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Biomedical subjects

B Millat

Publications and source records attributed to B Millat.

At least 55 records · Page 3Linked to original sources
PubMed1999

Laparoscopic versus open appendectomy: time to decide.

Although widely practiced, laparoscopic appendectomy (LA) has not met with universal approval. Several controlled trials have been conducted, some in favor, others not. The goal of this review was to ascertain (1) if laparoscopy was capable of improving the diagnostic and therapeutic difficulties encountered during open appendectomy (OA) and (2) if the introduction of laparoscopy in the overall management of acute appendicitis has changed anything in practice. Analysis and criticism of 17 controlled studies (nearly 1800 patients) on laparoscopic appendectomy and 2 randomized studies dealing with diagnostic laparoscopy are reported. Because of the questionable quality of randomized controlled trials (number of patients, exclusions, withdrawals, blinding, intention-to-treat analysis), publication biases, local practice variations (hospital stay, rate of enrollment), results regarding analgesia requirements, return to activity and work, duration of hospital stay, outcome, follow-up, and antibiotic prophylaxis the studies must be interpreted with caution. The real world of appendicitis probably differs greatly from the atmosphere under which controlled trials comparing LA and OA have been performed. Statistical significance is contrary to the clinical significance of the results. Consistently longer operating times [the difference ranging from 8 minutes (NS) to 29 minutes (p < 0.0001)], a minimal reduction in hospital stay [0. 1 day (NS) to 2.1 days (p < 0.007)], and, somewhat more controversial, an earlier return to normal activity were reported for LA. Data on analgesic requirements were confusing, but wound complications were more frequent after OA [pooled odds ratio for 10 studies: 2.6 (95% CI 1.3-5.2)]. Unsolved problems include national behavioral problems, age and experience of operating surgeons (LA or OA), and emergency conditions (availability of staff, instruments). Results of cost analysis vary according to the standpoint of disease, the patient, the surgeon, the treatment center, industry, and society. Three questions remain: Because of the competition of LA versus OA, OA has improved greatly. Can it be improved any more? Is there a place or need for further randomized controlled trials? Should we not conclude once and for all that LA is out?

Appendectomy↗
PubMed1999

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

OBJECTIVE: To evaluate the impact of randomised clinical trials (RCT) on decision-making and therapeutic policies among general and gastrointestinal surgeons in France. DESIGN: Telephone questionnaire. SETTING: Multicentre study, France. SUBJECTS: A random sample of 152 surgeons, mean (SD) age 50 (8) years. INTERVENTIONS AND MAIN OUTCOME MEASURE: Surgeons were asked 12 questions about their knowledge of RCT and how trials were conducted; influence of RCT on their treatment policies; means of obtaining information about treatments; how they evaluated their own results; whether they were willing to take part in RCT; and personal details including age, speciality, and type of practice. Surgeons were stratified according to age and type of practice. RESULTS: 148 questionnaires were suitable for analysis. 83 surgeons (56%) were under 50 years old, 38 (26%) were exclusively gastrointestinal surgeons, 82 (56%) worked in private practice, and 36 (24%) worked in teaching and university hospitals. The rest undertook mixed duties. When asked to say where they obtained their knowledge about antibiotics, 91 (61%) referred to RCT; these were mainly hospital-based, gastrointestinal, and younger surgeons. Asked to name a RCT-based policy, 81 (55%) gave medical rather than operative examples. 80 (54%) had already participated in a RCT; 79 (53%) said that they were willing to participate in a RCT that included random allocation of patients (there were no statistically significant differences in answers according to speciality or type of practice, although younger surgeons answered "yes" to both questions). Specialised journals were the main source of information for 115 (78%), and surgeons read a mean of 40 issues/year. 142 (96%) read journals in French and 66 (45%) in English, but this number fell to 10 (15%) of the 65 surgeons aged 50 or more. Personal experience was considered a more important source of therapeutic knowledge by older and specialist surgeons. 109 surgeons (74%) recalled patients during the first month postoperatively to evaluate their results. CONCLUSIONS: French surgeons, particularly those aged 50 or over, are not well informed about the nature, conduct, and value of RCT. Most of their information is acquired through reading and attending scientific meetings and congresses. Surgeons tended to attach more importance to the fame of the author than to the conduct of the study. The overall impact of RCT was weak among the surgeons questioned.

