Does laparoscopic colorectal resection for diverticular disease impair male urinary and sexual function?

BACKGROUND

Laparoscopic colorectal resection may induce bladder and sexual dysfunction secondary to injury to the autonomic nervous system. The aim of this study was to evaluate urinary and sexual function in male patients after laparoscopic colorectal resection for diverticular disease.

METHODS

From January 1997 to March 2002, we performed a retrospective analysis of urinary and sexual function in 56 consecutive male patients who had undergone laparoscopic colorectal resection for diverticular disease. Preoperative and 6-month postoperative assessment was carried out using data collected via standardized postal questionnaires.

RESULTS

Three patients were excluded (one had a prior prostatectomy, one had Peyronie's disease, and one was treated with neuroleptics). Fifty-three patients with a mean age of 54 A+/- 2 years were included in the study. There were no conversions. The morbidity rate was 9.4%. Mean follow-up was 27 A+/- 2 months. There was no significant difference in preoperative and postoperative urinary function. Fifty-one patients (96%) were sexually active preoperatively and were still sexually active postoperatively. Compared with the preoperative period, postoperative impairment of libido, erection, ejaculation, and orgasm were not significant. Every patient was able to achieve ejaculation after the intervention, and no retrograde ejaculations were reported. One patient was unable to have an erection after the intervention.

CONCLUSION

Laparoscopic colorectal resection for diverticular disease does not significantly impair urinary and sexual function.

Reversal of abnormal collagen production in Crohn's disease intestinal biopsies treated with regenerating agents

BACKGROUND

Crohn's disease (CD) is characterised by inflammation, muscle layer overgrowth, and collagenous fibrosis of the intestinal tract, with no effective therapy against collagen accumulation.

AIMS

We quantified production of collagen in resection specimens from normal and CD patients and investigated the effect of regenerating agents (RGTAs) on collagen production. RGTAs are chemically substituted dextrans engineered to mimic the growth factor protecting effects of heparan sulphates. RGTAs have been shown to enhance tissue repair in various in vivo models and to modulate in vitro collagen phenotype differentially according to their structure.

PATIENTS

We studied intestinal biopsies from two groups of CD patients: treated with glucocorticoids (CD-GC group: 10 patients) or not treated (CD group: seven patients), and from seven control patients.

METHODS

After 24 hours of ex vivo incubation with (3H) proline, collagen I, III, and V were extracted by pepsin and quantitatively separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. Biosynthesis of each collagen type was quantified on radiolabelled isolated collagen.

RESULTS

Total intestinal collagen production in CD patients compared with controls was increased up to 3.5-fold overall (p<0.001). In particular, collagen III biosynthesis was enhanced by 6.2-fold (p<0.001) in CD patients. In the CD-GC group, collagen production abnormalities were less marked. RGTAs added to the incubation medium in the CD group decreased total collagen production by 50% and decreased collagen III synthesis by 76%.

CONCLUSION

This finding offers a rationale for using RGTAs in the treatment of intestinal fibrosis in CD, thus opening up a potential new therapeutic field for this family of drugs.

Anal sphincter injury after forceps delivery: myth or reality? A prospective ultrasound study of 93 females

PURPOSE

This study was designed to estimate the prevalence of anal sphincter injury after forceps delivery in a large population of females managed by trained obstetricians in a French hospital and to identify factors predictive for anal sphincter injury.

METHODS

We performed a prospective study of healthy females older than 18 years with no history of anal incontinence, anorectal abnormalities, or anorectal surgery after their first vaginal delivery. All females were interviewed using a standardized questionnaire concerning intestinal transit and continence status. Physical examination and endoanal ultrasonography were performed after delivery.

RESULTS

Between November 1999 and November 2000, 93 females were included in the study after their first forceps delivery. Eleven patients (11.8 percent) had a partial defect involving the external sphincter, visible on ultrasonography. One patient (1.1 percent) had a partial defect of external sphincter with complete defect of internal sphincter (sequelae of primary repair of a third-degree perineal tear). Seventeen patients (18.2 percent) had flatus incontinence, and four patients (4.3 percent) had liquid stool incontinence. A high daily number of stools was significantly associated with sphincter defect visible on ultrasonography (P=0.02). The development of anal incontinence was not related to sphincter defect on ultrasonography. There was a strong association between perineal tear and sphincter defect visible on ultrasonography (odds ratio, 4.5 (range, 1.2-16.7)).

