[Results of pancreatic cancer surgery].
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Humans↗
Biomedical subjects
B Sastre
Publications and source records attributed to B Sastre.
[Feasibility of colorectal surgery without colonic preparation. A prospective study].
INTRODUCTION: Mechanical bowel preparation (MBP), aimed at reducing the infectious complications of colorectal surgery, was considered as indispensable. This benefit is actually disputed. The aim of this study was to report an experience of colorectal surgery without MBP. MATERIALS AND METHODS: Hundred ninety patients without MBP and without low residue diet, who underwent colorectal surgery with primary anastomosis not requiring a diverting stoma were included. The main outcome were the rate of mortality, anastomotic leak, wound infection and intra-abdominal abscess. Secondary outcomes were duration of intravenous perfusion, nasogastric aspiration, total hospitalisation stay and time to realimentation. RESULTS: The procedure was performed by laparotomy (n=142) or laparoscopy (n=48). Forty-eight patients underwent emergency surgery. Ninety-two patients were operated for malignancy. The rate of mortality was 6.3% in correlation with the scale of AFC. The rate of anastomotic leak was 3.7%. The rate of specific morbidity was independent of scale of AFC on the contrary to the frequency of non-specific complications. The mean duration of intravenous perfusion and nasogastric suction were 6 days and 0.3 day. The patient had normal diet to the 4th day (4+/-3 days). The mean hospital stay was 13.4 days. CONCLUSION: The colorectal surgery without MBP may be safely performed and could improve the quality of life of patients in the perioperatory period.
Age Factors↗
[Long term outcome following 26 surgical ampullectomies].
BACKGROUND: Pancreaticoduodenectomy (PD) is the standard surgical treatment for malignant ampullomas but is still associated with a mortality and morbidity still ranging from 0 to 10% and from 15 to 40%, respectively. Ampullectomy is an alternative to PD for benign ampulloma or, in high-risk patients, for invasive carcinoma. The aim of this study was to report early and long term results of surgical ampullectomy for presumed benign ampullomas. PATIENTS AND METHODS: From 1981 to 2004, 26 patients from two institutions underwent surgical ampullectomy. Of the 26 patients, 8 had familial adenomatous polyposis (FAP). Surgical ampullectomy was indicated on a multisciplinary basis. RESULTS: Final pathological examination revealed 15 adenomas, 4 in situ adenocarcinomas, 2 endocrine tumors, and 5 other benign lesions. There was no postoperative mortality. Specific morbidity was 8% (N=2). Mean follow-up was 86+/-70 months (range: 3-204). Actuarial overall 5-year survival was 92%. There were 4 local recurrences (none in patients with FAP). Four patients died during follow-up (including 3 from initial disease). CONCLUSION: Ampullectomy is a good alternative to PD in case of benign or non-invasive malignant ampullary lesion, including in selected cases of FAP.
Adenocarcinoma↗
Anatomic bases of graciloplasty using end-to-side nerve pudendal anastomosis.
The objective of this study was to evaluate the possibilities of reinnervation of the gracilis muscle, transposed around the anus, by the pudendal nerve using an end-to-side nerve anastomosis. This study was carried out in 14 cases (7 adult human cadavers bilaterally). The gracilis muscle and its vascular-nervous bundle have been dissected and the nerve innervating the gracilis muscle has been cut at its origin. The gracilis muscle, accompanied by its nerve, has then been transposed around the anus. The pudendal nerve has been dissected from its extrapelvic part. The reinnervation using an end-to-side nerve anastomosis has been considered as feasible when the proximal ending of the nerve of the gracilis was put into a tension-free contact with the extrapelvic part of the pudendal nerve. The extrapelvic part of the pudendal nerve has a common trunk in 12 cases. The width of the extrapelvic part of the pudendal nerve was 2.6+/-0.7 mm, range 1-3.5. The width of the proximal endings of the nerve innervating the gracilis muscle was 2.3+/-0.5 mm, range 2-3. The reinnervation of the gracilis muscle by the pudendal nerve has been possible in 14 cases. An average supplementary length of 17.4+/-15.4 mm was available (range 5-52). These results suggest an eventual practical aspect of this technique for the reconstruction of a functional sphincter using the gracilis muscle transposed around the anus.
Aged↗
[Pancreaticoduodenectomy in the era of evidence based medicine].
