Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research

OBJECTIVE

We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula).

METHODS

Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 +/- 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality.

RESULTS

After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups.

CONCLUSION

Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Senna vs polyethylene glycol for mechanical preparation the evening before elective colonic or rectal resection: a multicenter controlled trial. French Association for Surgical Research

HYPOTHESIS

Senna is more efficient than polyethylene glycol as mechanical preparation before elective colorectal surgery.

DESIGN

Prospective, randomized, single-blind study.

SETTING

Multicenter study (18 centers).

PATIENTS

Five hundred twenty-three consecutive patients with colonic or rectal carcinoma or sigmoid diverticular disease, undergoing elective colonic or rectal resection followed by immediate anastomosis.

INTERVENTION

Two hundred sixty-two patients were randomly allotted to receive senna (1 package diluted in a glass of water) and 261 to receive polyethylene glycol (2 packages diluted in 2-3 L of water), administered the evening before surgery. All patients received 5% povidone iodine antiseptic enemas (2 L) the evening and the morning before surgery. Ceftriaxone sodium and metronidazole were given intravenously at anesthetic induction.

MAIN OUTCOME MEASURES

Degree of colonic and rectal cleanliness.

RESULTS

Colonic cleanliness was better (P=.006), fecal matter in the colonic lumen was less fluid (P=.001), and the risk for moderate or large intraoperative fecal soiling was lower (P=.11) with senna. Overall, clinical tolerance did not differ significantly between groups, but 20 patients receiving polyethylene glycol (vs 16 with senna) had to interrupt their preparation, and 15 patients (vs 8 with senna) complained of abdominal distension. Senna, however, was better tolerated (P = .03) in the presence of stenosis. There was no statistically significant difference found in the number of patients with postoperative infective complications (14.7% vs 17.7%) or anastomotic leakage (5.3% vs 5.7%) with senna and polyethylene glycol, respectively.

CONCLUSION

Mechanical preparation before colonic or rectal resection with senna is better and easier than with polyethylene glycol and should be proposed in patients undergoing colonic or rectal resection, especially patients with stenosis.

Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research

OBJECTIVE

We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula).

METHODS

Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 +/- 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality.

RESULTS

After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups.

CONCLUSION

Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Omentoplasty in the prevention of deep abdominal complications after surgery for hydatid disease of the liver: a multicenter, prospective, randomized trial. French Associations for Surgical Research

BACKGROUND

Omentoplasty (OP) is thought to fill residual cavity, to assist healing of raw surfaces, and to promote resorption of serosal fluid and macrophagic migration in septic foci. Results published to date, whether retrospective or prospective, are not controlled and are discordant.

STUDY DESIGN

The authors investigated whether OP, either filling the residual cavity after unroofing, or covering the hepatic raw surface after pericystectomy, could reduce the rate or severity of deep abdominal complications (DAC) after surgical treatment of hydatid disease of the liver. Between January 1993 and December 1996, 115 consecutive patients (51 males and 64 females, mean age 42+/-16 years [range 10 to 80 years]) with previously unoperated uni- or multilocular hydatid disease of the liver, complicated or not, without other abdominal hydatid disease, were randomly allotted to OP (n = 58) or not (NO) (n = 57) after unroofing, total, or partial pericystectomy. Patients were divided into 2 strata according to the site of the cyst with respect to the diaphragm: a) posterosuperior segments II, VII, and VIII or b) anterior segments III, IV, V, and VI. Main outcomes measures included deep bleeding, hematoma, infection, or bile leakage. Subsidiary measures included wound complications, extraabdominal complications, duration of operation, and length of hospital stay.

RESULTS

Both groups were comparable regarding patient demographics, cyst characteristics, intraoperative procedures, search for bile leaks, and intraoperative transfusion requirements. On the other hand, more patients (86%) in NO had associated drainage of the abdominal cavity than in OP (64%) and the duration of operation was 9 minutes longer in OP, but neither of these differences was statistically significant. Less DAC occurred in OP (10%) than in NO (23%) (a posteriori gamma risk < 0.05) and fewer deep abdominal abscesses (0 versus 11%) (p < 0.03). Median duration of hospital stay, however, was similar.

CONCLUSIONS

OP decreases the rate of DAC and especially deep abdominal abscess after surgical treatment (unroofing or pericystectomy) for hydatid disease of the liver and should be recommended in this setting.

