Prospective evaluation of ultrasonic surgical dissectors in hepatic resection: a cooperative multicenter study

Blood loss is the major cause of postoperative mortality and morbidity associated with hepatic resection. A prospective multicenter study was conducted to determine if ultrasonic dissectors (USD) were useful in hepatic resection and could reduce this hemorrhagic risk. Forty-seven hepatic resections were performed in 42 consecutive patients during a two month period in 11 public, surgical centers. Twenty-one patients had primary or secondary malignancies, six had benign tumors, two had biliary cysts, one had cholangiocarcinoma, one had Caroli's disease, and 11 had hydatid cysts of the liver. Two different USD devices were evaluated (CUSA System-Lasersonics and NIIC-DX 101 T). The hepatic resections tested included a wide range of procedures. Each surgeon had the possibility of choosing between the USD and his own usual technique for each operative step and according to local conditions. The average volume of blood infused, irrespective of the underlying pathology or the procedure performed, was 1.0 L (range 0-4.8 L). Fourteen patients required no transfusions. No operative or immediate postoperative deaths were recorded. Five major complications, all unrelated to the use of the USD, developed in three patients. Access to intra and extraparenchymal arterial and venous tributaries and particularly the control of the hepatic veins were facilitated by USD. While transection of hepatic parenchyma was neither easier nor faster than with conventional techniques, it was found to be less hemorrhagic. Overall appraisal was expressed on an analog scale; the USD was found to be helpful or very helpful in 75 percent of all resections. With regard to the pathology being treated, total or partial excision of hydatid cysts was greatly enhanced by the use of the USD while this benefit was not found for wedge resections of other hepatic lesions. With regard to user friendliness and maintenance, the NIIC-DX 101 T device was preferred. We conclude that the USD facilitates formal hepatic resections. Converging opinions emerging from various surgical centers reinforce this conclusion.

[Antibiotic prophylaxis in abdominal surgery. Prospective randomized study organized by the French Surgical Research Association]

The effectiveness of cefazolin or cefotaxime as antibiotic therapy was compared with that of ceftriaxone in a multicentre prospective randomized trial involving 1,254 consecutive patients operated upon for abdominal diseases. Patients about to undergo surgery of the colon or who had localized or generalized peritonitis at the time of operation were excluded from the study. The patients entered were divided into 4 strata according to the degree of operative contamination and to risk factors. In each stratum, the patients were allocated at random to one or the other of 2 treatment groups. Group 1 patients received cefazolin or cefotaxime in 3 doses of 1 g administered 8-hourly, the first dose being injected during induction of general anaesthesia. Group 2 patients received one single 1 g dose of ceftriaxone injected during induction of anaesthesia. There was no significant difference between the two groups in the wound infection rate and in the frequency of post-operative intra-abdominal abscesses. Although the percentage of post-operative pulmonary and urinary tract infections was lower in the ceftriaxone group than in the cefazolin/cefotaxime group, no significant difference was observed between the two groups in the number of patients who required curative antibiotic therapy. This study shows that one single dose of ceftriaxone is as effective as three doses of cefazolin or cefotaxime in preventing would infections and post-operative intra-abdominal abscesses, and that it is more effective in preventing extra-abdominal infections complicating surgery.

Postoperative radiation therapy does not increase survival after curative resection for squamous cell carcinoma of the middle and lower esophagus as shown by a multicenter controlled trial. French University Association for Surgical Research

In 1978, postoperative radiation therapy was suggested to be an additive treatment of carcinoma of the esophagus. In 1987, we began a multicenter trial of patients with epidermoid carcinoma of the middle third or the lower third of the esophagus. Isolated surgical treatment (119 patients) was compared with surgical treatment followed by radiation therapy (102 patients). Randomization was performed according to the results of pathologic examination of all resected lymph nodes. Patients were divided into three groups: N0, no lymph node invasion; N+1, invasion of paraesophageal lymph nodes, and N+2, invasion of distal lymph nodes (recurrent, tracheal and celiac). All patients included in this trial had a curative esophageal resection. In the group receiving radiation therapy (102 patients), a total dose of 45 to 55 Grays was delivered in the mediastinal, right and left supraclavicular areas and also to the celiac area when celiac lymph node invasion was present. Two hundred and twenty-one patients were randomized and observed from three to nine years; life table method (log rank method) was used to compare survival and local recurrence. In all patients studied, the survival rate was significantly higher (p less than 0.01) in patients without lymph node invasion (group N0) than in patients with lymph node invasion (groups N+1 and N+2). Postoperative radiation therapy did not improve survival in any group. This lack of improvement in survival was present regardless of lymph node status. However, there were significantly fewer recurrences in patients receiving radiation therapy as compared with those not receiving radiation therapy.

