Passive vs. closed suction drainage after perineal wound closure following abdominoperineal rectal excision for carcinoma. A multicenter, controlled trial. The French Association for Surgical Research

PURPOSE

Because evacuation of effusion or collection could depend on the type of drainage, we compared the effects of closed suction drainage with passive drainage through tubes or undulated drains after abdominoperineal rectal excision for carcinoma on early and late perineal wound healing.

METHODS

Of 234 consecutive patients undergoing abdominoperineal rectal excision for carcinoma between January 1983 and August 1990, unsatisfactory hemostasis or gross intraoperative septic contamination were recorded in 48 patients who were not included in the trial. After rectal excision and closure of the perineum, the remaining 186 patients were randomized to receive passive drainage (PD; n = 96) or closed suction drainage (SD; n = 90). Eighteen patients were withdrawn because of protocol violation, and three were lost to follow-up, leaving 165 (89 PD and 76 SD) patients for analysis. Preoperative factors (sex, age, degree of obesity, weight loss, anemia, or presence of ascites), intraoperative and pathologic findings (Dukes stage), and postoperative courses (recurrence, late mortality) were similar in both groups. All patients were followed up for 12 months or until death.

RESULTS

The rate of perineums healed at one month was significantly lower (P < 0.05) in PD (55/89 = 61 percent) compared with SD (54/72 = 75 percent) patients. At three months, the rate of healed perineums no longer differed between the two groups (70/87 = 81 percent vs. 60/72 = 84 percent). The number of vaginal fistulas, secondary reopenings, and perineums not healed at 12 months was similar in both groups. Median duration to complete healing was similar in both groups (23 vs. 21 days, respectively). On the other hand, three retained drains were seen in PD patients only. The median duration of hospital stay was identical in both groups (22 days). Seven patients died in the early postoperative period, including one in the PD group and six in the SD group. There was no significant difference in the number of late deaths (3 vs. 7) in PD and SD patients, respectively.

CONCLUSION

These results suggest that closed suction drainage should be used after abdominoperineal rectal excision with satisfactory hemostasis or absence of gross introperative septic contamination.

Phylogenetic relationships of amphibian families inferred from DNA sequences of mitochondrial 12S and 16S ribosomal RNA genes

Nucleotide sequence comparisons were used to investigate ordinal and familial relationships within the class Amphibia. Approximately 850 base pairs of the mitochondrial 16S ribosomal RNA (rRNA) gene from representatives of 28 of the 40 families of extant amphibians were sequenced. Phylogenetic analyses of these data together with published data of the 12S rRNA gene for the same families and both genes for three more taxa (approximately 1,300 base pairs total for 35 taxa) support the monophyly of each of the three amphibian orders: Anura (confidence value with the interior-branch test: P(c) = 99%), Caudata (P(c) = 100%), and Gymnophiona (P(c) = 99%). An analysis using the four-cluster method cannot discriminate significantly between all three possible unrooted trees involving the three orders of amphibians and an outgroup. Within the Anura, there is support for the monophyly of the two suborders: Neobatrachia (P(c) = 100%) and Archaeobatrachia (P(c) = 97%); the latter was believed to be paraphyletic on the basis of morphology. Within the Archaeobatrachia, the following pairs of taxa cluster: Pelobatidae + Pelodytidae (P(c) = 99%), Pipidae + Rhinophrynidae (P(c) = 99%), Ascaphus + Leiopelmatidae (P(c) = 89%), and Bombina + Discoglossidae (P(c) = 99%). The latter six taxa cluster (P(c) = 94%) such that Pelobatidae + Pelodytidae forms a basal lineage within the Archaeobatrachia. Three major lineages are distinguished within the Neobatrachia: the superfamily Bufonoidea sensu Duellman (P(c) = 86%), the superfamily Ranoidea sensu Lynch (P(c) = 99%), and the Sooglossidae. Basal within the Bufonoidea, Myobatrachidae + Heleophrynidae cluster at P(c) = 96%. The enigmatic Dendrobatidae clusters with the bufonoid families (P(c) = 92%) and is excluded from the ranoid families (P(c) = 99%). (ABSTRACT TRUNCATED AT 250 WORDS)

A prospective multicenter evaluation of preoperative hemostatic screening tests. The French Associations for Surgical Research

BACKGROUND

Several retrospective and four prospective reports have questioned the need for routine preoperative hemostatic screening tests (PHST) in general surgery.