CONCLUSIONS

Anal sphincter injury after forceps delivery was identified in <13 percent of our large population of healthy females. Our study does not confirm previous observations that anal sphincter injury is common after forceps delivery; previously published studies may have overestimated the prevalence of this condition. The only factor with significant predictive value for anal sphincter injury was perineal tear. Anal endosonography should be recommended after obstetric perineal tear.

Teleconsultation before chemotherapy for recently operated on patients

BACKGROUND

Some operated on cancer patients require specialized complementary chemotherapy. Often, this takes place in another institution, where the patient consults the medical oncologist before hospitalization. The aim of this study was to analyze the potential benefit of a videoconference consultation within this framework.

METHODS

Sixteen operated on cancer patients hospitalized in the Surgical Unit received a teleconsultation in the presence of their surgeon and with the chemotherapist at some distance. During this period, the modalities of chemotherapy proposed, the duration of the teleconsultation, the economy of transport, and so on were noted. Twenty-four hours later each patient filled in a questionnaire aimed at, one, evaluating the quality of the image on an visual analogue scale (VAS) and the potential inconvenience involved; and two, evaluating the index of patient satisfaction on VAS. Furthermore, the last 12 patients filled in a questionnaire adapted to each of them, according to the information they had received. Each correct answer was noted 1, and each incorrect answer was noted 0. A memorization percentage was deduced.

RESULTS

The average age of the 16 patients was 63.4 years (range 46 to 78). The average duration of the teleconsultation was 27 minutes (12 to 40). The index of image satisfaction was 61.3%. As for the last 12 patients, 9.8 questions (7 to 12) enabled the calculation at 24 hours of the percentage of data retained by the patient (memorization index) based on the modalities and consequences of the chemotherapy. The percentage of correct answers was 80.5%. Fourteen of the 16 patients considered that teleconsultation had its advantages. Two patients would have preferred a classic consultation. The global satisfaction index was 79.9%. The average cost of functioning per patient was 187.76 FF A saving in transport of 509.92 FF was recorded per patient.

CONCLUSIONS

In the context of this original study, teleconsultation neither altered the doctor-patient relationship nor the quality of the message transmitted. Furthermore, it encourages closer links between complementary teams working at a distance and multidisciplinarity in cancerology.

[Pretherapeutic endosonography in rectal adenocarcinoma]

The advent of transrectal ultrasonography has contributed to improving therapeutic management of cancer of the rectum. The 7.5 MHz transrectal probe evidences five tissue layers in the rectal wall. The 10-12.5 MHz probe can visualize seven layers. Transrectal ultrasonography can also be used to explore the perirectal environment and detect possible nodes. Echographically, the tumor is seen as an hypoechogenic mass invading the rectal wall outwardly, disorganizing the wall structures. Parietal recurrence is seen as a hypoechogenic heterogeneous thickening. Ultrasonographic surveillance can be proposed for operable patients with a high risk of recurrence. Cautious interpretation is required due to the known limitations of transrectal ultrasonography. Truly invaded nodes may not be seen due to their small size (less than 2-3 mm) or their localization far from the probe (false negatives). Transrectal ultrasonography provides important information for therapeutic decision making in terms of surgical access and/or indications for possible adjuvant therapy. Transanal resection may also be ruled out if there are perirectal nodes. Patients may also be selected for preoperative radiotherapy, possibly associated with chemotherapy.

[Laparoscopic rectopexy: our experience in the treatment of complete rectal prolapse]

Surgical treatments of rectal prolapse still await a final arrangement. The aim of this work is to present Authors' experience with 12 female patients who underwent laparoscopic rectopexy. The patients, aged between 67 and 84 years, were suffering of a different degree of incontinence classified according to the Browing and Parks scale. Pneumoperitoneum was induced through the Veres needle end 5 trocars were placed. The technique used was the modified Orr-Loygue. One no death was observed and only two not serious intraoperative complications were registered, in both conversion to laparotomy was not necessary. Functional result as for incontinence has been really good (disappeared in 11 cases and improved in one). Whereas regarding the constipation, no improvement was observed in those in who in it was preexisting the operation, not appearing nevertheless, as on the contrary reported by other Authors, in those in whom it wasn't present before surgical treatment. The patients, all in follow-up (range between 10 and 36 months, average 25.08), still now experienced no relapse. In conclusion, on the base of Authors' experience, laparoscopic rectopexy is considered free of particular risks and excellent in the results even if, due to the slight number of series, any definitive judgement can be expressed.

[Videolaparoscopic treatment of paraesophageal hiatal hernia]

STUDY AIM

The aim of this prospective study was to report the results of videolaparoscopic repair in a series of ten patients with paraesophageal hernia.

