Jean-Jacques Tuech

PANCREATIC METASTASIS OF RENAL CELL CARCINOMA: PRESENTATION, TREATMENT AND SURVIVAL

PURPOSE The pancreas is an uncommon site of metastasis from renal cell carcinoma, comprising 2% of pancreatic tumors removed in sizable series of operations. To our knowledge the role of operative resection in the setting of metastatic malignancy to the periampullary region has not yet been defined. We reviewed the records of 6 women and 2 men who underwent pancreatic resection due to malignancy and analyzed various prognostic factors. MATERIALS AND METHODS Between 1985 and 1995, 269 patients underwent pancreatic resection for malignancy at our hospitals, including 150 (56%) for pancreatic duct cancer, 65 (24%) for carcinoma of the ampulla, 27 (10%) for distal bile duct cancer, 19 (7%) for duodenal carcinoma and 8 (3%) for renal cell carcinoma metastasis. We reviewed the records of these latter 8 cases, and analyzed demographics, primary tumor type, disease-free interval, resection type, concomitant other organ resection, histological examination of the specimen, morbidity, adjuvant therapy and survival. RESULTS Pancreatic metastasis of renal cell carcinoma was managed by duodenopancreatectomy in 5 patients and total pancreatectomy in 3. There were no perioperative deaths. Mean tumor size in cases of a solitary pancreatic metastasis was 4 cm. (range 1.5 to 8). In the 3 patients treated with total pancreatectomy there were 2, 5 and 3 pancreatic metastases, respectively. Pathological examination revealed negative lymph nodes in all cases. Mean survival was 48 months. At study end 6 patients were alive at 24, 26, 30, 46, 84 and 88 months, while 2 died at 13 and 70 months, respectively. CONCLUSIONS We advocate aggressive surgical resection when possible. Surgical removal of metastatic lesions prolongs survival but radical lymph node dissection is not mandatory. We also recommend careful long-term followup of patients with a history of renal cell carcinoma.

Primary anastomosis after intraoperative colonic lavage vs. Hartmann's procedure in generalized peritonitis complicating diverticular disease of the colon

Background and aimsFor complicated diverticulitis Hartmanns procedure remains the favored option in patients with acute complicated sigmoid disease, but there has been increasing interest in primary resection and anastomosis with intraoperative colonic lavage. This study compared primary resection with intraoperative colonic lavage and Hartmanns procedure.Patients and methodsBetween January 1994 and November 2001, 60 patients underwent emergency laparotomy for diverticular peritonitis (Hinchey stages III and IV). Primary resection and anastomosis with intraoperative colonic lavage was performed in 27 patients and Hartmanns procedure in 33. All data were collected prospectively on a standardized form.ResultsMortality with intraoperative colonic lavage was 11% and with Hartmanns procedure 12%. The incidence of postoperative complication was significantly higher after Hartmanns procedure. The mean hospital stay was significantly longer after Hartmanns procedure than after primary resection with intraoperative colic lavage.ConclusionPrimary resection with intraoperative colonic lavage compares favorably with Hartmanns procedure for diffuse purulent peritonitis in complicated diverticulitis. It should be an alternative to Hartmanns procedure in stercoral peritonitis.

COLOR: A Randomized Clinical Trial Comparing Laparoscopic and Open Resection for Colon Cancer

Background: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. Methods: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial which has started in September 1997. In 24 hospitals in Sweden, The Netherlands, Germany, France, Italy and Spain, 1,200 patients will be included. The primary end point of the study is cancer-free survival after 3 years. Results: Within <2 years, more than 540 patients have been randomized for right hemicolectomy (45%), left hemicolectomy (10%) and sigmoidectomy (45%). 33 patients (6%) were excluded after randomization. The accrual rate is approximately 25 patients/month. Current survival rates for the whole study group are: stage I: 95%, stage II: 98%, stage III: 93%, stage IV: 64%. For all patients with stage I disease, the mortality was not cancer related. Conclusions: Although laparoscopic surgery appears of value in colorectal malignancy, results of randomized trials have to be awaited to determine the definitive place of laparoscopy in colorectal cancer. Considering the current accrual rate, the COLOR study will be completed in 2002.

Laparoscopic versus open cholecystectomy: a prospective comparative study in the elderly with acute cholecystitis.