An analysis of the sequence of an infectious clone of rice tungro bacilliform virus, a plant pararetrovirus

The nucleotide sequence of an infectious clone of rice tungro bacilliform virus (RTBV) DNA has been determined. The circular genome has 8002 bp and one strand contains four open reading frames (ORFs). One ORF is potentially capable of encoding a protein of 24 kD (P24) and has no initiation (ATG) codon. The other three ORFs potentially encode proteins of 12 kD, 194 kD and 46 kD (P12, P194, P46) respectively. The functions of P24, P12 and P46 are unknown. Comparative analyses with retroviruses and Commelina yellow mottle virus suggest that the 194 kD putative product is a polyprotein that is proteolytically cleaved to yield the virion coat protein, a protease and replicase (reverse transcriptase and RNase H) characteristic of retroelements. The DNA sequence reveals other features which strongly support our belief that RTBV is a pararetrovirus. These include sequences at the mapped positions of two discontinuities in the virion DNA which are complementary to tRNA metinit and purine-rich, and may be the priming sites for minus- and plus-strand DNA synthesis respectively. As the positions of likely transcriptional signals suggest, a full-length viral transcript is observed by northern analysis. The predicted folding of the 645 bp 5'-region of this RNA resembles that of caulimoviruses. Comparisons with other reverse transcribing elements are discussed.

[Surgical treatment of portal hypertension]

The surgical treatment, by means of shunts or disconnections, of ruptured oesophageal varices in portal hypertension is always indicated but not always on the forefront. However, it remains the first-line treatment in segmental portal hypertension and in Budd-Chiari syndrome. It is on a par with the non-surgical treatments in case of prehepatic block but ranks second in case of pre- and intrasinusoid blocks. In all the hepatic diseases with threatening hepatocellular deficiency, liver transplantation is the most spectacular of current and future achievements.

[Surgical treatment of gastroesophageal reflux: which operation to choose: Nissen, Toupet or Lortat-Jacob? A multicenter randomized trial]

Five surgical centers conducted a clinical randomized prospective trial in order to objectively evaluate the two-year results of three anti-reflux procedures regularly performed in France: complete (360 degrees) fundoplication (Nissen), posterior partial (180 degrees) fundoplication (Toupet) and cardiophrenopexy (Lortat-Jacob). Fifty-two patients, mean age 53 years, range 28 to 74 yrs, with uncomplicated gastroesophageal reflux, as defined according to clinical, radiologic, endoscopic and pHmetry criteria, were included in this study. Twenty patients underwent a Nissen procedure, 18 had a Toupet procedure, while 14 had a Lortat-Jacob procedure. The main criterion of assessment was Minaire's pHmetry score evaluated at two years postoperative. All three groups were well matched for clinical, radiologic, endoscopic, manometry and pHmetry findings. At two years, the number of asymptomatic patients did not statistically differ within the three groups. Four patients, however, required reoperation for invalidating recurrences: three following Lortat-Jacob's procedure and one after Toupet's procedure. Nissen's and Toupet's procedures significantly improved pHmetry scores compared with Lortat-Jacob's procedure; pHmetry was improved, but non significantly, by Nissen's procedure, as compared with Toupet's procedure. Lower sphincter pressure was significantly increased (p less than 0.01) by Nissen's procedure as compared with the two other techniques. The lower sphincter was significantly lengthened by Nissen's and Toupet's procedures as compared with Lortat-Jacob's technique (p less than 0.01). The total length of esophagus was significantly increased (p less than 0.01) by Nissen's and Lortat-Jacob's procedures in comparison with Toupet's technique. The distance separating the lower sphincter of the esophagus and point of pressure reversal was significantly decreased (p less than 0.05) by the Nissen procedure only.(ABSTRACT TRUNCATED AT 250 WORDS)