PATIENTS AND METHODS

From January 1982 to September 1998, ten patients (three men and seven women, mean age: 68 years [range: 42-87]) were operated on for paraesophageal hernia. An intrathoracic gastric volvulus was present in four patients, a severe anemia in four and two were asymptomatic. All interventions were performed laparoscopically and included sac resection, crura closure and realization of a posterior gastric valve on 270 degrees.

RESULTS

There was one irruption of gastric juice in the bronchial tree at the beginning of the anesthesia which required assisted ventilation for 3 days. The mean follow-up was 17.5 months (range: 3-50). There was no postoperative diarrhea and no gas bloat syndrome. Eight patients complained of postoperative dysphagia which disappeared within 6 weeks, except in one patient with esophageal motility disorder postoperatively discovered. None of the patients had postoperative gastroesophageal reflux. A chest X-ray performed after 1 year detected no hernia recurrence in seven patients. There was no recurrent anemia after 6 months.

CONCLUSION

The videolaparoscopic repair of paraesophageal hernias is feasible without any technical difficulties even in aged patients with precarious physical conditions. The results are good with a mean follow-up of 17.5 months.

[Trocar-induced complications in laparoscopy]

Trocar-related injury can occur if the different procedures, including distension of the abdomen, pneumoperitoneum or anesthesia, are insufficient. Such injuries can be prevented by proper handling and good angulation of the trocar on the abdomen. In case of suspected vascular injury, conversion to open laparotomy is required to explore the abdominal cavity. If abdominal adhesions are discovered after introducing the first trocar, a second trocar must be introduced at some distance from the first one to visually check the absence of any digestive injury. The degree of wound dehiscence depends on the size, site and direction of introduction of the trocar.

[37 so-called biliary cysts of the liver in adults]

Clinical manifestations, clinical course and therapeutic schemes were studied in 37 patients with a surgical indication for biliary cysts of the liver observed in a surgery unit over 25 years. Cyst size varied from 2 to 30 cm and was greater than 10 cm in 12 cases. Yellowish-clear contents were observed in 23 cases and purulent or hemorrhagic contents in 3 each. Twenty-three patients were asymptomatic, 14 had pain and/or complications (hemorrhage 3, infection 3, compression 3, rupture 1). Therapy was abstention in 7 cases, puncture in 5, resection of the protruding dome in 17, complete exeresis in 5, and hepatectomy in 3. There were no deaths and morbidity reached 7%. Biliary cysts of the liver can be discovered fortuitously at surgery or imagery or in patients with abdominal pain, an abdominal mass or complications including compression, intraperitoneal rupture, intracystic hemorrhage, hemobilia, acute infection, torsion, cancerization. Diagnosis requires sonography and computed tomography. Therapeutic indications are: abstention for small asymptomatic cysts. For voluminous cysts, with complications or confirmed during a supramesocolic operation, the risk of recurrence or aggravation of the complications excludes puncture or injection of a sclerosing agent. Wide resection of the protruding part of the cyst with histology resection can be performed although prospective assessment is needed. Cystectomy is not indicated if there is a diagnostic doubt. Hepatectomy is an exceptional indication retained for patients with uncontrolable hemorrhage, intra-cystic tumors or voluminous cysts destroying the lobe.

Protective transverse loop colostomy associated with low colo-rectal anastomoses

A transverse loop colostomy to protect a low colorectal anastomosis should be carried out with minimal morbidity and mortality related to its creation and closure. A modification of the conventional technique is described.

Intraoperative and laparoscopic sonography of the liver

Intraoperative sonography is an important aid in the decision making process during open surgery because it can detect additional small liver tumours that may not be depicted preoperatively, even with the use of modern non invasive imaging modalities. A continued important role of intraoperative sonography is to determine hepatic anatomy, allowing for safer and easier hepatic surgery with increased parenchymal preservation. Intraoperative sonography is also used for monitoring cryogenic ablation of hepatic tumour. To overcome the inherent limitations of laparoscopic surgery, laparoscopic sonography can now be used to provide information not available during laparoscopy or laparoscopic surgery alone. In this article, the authors present the most recent techniques for intraoperative sonography. Also they emphasize the important role of intraoperative sonography and laparoscopic sonography in the surgical decision-making process in patients with hepatic or biliary disease and report the most recent advances in intraoperative sonography with respect to the treatment of hepatic tumours. Finally, they try to look forward at the possible use for intraoperative technologies that are now in their early stages.