The aim of this prospective comparative study was to determine the feasibility and the efficacy of laparoscopic cholecystectomy for acute cholecystitis in patients older than 75 years of age and to compare the results with those of open cholecystectomy. From January 1992 to December 1999, 139 patients older than 75 years of age underwent cholecystectomy for acute cholecystitis. The two groups of patients with cholecystolithiasis included 50 patients who underwent laparoscopic cholecystectomy (group 1) and 89 patients who underwent open cholecystectomy (group 2). Group 1 consisted of 30 women and 20 men, with a mean age of 81.9 years (range, 75–98). Group 2 consisted of 51 women and 38 men, with a mean age of 81.9 years (range, 75–93). There was no difference in the American Society of Anesthesiologists classification in both groups. The length of the surgery (103.3 vs. 149.7 minutes), postoperative length of stay (7.7 vs. 12.7 days), and inpatient rehabilitation (15 vs. 42 patients) were significantly shorter in group 1 than in group 2. The postoperative morbidity rate was not different between the groups. There was no mortality in group 1, but four patients died in group 2 (P = 0.29). The conversion rate was 32% (n = 16) in group 1. In summary, laparoscopic cholecystectomy in elderly patients with acute cholecystitis is safe and effective. Laparoscopic cholecystectomy in elderly patients restores them to the best possible quality of life with the lowest cost to them physiologically.

Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma

PurposeThe treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of the study was to evaluate the results of its management by emergency subtotal or total colectomy with immediate anastomosis without diversion.MethodsAn emergency subtotal/total colectomy was performed in 72 patients (mean age 74.9 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability, and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers.ResultsPostoperative mortality was 9.7% (7 patients). An 83-year-old woman died as a result of an anastomotic dehiscence; the six other deaths resulted of cardiopulmonary complications. Postoperative morbidity was 15% (11 patients) including two fistulas, which recovered without surgery. There were eight synchronous colon carcinomas. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy.ConclusionEmergency subtotal colectomy achieves in one-stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serous tears on the cecum. It ensures restoration of gut contiguity via a “safe” ileocolonic anastomosis and removes occasional lesions proximal to the index cancer.

Treatment of hemorrhoids with circular stapler, a new alternative to conventional methods: a prospective study of 140 patients.

BACKGROUND Surgical hemorrhoidectomy has a reputation for being a painful procedure. The aim of this study was to determine the efficacy and safety of a new procedure for surgical treatment of hemorrhoid disease. STUDY DESIGN From April 1998 to August 1998, 140 patients (83 men and 57 women) with an average age of 43.8 years (range 19 to 83 years) underwent hemorrhoidectomy using a circular stapler. Operative times, pen- and postoperative complications, mean hospital stay, assessment of the postoperative pain, period of incapacity for work, and functional results were collected. All patients were evaluated at 2 weeks, 2 months, and 18 months after operation. RESULTS The average length of the operation was 18 minutes (range 8 to 60 minutes). There were no perioperative complications. The postoperative complication rate was 6.4% (n = 9). Mean hospital stay was 36 hours (range 8 to 72 hours). Paracetamol was the only analgesic used. Eighty-three patients (59.3%) required analgesic for less than 2 days, 45 patients (32.1%) between 2 and 7 days, and 12 patients (8.6%) more than 7 days. No patients had anal wound care. One hundred four patients had professions. The period of incapacity for work was less than 3 days for 22 patients (21.1%), between 3 and 7 days for 13 patients (12.5%), between 7 and 14 days for 62 patients (59.6%), and more than 14 days for 7 patients (6.8%). At 18 months, 95.7% of patients were fully satisfied with the results, 3.6% were somewhat satisfied (n = 4), and 0.7% were unsatisfied. CONCLUSIONS Treatment of hemorrhoids with a circular stapler appears to be safe, effective, and rapid, causing few postoperative complications and minimal postoperative pain. At 18 months, 95.7% of the patients were fully satisfied with the results.