Adult↗
PubMed1999

Management of intraductal papillary mucinous tumours of the pancreas.

OBJECTIVE: To focus attention on the management and outcome of patients with intraductal papillary mucinous tumours of the pancreas. DESIGN: Retrospective study and analysis of published reports. SETTING: University hospital, France. SUBJECTS: 111 patients (101 published cases and our own 10 cases) divided in two groups: the first including malignant tumours (n = 46), and the second group benign or in situ tumours (n = 61). In 4 patients the type of tumour was not known. MAIN OUTCOME MEASURE: Resectability, mortality and recurrence. RESULTS: More men had benign or in situ tumours [48/61 (79%) compared with 28/46 (61%), p = 0.054]. Pancreatitis was more common among benign than malignant tumours [34/61 (58%) compared with 21/46 (46%), p = 0.33]. In group I, 39 patients had diabetes. A total of 107 patients were operated on: pancreaticoduodenectomy (n = 54, 50%), distal pancreatectomy (n = 25, 23%), total pancreatectomy (n = 4,4%), bypass (n = 2,2%). The type of resection was not mentioned in 22 records (21%). Four patients were not operated on because of their poor general condition. The resectability rate was 98% (105/107). Eleven patients had died at the time of publication. Hospital mortality rate was 3% (n = 3), mainly because 2 of the 4 who had total pancreatectomy died. With a median follow-up of 37 months, recurrence was 5% (n = 5). CONCLUSION: Intraductal papillary mucinous tumours of the pancreas are well known distinctive pancreatic tumours that are usually intraductal but may develop into invasive carcinoma. They should be resected, and have a good prognosis and low recurrence rate.

Adult↗
PubMed1998

General and gastrointestinal tract surgery in France.

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

Digestive System Surgical Procedures↗
PubMed1998

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

OBJECTIVE: To compare surgical treatment (ST) with endoscopic management (EM) in patients with suspected common bile duct stones. PATIENTS: Two hundred twenty eligible patients originating from 18 surgery units. Patients enrolled in this multicenter randomized study had clinical symptoms that included jaundice, mild pancreatitis (Ranson score < or = 2), or mild acute cholangitis; biliary colic (with increased alkaline phosphatase levels); and common bile duct stones or a common bile duct diameter of 1 cm or larger on ultrasonography. METHODS: Two hundred two patients were randomly assigned to either ST (n=105) or EM (n=97) during a 5-year period. Both groups were comparable with respect to age, sex, American Society of Anesthesiologists score, and clinical presentation. MAIN OUTCOME MEASURES: The rates of early postoperative additional procedures necessary to deal with the impossibility to perform the initial procedure, complications, and retained stones after ST or EM. Subsidiary endpoints were intention-to-treat analyses of mortality and of major complications and the duration of hospital stay. RESULTS: Surgical treatment was associated with a significantly (P<.001) lower rate of 1 or 2 additional procedures (8% vs 29%) due to a significantly lower rate of the impossibility to perform the initial procedure (0% vs 5%) (P<.05), major complications (4% vs 13%) (P<.05), and retained stones (6% vs 16%) (P<.04). Minor complications occurred more often in patients having ST (4%) than in those having EM (0%) (P<.01). Cholecystectomy was performed routinely in 102 patients having ST and electively in 36 patients having EM. There was 1 death in each group initially. On an intention-to-treat analysis, 3 deaths (3.1%) occurred after EM and 1 (0.9%) after ST; this difference was not statistically significant (P=.56). Major complications occurred in 4% of patients having ST compared with 1 1% of patients having EM (P<.002). The median duration of hospital stay was 16 days in patients having ST and 12 days in those having EM; this difference was not statistically significant (P=.09). CONCLUSION: Whether an additional cholecystectomy is performed routinely or electively, the high risk of additional procedures after EM precludes its use as the optimal therapy in patients with symptomatic common bile duct stones, except in those with severe cholangitis.