PATIENTS AND METHODS

The results of four standard tests (prothrombin time, activated partial thromboplastin time, platelet count, and bleeding time) were prospectively compared with patient history and clinical data in a multicenter study of 3,242 consecutive patients. The patients were divided into four groups: group A (n = 1,951) had no clinical or PHST abnormalities; group B (n = 340) had no clinical and one or more PHST abnormalities; group C (n = 779) had one or more clinical and no PHST abnormalities; group D (n = 172) had both clinical and PHST abnormalities.

RESULTS

Preoperative modifications of guidelines (postponed operations and ordering of additional hemostatic tests) were significantly more frequent in both groups of patients with PHST abnormalities (groups B and D), but specific treatment to correct hemostatic disorders was prescribed only when clinical abnormalities were also present (group D). Intraoperatively, modifications of anesthetic and surgical vigilance (planning of increased number of blood units, vascular catheter placement, and number of patients requiring transfusion) were significantly more frequent in group D. Postoperatively, all groups had similar incidences of hematoma or bruises, volumes of blood loss per drainage, reoperations to control hemorrhage, and mortality due to bleeding (n = 5).

CONCLUSIONS

Our results suggest that PHST should not be performed routinely, but only in patients with abnormal clinical data. Such a policy necessitates a thorough history--including answers to a specific questionnaire like those used in prospective studies--and a rigorous, well-conducted physical examination.

[Quantified semiology of acute sigmoid diverticulitis. Associations de Recherche en Chirurgie]

Using a data base of 7,000 acute abdominal pains, we have described the assessed clinical features of acute diverticulitis of the sigmoid colon. Percentages of sensitivities have been replaced by adverbs or adjectives, applying a scale of equivalence. The modifications of the positive predictive values have been also replaced by verbs or typical expressions. In this article, abscesses, fistulas, generalized peritonitis and hemorrhage arising from an acute diverticulitis of the sigmoid colon were not studied.

Preoperative evaluation of the probability of common bile duct stones. French Association for Surgical Research

BACKGROUND

This study was done to determine if certain criteria could predict the presence of common bile duct stones in patients with symptomatic gallstones. It was hoped that patients could be identified in whom intraoperative cholangiography was unnecessary.

STUDY DESIGN

One hundred seventy-five patients, from 15 surgical centers, were prospectively enrolled. For each patient, the preoperative score (Huguier score) previously published was calculated according to clinical and ultrasound data: age, diameter of the common bile duct, diameter of the smallest gallstone, history of biliary colic, and acute cholecystitis. All patients underwent an open cholecystectomy and an intraoperative cholangiography. The absence or presence of a common bile duct stone was evaluated during the operation, if necessary, after an instrumental investigation of the common bile duct.

RESULTS

Ultrasound was not interpretable in eight (5 percent) of 175 patients. Final analysis was made from the charts of the 167 remaining patients. Thirty (18 percent) had common bile duct stones. When the score was equal to or greater than 3.5, the risk of having a common bile duct stone was 24 percent (27 of 111). When the score was less than 3.5, this risk was 5 percent (three of 56).

CONCLUSIONS

Huguier's score is well assessed and can be safely used. Intraoperative cholangiography could be avoided in 33 percent of patients when the score is less than 3.5 (56 of 167).

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

BACKGROUND

Disagreement continues among several studies as to the relative advantages and disadvantages of stapled versus sutured colorectal anastomoses.