Permeability and functionality of pancreaticogastrostomy after pancreaticoduodenectomy with dynamic magnetic resonance pancreatography after secretin stimulation

BACKGROUND The aim of this study was to evaluate pancreatogastrostomy (PG) permeability after duodenopancreatectomy (PD) and to determine a correlation with pancreatic endocrine and exocrine functions. STUDY DESIGN This prospective study included 19 patients who underwent PD with PG between 1992 and 1999. There were 12 men and 7 women, with a mean age of 58 years (range 35 to 76 years). The mean interval between operation and evaluation was 40.3 months (range 3 to 104 months). Indications for pancreatectomy were benign lesions (n = 13) or adenocarcinoma (n = 6). Histology of the pancreatic resection margin was normal in all patients with malignancy, and the pancreatic remnant was macroscopically normal without evidence of obstructive pancreatitis. Pancreatic exocrine and endocrine functions were respectively evaluated by fecal-1 elastase and fasting blood glucose concentrations. PG permeability was determined by secretin magnetic resonance cholangiopancreatography (Secretin-MRCP). RESULTS Anastomotic permeability was considered good in seven patients (group 1, 36.8%), moderately stenosed in six patients (group 2, 31.6%), significantly stenosed in four patients (group 3, 21.1%), and obstructed in two patients (group 4, 10.5%). Fecal-1 elastase concentration was decreased in 18 patients, with a mean concentration of 80 microg/g in group 1, 98 microg/g in group 2, 67 microg/g in group 3, and 0 microg/g in group 4. There was a statistically significant correlation between Secretin-MRCP group and fecal-1 elastase concentration. Results of fasting glucose estimation were normal for 14 of 19 patients. There was no correlation between pancreatic endocrine function and Secretin-MRCP group. CONCLUSIONS Exocrine pancreatic insufficiency was presented in 95% of the patients despite a PG permeability in 68.4%. These results may be explained in part by neutralization of pancreatic enzymatic secretions by gastric acid.

Emergency Pancreaticoduodenectomy with Delayed Reconstruction for Bleeding: A Life Saving Procedure.

SummaryEmergency pancreaticoduodenectomy with delayed reconstruction can be performed as a life saving procedure in case of massive bleeding uncontrolled with conventional hemostatic techniques. The authors report herein the case of a 39-yr-old patient with an acute episode of chronic pancreatitis-induced massive bleeding successfully treated by this unorthodox technique.The concept of damage control surgery with abbreviated laparotomy and planned reconstruction could be useful in selected cases outside the trauma setting.

Laparoscopic cholecystectomy in cirrhotic patients.

Since 1992, laparoscopic cholecystectomy has been the treatment of choice for symptomatic gallstones. The advantages of laparoscopic cholecystectomy for most patients have been extensively published. However, its benefits and successful use in patients with cirrhosis are less well documented. The aim of this study was to determine the efficacy and safety of laparoscopic cholecystectomy in cirrhotic patients. We did a retrospective review of the records of 26 consecutive laparoscopic cholecystectomy procedures performed on cirrhotic patients between January 1992 and September 2000. Twenty-two patients were classified as having Childs class A cirrhosis, and 4 patients were classified as having Childs class B. No patients were classified as having Childs class C cirrhosis. There were 20 men and 6 women, with a mean age of 57 years (range, 37–76). All procedures were completed laparoscopically. There was histologic confirmation of cirrhosis in all patients. The mean operative time was 126 minutes (range, 60–184). The mean estimated blood loss was 110 mL (range, 40–380). Complications occurred in 7 patients (27%). No operative mortality occurred in this study. The mean length of hospital stay was 5 days (range, 3–14). Our results and the results of others show that laparoscopic cholecystectomy in cirrhotic patients seems to be safe in selected Child–Pugh class A and B patients with compensated cirrhosis. Cholecystectomy remains a high-risk procedure in cirrhotic patients, and indications for cholecystectomy should be evaluated carefully. Controlled trials are required to confirm the safety of this procedure, and further studies are also required to evaluate the management of gallbladder disease in patients with Child–Pugh class C cirrhosis.

Laparoscopic suture closure of perforated duodenal peptic ulcer.

The aim of this study was to assess the outcome of a continuous series of 30 patients with perforated duodenal peptic ulcers treated by a laparoscopic approach. Between January 1996 and December 1998, 30 patients (24 males, 6 females) with a mean age of 69.2 years were operated on with a laparoscopic approach. Laparoscopic treatment included peritoneal lavage, suture of the perforation, and omental patching in 24 cases. A conversion to laparotomy was necessary in five patients (16.6%). Mean operative time was 92 minutes (range: 58–114) and mean hospital stay was 6 days (range: 4–16). Mortality and morbidity rates were 6.6% (n = 2) and 16.6% (n = 5). With a median follow-up of 12 months, 96% of the patients were in good condition; one patient had recurrent duodenal ulceration. The results of our study show the feasibility of the laparoscopic approach for perforated peptic ulcer repair, with acceptable mortality and morbidity rates.