Nucleotide sequence of the coat protein gene of a necrotic strain of potato virus Y from New Zealand

The sequence of the 3'-terminal 1,134 nucleotides of the genome of a New Zealand isolate of a necrotic strain of potato virus Y (PVYN) has been determined. This sequence contains one large open reading frame of 796 nucleotides, the start of which was not identified, which is capable of encoding a protein of 264 amino acid residues with a molecular weight of 29,631. Comparison of the amino acid sequence with a published coat protein sequence of another strain, PVY-D, and with the amino acid sequence deduced from PeMV cDNA sequence data, confirms that the 3' cistron encodes the viral coat protein in PVYN. Adjacent to the 3' end of the coding region there is an untranslatable sequence of 326 nucleotides terminating in a polyadenylate tract. An alignment of the PVYN amino acid sequence with the coat protein sequences of six other potyviruses revealed significant sequence similarities in the internal and carboxy terminal regions. Much amino acid sequence similarity was found between PVYN, PVY-D, and PeMV (91-93%), suggesting that PeMV should be regarded as a PVY strain. An analysis of the 3'-untranslated region of the six potyviruse revealed PVYN and PeMV as the only viruses displaying sequence similarity in this region. The 3'-untranslated sequences of PVYN and PeMV were further examined for secondary structure.

Prophylactic antibiotherapy in abdominal surgery. First- vs third-generation cephalosporins

To compare the efficiency of antibioprophylaxis by cefazolin sodium or cefotaxime sodium, 3137 consecutive patients undergoing abdominal surgery were included in a prospective, randomized, controlled, multicenter study. The patients were divided into four strata, according to the degree of contamination during the operation and the risk factors. Within each stratum, the patients were randomized into three groups of treatment: (1) cefazolin, (2) cefotaxime, and (3) nontreatment (control). Antibiotics were administered perioperatively in three intravenous doses of 1 g at eight-hour intervals. Patients undergoing colon surgery or with peritonitis at the time of the operation were excluded from the study. The wound abscess rate was significantly lower in the treated groups than in the control group, except in stratum 3 (contaminated surgery). The percentage of postoperative peritonitis was twice as low in the treated groups as in the control group. There was no difference between the groups receiving cefazolin or cefotaxime. The patients in the treated groups received significantly less postoperative antibiotics than the patients in the control group. In terms of cost, antibioprophylaxis by cefazolin seems to be warranted in all operations with a low anaerobic contamination.

Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study

In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.

Povidone-iodine enema as a preoperative bowel preparation for colorectal surgery. A bacteriologic study

To evaluate the effects of povidone-iodine (PI) enema on the bacterial flora of colorectal mucosa, the authors studied 113 patients who were candidates for colorectal surgery. The study of the rectum included 72 patients. Total bacterial concentrations after a PI enema (N = 44) were significantly lower than after a simple water enema (N = 12, P less than 0.001), or than after a water enema associated with intravenous metronidazole (N = 16, P less than 0.01). The study of the colon included 41 patients. Total bacterial concentrations did not differ after a PI enema (N = 24) than after a water enema (N = 11); both groups were associated with intravenous metronidazole. In contrast, both preparations significantly reduced bacterial concentrations when compared with oral administration of polyethyleneglycol (N = 6, P less than 0.01). Similar results were observed in rectal and colonic studies, when analysis was restricted to the anaerobic flora. PI is an antiseptic that, when administered alone in an enema or in association with metronidazole, significantly reduces bacterial concentrations in the mucosa of the colon and rectum. It may be proposed as a simple preoperative preparation for colorectal surgery.