METHODS

One hundred and thirteen consecutive patients (48 men and 65 women, mean age: 67 +/- 12 years) were randomized to either hand-sewn (n = 59) or stapled (n = 54) infraperitoneal colorectal anastomosis. Both groups had similar patient demographics except that fewer patients (4 versus 15) had chronic disease (p < 0.02) and were undergoing side-to-end (11 versus 39) and more patients were undergoing end-to-end (37 versus 20) anastomosis in the stapled group (p < 0.001).

RESULTS

Overall mortality was 6% (7 of 113 patients), with no difference found between the two types of anastomosis. Fewer anastomotic leaks occurred in the stapled group (11 versus 7), with an a posteriori gamma error of 11%, whereas the other early postoperative complications occurred with similar frequency in the two groups. Nine mishaps occurred in the stapled group. Stapled anastomoses took less time (median, 42 versus 30 minutes) to perform (p < 0.02). At 8 months, two strictures occurred in the hand-sewn group (n = 52) compared with eight strictures in the stapled group (n = 50) (p < 0.001).

CONCLUSIONS

It was not possible to prove that lower anastomosis can be achieved with the stapling device. Routine or regular use of stapling instruments for infraperitoneal colorectal anastomosis cannot be advocated because of higher incidence of mishaps and strictures, even though the operation takes less time to perform and anastomotic leakage occurs less often.

Perineal wound management after abdominoperineal rectal excision for carcinoma with unsatisfactory hemostasis or gross septic contamination: primary closure vs. packing. A multicenter, controlled trial. French Association for Surgical Research

PURPOSE

This study was designed to compare the results of two methods on the rate of postoperative perineum healing.

PATIENTS AND METHODS

In this prospective, randomized, multicenter trial of 234 consecutive patients undergoing abdominoperineal rectal excision for carcinoma, 48 had unsatisfactory hemostasis or intraoperative gross septic contamination. Three patients were withdrawn because of protocol violation. Of the 45 remaining patients, 21 were randomized to undergo primary closure of the perineum with drainage while 24 underwent packing. Preoperative factors (sex, age, degree of obesity, weight loss, anemia, or presence of ascites), intraoperative findings (Dukes stage, degree of hemostasis, gross septic contamination), and postoperative oncologic courses (recurrence, mortality rate) were similar in both groups. All patients were followed for at least 12 months or until their demise.

RESULTS

There was no significant difference in the number of early (one vs. zero) or late (five vs. four) deaths between primary closure and packing groups, respectively. Median duration of hospital stay was 25 and 27 days, respectively. Primary closure was associated with a significantly higher rate of healed perineums at one month (30 percent vs. 0 percent) (P = 0.01) and a shorter delay to complete cicatrization (median, 47 vs. 69 days) (P < 0.01). From three months onward, there was no difference in healing between the two groups, but two patients in the packing group had not healed at one year. Conversely, hematoma, perineal abscess, and reoperations were significantly more frequent (P < 0.01) in the primary closure group.

CONCLUSION

Primary closure associated with drainage after abdominoperineal resection for carcinoma expedites perineal healing but morbidity is higher.

MRI of Budd-Chiari syndrome

A retrospective study was undertaken to reassess the various magnetic resonance imaging (MRI) features of Budd-Chiari syndrome (BCS). MRI examinations of 22 patients with pathologically confirmed BCS were studied. Spin-echo (SE) T1- (TR = 300-450 ms/TE = 12-15 ms), and SE T2-weighted (TR = 1600-2000 ms/TE = 30-60/90-120 ms) MRI images were obtained in all patients. Gradient-recalled-echo (GRE) images (TR = 7-60 ms/TE = 3-19 ms, flip angle = 10-40 degrees) were obtained in 14 patients. MRI showed thrombosis of three or two hepatic veins in 19 (86%) and 3 (14%) patients, respectively. Spontaneous intrahepatic anastomoses was depicted in five (23%) patients. Ascites appeared in 15 patients (68%). Thrombosis or external compression of the inferior vena cava (IVC) by an enlarged caudate lobe was depicted in six (27%) and five (23%) patients, respectively. Prominent azygos and hemiazygos veins were demonstrated in seven (32%) patients (six of whom had thrombosis of the IVC). MRI showed hepatomegaly in all patients and enlarged caudate lobe in 18 (82%) patients. SE T1- and SE T2-weighted MRI images revealed inhomogeneous signal intensity of hepatic parenchyma in 14 (64%) patients. SE T1- and SE T2-weighted MRI images showed homogeneous signal intensity of hepatic parenchyma in eight (36%) patients. Our results demonstrate that BCS displays various features on MRI images, and such information is important for diagnosis.