The aim of this comprehensive literature review was to analyse evidence based data in the field of pancreaticoduodenectomy. Pylorus preserving does reduce mortality or morbidity of the standard procedure and could increase the risk of delayed gastric emptying. Pancreaticogastrostomy does not decrease the rate of postoperative pancreatic fistula and is not superior to the pancreaticojejunal anastomosis which is more physiological. No other procedure (chemical occlusion, octreotide, stenting) has been demonstrated to prevent pancreatic fistula. Octreotide injection could be advocated in centres where there is a high rate of pancreatic fistula, when pancreatic parenchyma is soft and the main pancreatic duct thin. Intra-abdominal drainage is not beneficial and could be associated with some morbidity. Its use needs to be further evaluated. When a resection is done for pancreatic cancer, less than 5% of patients are a live five years after surgery with postoperative mortality rate of 5% in expert centres and a high morbidity rate (25-50%). Extended lymphadenectomy does not increase survival. The first trials showed that adjuvant therapies could be beneficial for pancreatic cancers, but further trials did not confirm these findings. Adjuvant therapy is not validated for pancreatic cancers and needs to be considered only in the settings of clinical trials.
Chemotherapy, Adjuvant↗
[Reconstruction of the anus by the gracilis muscle reinnervated by the pudendal nerve. A preliminary anatomical study].
UNLABELLED: The aim of this study is to evaluate the possibilities of reinnervation of the gracilis muscle, transposed around the anus, by the pudendal nerve with an end-to-side nerve anastomosis. METHODS: This study was carried out in 10 cases. The gracilis muscle and its vascular-nervous pedicle have been dissected. The nerve of the gracilis muscle has been cut at its origin. The gracilis muscle was transposed around the anus. The nerve of the gracilis muscle was transposed in the gluteal area. The pudendal nerve has been dissected from its extra-pelvic part. The reinnervation with an end-to-side nerve anastomosis has been considered as feasible when the proximal ending of the nerve of the gracilis was put into a tension free contact with the extra-pelvic part of the pudendal nerve. RESULTS: The reinnervation of the gracilis muscle by the pudendal nerve has been possible in all cases. The extra-pelvic part of the pudendal nerve has a common trunk in 8 cases. The width of the extra-pelvic part of the pudendal nerve was 2.8 +/- 0.8 mm (1-3.5). The width of the proximal endings of the nerve innervating the gracilis muscle was 2.5 +/- 0.5 mm (2-3). After transposition of the nerve of the gracilis muscle in the gluteal area an average supplementary length of 20.9 +/- 16.8 mm was available (range 5-52). CONCLUSIONS: These results suggest that a reconstruction of the anal sphincter with a gracilis muscle transposed around the anus and reinnervated by the pudendal nerve with end-to-side nerve anastomosis is possible.
Aged↗
[Coelioscopic treatment of pancreatic polycystic disease].
Ten per cent of patients with polycystic hepato-renal disease have cysts of the pancreas. This cysts are generally uncommon and asymptomatic. An extension of the whole pancreas is rare. We report about case of a patient with a pancreatic polycystic disease associated with a minor polycystic hepato-renal disease. The symptoms was related to the number and the size of the cysts. The pancreatic cysts have been treated by laparoscopic fenestration with a satisfying result in a medium term.
Adult↗
[Is a diverting stoma necessary in rectal carcinoma resection?].
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Anastomosis, Surgical↗
[Cephalic pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas: does pylorus preservation change morbidity and prognosis?].
STUDY AIM: To evaluate the influence of a pylorus-preserving on the morbidity and prognosis of patient with pancreaticoduodenectomy for adenocarcinoma of pancreas. PATIENTS AND METHODS: Between 1985 and 1999, 183 patients were operated on for pancreatic adenocarcinoma. Among them, 63 patients (40 men, mean age 63 years, range 41-77 years) had curative resection and were included in this retrospective study. They were classified according to the type of resection. In the group I, the procedure included a pylorus-preserving pancreaticoduodenectomy (n = 35). In the group II, the procedure included polar inferior gastrectomy (n = 28). The prognosis was compared. Parameters for comparison were rate of local recurrence, rate of metastatic evolution and duration of survival. RESULTS: The operative length and mortality rate (group I: 0%, group II: 3%), general (p = 0.37) and specific morbidity (p = 0.30), frequency of delayed gastric emptying were similar in the 2 groups (group I: 20%, group II: 35%, p = 0.88). The duration of naso-gastic aspiration was shorter in the group I (6 days vs 8, p = 0.01). The prognosis was the same in the 2 groups (metastasis: group I: 39%, group II: 56%, p = 0.12, local recurrence: group I: 58%, group II: 43%, p = 0.09, mean survival: group I: 18 months, group II: 19 months, p = 0.77). CONCLUSION: These results suggest that pylorus preserving pancreatoduodenectomy could be performed for patients with adenocarcinoma of the head of the pancreas and does not compromise survival.