[Ischemic colitis. A surgical series of 88 cases]

We report our experience in 88 cases of ischemic colitis including 76 cases of gangrene with 17 perforations, 6 cases with stenosis and 6 cases which regressed. The left colon was involved in 59 cases with extension to the transverse colon in 20 the right colon in 10 and global involvement in 18. Abdominal pain, diarrhea, and meteorism occurred in 81, 62 and 78% of the cases respectively. Coloscopy was performed in 61 cases, a barium study in 27. A colectomy was required in 77 patients: 50 left colectomies with 16 extensions to the transverse colon, 17 total colectomies and 10 right colectomies. Morbidity was 53% in cases with perforated gangrene and 28% without perforation. There was no morbidity in stenosis and regressive forms. Normal tube flow was conserved or reestablished in 51 of the 62 survivors. The 88 patients were referred from cardiovascular units (36%), intensive care (28.5%), or internal medicine (22%). All had intramural ischemia due to local or general lesions which progressed to parietal gangrene in 76 cases. The diagnosis was based on clinical signs and confirmed by coloscopy which determined the stage and extension. Stage II ischemia required rapid colectomy adapted to the endoscopic lesions and not the exterior aspect of the colon; immediate anastomosis is usually not used.

Non-breath-hold fast spin-echo versus breath-hold fast spin-echo and spoiled gradient-recalled echo MR imaging in the detection of hepatic tumors: correlation with surgical findings

OBJECTIVE

Our objective was to compare the sensitivity of non-breath-hold T2-weighted fast spin-echo with and without fat suppression, breath-hold T2-weighted fast spin-echo without fat suppression, and spoiled gradient-recalled echo (GRE) MR imaging for detecting hepatic tumors using surgical findings as the standard of reference.

SUBJECTS AND METHODS

Eighteen patients with 36 surgically proven hepatic tumors had non-breath-hold T2-weighted fast spin-echo (6000/117 [TR/effective TE; echo train length, 16) MR imaging with and without fat suppression, breath-hold T2-weighted fast spin-echo MR imaging (2700/105; echo train length, 20), and spoiled GRE images (10.1/1.9; flip angle, 30 degrees) obtained before and after injection of a gadolinium chelate. Images were analyzed separately by two independent readers, with disagreements resolved by consensus reading.

RESULTS

Non-breath-hold T2-weighted fast spin-echo MR imaging with and without fat suppression depicted 22 (61%; 95% confidence interval [CI], 43-77%) and 20 (56%; 95% CI, 37-72%) of 36 hepatic tumors, respectively. Breath-hold T2-weighted fast spin-echo imaging allowed detection of 19 (53%; 95% CI, 35-69%) of 36 hepatic tumors. Unenhanced and gadolinium chelate-enhanced spoiled GRE images allowed depiction of 18 (50%; 95% CI, 33-67%) and 29 (81%; 95% CI, 63-91%) of 36 hepatic tumors, respectively. Gadolinium chelate-enhanced spoiled GRE images allowed depiction of significantly more hepatic tumors than any of the other pulse sequences.

CONCLUSION

Gadolinium chelate-enhanced spoiled GRE imaging is more sensitive than T2-weighted MR imaging obtained with a breath-hold or a non-breath-hold technique.

[Ogilvie's syndrome or colonic pseudo-obstruction. Apropos of 26 cases]

From twenty six personal cases, the authors make a review of the literature. 92% of their cases are met in a post operative (28%), neurological (28%), general (24%) context, or in intensive care with assisted ventilation (36%). The major symptom is the meteorism (100%) with in one out of three cases, abdominal pain, vomiting, right iliac defense, absence of bowel sounds. Radiological distension involves mostly the right colon and the coecum (28%), right and transverse colon (40), sometimes the whole colon (32%). The mean diameter of the coecum reached 12 cm (9 to 25 cm). Early coloscopy was mandatory in 20 patients, of which 14 were cured, 13 patients were operated on, for suspicion of ischemia or perforation, because incertain diagnosis, or failure of colonoscopy. Ceocostomy or right hemicolectomy (55%) were performed rather than transverse colostomy. The surgical approach must be adapted to the anatomical lesions. Total mortality was 4% in this series. Early diagnosis of pseudo obstruction, early colonoscopy with intubation must allow to avoid surgery.

