Philippe Gertsch

Malignant cells are collected on circular staplers.

Anastomotic recurrence after resection of colorectal carcinoma has been attributed to insufficient clearance, migration of tumor cells into lymphatics, or implantation of exfoliated malignant cells during anastomosis. We studied 10 patients submitting to low anterior resection for cancer 6 to 16 cm (mean, 12.6 cm) from the anal verge. The anastomosis was performed with a circular stapler introduced transanally into the rectum using the established technique. No lavage of the rectal stump with a cytotoxic agent was conducted before the anastomosis was performed. Having completed the anastomosis, the stapler and the doughnuts were washed with saline, which was collected for cytologic examination. The doughnuts were then examined histologically; all were tumor free. In 9 of the 10 cases, malignant cells were identified in the centrifuged saline. It may be that malignant cells collected by the stapler are implanted during anastomosis and cause subsequent anastomotic recurrence.

Multiple tumors of the biliary tract

Multiple synchronous tumors of the extrahepatic biliary tree are not frequently reported. Over a 2-year period, 54 operative procedures were performed for tumors of the extrahepatic biliary tract or periampullary region. In five of these cases, unsuspected tumors were observed. Of these, one patient had multiple benign papillomatosis of the extrahepatic biliary tree. All four of the other patients were found to have unsuspected small carcinomas of the gallbladder in association with mid- or low bile duct cancer. Multiple tumors of the extrahepatic biliary apparatus may occur more frequently than previously thought, and the incidence of unsuspected gallbladder cancer in association with bile duct cancer may be high. These tumors should be suspected and looked for in each instance by intraoperative endoscopy and careful histologic examination of the gallbladder.

Post-Operative Hepatic Necrosis due to Reduction in Hepatic Arterial Blood Flow during Surgery for Chronic Biliary Obstruction

Three patients with malignant biliary obstruction, who developed postoperative hepatic necrosis due to compromise of the hepatic arterial blood flow, are reported. Two patients had major hepatic necro

Biliary Stricture Following Hepatic Resection

Anatomic distortion and displacement of hilar structures due to liver lobe atrophy and hypertrophy occasionally complicates the surgical approach for biliary stricture repair. Benign biliary stricture following hepatic resection deserves special consideration in this regard because the inevitable hypertrophy of the residual liver causes marked rotation and displacement of the hepatic hilum that if not anticipated may render exposure for repair difficult and dangerous. Three patients with biliary stricture after hepatectomy illustrate the influence of hepatic regeneration on attempts at subsequent stricture repair. Following left hepatectomy, hypertrophy of the right and caudate lobes causes an anteromedial rotation and displacement of the portal structures. After right hepatectomy, the rotation is posterolateral, and a thoracoabdominal approach may be necessary for adequate exposure. Radiographs obtained in the standard anteroposterior projection may be deceptive, and lateral views are recommended to aid in operative planning.

Experimental Evaluation of an Endoscopic Balloon for Manometry of Esophageal Varices

Measurement of pressure in esophageal varices may be performed using an endoscopic balloon technique. Improvements in this technique are described, and a complete experimental assessment of its potentials and limitations using an in vitro model consisting of an artificial esophagus containing a water-filled tube (varix) is reported. The influence of the varix diameter (3, 5, and 7 mm) and wall thickness (0.031, 0.144, and 0.256 mm) and the possible effect of the elasticity or peristalsis of the esophageal wall were investigated. Four hundred eighty pressure measurements were performed between 5 and 40 cm H2O. Linear regression analysis showed a good correlation between the pressure in the varix and that measured endoscopically (r greater than 0.9). No obvious measurement bias was found for any of the varices. Variability in pressure measurement was low in all thin-walled varices, and only in a 3-mm thick-walled varix was it found to be high [lower limit, -11.2 (1.4) cm H2O; upper limit, 6.4 (1.4) cm H2O]. Pressure measurement in a 7-mm varix was not affected by simulated peristalsis or esophageal wall elasticity. Intraobserver and interobserver reliability of measurement assessed in a series of 324 pressure measurements by three endoscopists was excellent. The authors conclude that this method may give reliable results in large and medium-sized varices and may be unaffected by peristalsis or esophageal wall elasticity. However, further assessment in vivo remains necessary.

Evaluation of adaptive changes by non-invasive imaging in hepatic vein outflow obstruction.

Hepatic vein outflow obstruction induces remarkable changes of intra–hepatic blood circulation; the significance of these changes remains uncertain. Six patients with obstruction of the hepatic veins were evaluated by duplex Doppler ultrasound and computed tomography. The adaptive changes secondary to obstruction were analyzed and their significance was correlated with the clinical findings. Four patients presenting unilateral hepatic vein occlusion had unilateral reversed portal flow. Two of them, with lobar liver atrophy and contralateral compensatory hypertrophy required operation; the other two, with normal appearance of the liver, benefitted from conservative treatment. Two patients with bilateral hepatic vein occlusion, intra-hepatic bypasses, bilateral lobar atrophy and caudate lobe hypertrophy, received operations. Intrahepatic unilateral portal flow reversal compensates for unilateral hepatic outflow obstruction. The combination of complete or subtotal hepatic vein obstruction and atrophy–hypertrophy complex predicates advanced disease despite flow reversal or spontaneous shunt.

