François Fekete

Splenic and portal venous obstruction in chronic pancreatitis. A prospective longitudinal study of a medical-surgical series of 266 patients.

The aim of this study was a prospective search for splenoportal venous obstruction (SPVO) in a medical-surgical series of 266 patients with chronic pancreatitis who were followed up a mean time of 8.2 years. SPVO was systematically searched for using ultrasonography and then confirmed by angiography or computed tomography. SPVO was found in 35 patients (13.2%) but was symptomatic in only two. Initial obstruction involved the splenic vein in 22 patients, the portal vein in 10, and the superior mesenteric vein in three. Since venous obstruction extended from the splenic to the portal vein in five patients, the prevalence of portal obstruction was 5.6% (15/266). Acute pancreatitis and pseudocysts were the probable cause of SPVO in 91.4% of our cases. Half the cases of splenic venous obstruction were related to pseudocysts of the caudal pancreas. Esophageal varices were found in two patients and gastric varices in four at the time of diagnosis and during follow-up. At the end of follow-up, 12 patients had undergone splenopancreatectomy (N=11) or splenectomy (N=1). Only one patient was operated on for massive esophageal variceal bleeding, and another patient died due to intractable colic variceal bleeding. In four of six patients operated on with portal vein obstruction, surgery was difficult due to venous collaterals. Ten patients were not operated on and 13 patients operated on were not treated for SPVO. The mean follow-up after diagnosis of SPVO for these final 23 patients was 28.9 months. None of these patients bled. We concluded that in chronic pancreatitis: (1) the prevalence of SPVO is 13.2%; (2) SPVO should be systematically searched for in patients with acute pancreatitis or pseudocysts, especially if therapeutic decisions would be modified by a diagnosis of SPVO; (3) the risk of digestive variceal bleeding is lower than previously reported; and (4) portal vein obstruction seems to be riskier than splenic vein obstruction, especially if surgery is needed.

Drainage after elective hepatic resection. A randomized trial.

ObjectiveThis prospective randomized study determined the influence of closed-suction drainage on the incidence of postoperative complications after elective hepatic resection. Summary Background DataRoutine drainage is no longer advocated after several intra-abdominal surgical procedures. MethodsA series of 81 patients who underwent elective hepatic resection were randomly allocated to either a nondrainage group (n = 39) and a drainage group with closed-suction drainage (n = 42). Indications for resection were 42 benign lesions and 39 malignant tumors, including 19 with cirrhosis. Major hepatic resection was performed in 25 patients and minor resection, in 56. All patients underwent ultrasonography with puncture for bacteriologic cultures of all fluid collections within the first 5 postoperative days. ResultsOne patient died in each group. Ultrasonography found a significantly higher rate of subphrenic collections in the drainage group compared with the nondrainage group (respectively, 36% vs. 15%, p < 0.05). These collections were more frequently infected in the drainage group (n = 6) than in the nondrainage group (n = 2). After major liver resection, the rate of intra-abdominal postoperative complications (i.e., subphrenic fluid collections, hematomas, and bilomas) was similar between the two groups. ConclusionMinor liver resection is safer without drainage. Major liver resection can be performed with or without abdominal drainage.

Impact on survival of surgery after concomitant chemoradiotherapy for locally advanced cancers of the esophagus.

BACKGROUNDnTo evaluate the results of chemoradiotherapy with or without surgery in locally-advanced esophageal carcinomas (T3 and/or nodal involvement).nnnMETHODSnOne hundred twelve patients with locally-advanced carcinoma of the esophagus without histologically proven invasion of the tracheobronchial tree or distant visceral metastases were treated with concomitant chemoradiotherapy followed by re-evaluation; surgery was performed or chemoradiotherapy continued, based on tumor regression and the patients general status. Chemoradiotherapy consisted of concomitant 5-fluorouracil (5FU)(1 g/m(2) day 1-3), cisplatinum (50 mg/m(2) day 1 and 2), and external beam irradiation up to a dose of 40 or 43.2 Gy. After a 4-week rest period, radical esophagectomy or a new cycle of chemoradiotherapy (up to a total dose of 65 Gy) was performed.nnnRESULTSnA complete clinical response was obtained in 25.7% of the patients and a partial response in 45.9%. Fifty patients underwent surgery, but only 38 patients had an esophagectomy. Post-esophagectomy mortality was 5.3%. A complete histologic response rate of 23.7% was obtained. Two- and 5-year survival rates were, respectively, 41.5% and 28.6% for the whole population. According to multivariate analysis, prognostic factors for survival were Karnofsky index, esophagectomy, and response to chemoradiotherapy. Five-year survival for patients who experienced a partial response to radiation and chemotherapy was 49.1% for those who had surgery and 23.5% for those treated without surgery (p = 0.003). There was no obvious benefit for the small number of patients treated surgically after complete response to radiation and chemotherapy. Toxicity, essentially hematologic, was moderate.nnnCONCLUSIONnFor locally-advanced esophageal carcinomas, esophagectomy, after concomitant chemoradiotherapy, could improve the survival rate, especially for patients who responded partially to the latter.