Survey of the impact of randomised clinical trials on surgical practice in France. French Associations for Research in Surgery (AURC and ACAPEM). Association Universitaire de Recherche en Chirurgie. Association des Chirurgiens de l'Assistance Publique pour l'Evaluation Médicale

OBJECTIVE

To evaluate the impact of randomised clinical trials (RCT) on decision-making and therapeutic policies among general and gastrointestinal surgeons in France.

DESIGN

Telephone questionnaire.

SETTING

Multicentre study, France.

SUBJECTS

A random sample of 152 surgeons, mean (SD) age 50 (8) years. INTERVENTIONS AND MAIN OUTCOME MEASURE: Surgeons were asked 12 questions about their knowledge of RCT and how trials were conducted; influence of RCT on their treatment policies; means of obtaining information about treatments; how they evaluated their own results; whether they were willing to take part in RCT; and personal details including age, speciality, and type of practice. Surgeons were stratified according to age and type of practice.

RESULTS

148 questionnaires were suitable for analysis. 83 surgeons (56%) were under 50 years old, 38 (26%) were exclusively gastrointestinal surgeons, 82 (56%) worked in private practice, and 36 (24%) worked in teaching and university hospitals. The rest undertook mixed duties. When asked to say where they obtained their knowledge about antibiotics, 91 (61%) referred to RCT; these were mainly hospital-based, gastrointestinal, and younger surgeons. Asked to name a RCT-based policy, 81 (55%) gave medical rather than operative examples. 80 (54%) had already participated in a RCT; 79 (53%) said that they were willing to participate in a RCT that included random allocation of patients (there were no statistically significant differences in answers according to speciality or type of practice, although younger surgeons answered "yes" to both questions). Specialised journals were the main source of information for 115 (78%), and surgeons read a mean of 40 issues/year. 142 (96%) read journals in French and 66 (45%) in English, but this number fell to 10 (15%) of the 65 surgeons aged 50 or more. Personal experience was considered a more important source of therapeutic knowledge by older and specialist surgeons. 109 surgeons (74%) recalled patients during the first month postoperatively to evaluate their results.

CONCLUSIONS

French surgeons, particularly those aged 50 or over, are not well informed about the nature, conduct, and value of RCT. Most of their information is acquired through reading and attending scientific meetings and congresses. Surgeons tended to attach more importance to the fame of the author than to the conduct of the study. The overall impact of RCT was weak among the surgeons questioned.

5-Fluorouracil and cisplatin as palliative treatment of advanced oesophageal squamous cell carcinoma. A multicentre randomised controlled trial. The French Associations for Surgical Research

OBJECTIVE

To compare chemotherapy with no chemotherapy as palliative treatment for oesophageal squamous cell carcinoma.

DESIGN

Randomised study.

SETTING

Multicentre trial in France.

SUBJECTS

Of 161 patients with histologically confirmed oesophageal squamous cell carcinoma located more than 5 cm from the mouth of the oesophagus, five were withdrawn because of protocol violation. The remaining 156 patients, 149 men and 7 women, mean (SD) age 58 (9) years range 36 to 77, were randomly allocated to either a control group without chemotherapy (n = 84) or a group treated by chemotherapy (n = 72). Patients were divided into four strata: I = complete resection of the tumour but with lymph node involvement (n = 62); II = incomplete resection of tumour leaving gross tumour behind (n = 58); III = no resection because of local or regional invasion (n = 22) ; and IV = no resection because of distant metastasis (n = 14). Exclusion criteria were histologically confirmed tracheobronchial involvement, oesophagotracheal fistula, Karnosky score < 50, cerebral metastases, or hepatic metastases occupying more than 30% of the liver, peritoneal carcinomatosis, associated or previously treated ear-nose-throat carcinoma, or complete resection of tumour without lymph node involvement.

INTERVENTIONS

5 fluorouracil (5FU) and cisplatin (CDDP) were given in 5-day courses, once every 28 days, for a maximum of eight cycles. 5 FU, 1 g/m2, was infused for 24 hours after a water overload, during five days. Cisplatin was given either in one dose of 100 mg/m2 at the beginning of the cycle or 20 mg/m2/day over three hours for five days. Duration of treatment ranged from 6-8 months.

OUTCOME MEASURES

Median and actuarial survival. The subsidiary endpoint was quality of survival judged by complications of treatment, swallowing disorders, and the duration of ability to feed normally.

RESULTS

There was no difference in survival, either overall (median = 12 months) or in any of the strata. There were however significantly more patients with neurological (p < 0.003), haematological (p < 0.0001), and renal (p < 0.0002) complications in the treated group compared with the control group. Four patients (6%) died of complications of chemotherapy. The course of swallowing disorders did not differ between the two groups. The duration of autonomous oral feeding was exactly the same in both groups (median = 10.5 months).