Aged↗
PubMed1998

Laparoscopic splenectomy for benign and malignant hematologic diseases: 35 consecutive cases.

The feasibility and safety of laparoscopic splenectomy (LS) has been shown for a variety of diseases with small or moderately enlarged spleens. Immune thrombocytopenic purpura thus has become the typical indication for LS, although few data are available to demonstrate any superiority of the laparoscopic approach over conventional surgery for this indication. We retrospectively analyzed 35 cases of LS for benign (22 patients) or malignant (13 patients) hematologic disorders. LS was attempted irrespective of the volume of the spleen. The overall operative mortality rate was 2.9%, and complications occurred in 23% of all patients. The conversion rate was 9%, and accessory spleens were found in 17% of patients. Although the patients with malignant disease were significantly older, were higher operative risks (ASA score), had much larger spleens, and required longer operative times, more conversions to laparotomy, and more blood transfusions than patients with benign disease, their mortality and complication rates and the duration of their hospital stays were not significantly different from those with benign disease. They also compare favorably with the results of conventional surgery for the same indications. Patient selection, operative technique, and outcome of laparoscopic and conventional splenectomy are discussed with regard to the literature. Although the experience with LS for these indications is still limited, the reported results indicate that LS may be as beneficial for patients with malignant as for those with benign hematologic conditions.

Adult↗
PubMed1998

[Is it necessary to monitor patients surgically treated for colorectal cancer?].

Survival improvement in patients operated on for colorectal cancer might be the consequence of early diagnosis, rather than improvement in the treatment and follow-up. Therefore the question is: how to follow-up patients operated on for colorectal cancer? And even: is it necessary to follow-up these patients? Follow-up has two intentions, to diagnose metachronous tumors (adenomas and cancers), and to reveal a relapsing disease. However more than a relapse, diagnosis of a "residual" disease is questioned. This residual disease was present after what was thought to be a "curative" treatment, but lack of sensitivity of our diagnosis tools delayed the diagnosis. Follow-up is worthwhile if prognostic of patient treated of their "residual" disease is better when diagnosis is made during this follow-up, rather than when it is postponed until the disease become symptomatic. This has never been proved. Exams which should not be performed anymore are: CA 19-9, liver tests, systematic CT scan (as a diagnosis exam, but CT scan is worthwhile when a curative treatment is expected), systematic repeated colonoscopy. Conclusions on follow-up proposed at a recent consensus conference reached consensus in that it justified exams which effectiveness was never proved....

CA-19-9 Antigen↗
PubMed1997

[Treatment of inguinal hernias: indications].

Inguinal hernia represents the second most frequent indication in general surgery after appendectomy in France. The dogma in France is to operate all inguinal hernia. Inguinal hernia repair is responsible for 500,000 hospital days and 3,500,000 days off work per year, to which must be added the operative costs, a 15% postoperative complication rate, and 6 to 12% reoperations for recurrence. Hernia strangulation and surgery are the only circumstances which can be fatal whereas otherwise, inguinal hernia is a functional disorder. Socio-economical analysis of routine inguinal hernia repair, once diagnosed, has to come with ends as regard costs, risks, and benefits of treatment. In view of the multiplicity of factors such as the type of hernia, medical status of patients, functional compromise, and socio-economical impact which can influence indications for inguinal hernia repair, it seems likely that one same technique might not the best for all patients. The Shouldice repair is cited as being the best because it is the only technique whose results have been validated with rigor. In future trials, other techniques, and notably laparoscopic hernia repair, must therefore be compared to the Shouldice technique.

Health Care Costs↗
PubMed1997

Frequency and risk factors of recurrent pain during refeeding in patients with acute pancreatitis: a multivariate multicentre prospective study of 116 patients.