Adenocarcinoma↗
[Crohn's disease and small intestine adenocarcinoma].
INTRODUCTION: The relationship between digestive neoplasia and Crohn's disease remains debated but several cases of carcinoma have been reported in the past 10 years. EXEGESIS: We report two cases of intestinal adenocarcinoma found in young people. Patients were asymptomatic during 15 years after the diagnosis of inflammatory bowel disease and presented a sudden occlusive syndrome. Carcinoma was observed incidentally at gross examination, and histopathological study showed dysplasia adjacent to neoplasia. Despite adequate surgical resection, death occurred quickly. CONCLUSION: Crohn's carcinoma should be suspected in patients with long-standing disease, poor symptomatology, and stenosis. Intestinoscopy surveillance remains illusory because inflammatory stenosis is often present and infiltrative neoplasia is invisible. Thus, it is important to be vigilant in this clinical presentation.
Adenocarcinoma↗
Short-term functional outcome following elective surgery for complicated sigmoid diverticular disease: sutured or stapled end-to-end anastomosis to the proximal rectum?
OBJECTIVE: The aim of this retrospective non-randomized study was to evaluate the short-term functional outcome following elective resectional surgery for complicated sigmoid diverticular disease, and to compare results of patients having hand-sewn or stapled end-to-end colonic anastomosis to the proximal rectum. PATIENTS AND METHODS: Between 1983 and 1995, of 182 consecutive patients referred to our Institution for surgical treatment of complicated sigmoid diverticular disease, 137 underwent elective left hemicolectomy with primary colonic anastomosis to the proximal rectum, at a level above the peritoneal reflection. Twenty-one patients were excluded from the study because of a covering stoma (n=15), or a side-to-end (n=5) or side-to-side (n=1) anastomosis. All remaining 116 patients had an end-to-end anastomosis without covering stoma. Two groups were compared according to the type of anastomosis performed. Group I comprised the 67 patients who had a hand-sewn anastomosis, and group II the 49 patients whose anastomosis was stapled. Outcome was assessed at 6 months after surgery and compared in the two groups. Assessment included specific morbidity (anastomotic leakage, haemorrhage, fistulation and stenosis, pelvic sepsis), faecal incontinence, constipation, dyschesia, daily stool frequency, and stool consistency. RESULTS: Preoperative patient details were comparable in both groups. There was no post-operative mortality, and the general morbidity rate was similar in both groups (P=0.85). There was no anastomotic leakage or haemorrhage, and no fistulation or pelvic sepsis in either group. One patient in group I, and two from group II, developed flatus incontinence, and a further patient from group II developed incontinence to liquid stool (P=0.17, group I vs group II). We observed better functional outcome following hand-sewn anastomosis. Three group II patients developed anastomotic stenosis compared with none in group I (P=0.04). Constipation (9% vs 28%, P=0.005) and dyschesia (18% vs 39%, P=0.03) were more frequent in group II. Excluding constipated patients (n=20), daily stool frequency was lower (mean 1.2 +/- 0.6 vs 2 +/- 1.3, P=0.0002), and more frequently of normal consistency (79% vs 43%, P=0.0001) in group I. Subgroup analysis failed to show significant differences in functional outcome in both groups in relation to the specific indications for surgery. CONCLUSION: These retrospective data suggest for the first time in the reported literature that hand-sewn colonic anastomosis to the proximal rectum provides a better short-term functional outcome than stapled anastomosis following elective resectional surgery for complicated sigmoid diverticulosis.
Journal Article↗
Intraductal papillary or mucinous tumors (IPMT) of the pancreas: report of a case series and review of the literature.