CONCLUSION

The results suggest that 5FU and CDDP do not help in patients with squamous cell carcinoma of the oesophagus whether or not the tumour has been resected.

Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. French Associations for Surgical Research

OBJECTIVE

To compare surgical treatment (ST) with endoscopic management (EM) in patients with suspected common bile duct stones.

PATIENTS

Two hundred twenty eligible patients originating from 18 surgery units. Patients enrolled in this multicenter randomized study had clinical symptoms that included jaundice, mild pancreatitis (Ranson score < or = 2), or mild acute cholangitis; biliary colic (with increased alkaline phosphatase levels); and common bile duct stones or a common bile duct diameter of 1 cm or larger on ultrasonography.

METHODS

Two hundred two patients were randomly assigned to either ST (n=105) or EM (n=97) during a 5-year period. Both groups were comparable with respect to age, sex, American Society of Anesthesiologists score, and clinical presentation.

MAIN OUTCOME MEASURES

The rates of early postoperative additional procedures necessary to deal with the impossibility to perform the initial procedure, complications, and retained stones after ST or EM. Subsidiary endpoints were intention-to-treat analyses of mortality and of major complications and the duration of hospital stay.

RESULTS

Surgical treatment was associated with a significantly (P<.001) lower rate of 1 or 2 additional procedures (8% vs 29%) due to a significantly lower rate of the impossibility to perform the initial procedure (0% vs 5%) (P<.05), major complications (4% vs 13%) (P<.05), and retained stones (6% vs 16%) (P<.04). Minor complications occurred more often in patients having ST (4%) than in those having EM (0%) (P<.01). Cholecystectomy was performed routinely in 102 patients having ST and electively in 36 patients having EM. There was 1 death in each group initially. On an intention-to-treat analysis, 3 deaths (3.1%) occurred after EM and 1 (0.9%) after ST; this difference was not statistically significant (P=.56). Major complications occurred in 4% of patients having ST compared with 1 1% of patients having EM (P<.002). The median duration of hospital stay was 16 days in patients having ST and 12 days in those having EM; this difference was not statistically significant (P=.09).

CONCLUSION

Whether an additional cholecystectomy is performed routinely or electively, the high risk of additional procedures after EM precludes its use as the optimal therapy in patients with symptomatic common bile duct stones, except in those with severe cholangitis.

Diagnosis of asymptomatic common bile duct stones: preoperative endoscopic ultrasonography versus intraoperative cholangiography--a multicenter, prospective controlled study. French Associations for Surgical Research

BACKGROUND

In patients with symptomatic cholelithiasis, preoperative diagnosis of common bile duct (CBD) stones can modify the therapeutic strategy. The aims of this prospective, controlled multicenter study were to assess the feasibility, concordance, discordance, and indexes such as sensitivity, specificity, positive and negative predictive values, and accuracy of preoperative endoscopic ultrasonography compared with those of intraoperative cholangiography (IOC) in the diagnosis of asymptomatic CBD stones (i.e., patients undergoing cholecystectomy with no clinical or biologic evidence of CBD stones).

METHODS

From October 1993 to October 1995, 240 consecutive patients with symptomatic cholelithiasis, scheduled for cholecystectomy in 14 surgical centers, were enrolled in this study. All patients were selected for this study according to a preoperative high-risk CBD stone predictive score. Each patient underwent both endoscopic ultrasonography and IOC, as well as surgical exploration of the CBD when stones were detected during one or both preoperative investigations. All patients were seen 1 months and 1 year after operation to check for residual stones.

RESULTS

The feasibility of endoscopic ultrasonography was significantly higher overall than that of IOC (99% vs 90%; p < 0.001), except when IOC was through a laparotomy (97% vs 93%; p = 0.16). The number of patients available for study was 215. In 198 cases (92%), results of both investigations were in concordance (161 negative and 37 positive values). Seventeen cases (8%) were discordant. There was overall concordance between the two investigations (kappa coefficient 0.764; 95% confidence interval 0.66 to 0.87), but the percentage of discordance was in favor of IOC. Sensitivity and specificity of IOC were significantly higher than those of endoscopic ultrasonography (1.00 and 0.98 vs 0.85 and 0.93, respectively). With a prevalence of CBD stones of 19%, positive and negative predictive values of IOC were significantly higher than those of endoscopic ultrasonography (0.93 and 1.00 vs 0.75 and 0.96, respectively).