Curative resection for left colonic carcinoma: hemicolectomy vs. segmental colectomy. A prospective, controlled, multicenter trial. French Association for Surgical Research

PURPOSE

This study was developed to compare median and actuarial survival after left hemicolectomy vs. left segmental colectomy.

METHODS

Between January 1980 and January 1985, 270 consecutive patients (133 males and 137 females; mean age, 64 +/- 12 (range, 18-91) years with left colonic carcinoma located between the left third of the transverse colon and (but not, including) the colorectal juncture were randomly allotted to undergo either left hemicolectomy or left segmental colectomy. Left hemicolectomy removed the entire left colon along with the origin of the inferior mesenteric artery and the dependent lymphatic territory. Left segmental colectomy removed a more restricted segment of the colon and left the origin of the inferior mesenteric artery unmolested.

RESULTS

After elimination of 10 patients for protocol violation, 131 patients with left hemicolectomy and 129 with left segmental colectomy were analyzed. Both groups were similar with regard to preoperative risk factors (age, sex, obesity, weight loss, anemia, diabetes, cirrhosis, kidney failure, steroid therapy or radiation therapy performed for any cause other than cancer), pathology findings (size, degree of differentiation, Dukes stage, invasion of lymph nodes at the origin of the inferior mesenteric artery), and associated lesions. Only the length of tumor-free margins of colon removed was significantly longer in left hemicolectomy. The number of early postoperative abdominal and extra-abdominal complications was similar in both groups. Overall, early postoperative mortality was 4 percent higher, but not significantly in left hemicolectomy (eight deaths, 6 percent) than in left segmental colectomy (three deaths, 2 percent). Median survival was 10 years and nearly equivalent in both groups. The two actuarial survival curves were similar. Bowel movement frequency was significantly increased after left hemicolectomy during the first postoperative year. Our results suggest that survival after left segmental colectomy is equivalent to that of left hemicolectomy. Notwithstanding the observation of other carcinologic rules, left segmental colectomy rather than left hemicolectomy may theoretically be performed under laparoscopy without compromising the carcinologic outcome.

[Treatments of inguinal hernia under local anesthesia]

Potentiated local anaesthesia has been generally used for repair of inguinal hernia since the Shouldice technique was first introduced in France in the early 80s. The technique requires a correct understanding of inguinal innervation and the properties of the local anaesthetic. The local anaesthetic is injected into the abdomino-genital and genito-crural nerves and at the line of incision allowing smooth surgical repair. Potentiation relieves patient apprehension. This method can be used for all types of inguinal hernia, whether simple or complicated and in all patients. There is no limitation for age or general condition. Contraindications are rare and include allergy or uncontrolled (no pacemaker) arrhythmias.

Emergency surgical treatment for bleeding duodenal ulcer: oversewing plus vagotomy versus gastric resection, a controlled randomized trial. French Associations for Surgical Research