[Evolution of Hartmann's procedure. 249 interventions]

A retrospective study of 249 patients undergoing Hartmann's procedure over twenty-five years was undertaken to analyse the evolution of indications and results. Patients were divided into three time period groups: from 1969 to 1978, 1979 to 1990 and 1991 to 1994. Mean age was 68 years old. Major indications were complicated diverticular disease (42.9%), colo-rectal malignancies (35.7%) and ischemic colitis (14%). Operative mortality is 10.8%, higher in ischemic colitis (20%) than in complicated diverticulitis (6.5%) and cancer (13.4%). Overall morbidity has significantly reduced, from 65.51% to 17.24%. General complications have changed a little, while local and/or inherent operative complications have reduced from 22.4% to 1.72. Restoration of colorectal continuity was done in 59.54% of patients, increasing from 36% to 71% during the three periods. This is variable depending on initial disease: 92% in diverticular disease, 69% in ischemic colitis but remains stable for carcinoma at 33%. Overall mortality since 1981 is 2.5% and morbidity is 19.13%. Mean Hospital stay was 20 days for the initial operation and 15 days for secondary restoration of colorectal continuity. Hartmann's procedure is well indicated as emergency surgery in colonic perforations, abscessus and ischemia. Progressive improvement of its results is essentially due to persistent attention to indications and technical details.

Gallstone recurrence after successful lithotripsy

We report the recurrence rate of gallstone within 5 years after successful lithotripsy. One hundred and fifty consecutive patients (solitary stones, 102 patients; multiple stones, 48 patients) were followed up for a median of 42 months (range 6-72) after stone clearance and cessation of bile acid therapy. No patient received any therapy to prevent recurrence. Thirty-seven patients developed recurrent gallstones. Probabilities of recurrence were (mean +/- SD) 6.6% +/- 2%, 15.7% +/- 3%, 22.8% +/- 3.6%, 29.7% +/- 4.5%, 32.2% +/- 5% at 1, 2, 3, 4 and 5 years, respectively. The recurrence rate was lower in patients who had solitary stones than in patients with multiple stones (26.1% versus 47% at 5 years, respectively; p<0.009 - log rank test). Only five patients developed recurrent symptoms or stone complication (14%). We conclude that the recurrence rate after successful lithotripsy is lower than expected from dissolution studies, due to a low recurrence rate in patients who had solitary stones.

A 270 degree laparoscopic posterior fundoplasty in the treatment of gastroesophageal reflux

BACKGROUND

The aim of this prospective study was to evaluate the results of laparoscopic treatment of gastroesophageal reflux using a posterior fundoplasty.

STUDY DESIGN

Fifty-one patients with gastroesophageal reflux or paraesophageal hernia, or both, documented by fibroscopy, acid reflux monitoring, and manometry were evaluated. The operative technique consisted of abdominal esophagus mobilization, approximation of the crura, and construction of a 270 degree posterior gastric valve, 5 to 7 cm in height. A clinical examination was performed after two weeks, four months, one year, and two years, and fibroscopy, acid reflux monitoring, and manometry were done at four months.

RESULTS

One patient required a conversion to laparotomy. One opening of the gastric valve was repaired laparoscopically. There was no perioperative death. Morbidity was limited to one case of pulmonary aspiration of gastric juice. All patients but one who were operated on laparoscopically have been clinically evaluated between four and six months after surgery. There was no dysphagia, diarrhea, or gas bloating reported after two months. Four patients without clinical symptoms refused to go through postoperative explorations. Among the 45 remaining patients, one had a reflux recurrence and another only an abnormality on acid reflux monitoring. There was no degradation of the clinical result among the 26 and 12 patients seen at one and two years, respectively.

CONCLUSIONS

A 270 degree posterior fundoplasty can be performed laparoscopically without major morbidity. A short follow-up examination confirms the efficacy of the procedure and the absence of specific morbidity. If these results are confirmed, they could be an argument to broaden the indications of the antireflux procedure as compared to prolonged medical treatment.

[Post-surgical or traumatic anal incontinences. Prospective study in 40 patients explorated by endorectal ultrasonography and electromyography]

OBJECTIVES

Anal endosonography is used to assess anal canal structure and external anal sphincter. The purpose of this study was to compare findings at anal endosonography with electromyographic tests in patients with faecal incontinence.

METHODS

Fourty patients (31 women; median age: 47 years) were referred for exploration of the anal sphincter: 15 patients had previous anal surgery, 16 patients had obstetrical trauma, 3 patients had accidental trauma, 6 women had obstetrical trauma and previous anal surgery.

RESULTS

Anal endosonography demonstrated an external sphincter defect in 19 patients (partial n = 4, complete n = 15); 18 of these patients had an electromyographic study: an external sphincter defect was demonstrated by mapping in 15 cases; 3 partial defects were not found. Eight patients had associated pudendal nerve terminal motor latency delayed due to neuropathic impairment of pudendal nerve. Surgery was performed in 12 patients; external sphincter lesion was confirmed in all cases.