CONCLUSIONS

Although endoscopic ultrasonography is feasible more often than IOC, IOC is associated with a slightly lower degree of discordance and better information indexes and remains an efficient method of investigation for CBD stones. Endoscopic ultrasonography can be suggested in preference to endoscopic retrograde cholangiography when postoperative residual stones are suspected but need not be performed routinely before cholecystectomy.

General and gastrointestinal tract surgery in France

Forty-three state-run medical schools admit 30000 students per year but only 3500 receive their diploma after 6 years of studies. After passing a special examination, 480 of 2000 residents choose surgery and train during twelve 6-month rotations. Surgical research is organized through government agencies, individual units, or volunteer groups. In 1992, of 8268114 procedures, appendectomy represented 4.15%; hernia, 4.09%; varicose veins, 3.61%; and cholecystectomy, 1.82%. Appendectomy has decreased from 306500 per year in 1980 (34% of all gastrointestinal surgical procedures) to 159900 (15%) in 1996, whereas cholecystectomy has increased from 64700 to 95300. Emergency gastrointestinal procedures represented 15% of all surgical procedures in 1996, doubling in the last 4 years (essentially for labor and endoscopic procedures). Ambulatory procedures have increased 12-fold since 1980, essentially (75%) in private practice. About 27% of 160000 appendectomies and 77% of 95300 cholecystectomies were performed laparoscopically in 1997. One person of 4 in France has or has had cancer, mainly due to tobacco abuse. In 1993, 32000 surgical procedures were performed for gastrointestinal cancer. Of 532000 deaths (1992), about 150000 were due to cancer, 10000 to alcohol-related disease, and 22000 to trauma. Transplantation in France increased from 3180 procedures in 1993 to 2807 in 1996, essentially lungs and heart and lungs. Between 60% and 100% of health expenditures are reimbursed by the government, the remaining being covered by private insurances. Approximately 60% of 4500 French surgeons are in private practice; 25% also have part-time hospital employment. Almost 40% of surgeons work full-time in hospitals.

Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. French Associations for Surgical Research

BACKGROUND

Only 4 controlled trials have investigated whether prophylactic abdominal drainage was of value after colonic resection. None have been able to find any statistically significant difference, but the number of patients was small and the beta error risk was high.

OBJECTIVES

To compare patients who underwent abdominal drainage with those who did not for the rate and severity of complications after elective colonic resection followed immediately by anastomosis of the suprapromontory colon and to compare suction drains with nonsuction drains.

PATIENTS

Between September 1990 and June 1995, 319 patients (135 men and 184 women), whose mean age was 67 years (range, 22-95 years), with carcinoma, benign tumors, or colitis, located anywhere between the ascending and sigmoid colons, were included in the study. Patients were comparable for demographic characteristics, except that there were more patients with ascites in the group that did not undergo abdominal drainage (P<.02).

INTERVENTIONS

After 2 protocol violations, 156 patients were randomized to the abdominal drainage group and 161 to the no abdominal drainage group. All 317 anastomoses were tested for airtightness intraoperatively and repaired if leakage was found (n=71), and all patients with anastomoses received a routine diatrizoate sodium enema to detect infraclinical leakage.

MAIN OUTCOME MEASURES

The postoperative complications possibly influenced by drainage included (1) deep complications for which drainage can lead to early diagnosis, such as generalized or localized peritonitis, intraabdominal hemorrhage, or hematoma; (2) complications believed to be enhanced by drainage, such as an operative wound (an abscess, disruption, or incisional hernia) or pulmonary (microatelectasis) and intestinal obstructions; and (3) complications directly due to the drains, such as ulcerations leading to fistulae, hemorrhages, drainage tract infections, difficulty in removal, intra-abdominal retention, and incisional disruptions. Subsidiary end points were the severity of these complications as assessed by the number of related subsequent operations and deaths.

RESULTS

Twenty-six patients overall (8%) had postoperative complications possibly influenced by drainage (9% in the group that underwent abdominal drainage and 8% in the group that did not). This difference was not statistically significant (P<.90). One patient had a fistula directly imputable to drainage. There was no difference between suction and nonsuction drainage (P<.90).

CONCLUSIONS

Routine abdominal drainage after colonic resection and immediate anastomosis decreases neither the rate nor the severity of anastomotic leakage. It can, occasionally, be detrimental.

[Symptomatic common bile duct lithiasis: endoscopic treatment or surgical treatment?]