The best surgical procedure to treat bleeding bulbar peptic ulcer is unknown. The rates of postoperative bleeding recurrence, duodenal leakage, and mortality were compared in patients undergoing oversewing plus vagotomy (O+V) or gastric resection (GR) with ulcer excision. Of 202 patients undergoing emergency surgery for massive, persistent, or recurrent bleeding from bulbar peptic ulcer, 120 patients were enrolled in a prospective randomized trial. Fifty-nine were assigned to O+V and 61 to GR. One patient in each group was excluded after randomization. The two groups were well matched with respect to clinical and prognostic factors. The rate of postoperative bleeding recurrence was 17% after O+V and 3% after GR (p < 0.05). The duodenal leak rate was higher after GR than after O+V (13% vs. 3%) (p < 0.10) but was not different when the morbidity of reoperations for bleeding recurrence after O+V was considered on an "intention to treat" basis (12% vs. 13%). Overall postoperative mortality was similar: 22% (O+V) versus 23% (GR). Sixteen deaths were unrelated to the surgical procedure itself. Of 82 nonrandomized patients, 10 were not analyzed. In the 72 other nonrandomized patients, bleeding recurrence, duodenal leakage, and postoperative mortality rates were consistent with the results of the controlled trial, as they were 29% (O+V 32%; GR 0.7%), 16% (O+V 0.7%; GR 26%) and 27% (O+V 18%; GR 33.3%), respectively. We conclude that GR with ulcer excision is the procedure of choice for the emergency surgical treatment of bleeding duodenal ulcer because postoperative bleeding recurrence is lower, and the overall rates of mortality and duodenal leakage are the same as with O+V.

Factors associated with early discharge after inguinal hernia repair in 500 consecutive unselected patients. French Associations for Surgical Research

The feasibility of discharge within 48 h of surgery was evaluated in 500 consecutive men with unilateral uncomplicated non-recurrent inguinal hernia. Eighty-nine [corrected] patients were unsuitable for short-stay surgery on medical or social grounds. Of 411 patients suitable for early discharge, 107 stayed longer than 48 h. Early discharge was declined by 84 otherwise suitable patients and contraindicated because of local or general complications in 42. A total of 304 patients were discharged within 48 h; 1-day surgery was performed in 51 patients. Employment, low physical requirements, a lower age and fewer than two medical risk factors were associated with feasible and successful short-stay surgery. These factors may not be independent variables.

Long term results of choledochoduodenostomy versus choledochojejunostomy for choledocholithiasis. The French Association for Surgical Research

The current randomized study was done to compare the results of choledochoduodenostomy (CD) and choledochojejunostomy (CJ) for choledocholithiasis, with special reference to long term results and the risk of ascendant cholangitis. From January 1978 to January 1990, 130 patients were included in the study--64 with CD (side to side, in all patients) and 66 with CJ (side to side in 25 patients and end to side in 41). No significant difference was observed between the CD and CJ groups for postoperative mortality (3.8 percent) and morbidity rates. One hundred and twenty patients (58 CD and 62 CJ) were available for long term follow-up evaluation (mean follow-up period of 29 +/- 11 months). One hundred and seven patients had no symptoms attributable to biliary disease or operation. Five patients in this group died of unrelated causes. Thirteen patients experienced biliary symptoms suggestive of cholangitis, or at least related to the bilioenteric anastomosis--six patients in the CD group and seven in the CJ group. Cholangitis was observed in the first postoperative year in eight of these 13 patients and during the second year for the five others. In the CD group, cholangitis was the result of sump syndrome (n = 3), anastomotic stricture (n = 1) and unknown causes (n = 2). In the CJ group, cholangitis was the result of anastomotic stricture (n = 3), residual intrahepatic stones (n = 1) and unknown causes (n = 3). The results of the current study confirm the good long term results of both procedures. However, it suggests that CD is preferable for choledocholithiasis for two reasons--it is technically easier and faster to perform than CJ and, unlike CJ, CD permits easy access to further endoscopic exploration or treatment if necessary.

[Acute intestinal obstructions in adults: quantified semiology (signs and their value) and surgical treatment]

The prevalence of signs and symptoms of acute intestinal obstruction in the adult was studied in a prospective study of 600 cases extracted from a data base on acute abdomen in 7,000 patients. This study of prevalence allows a precise definition of intestinal obstruction syndrome and to differentiate two types of presentations according to the site of obstruction on the small bowel or the colon. However, it is more difficult to differentiate simple bowel obturation from vascular strangulation. Surgical treatment depends mainly on the cause of obstruction.