Portal hypertension promotes bacterial translocation in rats mono- and non mono-associated with Escherichia coli C25.

The basis for the high incidence of infectious complications in portal hypertension (PHT) remains unclear. The hypothesis that PHT induces bacterial translocation (BT) was tested in a rat model with or without mono-association with streptomycin resistant Escherichia coli C25 and with or without hypovolemic shock. PHT was achieved by partial portal vein ligation and three weeks later hypovolemic shock (HS) was induced. Blood, liver, spleen and mesenteric lymph nodes cultures were performed twenty-four hours later. PHT promoted BT to mesenteric lymph nodes in indigenous flora (4/6 [67%]) and mono-associated animals (7/9 [78%]) compared to sham laparotomy and sham shock (SL + SS) animals (0/6 [0%] and 2/9 [22%] respectively) (p = 0.03). The combination of PHT and HS resulted in increased mortality in mono-associated (7/15 [47%]) and non mono-associated animals (8/15 [53%]). No significant translocation was noted in liver and spleen and bacteremia was found only in the PHT + HS mono-associated animals (4/8 [50%]). PHT induces BT to mesenteric lymph nodes and this may account for the high incidence of septic complications associated witti PHT. In this model, the addition of HS to PHT leads to an increased mortality but without uniform translocation of the gut flora beyond mesenteric lymph nodes.

Pylorus-Preserving Pancreatoduodenectomy. Experience in 20 Patients

Twenty patients underwent a pylorus-preserving pancreatoduodenectomy for benign or malignant periampullary and pancreatic disease. Eighteen patients had a partial and two patients a total pancreatectomy. There were 19 elective and 1 emergency operations. Post-operative mortality was 4% (1/20 patients) and the median follow up was 31 months (range, 15– 75 months), during which period 8 patients with a malignant disease died. Pylorus-preserving pancreatoduodenectomy did not compromise survival in ampullary cancer. One patient developed a marginal ulcer during the study period and one of twelve patients, examined by technetium scintigraphy (done more than 3 months after the procedure), had delayed gastric emptying. Two patients presented with a gastric retention as the first sign of recurrent pancreatic cancer. The result of the operation was judged as excellent in 7 patients, good in 8 and as bad in only 2 of the 17 patients who survived more than 6 months . Body weight was studied in 15 patients surviving more than one year after operation; five patients had gained weight, two had lost weight and in 8 there was no difference. Pylorus-preserving pancreatoduodenectomy seems to be a valuable alternative in the treatment of patients with benign and selected malignant pancreaticobiliary disease.

Laparoscopic Taylor procedure in Chinese patients

Laparoscopic t r e a t m e n t of condit ions prev ious ly approached wi th open techniques has been used in a va r i e ty of surgical d iseases including chronic duodenal ulcers. 1 Pa r i e t a l cell vago t om y as a n open procedure, h a s genera l ly b e e n accepted as the op t ima l ope ra t ion for the elective t r e a t m e n t of chronic uncompl icated duodenal ulcers, bu t the exper ience wi th its laparoscopic va r i a t ion h a s r e m a i n e d l i m i t e d ) In 1978 Hill and B a r k e r 2 descr ibed the pos ter ior t runca l vago tomy along wi th h ighly selective an te r io r vagotomy. Pa r i e t a l cell vago tom y achieves a complete denervat ion of the ac id-secre t ing gas t r ic m u c o s a while prese rv ing the funct ion of the an t ropylor ic pump. The opera t ion descr ibed by Hill and B a r k e r was des igned to reduce the t ime requ i red for comple te dene rva t ion of the lesser curve of the s t om ach and to overcome va r i a t ions prev ious ly observed in the longte rm resul ts of pa r i e t a l cell vagotomies . I n a f u r t h e r a t t e m p t to s impl i fy th is technique, Tay lo r and coworkers 3 descr ibed in 1982 a n opera t ion whe reby the an te r io r h ighly select ive vago t om y of the procedure by Hill and B a r k e r 2 was rep laced by an ante r ior lesser curve se romyotomy. The exper ience wi th this opera t ion has shown t h a t the resu l t s a re as good as those ob ta ined wi th pa r i e ta l cell vagotomies . 4-6 Therefore , i t seems app rop r i a t e for laparoscopic surgeons to adop t the Taylor procedure , because it is technical ly eas ie r to pe r fo rm t h a n a fo rmal pa r ie ta l cell vagotomy. This laparoscopic technique has been used by iso la ted t eams . 1 We repor t our exper ience in a ser ies of 15 Chinese pa t i en t s undergo ing su rge ry for chronic duodenal ulcers over a 2-year period. The ana tomic charac te r i s t ics of the e sophagea l h i a t u s in our pa t i en t s have led us to modify the laparoscopic technique descr ibed by o the r groups. 7

Complications of Chronic Pancreatitis

In order to define the risk factors resulting in morbidity and mortality, 154 patients referred to a surgical clinic because of suspected complications of chronic pancreatitis were studied. Pain was s