Associated primary esophageal and lung carcinoma: A study of 39 patients

From 1979 to 1992, of 1,294 patients with esophageal squamous cell carcinoma, 39 patients (3.2%) (38 male patients, 1 female patient; mean age, 58 years) had associated primary lung carcinoma. Criteria for the diagnosis of primary lung carcinoma were: (1) non-squamous cell carcinoma tumors, (2) tumors existing before the esophageal squamous cell carcinoma, and (3) solitary squamous cell carcinoma presenting with endobronchial involvement. The two tumors were observed synchronously in 22 patients (56%) and metachronously in 17, with a mean tumor-free interval of 46 months (range, 18 to 77 months). In patients with synchronous disease, 10 underwent nonoperative treatment or a palliative surgical procedure, and 12 (55%) underwent a curative operation. In patients with metachronous disease, a curative operation was performed in all for the first tumor and in 9 (53%) for the second tumor. The overall postoperative mortality rate was 15%. Two patients (10%) died after the curative operation. None of the patients died who underwent curative esophagectomy combined with lobectomy. For the patients with synchronous disease, the 5-year survival rate was 11% in those who underwent a curative operation, and the longest survival in those who received palliative treatment was 18 months. For the patients with metachronous disease, the 5-year survival rates from the date of the diagnosis of the second tumor were 17% for those who had a curative operation and 11% for those who received palliative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Symptomatic duodenal stenosis in chronic pancreatitis : a study of 17 cases in a medical-surgical series of 306 patients

The aim of this study was to assess the prevalence, presentation, cause, and location of symptomatic duodenal stenosis, and its relation to the natural course of chronic pancreatitis in a medical-surgical series of 306 patients (86% alcoholics). Mean follow-up of the series was 7.9 years. Symptomatic duodenal stenosis occurred in 17 patients (5.6%). Diagnosis was confirmed by a barium series. The cause of stenosis was compression by the pancreatic head in all patients, associated with a pancreatic abscess in two. No pseudocysts were found at the time of diagnosis. The location was the 1st and 2nd part of the duodenum or the entire duodenal loop in 4, 6, and 7 patients, respectively. Cholestasis due to common bile duct stenosis occurred in association with duodenal stenosis in 9 patients. Fifteen patients were treated surgically; 11 for gastroenterostomy, and 4 for duodenopancreatectomy. Two patients were not treated surgically. We conclude that during the course of chronic pancreatitis, symptomatic duodenal stenosis occurred in 5.6% of patients, mainly during the first years of the clinical course of chronic pancreatitis, was due to pancreatic head compression and not pseudocysts, usually involved the 2nd part of the duodenum and, was associated with biliary stenosis in half of the cases. Since these two complications require surgery, common bile duct stenosis should be investigated when symptomatic duodenal stenosis is diagnosed.

Roux-en-Y diversion and fundoplication for gastro-oesophageal reflux

In 1949 Wangensteen and Levin noticed that a distal gastrectomy resulted in improvement in patients suffering from peptic stenotic oesophagitis. Others1–3 have also promoted the use of an antrectomy with Roux-en-Y diversion to treat peptic stenosis. Duodeno-gastric reflux when associated with peptic acid reflux plays an important role in the development of severe oesophagitis4 and perhaps also of Barrett’s metaplasia, and it is for this reason that duodenal diversion is advocated in complicated cases.