Ileocolonic anastomosis after right hemicolectomy for carcinoma: stapled or hand-sewn? A prospective, multicenter, randomized trial

440 patients were prospectively enrolled in a randomized, multicenter trial to compare 4 types of manual (84 interrupted end-to-end, 77 continuous end-to-end, 82 interrupted end-to-side, and 91 continuous end-to-side) (polyglycolic derived suture) and 1 type of stapled (106 side-to-side with GIA+TA devices) ileocolonic anastomosis after right hemicolectomy for carcinoma. The trial was designed according to Schwartz' pragmatic formulation. All 5 groups were well-matched, except for a lower rate of intraoperative sepsis in the stapled group (P < 0.02). The main end point was anastomotic leakage detected clinically or by routine sodium diatrizoate enema on the 8-10th postoperative day. Results showed that stapled ileocolonic anastomosis was associated with less anastomotic leakages (2.8%) than all the other techniques combined (8.3%). In spite of the fact that staples are approximately ten times more expensive, our results suggest performing side-to-side (GIA+TA) mechanical anastomosis after right resection for carcinoma.

Single-dose ceftriaxone, ornidazole, and povidone-iodine enema in elective left colectomy. A randomized multicenter controlled trial. The French Association for Surgical Research

Patients undergoing elective left colectomy for colonic carcinoma or diverticulosis (n = 341) were randomly assigned to three groups. Patients in groups 1 (102 patients) and 2 (122 patients) had two 5% povidone-iodine enemas whereas those in group 3 (117 patients) had saline enemas. Groups 1 and 3 received 24-hour intravenous cefotaxime sodium and metronidazole hydrochloride. Group 2 received single injections of ceftriaxone sodium (1 g) and ornidazole (1 g). Senna concentrate was administered the evening before surgery. There was no statistically significant difference found between groups 1 and 2 concerning the number of infected patients (eight vs 11), anastomotic leakages (four vs four), extra-abdominal complications (32 vs 29), or infection-related deaths (one vs zero). Despite poorer tolerance, povidone-iodine enema was more effective than saline enemas, as there were less infected patients in group 1 (8%) or groups 1 + 2 (8.5%) than in group 3 (13%). Single-dose ceftriaxone-ornidazole combined with povidone-iodine enemas is effective against infective complications in elective left colonic surgery for carcinoma or diverticular disease. Single-dose antibiotic prophylaxis reduces costs and work for the nursing staff.

Mesoinnominate shunt for the treatment of Budd-Chiari syndrome: evaluation with multimodality imaging

The construction of a mesoinnominate shunt between the superior mesenteric vein and the left innominate vein is a recent surgical procedure for the treatment of Budd-Chiari syndrome with vena caval obstruction. The purpose of this study was to determine the role of the different imaging modalities for the follow-up of mesoinnominate shunts. Doppler US (n = 32), and MR imaging examinations (n = 32) were prospectively performed in 10 patients with mesoinnominate shunts. Shunt patency or thrombosis was confirmed with angiography (n = 32) and transhepatic portography with pressure measurement (n = 6). For each follow-up evaluation, all examinations were performed within 4 days. Shunt patency was correctly demonstrated in 28/28 cases with Doppler US, CT and MR imaging. Shunt thrombosis was correctly demonstrated in 4/4 cases with Doppler US, CT and MR imaging. Since Doppler US, CT and MR imaging have the same accuracy for diagnosing mesoinnominate shunt patency and detecting thrombosis, our study suggests that redundant screening methods can be avoided. Doppler US is accurate enough and should be the preferred technique in the evaluation of mesoinnominate shunts.