OBJECTIVE: Despite a better understanding of these conditions, intraductal papillary or mucinous tumors (IPMT) of the pancreas still present difficulty relating to the predictive factors of malignancy and the risk of relapse after surgical resection. The aim of this study was to report on our experience and to compare it to previously published cases. METHODS: We studied retrospectively 26 patients (mean age 60.3 yr) presenting with IPMT. Of the 26 patients, 19 had surgical resection and seven did not. The main clinical feature was acute pancreatitis occurring in 38% of the patients. Segmental pancreatectomy was performed in all the cases. At pathological assessment of resection margins, tumor resection was considered as complete in 17 cases. Margins exhibited benign mucinous involvement, and resection was considered to be incomplete in one multifocal case and in one case with diffuse spread of the tumor. RESULTS: A total of 11 tumors were benign and five were malignant. Carcinomas were invasive in four cases (two invading the pancreatic parenchyma, one the duodenum, and one the peripancreatic nodes) and in situ in one case. Malignancy was not diagnosed preoperatively except when invasion was evident (duodenal spread). Although main pancreatic duct type and obstructive jaundice appeared as suggestive features for the risk of malignancy, no reliable preoperative predictive factors for malignancy could be identified as regarding to clinical parameters, biological examinations, carcinoembryonic antigen or CA19-9 levels in serum or in pure pancreatic juice, imaging, and cytological methods. Within 40.8 months mean follow-up after surgery (range 2-96 months), three patients (16%), two with malignant and one with benign tumor, had tumor relapse after respectively 7, 27, and 14 months. Margins were positive without malignant features in the two malignant cases and negative in the other case. Tumor relapse was malignant with diffuse spreading in the three cases, and the patients died within 34 months after surgical resection. CONCLUSIONS: Our series and the review of the literature indicate that preoperative indicators of malignancy in IPMT are still lacking. Concerning resection margins, complete tumor resection is usually possible by segmental pancreatectomy. Malignant relapses are not exceptional. Incomplete resection and diffuse or multifocal tumor represent poor prognostic factors. Total pancreatectomy should be considered in such cases.
Adenocarcinoma, Mucinous↗
Prevention of deep abdominal complications with omentoplasty on the raw surface after hepatic resection. The French Associations for Surgical Research.
BACKGROUND: Several methods have been suggested to treat the hepatic raw surface after resection. Among these, omentoplasty (OP) has been employed occasionally but there are no clinical studies that clearly demonstrate its usefulness. METHODS: Of 172 randomized patients undergoing hepatic resection between January 1991 and December 1994, 5 were withdrawn for protocol violation, leaving 167 who were randomly allotted to undergo OP (n = 87) on the hepatic raw surface or not (NO; n = 80). This procedure was performed for malignant tumor in 125 cases, benign tumor in 33, and for other causes in 15. Six patients had more than two types of lesions, and 32 patients had associated cirrhosis. Sixty-five major and 102 minor hepatic resections were performed. The main outcome measures studied were the number of patients with deep abdominal complications (DAC; deep bleeding or hematoma, deep infection, with or without pus discharge through drains, bile leakage), as well as repeat operations and postoperative death. Patients were divided into two strata according to the site of the lesion with respect to the diaphragm: (1) in contact (posterosuperior segments II, VII and VIII) or (2) not in contact (anterior segments III, IV, V, and VI). RESULTS: Both groups were comparable as regards patient demographics, intraoperative procedures, intraoperative search for bile leaks and intraoperative transfusion requirements. Fewer patients had DAC in OP (n = 11) than in NO (n = 15) (difference not significant). Ten patients (6%) required repeat operations: 4 in OP without immediate mortality and 6 in NO, 3 followed by death. One further patient in OP required repeat operation after discharge and died. Four patients died in OP and 7 in NO, 1 and 4 of DAC, respectively (not significant). Deep abdominal complications were significantly associated with major hepatic resection (P <0.05) whereas postoperative death was significantly correlated with cirrhosis (P <0.05). CONCLUSIONS: OP on the raw surface after hepatic resection lowers the rate of all complications related to DAC (except biliary leaks) and their severity (repeat operations and death) but not significantly so. OP is not recommended as a routine measure to complete elective hepatic resections.
Abdomen↗
[Perineal gangrene: new bacteriologic approach. Results of medico-surgical treatment (81 cases)].
STUDY OBJECTIVE: The objective of this retrospective study was to report the results of a series of 81 cases of perineal gangrene treated in the same center. PATIENTS AND METHODS: From 1988 to 1998, 81 patients (64 males, 17 females, mean age: 58 years) with perineal gangrene were treated by a medico-surgical team, by means of a protocol combining appropriate intensive care measures based on a new bacteriologic concept of infectious agents, extensive excisions and drainage of the infraperitoneal region and hyperbaric oxygen therapy. RESULTS: The mortality rate was 24.7%. Mean duration of intensive care stay was 19 days, mean duration of hospital stay was 31 +/- 4 days (range: 6 to 60 days). Risk factors were: age > 68 years (p = 0.001), shock (p = 0.83), subcutaneous crepitation (p = 0.25) and severity index > 10 (p = 0.003). Sequelae were anal incontinence (n = 3) and permanent colostomy (n = 5). Secondary plastic reconstruction was necessary in four patients. There were no urologic or genital sequelae. CONCLUSION: Perineal gangrene is still a very serious disease. The time to treatment, the simplified severity index and consideration of bacteriologic combinations are the main prognostic factors.