Since 1974, endoscopic sphincterotomy (ES) has been considered by most practitioners as the gold standard for the treatment of symptomatic common bile duct lithiasis (CBDL). Results of the seven prospectives randomized controlled trials comparing ES to surgery in the treatment of CBDL, acute pancreatitis and angiocholitis excluded, demonstrated that: 1) the rate of feasibility of ES ranged from 90 to 100%; 2) the rate of residual stones after first extraction attempt ranged from 4 to 23% and after second extraction attempt from 6 to 25%. After surgery, rate of residual stone ranged from 2 to 14%; 3) major complications were more frequent after ES than after surgery; on the opposite, minor complications were more frequent after surgery than after ES; 4) immediate mortality was higher after ES than after surgery; 5) cost of ES with or without de principle cholecystectomy was higher than surgery. In conclusion ES should not be the first treatment of symptomatic CBDL.

Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research

OBJECTIVE

To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection.

SUMMARY BACKGROUND DATA

It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this.

METHODS

Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths.

RESULTS

Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups.

CONCLUSION

OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Hepatic venous outflow block caused by short-length hepatic vein stenoses

In contrast with the well-recognized membranous obstruction of the inferior vena cava, short-length hepatic vein stenoses are not well-recognized causes of hepatic venous outflow block. The aim of this study was to ascertain the prevalence, causes, manifestations, and outcome of short-length hepatic vein stenoses. We performed a retrospective study of patients with short-length hepatic vein stenosis among 86 patients with hepatic venous outflow block who were seen between 1970 and 1992. There were 25 patients with short-length hepatic vein stenosis. A thrombogenic condition was identified in 14 patients (56%). The lesions of the accompanying hepatic veins in these patients were variable (short-length stenoses, thromboses, or nonspecific changes) and similar to that seen in patients without short-length hepatic vein stenosis. In 3 necropsied cases, the venous lesions were suggestive of fibrous sequela of prior thromboses. In patients with short-length hepatic vein stenosis, splenomegaly (28% vs. 55%, P < .05) and hypersplenism were significantly less common; serum transaminase (P < .001) and creatinine levels (P < .02) were lower, prothrombin was higher (P < .001), and 5-year survival was significantly better (Kaplan-Meier estimates: 80% vs. 50%, P < .05). In patients with hepatic venous outflow block, short-length hepatic vein stenosis is a common lesion that appears to be the sequela of localized thrombosis. Long-term anticoagulation and percutaneous angioplasty (with or without stenting) are potentially applicable in these lesions. The long-term results of these treatments merit further evaluation.

Factors influencing long-term survival in 100 cases of small intestine primary adenocarcinoma

BACKGROUND

Factors influencing long-term survival in patients undergoing operation for adenocarcinoma of the small intestine are poorly recognized.

METHODS

Retrospective study of 100 cases culled within a 10-year period by questionnaire, including 59 males and 41 females, median age 61 years (range 30 to 86). No patients were lost to follow-up (median 27 months). All patients underwent operation: curative in 65% and palliative in 35%.

RESULTS

Overall actuarial 5-year survival was 38%, 0% after palliative treatment and 54% after curative resection. In patients undergoing curative resection, 5-year survival was 63% when the lymph nodes were not involved, and 52% when they were; 57% when the serosa was not involved, and 53% when it was; 56% when the tumor was well or moderately well differentiated and 40% when it was undifferentiated. Other factors influencing long-term survival were the emergency setting, the site, the multiplicity, and the size of tumor (none with statistically significant differences). Five and 10-year survival was 78% and 69%, respectively, when the patient was anemic compared with 35% and 17%, respectively when the patient was not (P <0.01). There were 14 patients with previous carcinoma, 2 with Crohn's disease, and 1 each with celiac disease and ileal tuberculosis. There were also 8 patients with associated duodenal and proximal jejunal polyps. Thirteen patients sustained a total of 14 further cancers.

CONCLUSIONS

Patients should be followed up closely because the possibility of sustaining another abdominal carcinoma is high (16%). As associated polyps are nearly always duodenal or jejunal, preoperative or intraoperative endoscopy of the upper gastrointestinal tract including the initial portion of the jejunum should be able to detect their presence and reduce the risk of early recurrence.

Management of the pelvic space with or without omentoplasty after abdominoperineal resection for carcinoma of the rectum: a prospective multicenter study. The French Association for Surgical Research

OBJECTIVE

To compare perineal healing with or without omentoplasty after abdominoperineal resection for carcinoma of the rectum.

DESIGN

Prospective multicentre study.

SETTING

15 centres (three university, nine non-university teaching hospitals and three private clinics), France.