[Retrograde cholangiopancreatography and endoscopic sphincterotomy for biliary lithiasis. Prospective evaluation in surgical circle]

Between January 1982 and 1987, 772 consecutive endoscopic retrograde cholangiopancreatographic examinations (ERCP) were performed in 673 consecutive patients suspected of having biliary tract lithiasis (mean age: 62.1 +/- 18.2 years). Two hundred and thirty-two were emergency procedures (30%). Endoscopic sphincterotomy was performed for common bile duct stones (CBDS) in 257 cases (38.0%), of whom 143 (55.6%) had undergone previous cholecystectomy. In 17.2% of cases, ERCP was either a complete (7.8%) or partial (9.4%) failure. In 124 patients for whom microlithiasis was not identified by sonography and who underwent operation, sensitivity and specificity of ERCP was 70% and 87%, respectively. Of 266 patients in whom ES was attempted, 96.6% were achieved and the common bile duct was cleared of stones in 72% of cases. Nineteen percent of patients required two or more attempts at extraction. After ERCP without ES, mortality and morbidity rates were 0.96 and 3.6% respectively. After ES, complications followed in 12.1% of patients and 3.9% died. Mortality and morbidity directly related to ES were 3.1% and 11.3% respectively. The most common complications after ERCP were acute cholangitis and pancreatitis, whereas after ES, acute cholangitis was the most common complication, followed by hemorrhage and duodenocholechocal perforations. These complications occurred independently of age and previous cholecystectomy but was closely related to stone clearance (P < 0.05). Seventy-one patients (10.5%) required operation. Twenty-nine patients underwent emergency surgery for complications with a mortality rate of 17%. Forty-two patients underwent elective surgery for retained CBDS after ES without any mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of inguinal hernia in short-term hospitalization. Prospective survey of 500 consecutive unselected cases. Associations Francaises de Recherche en Chirurgie]

Individual medical and social factors associated with the acceptance and success of short stay surgery for unilateral, uncomplicated inguinal hernia were looked for in 500 consecutive unselected patients. The mean duration of postoperative hospital stay was 3.4 days. Sixty percent of the patients were discharged within the first 48 hours following surgery, including 10 percent who left the hospital in the evening of the operation day. Twenty-two percent of the patients who could have left during these 48 hours refused to do so. The most predictive variable for acceptance and success was a profession requiring little physical activity. Local anaesthesia has been associated with success in the so-called ambulatory surgery, but the methodology of the present study did not permit to establish a cause-effect relationship.

Hepatic arterial infusion of floxuridine in patients with liver metastases from colorectal carcinoma: long-term results of a prospective randomized trial

PURPOSE

A multicentric randomized study that compared patients who received intrahepatic arterial infusion (HAI) to a group of patients who did not receive HAI (control group) was performed for unresectable hepatic metastases from primary colorectal carcinoma.

PATIENTS AND METHODS

One hundred sixty-six patients were assigned randomly to HAI of floxuridine (5 fluoro-2'deoxyuridine [FUDR]) 0.3 mg/kg/d for 14 days every 4 weeks or to the control group; this latter group, depending on the investigator's choice, was either under observation or received systemic fluorouracil (5-FU). The same regimen of systemic 5-FU also was administered to the HAI group in the event of extrahepatic progression. No crossover from the control group to the HAI group was permitted. The mean duration of follow-up was 54 months (range, 31 to 72), and 163 patients were analyzed.

RESULTS

A significant improvement was observed in the survival rate for the 81 patients assigned to HAI group (P less than .02) with a 1-year survival rate of 64% versus 44% in the control group (82 patients). The 2-year survival rate was 23% versus 13%. The median survival was 15 months versus 11 months for the HAI group and the control group, respectively. Survival was better for patients with a less than 30% liver involvement, and for those treated in more specialized centers. The hepatotoxic effects of HAI were observed in 47 patients (chemical hepatitis [n = 28], and biliary sclerosis [n = 19]). The 1-year rate of sclerosing cholangitis was equal to 25%. Gastrointestinal toxicity was infrequent and consisted of gastritis or diarrhea.