Aged↗
Long term results of lateral pancreaticojejunostomy for chronic alcoholic pancreatitis.
OBJECTIVE: To assess our long term results of lateral pancreaticojejunostomy in patients with alcoholic pancreatitis. DESIGN: Retrospective study. SETTING: University hospital, France. SUBJECTS: 57 patients (48 men, 9 women, mean (SD) age 46 (7) years who required surgical treatment of chronic alcoholic pancreatitis between January 1977 and October 1995. INTERVENTIONS: Lateral pancreaticojejunostomy with or without another procedure. Outcome classified as excellent, good, fair, or poor. MAIN OUTCOME MEASURES: Postoperative morbidity and mortality; relief of pain; reduction in use of analgesics and exocrine supplements; effect on exocrine and endocrine insufficiency; and return to paid work. RESULTS: There were no postoperative deaths and no pancreatic fistulae, but there were 17 other postoperative complications (30%). Median follow up was 65 months (range 8-206), during which 12 patients died (21%). Result was judged excellent in 16 (28%), good in 27 (47%), fair in 5 (9%), and poor in 9 (16%). Pain control was significantly improved, analgesic usage decreased, less pancreatic enzyme supplementation was required, and 25 patients returned to paid work (p = 0.0001 in each case). Exocrine and endocrine function remained stable. The results were better if the patient gave up misusing alcohol (p = 0.03) and if the operation was done within 4 years of the development of pancreatitis (p = 0.03). CONCLUSIONS: Lateral pancreaticojejunostomy is a safe procedure that can improve functional outcome in patients with chronic alcoholic pancreatitis, and does not worsen pancreatic function.
Chronic Disease↗
[Cephalic duodenopancreatectomy].
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Anastomosis, Surgical↗
[Unusual chronic pancreatitis revealing a cystic fibrosis at an adult age].
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Adult↗
Selection criteria for internal rectal prolapse repair by Delorme's transrectal excision.
PURPOSE: The aim of this study was to review our results of Delorme's transrectal excision for internal rectal prolapse, with a view to determining preoperative selection criteria associated with a satisfactory outcome. METHODS: Between 1992 and 1998, 20 patients with internal rectal prolapse underwent Delorme's transrectal excision. The last patient was excluded from the study because of a follow-up period shorter than six months. The remaining 19 patients were prospectively followed up and classified into two groups according to their preoperative selection criteria. Group I consisted of eight patients operated on between January 1992 and October 1993 who were selected for surgery after medical treatment during a three-month period failed to improve symptoms. Initial results were reviewed, with a follow-up of at least six months, to assess predictive criteria correlating with poorer surgical outcome. These adverse criteria were used to exclude patients from selection into Group II, which included 11 patients operated on between June 1994 and June 1997. In each group the degree of improvement of symptoms was graded: Grade 1 = complete improvement with resolution of all symptoms; Grade 2 = significant improvement with resolution of dyschezia but not of other symptoms; Grade 3 = no improvement; and Grade 4 = worsened condition or reoperation. The two groups were compared according to ultimate outcomes. RESULTS: Of the Group I patients, three had preoperative chronic diarrhea, one had proximal internal rectal prolapse with rectosacral separation at defecography, and the other two were incontinent to liquid stool. An additional patient had incontinence to liquid stool but no diarrhea. Three other patients had major perineal descent (>9 cm). Results were Grade 1 for one patient, Grade 2 for one patient, Grade 3 for five patients, and Grade 4 for one patient (subsequent abdominal rectopexy). Data review showed that proximal internal prolapse with rectosacral separation at defecography, preoperative chronic diarrhea, fecal incontinence, and descending perineum (>9 cm on straining) were associated with a poorer outcome (Grades 3 and 4). These adverse criteria were used to exclude patients from selection into Group II. In this group results were Grade 1 for seven patients and Grade 2 for four patients. During the course of follow-up (mean, 43; standard deviation, 19; range, 8-73 months), outcome was better in Group II (P = 0.007). CONCLUSION. These data suggest that a favorable outcome can be achieved after Delorme's transrectal excision for internal rectal prolapse by applying stringent patient-selection criteria.
Adult↗