SUBJECTS

186 consecutive patients (between January 1983 and August 1990): 21 were withdrawn because of protocol violation leaving 165 for analysis.

INTERVENTIONS

Abdominoperineal resection for adenocarcinoma of the distal third of the rectum followed by omentoplasty (n = 64) to the pelvic space or not (n = 101).

MAIN OUTCOME MEASURES

Number of healed perineums at one month, and the time interval to complete healing.

RESULTS

7 patients (4%) died, 4 of whom had had omentoplasty and 3 who had not (one perineal abscess). The number who developed immediate postoperative complications (11/64, 17% and 18/101, 18%) and median duration of hospital stay (21 days, range 8-191, and 22 days, range 8-132) were similar. The median time to complete healing (20 and 21 days), the rate of healed perineums at one month (42/62 and 67/99, both 68%) and the number of persisting sinuses at 12 months were also similar. The number of dehiscences of the perineum was significantly higher (p = 0.04) in the no omentoplasty group (16 compared with 3). There were 3 late deaths in the omentoplasty group and 7 in the no omentoplasty group, 1 and 5 with local recurrence, respectively. There were more recurrences in the no omentoplasty group but not significantly so.

CONCLUSIONS

Although this study was not randomised, the results suggest that omentoplasty to the pelvic space promotes perineal healing after abdominoperineal resection for carcinoma of the rectum by significantly reducing the need for secondary opening.

[Treatment of inguinal hernias: methods]

After a short description of the anatomy of the inguinal area, especially of muscular walls and rings, weaken areas through which hernia could appear, we describe surgical procedures, using or not prosthesis, to strength the posterior wall. The most usual procedures using no prosthesis are Bassini's, Mac Vay's and Shouldice's techniques. The procedures using prosthesis are Lichtenstein's, plug's, Stoppa and Rive's, and Pouliquen's techniques. Finally, we describe coelioscopic procedures (intra- and extraperitoneal approach). We conclude that actually, the best technique employing nonprosthesis is the Shouldice repair. Concerning techniques employing a prosthesis, we do not know, at the present time, which is the best. Clinical trials are on run to answer this question.

Manual versus mechanical esophagogastric anastomosis after resection for carcinoma: a controlled trial. French Associations for Surgical Research

BACKGROUND

Mechanical anastomosis has been claimed to reduce the rate of leakage compared with manual anastomosis. No randomized trials have been performed to date to prove this specifically in esophagogastric anastomosis.

METHODS

One hundred fifty-four patients, 139 men and 15 women ranging in age from 36 to 83 years (mean, 50 +/- 10 years) and undergoing elective resection of esophageal or cardial carcinoma, were included in this multiinstitutional (14 centers) randomized study comparing the rate of anastomotic leakage after esophagogastric anastomosis performed manually or mechanically. Eligible for this study were patients with esophageal or cardial carcinoma located between the esophagogastric junction (included) and the upper border of the aortic arch. The choice between resection with or without thoracotomy was left to the discretion of the operating surgeon. Proximal resection of the fundus was mandatory. Intestinal tract continuity was reestablished in a one-stage procedure by an esophagogastric anastomosis without interposition of either the jejunum or the colon. The site of the anastomosis could be either intrathoracic or cervical. The principal end point was anastomotic leakage as judged by (1) egress of intestinal fluids or orally ingested methylene blue through drains, (2) sodium diatrozate swallow prescribed either routinely for all patients between postoperative days 3 and 8 or because of signs of leakage, or (3) reoperation or autopsy.

RESULTS

After two patients were withdrawn for protocol violation, 152 patients, 74 in the manual group and 78 in the mechanical group, were studied. The number of anastomotic leakages was identical in both groups (n = 12, 16% and 15%, respectively). Overall 30-day mortality was 11%. Fewer deaths occurred in the manual group (7%), which had three anastomotic leakages, than in the mechanical group (15%), which had five anastomotic leakages, and fewer repeat operations were done in the manual group (n = 9) than in the mechanical group (n = 13), but both of these differences were not statistically significant. The duration of anastomosis and of operation was similar in both groups. In the mechanical group 16 anastomoses (20%) gave rise to technical mishaps (either in the fashioning of the purse-string, dilation of the esophagus, or in stapling). Among the factors recognized as potentially preventing leakage, only testing for airtightness was significantly correlated with less postoperative leakage (p < 0.05). Eight postoperative strictures were recorded at 3 months in 62 (13%) patients in the manual group, whereas seven strictures occurred in 53 (13%) patients in the mechanical group.