CONCLUSIONS

Anal endosonography and electromyography mapping easily recognize external sphincter disruption with high concordance. Partial defects are better diagnosed by anal endosonography. A study of pudendal nerve terminal motor latency is useful in the exploration of faecal incontinence because pudendal neuropathy occurs frequently in association with a sphincter defect.

[Reoperation for locoregional recurrence of cancer of the rectum]

71 recurrences after rectal resections for adenocarcinoma have been operated upon. After 43 initial anterior resections (AR), the treatment of recurrence was in 19 patients a new resection and in 18 a simple colostomy. When the initial treatment was a Mile's operation (APR in 23 patients), it has been performed 10 new exerses and 5 electrocautery. In the whole series, mortality and morbidity were respectively 17.5 per cent and 8 per cent. After AR the long term survival was 40 months when the initial tumour was classified Dukes A, and only 12 months when it was classified Dukes B or C. After APR the median long term survival was only 12 months. 75 per cent of the recurrences are observed during the first two years after initial resection. The screening includes repeated clinical examination, CEA dosage, endorectal sonography, endoscopy and CT scan. The appreciation of extirpability requires clinical examination, CT scan, MRI imaging. The aim is 1. to avoid exploratory and/or palliative operations. 2. to appreciate operating difficulties and to choose an adequate approach. The indication of systematic enlarged resections has to be appreciated related to patient's comfort and survival.

Laparoscopic hepatic sonography

Laparoscopic hepatic sonography is becoming a standard procedure with the arrival of specifically designed probes. The technique of liver exploration used in open surgery has to be adapted. The technique we propose is initiated by a sagittal sonography associated with rotation movements. The basic exploration follows firstly the hepatic veins and then the portal branches. During the period of vascular exploration, the corresponding liver parenchyma is examined. As the quality of the laparoscopic sonography is becoming equivalent to that observed in open surgery, in the near future the results of laparoscopic and open surgery sonography will probably be identical.

Low early gallstone recurrence rate after successful extracorporeal lithotripsy in patients with solitary stones

Piezoelectric lithotripsy with the EDAP LT-01 machine combined with adjuvant bile acid therapy results in complete clearance of radiolucent gallstones in selected patients. We assessed stone recurrence rate in 84 patients with complete clearance of stone fragments and followed up at least 12 months after cessation of bile acid therapy (mean 17 months, range 12-33). Fifty-four patients had a solitary stone and 30 multiple stones. Bile acid therapy was continued for 3 months after complete fragment stones clearance which was ascertained by two consecutive ultrasound examinations. Stone recurrence was assessed by ultrasonography at 6 and 12 months, and then at least once a year. Gallstone recurrence occurred in 5 patients (6%) between 9 and 12 months with no further recurrence up to 33 months. The rate of recurrence at one year was 3.7% in patients with a solitary stone and 10% in patients with multiple stones. Only one patient with stone recurrence had recurrent biliary pain. We concluded that early gallstone recurrence rate after successful lithotripsy seems to be low in patients with solitary stones.

Intraoperative sonography during cholecystectomy for gallstones

The current study reports on the ease and results of intraoperative sonography in 131 patients operated upon for gallstones. Sonography was performed through a standard incision or a small incision, without duodenal mobilization and prior to systematic cholangiography. Sonography or cholangiography, or both, detected biliary duct stones in eight patients. The entire biliary tract was visualized by ultrasound in 123 patients. Sonography identified seven patients with stones in the major biliary ducts and overlooked only a single stone of the cystic duct. In contrast, intraoperative cholangiography failed to reveal stones in a right hepatic duct and led, in another instance, to unnecessary choledochotomy. During cholecystectomy for gallstones, sonography is a simple efficient technique providing good detection of biliary stones. It is the study of choice and cholangiography is required in only selected instances in which sonographic visualization is incomplete. There may be future value in sonographic applications for laparoscopic cholecystectomy.

Treatment of gallstones with piezoelectric lithotripsy and oral bile acids. A multicenter study