BACKGROUND/AIMS: The period of refeeding in patients with acute pancreatitis is critical because they may have pain relapse. A multicentre, multidimensional, prospective study was performed to assess the frequency and the risk factors of pain relapse in these patients. METHODS: Patients were included if they had acute pancreatitis severe enough to stop oral feeding for more than 48 hours. Clinical, biochemical, radiological, and therapeutic data were prospectively recorded and analysed by unidimensional and multidimensional analysis. The moment to refeed patients was chosen by the clinician but the diet was the same in all centres. RESULTS: A total of 116 patients were included with a Ranson's bioclinical score > or = 3 in 35% and a Balthazar's CT score > or = D in 42%. The cause of acute pancreatitis was biliary in 47% and alcohol misuse in 31%. During the oral refeeding period, 21% of the patients had pain relapse. This occurred on days 1 and 2 in 50% of patients. The duration of the painful period was longer in patients who relapsed than in others (p < 0.002). Pain relapse occurred in 39% of patients with a serum lipase concentration > 3x the upper limit of the normal range the day before refeeding and in 16% of other patients (p < 0.03). Patients with higher Balthazar's CT scores had pain relapse more often than the others (p < 0.002). None of the therapeutic procedures significantly modified the frequency of pain relapse. Using multidimensional analysis, Balathazar's CT score, period of pain, and serum lipase concentration the day before refeeding were independently associated with an increased risk of pain relapse. At a threshold of 0.5, a logistic score had a 37% sensitivity, 95% specificity, and 83% accuracy to predict pain relapse. Pain relapse nearly doubled total hospital stay and hospital stay after the first attempt at oral refeeding. CONCLUSION: Pain relapse occurred in one fifth of the patients with acute pancreatitis during oral refeeding and was more common in patients with necrotic pancreatitis and with longer periods of pain. The results of this study can be used to predict high risk patients and are a first step in the prevention of pain relapse.

Acute Disease↗
PubMed1997

Laparoscopic antireflux surgery--technique and results.

Although gastroesophageal reflux disease (GERD) can be effectively treated by proton-pump inhibitors, surgery is still the only means of definitive cure of the disease. After introduction of laparoscopic surgery, there has been a clear trend to surgical repair of the incompetent cardia. The indications for surgical treatment are: endoscopically proven esophagitis, persistent or recurrent complaints under medical treatment, esophageal stricture and/or pH-metrically proven acid reflux as well as reflux-induced coughing (chronic aspiration). Although the laparoscopic antireflux operations is a technically demanding procedure, it can be performed with similar results as compared to conventional surgery. The operative technique is reported in detail. From January 1992 to March 1997, 146 consecutive patients with GERD have been operated on laparoscopically. The overall conversion rate was 8.2% (n = 12). 133 patients were operated on according to the Nissen procedure including hiatoplasty. The Toupet operation was performed in only one case. 84 men and 42 women had a mean age of 49 years (20-76). The median duration of symptoms was 48 months (1-600). Except five patients all had medical treatment for at least 2 years. Twice pneumatic balloon dilatation of an esophageal stricture was necessary preoperatively. The median operation time was 210 minutes (70-660). Conversion to open surgery because of intraoperative complications was necessary in 6 patients. Postoperative complications occurred in 14 patients, all of them being successfully treated conservatively. No patient died. 121 patients (90.3%) had follow up examinations for at least 6 months. Retreatment was necessary in 5 cases: 1x slipped Nissen (laparoscopic repair), 1x intrathoracic hernia (conventional reoperation), 2x dysphagia > 4 months postoperatively (endoscopic balloon dilatation) and 1x recurrent ulcer (conventional operation). With a correct indication, laparoscopic Nissen repair for GERD is a suitable, safe and definitive treatment.

Adult↗
PubMed1996

Tolerance of laparoscopy for resection of phaeochromocytoma.

We describe two patients who underwent resection of phaeochromocytoma by a laparoscopic approach. Although outcome from surgery was successful, there was marked variability in hormonal and haemodynamic changes. In one patient, despite an infusion of nicardipine, peritoneal insufflation produced a marked increase in catecholamine concentrations associated with transient but intense vasoconstriction, but there was no change in the second patient. In both patients, exsufflation caused no significant haemodynamic changes in spite of the high doses of nicardipine given throughout the procedures.

Adrenal Gland Neoplasms↗