CONCLUSIONS

When mechanical staples rather than manual sutures are chosen, the disadvantages (technical mishaps and higher costs) are not counterbalanced by a gain of time or a decrease in the rate or severity of anastomotic leakage.

Are routine preoperative chest radiographs useful in general surgery? A prospective, multicentre study in 3959 patients. Association des Chirurgiens de l'Assistance Publique pour les Evaluations médicales

OBJECTIVE

To find out which patients about to undergo general or gastrointestinal operations could have the routine preoperative posteroanterior chest radiograph omitted.

DESIGN

Prospective open multicentre study.

SETTING

8 Public hospitals, France.

SUBJECTS

3959 consecutive patients about to undergo operations for benign disease were divided into 4 groups depending on the number of risk factors for cardiopulmonary complications (coexisting bronchopulmonary or cardiac conditions, abnormal clinical cardiopulmonary findings): group 1 (n = 2092) had no risk factors, group 2 (n = 946) had 1, group 3 (n = 645) had 2, and group 4 (n = 276) had 3 risk factors or more.

INTERVENTIONS

Routine posteroanterior chest radiographs.

MAIN OUTCOME MEASURES

Whether the findings on the radiograph (read by the anaesthetist) led to modifications in the type of anaesthesia or operative technique, or both, and whether radiographs were helpful in the postoperative management.

RESULTS

912 (23%) of the radiographs showed some abnormality. Changes were made in anaesthetic or surgical policy in 22 (0.1%), 11 (0.3%), 8 (1%), and 4 (1%) of patients in groups 1-4, respectively. The preoperative films were of some help in the management of about half the patients who developed postoperative cardiopulmonary complications.

CONCLUSIONS

Preoperative chest radiographs should be routine for patients about to undergo general and gastrointestinal operations with three or more risk factors, and done selectively for patients with one or two. Routine preoperative films are unnecessary for patients with no risk factors.

5-Fluorouracil and cisplatin therapy after palliative surgical resection of squamous cell carcinoma of the esophagus. A multicenter randomized trial. French Associations for Surgical Research

BACKGROUND

The curative rate of surgical resection of squamous cell carcinoma of the esophagus is low. Reports on the efficacy of preoperative and postoperative chemotherapy are conflicting or have included limited disease or radical surgery alone.

OBJECTIVE

The authors' objective was to study the results of chemotherapy on the duration and quality of survival in patients who have undergone palliative surgical resection for esophageal squamous cell carcinoma.

PATIENTS AND METHODS

Of 124 patients with histologically proven esophageal squamous cell carcinoma situated more than 5 cm from the upper end of the esophagus, 4 patients were withdrawn for failure to comply with the protocol. The remaining 120 patients, 116 males and 4 females (mean age, 57 +/- 9 years), were randomly assigned to either a control group who were to receive no chemotherapy (68 patients) or to a group who were to be treated with chemotherapy (52 patients). Patients were subdivided into two strata as follows: (1) stratum I, complete resection of the tumor with lymph node involvement (62 patients) and (2) stratum ii, incomplete resection leaving macroscopic tumor tissue in situ or with metastases. Noninclusion criteria were histologically proven tracheobronchial involvement, esotracheal fistula, major alteration of general health status (Karnofsky score <50), cerebral or extensive (>30% of parenchyma) hepatic metastasis, peritoneal carcinomatosis, associated or previously treated upper airway cancer, or, conversely, complete resection of tumor without lymph node involvement. Chemotherapy was given in 5-day courses, every 28 days, with a maximum of 8 courses. Cisplatin was administered either as a single dose of 100 mg/m2 at the beginning of the course or as 20 mg/m2/day for 5 days given over 3 hours. 5- Fluorouracil (5-FU) (100 mg/m2/day) was infused over 24 hours for 5 days. The duration of treatment ranged from 6 to 8 months. The main aim was to establish median survival and actuarial survival curves. The subsidiary aim was to evaluate quality of survival as judged by complications due to treatment and the duration of autonomous oral feeding, that is, without palliative endoscopic treatment. No difference in survival was noted between the two groups, overall (median, 14 months), or between the strata. Conversely, significantly more patients in the treated group had hematologic, neurologic, and renal complications compared with the control group. Four patients died of complications of chemotherapy. The duration of autonomous oral alimentation was exactly the same in both groups (median, 12 + months).

CONCLUSION

The results of this study suggest that 5-FU and cisplatin are not useful for patients with squamous cell carcinoma of the esophagus who have not undergone curative resection.