CONCLUSIONS

Therapy with HAI of FUDR improves the survival of patients with liver metastases over colorectal carcinoma. However, the methods that are used to diminish the toxicity of HAI and efficient systemic chemotherapy, such as a combination of 5-FU and leucovorin, are required to prevent extrahepatic metastases.

Is steroid dependent Crohn's disease a separate entity?

Crohn's disease has been sometimes considered as a syndrome including different entities. In this prospect we tried to assess whether steroid dependent Crohn's disease could be a separate sub-group. Eighty five patients (mean follow-up: 6 years) with documented Crohn's disease were classified into 3 groups: 1--patients never treated with steroids (NS) (N = 37); 2--patients in whom steroids had been given but had been withdrawn (NSD) (N = 37); 3--patients dependent on continuous steroid therapy (SD) (N = 11). Ten variables were considered: age at onset, sex, CDAI, cumulative topography of lesions, extra-intestinal symptoms, albuminemia, ESR, surgical operations, annual frequency of relapses. Monofactorial analysis (analysis of variance and CHI2 test) showed group SD to be significantly different from group NS and in term of age at onset, CDAI, ESR, annual frequency of relapses, extra-intestinal symptoms, surgical operations. In contrast, a multivariate analysis of correspondences applied to the 3 groups and to 9 dichotomous variables showed that group SD is not a separate entity, but the limit of a continuum extending from group NS to group NSD. This was ascertained by a CHI2 test applied to the dichotomous variables. Thus, within the limits of this study Crohn's disease appears to be a homogeneous entity rather than a heterogeneous syndrome.

[Quantified symptomatology of acute appendicitis in adults. The signs and their value]

Using a data base of 7,000 acute abdominal pains, we here described the assessed clinical manifestations of the main diseases responsible for right lower quadrant pain. However, percentages of sensibilities have been replaced by adverbs or adjectives, applying a scale of equivalence. The possible modifications of the positive predictive values have been also replaced by verbs or typical expressions. We first described the acute appendicitis syndrome (which covered congestive endoappendicitis and suppurated appendicitis) with the clinical shades or the gathered and gangrenous forms or even of the diffuse peritonitis. Features of the acute appendicitis contrast with those of the so called "non specified abdominal pains" (a new entity), and those of the subacute or chronic appendicitis. We found a good correlation between clinical and pathological findings. One of the difficulties has been to determine if a subgroup of subacute appendicitis should be or not included into the acute appendicitis.

[Is preoperative systematic chest x-ray useful in general surgery? A multicenter prospective study of 3959 patients. ACAPEM. Association des Chirurgiens de l'Assistance Publique pour les Evaluations Médicales]

In order to define which patients may not require a routine preoperative chest X-ray, a prospective multicenter study was carried out. It included 3,959 consecutive fifteen, or more, year-old patients, free from any cancer, scheduled for a general or gastrointestinal surgical procedure other than thoracotomy, and had a plain chest X-ray beforehand. This investigation was prescribed before surgery, either by the surgeon or the anaesthetist. Patients were classified according to selected risk factors: age, smoking, emergency surgery, a past history of lung, heart or vascular disease, abnormal clinical findings related to the cardiovascular and respiratory systems, and a previous chest film made less than one year before. There were 2,092 patients in Group I (no risk factors), 916 in group II (one risk factor), 645 in Group III (two risk factors), and 276 in group IV (three risk factors). Three endpoints were selected: a modification of operative schedule or anaesthetic technique, a change in surgical procedure, and the diagnosis of postoperative complications. A rate of 23.2% of preoperative chest films were considered to be abnormal. This rate increased with age and the number of risk factors: 6.2% in Group I and 72.5% in Group IV. Surgical and anaesthetic procedures were modified as a result of the chest X-ray in only 0.5% of patients: 0.1% in Group I, 0.3% in Group II, 1.2% in Group III and 1.4% in Group IV. When pulmonary or cardiac complications did occur after the surgery, the preoperative chest film was of no help for making this diagnosis in more than 50% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)