[Budd-Chiari syndrome with thrombosis of the inferior vena cava. Treatment by mesenterico-innominate shunt]

We report two cases of patients, 12 and 28 years old, suffering from a Budd-Chiari syndrome with a thrombosed inferior vena cava, who were treated by a shunt interposed between the superior mesenteric vein and the left innominate vein. The aim of this shunt was to avoid pericardiotomy in these patients with peroperative ascites, in order to reduce the risk of pericarditis after surgery. A reinforced polytetrafluoroethylene prosthesis (Gore-Tex) was used, associated with an interposition jugular vein graft in the 12-year old child, alone in the other case. The left innominate vein was isolated through a midline sternotomy, and the prosthesis was placed in a retrosternal position. Operation and postoperative course were uneventful. All signs of ascites disappeared. The patients were free of symptoms, 8 and 4 months after surgery respectively. Shunt patency was documented by angiography and magnetic nuclear resonance.

Budd-Chiari syndrome in children: report of 22 cases

Clinical, radiologic, and histologic features in 22 children with Budd-Chiari syndrome are reported. Three children had acute refractory ascites; all the others had hepatomegaly, which was detected either fortuitously or because of abdominal pain or distention. Results of liver function tests were normal or only moderately abnormal. In most cases a combination of ultrasonography and needle liver biopsy pointed to the diagnosis of Budd-Chiari syndrome, which was confirmed by angiography. Eighteen children underwent surgery involving various techniques, depending on the degree of patency of the inferior vena cava. Five children died postoperatively. Histologic studies of the liver, carried out in 12 of the surviving children, showed disappearance or regression of centrilobular hemorrhagic infiltration. Half of the surviving surgical patients are now free of complications after a follow-up of 7 months to 7 years; the others have either secondary thrombosis of the inferior vena cava or stenosis of the shunt or have experienced late pulmonary complications. Our results suggest that (1) Budd-Chiari syndrome must be considered a possible diagnosis in children with firm hepatomegaly and normal or near normal liver function, (2) surgery provides good results in many instances, and (3) the possibility of late complications requires careful follow-up.

[Nutritional status of patients with digestive system cancer: preoperative prognostic significance]

We have attempted to establish a prognostic nutritional index prospectively in 633 patients with digestive carcinoma making it possible to predict tumor resectability and occurrence of postoperative complications. The following factors were studied prior to surgery: age, sex, weight loss index, triceps skinfold thickness, midarm circumference, lymphocyte count, plasma albumin, transferrin and prealbumin levels, delayed hypersensitivity as investigated by 8 skin tests. The prognostic nutritional index was calculated using Mullen's formula. Unidimensional and multidimensional studies (linear discriminant and logistic discriminant analyses with partial correlations) were used for the statistical analysis. Mortality was 6,7 p. 100 while 16,2 p. 100 of patients presented a postoperative complication. The following variables showed a significant correlation with the resectability of the tumour: weight loss (p less than 0.0001), triceps skinfold thickness (p less than 0.01), midarm circumference (p less than 0.01), total lymphocyte count (p less than 0.01), plasma transferrin (p less than 0.01), delayed hypersensitivity (p less than 0.05). In the occurrence of postoperative complications there was a statistically significant value only to weight loss (p less than 0.001) and delayed hypersensitivity (p less than 0.05). Logistic discriminant analysis gave a linear model predicting tumor resectability in 78 p. 100 of patients and postoperative complications in 86 p. 100 of patients in which weight loss and delayed hypersensitivity were statistically significant. No prognostic value of Mullen's index was found. This study shows that assessment of the preoperative nutritional status of patients with gastrointestinal cancer makes it possible to predict tumor resectability and postoperative complications.

Chylous ascites and encapsulating peritonitis: unusual complications of spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis was diagnosed in a 36-yr-old woman 3 wk after she had delivered. The patient had no past history of abdominal or pelvic disease. Ampicillin therapy was started and determined complete resolution of infectious manifestations. Ten days later, chylous ascites and chyluria were evidenced. Thereafter an ascitic effusion persisted for 2 months, when an occlusive syndrome developed, requiring emergency surgery. An encapsulating peritonitis was recognized, encasing small bowel loops, stomach and partially, pelvic organs. In this case, encapsulating peritonitis was most likely a consequence of simultaneous bacterial infection and transient lymphatic blockade. Both mechanisms should be considered in the development of this rare and usually unexplained disease.