Shouldice inguinal hernia repair in the male adult: the gold standard? A multicenter controlled trial in 1578 patients

BACKGROUND

Hernia repair is the second most frequently performed operation in France and in the United States, the prevalence being 36 for every 1000 males. Lowering the recurrence rate by 1% would mean 1000 fewer operations for hernia repair per year in France.

METHODS

Between 1983 and 1989, 1578 adult males with a total of 1706 nonrecurrent inguinal hernias were prospectively and randomly allotted to undergo either a Bassini's repair, Cooper's ligament, or Shouldice repair with polypropylene or a Shouldice repair with stainless steel for determination of which technique was associated with the lowest recurrence rate. Fifty-nine hernia repairs were withdrawn after inclusion. Of the 1647 remaining hernias, 52.2% were indirect, 25.6% were direct, and 23.2% were combined. Patients were seen every 6 months for 3 years and then every year. Median follow-up was 5 years 8 months (range, 3 months-8.5 years).

RESULTS

At 8.5 years, 5.6% of hernias were lost to follow-up. Ninety-seven hernia repairs failed, 50% during the first 2 years. The actuarial recurrence rate was 7.94% at 8.5 years. The Shouldice repair (stainless steel or polypropylene) was associated with fewer recurrences (6.1%) than either the Bassini's (8.6%) or Cooper's ligament repair (11.2%) technique (p < 0.001). This difference remained significant even when the maximal bias test was used. Fewer recurrences (5.9%) were observed with the stainless steel wire Shouldice repair than with polypropylene version (6.5%), but the difference was not significant.

CONCLUSIONS

Shouldice hernia repair provides the patient with the best chances of nonrecurrence regardless of the anatomical type of hernia. The Shouldice hernia repair should be the gold standard for inguinal hernia repair in men and serves as the basis for comparison with all other techniques, be they prosthetic or laparoscopic.

Budd-Chiari syndrome secondary to carcinoma: report of two cases

In two patients who had Budd-Chiari syndrome secondary to carcinoma, the diagnosis was made intraoperatively at the time of emergency right atrial clearance required for severe cardiovascular distress. Curative resection was not possible and both patients died. As previously noted in the literature, it is extremely difficult to relate carcinoma to the origin of Budd-Chiari syndrome. Retro- and suprahepatic involvement of the vena cava is associated with a very poor prognosis. Complete resection of these tumors is the only potentially curative treatment. We suggest ways to obtain a simple and early histologic diagnosis before initiating appropriate and radical surgical treatment.

Surgical mortality and morbidity in malignant obstructive jaundice: a prospective multivariate analysis

OBJECTIVE

To construct prognostic scores using multivariate analysis for morbidity and mortality in jaundiced patients with malignant biliary obstruction.

DESIGN

Prospective study.

SETTING

16 university and 12 general hospitals affiliated to the French Association for Surgical Research.

MAIN OUTCOME MEASURES

Results of application of severity indexes for mortality and morbidity constructed from 17 variables. That for mortality was: 0.0497 x age + 0.9219 x American Society of Anesthesiologists' (ASA) grade + 0.0037 x serum bilirubin concentration minus 0.0239 x prothrombin time + 0.0001 x white cell count minus 5.593. That for morbidity was: minus 0.7499 x ASA grade + 0.0294 x prothrombin time + 1.4220 x cause (0 = carcinoma of bile duct, 1 = pancreatic cancer) minus 1.5080 x operation (0 = bypass, 1 = resection) minus 1.537.

RESULTS

The scores correctly predicted mortality in 77% and morbidity in 65% (infective morbidity in 73%).

CONCLUSIONS

We recommend that when the mortality index is negative operation should be the treatment of choice, and when it is positive the patient should be advised to have non-surgical palliative treatment. When the morbidity index is negative the risk of complications is high, and when it is positive the risk is low. The application of these indexes allows for better choice of patients suitable for operative treatment of malignant biliary obstruction.

Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research

BACKGROUND

Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates.

METHODS

One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8 +/- 12.1 years) were randomized to undergo hand-sewn (n = 74) or circular stapled (n = 85) supraperitoneal colorectal anastomosis after left colectomy.

RESULTS

Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n = 10) and hemorrhage (n = 5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p < 0.001), but this time gain did not significantly influence the overall duration of operation (identical median times). The median duration of hospitalization was 13 and 14 days, respectively (NS). At 8 months there were 2 of 74 strictures in the hand-sewn group and 4 of 85 strictures in the stapled group (NS).

CONCLUSIONS

According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.