than 3. More specific diagnostic tools are needed, and higher cutoff levels for prognostic scores are required for the prediction of severe GAAP, particularly in view of selecting patients for potentially dangerous approaches such as urgent endoscopic sphincterotomy.

Prospective Trials in Laparoscopic Bile Duct Exploration

Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. Laparoscopic intraoperative cholangiography (IOC) versus ultrasonography (LUS) and laparoscopic versus endoscopic extraction of CBD stones were compared through a review of the prospective, comparative studies, randomized or not, evaluating these different techniques. Cystic duct cholangiography and fluoroscopic imaging are the standards for IOC. The potential protective effect of IOC regarding the risk or severity of CBD injuries might be the major argument for a routine use of laparoscopic IOC. Most if not all the purported advantages of LUS versus IOC for the diagnosis of CBD stones remain to be proven. Laparoscopic intraoperative diagnosis of CBD stones by cholangiography or ultrasonography followed by the laparoscopic extraction or, in case of failure, by postoperative endoscopic sphincterotomy, might represent the future for the diagnosis and treatment of CBD stones. Copyright

PROSPECTIVE EVALUATION OF ULTRASONIC SURGICAL DISSECTORS IN HEPATIC RESECTION A COOPERATIVE MULTICENTER STUDY

Blood loss is the major cause of postoperative mortality and morbidity associated with hepatic resection. A prospective multicenter study was conducted to determine if ultrasonic dissectors (USD) were useful in hepatic resection and could reduce this hemorrhagic risk. Forty-seven hepatic resections were performed in 42 consecutive patients during a two month period in 11 public, surgical centers. Twenty-one patients had primary or secondary malignancies, six had benign tumors, two had biliary cysts, one had cholangiocarcinoma, one had Caroli’s disease, and 11 had hydatid cysts of the liver. Two different USD devices were evaluated (CUSA System-Lasersonics and NIIC-DX 101 T). The hepatic resections tested included a wide range of procedures. Each surgeon had the possibility of choosing between the USD and his own usual technique for each operative step and according to local conditions. The average volume of blood infused, irrespective of the underlying pathology or the procedure performed, was 1.0 L (range 0-4.8 L). Fourteen patients required no transfusions. No operative or immediate postoperative deaths were recorded. Five major complications, all unrelated to the use of the USD, developed in three patients. Access to intra and extraparenchymal arterial and venous tributaries and particularly the control of the hepatic veins were facilitated by USD. While transection of hepatic parenchyma was neither easier nor faster than with conventional techniques, it was found to be less hemorrhagic. Overall appraisal was expressed on an analog scale; the USD was found to be helpful or very helpful in 75 percent of all resections. With regard to the pathology being treated, total or partial excision of hydatid cysts was greatly enhanced by the use of the USD while this benefit was not found for wedge resections of other hepatic lesions. With regard to user friendliness and maintenance, the NIIC-DX 101 T device was preferred. We conclude that the USD facilitates formal hepatic resections. Converging opinions emerging from various surgical centers reinforce this conclusion.