The efficacy of the combination of piezoelectric lithotripsy and oral bile acids in the treatment of gallbladder stones was assessed. Three hundred and sixty-three patients with symptomatic radiolucent gallstones in functioning gallbladder were treated in five medical centers using the same protocol with the EDAP LT 01 lithotripter. No anesthesia, analgesia or sedation was used. After one session of lithotripsy, fragmentation was observed in 89% of the patients, and satisfactory fragmentation (fragments less than or equal to 5 mm) in 29%. The satisfactory fragmentation rate was higher in patients with solitary stones less than or equal to 20 mm than in patients with solitary stones 21-35 mm or multiple stones (p less than 0.001). After multiple sessions (mean 1.6 session/patient, range 1-5) the overall rate of satisfactory fragmentation was 50%. After 12 months on oral bile acid therapy, complete clearance of the gallbladder was observed in 69% of patients with solitary stones less than or equal to 20 mm, 25% of patients with solitary stones 21-35 mm and 37% of patients with multiple stones. No complication was observed during the lithotripsy. During follow-up under bile acid therapy, there were five complications (1.4%): four patients had acute cholecystitis and one had mild, self-limited pancreatitis. We conclude that piezoelectric lithotripsy with the EDAP lithotripter is a safe and effective treatment which can be performed in outpatients. Satisfactory fragmentation and rapid disappearance of stones are obtained mainly in patients with solitary stones less than or equal to 20 mm.

[Adenocarcinoma of the duodenum. 17 cases]

Seventeen cases of duodenal adenocarcinoma are reported and compared with cases from the literature. Ten tumours were located in the second part of the duodenum, 9 were around the hepatopancreatic ampulla, 4 were above and 4 below this ampulla. Four tumours (23 per cent) had limited intramural expansion (Dukes' stage A or B) and 6 (35 per cent) involved the lymph nodes. The major clinical signs were loss of weight (11 cases), signs of obstruction (9 cases), bleeding (6 cases) and jaundice (6 cases). The paraclinical examinations that were determinant for the diagnosis were gastroduodenal radiographic study (16 cases) and endoscopy with biopsy (9 cases). Computerized tomography was useful for preoperative evaluation. The respective values of these examinations for early diagnosis and excisability of these tumors are discussed. All 17 patients were operated upon: 11 (64.7 per cent) underwent radical excision, 5 had duodenal bypass and 1 had exploratory laparotomy. The overall operative mortality rate was 5.8 per cent, with no deaths for bypasses and excisions. Mean survival after bypass was 5 1/2 months. The one year survival was 63.5 per cent in 5 patients with excision and 83.3 per cent in 6 patients with cephalic duodenopancreatectomy, but none of these patients survived for more than 5 years.

[Anal metastases from cancer of the colon]

Two cases of anal metastases from sigmoid carcinoma are reported. The two patients were treated by local excision. The various mechanisms of tumoral spread are discussed from a review of the literature; the most frequent mechanism is cellular exfoliation. The most commonly used therapeutic approach is local excision combined, if necessary, with reconstruction of the sphincters.

Endorectal sonography in the management of rectal villous tumours

Thirty-seven patients with rectal villous tumours were investigated by endorectal sonography to assess the integrity of the rectal muscularis propria at the tumour level. In four cases assessment of invasion was impossible. In 24 patients, endosonography revealed an ultrasonically superficial lesion not infiltrating the muscular layer. This was confirmed either, in the case of laser treatment, by the absence of malignant recurrence during the follow-up period or by histological examination after surgical resection. In nine patients, endosonography showed infiltration of the muscular layer. This was histologically confirmed in five operated patients. In the remaining four, laser destruction was performed: in two, a rectal adenocarcinoma was present 3 and 6 months later, respectively. These findings show that endosonography has a place in the management of rectal villous tumours, demonstrating invasive cancer in cases where other forms of assessment were wrongly reassuring.

[Extracorporeal lithotripsy of gallbladder calculi. Tolerability, complications and early results]

The purpose of this prospective study, conducted on 88 patients, was to assess the tolerance, efficiency and early complications due to a piezo-electric lithotriptor in the destruction of gallbladder stones. One hundred and sixty one sessions were performed in 82 patients. All patients had symptomatic, uncomplicated lithiasis, the diameter of which was less than, or equal to, 30 mm. All patients had less than 7 stones in a functional gallbladder. In 22 patients, the stones were calcified. Lithotripsies were carried out without anesthesia or premedication, except in an 8-year-old child who had to be anesthetized. In 3 cases it was impossible to visualize the gallstones and in 3 other patients, the procedure was discontinued because of abdominal pain. Following the procedure, biliary pain occurred in 20 per cent of the patients. One patient only had biliary colic with transient anicteric cholestasis. Clinical examination, sonography, biological tests were found to be normal in all other patients. Endoscopic sphincterotomy or emergency surgery was never required. Stones were found to be unaltered in 6 patients following 2 lithotripsy sessions. The 76 other patients had fragmentation of their stones. The free gallbladder rate was 15.8 per cent between 0 and 2 months, 24.6 per cent between 2 and 4 months and 51.3 per cent between 4 and 8 months. These results tend to show that the destruction of biliary stones by piezo-electric lithotriptor is efficient and well tolerated. As repeated routine examinations were always negative, the three-day hospitalisation period no longer seems necessary.

[Treatment of complicated peptic esophagitis. Role of total duodenal diversion]

Total duodenal diversion was performed in 60 patients with reflux oesophagitis complicated by stricture, brachyoesophagus, endobrachyoesophagus or previous oesophago-gastric surgery. The standard operation (truncal vagotomy, antrectomy, 70 cm Roux-en Y anastomosis) was carried out in 41 patients; technical adjustments were necessary in 19 patients previously operated. One patient died of post-operative pulmonary embolism. Lasting cure of the oesophagitis was obtained within less than 3 months in 56/59 patients (93 per cent). Three-hour post-prandial pH measurements showed control of the reflux in 48/52 patients (92 p. 100). Anastomotic ulcers developed in 3 patients who did not have vagotomy. One case of complete remission of endobrachyoesophagus was observed, and 4 cases are now in partial remission. Digestive tract sequelae were found in 9 patients who had undergone surgery, but they were disabling in only one of these. These results suggest that total duodenal diversion is a suitable treatment of complicated reflux oesophagitis.

[Mirizzi's syndrome]

Six cases of Mirizzi syndrome are reported. The syndrome consists of a special anatomical variant of the cystic duct, which has a low opening but runs side-by-side with the common bile duct, associated with entrapment of a gallstone in the cystic duct or the neck of the gallbladder, partial or total obstruction of the hepatic duct by the stone and by inflammatory lesions, and recurrent cholangitis. Clinical signs are non-specific and suggest at first sight an obstructive jaundice. Pre-operative morphological examination seldom provide a diagnosis before surgery. In the most typical cases ultrasonography shows dilatation of the upper biliary tract with narrowing of the hepatic duct below the dilatation, due to a stone located outside the common bile duct. Opacification of the biliary tract by endoscopic retrograde catheterization of the papilla duodeni or by transparietohepatic puncture give suggestive images (non-opacification of the cystic duct, narrowing of the hepatic duct opposite the extrinsic compression, with overlying dilatation), but these images are not specific. The per-operative diagnosis is difficult owing to the inflammatory lesions, and a diagnosis of cholangiocarcinoma may be envisaged. Cholecystectomy with recanalization of the cystic duct suppresses the extrinsic compression and helps the inflammatory lesions to regress. However, opening and draining the common bile duct is often necessary.

Preoperative assessment of the extension of rectal carcinoma: correlation of MR, surgical, and histopathologic findings

Nineteen patients with rectal carcinoma were evaluated prospectively. The extent of tumor and the relationship of the tumor to the levator ani muscle were studied as this determines the choice of the surgical procedure (abdominoperineal resection versus low anterior resection). Peroperative assessment and detailed evaluation of the pathologic specimens were correlated with magnetic resonance (MR) features. Magnetic resonance staging and surgical findings were at variance in four of 15 cases (27%). Magnetic resonance had sensitivities and specificities of 75 and 100% in the detection of perirectal growth. Magnetic resonance demonstrated invasion of adjacent pelvic side wall and sacrum in two of two cases. The comparison with TNM classification demonstrated that MR correctly staged 15 of 19 cases (79%). This study shows that MR is a good examination to evaluate the involvement of perirectal fatty tissues and adjacent structures. The low prevalence of involved lymph nodes in our cases prevents significant positive predictive values. Nevertheless, MR can help to select patients for local excision or for preoperative radiotherapy.

[Endorectal ultrasonography: evaluation of locoregional extension of cancers of the rectum]

The treatment of rectal carcinoma is mainly determined by its local extension, which is difficult to assess before surgery. Our purpose was to determine the reliability of endorectal echography (ERE) in order to provide preoperative assessment of local extension of rectal tumors. Twenty-five patients with rectal adenocarcinoma were included in this study. Seventeen tumors could be felt by rectal examination. ERE was impossible in one case. Echographic data were compared with anatomic findings in 24 patients. ERE provided an accurate assessment of the parietal involvement in 22 cases. The sensitivity and specificity of ERE in determining the spread of the tumor to the rectum alone were 1 and 0.89, respectively, superior to the results provided by clinical examination alone (sensitivity 0.84-specificity 0.76). When the results of the two investigations were identical, all patients were well classified. For lymph node involvement, the sensitivity and specificity of ERE were 0.71 and 0.76 respectively. These results show that ERE is one of the best investigations currently available for assessing parietal involvement of rectal tumors. ERE might be able to determine the appropriate place of radiation therapy, local excision or anal sphincter preservation.