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C Barrat

Publications and source records attributed to C Barrat.

At least 37 records · Page 2Linked to original sources
PubMed1999

[Impact of learning and experience on the laparoscopic treatment of gastroesophageal reflux].

STUDY AIM: Laparoscopic treatment of gastroesophageal reflux disease (GERD) by partial (PF) or total (TF) fundoplication is the most appropriate surgical treatment after failure of medical treatment. The aim of this study was to compare the results of the same series in three consecutive periods in order to determine the effects of the learning curve and experience on the technique and outcome. PATIENTS AND METHODS: From January 1993 to January 1998, 150 patients (84 men and 66 women) with a mean age of 52.2 years (18 to 78) were included. Three groups of 49, 50 and 51 patients were chronologically defined. The comparison was established on the following criteria: the operative technique; the conversion rate; the mortality and morbidity rate; the duration of surgery and hospitalization and the results with short and medium follow-up. RESULTS: The three groups were comparable with respect to patients and GERD characteristics. One hundred and thirty two patients had a TF and 18 had a PF. Rossetti's type TF became the reference procedure (80.3% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between group I and the two other groups (138, 100, 80 min). The rate of conversion decreased from 10.2% to 4% and then 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 14.3% to 4% and then 0%. Seven cases of recurrence occurred (4.6%), 5 in group I (10.2%), 2 in group II (4%), and 0 in group III, (with a shorter follow-up). CONCLUSION: The effect of the learning curve has to be taken into account in the training of surgeons (within experienced departments, with "guidance" during initial interventions) and also in the evaluation of results, in order to allow a more accurate comparison between the different treatments for GERD.

Adolescent↗
PubMed1999

[Post mortem diagnostic laparoscopy].

The authors report a case of laparoscopy post mortem for unexplained inpatient death. It is minimally invasive, easy to perform, accurate, and not disfiguring. As well, it is easy to accept among mourning families. It should be considered when consent for conventional autopsy is lacking.

Aged↗
PubMed1999

[Effects of surgical education and training on the results of laparoscopic treatment of inguinal hernias].

STUDY AIM: The aim of this retrospective study was to compare two concurrent series of patients operated on for inguinal hernia with the same laparoscopic procedure, the first one in a teaching hospital with a number of trained surgeons and the second one in a private center with only one trained surgeon. PATIENTS AND METHOD: Five hundred and forty-one patients with 757 hernias were operated on over a period of six years by a totally pre-peritoneal laparoscopic approach. Two hundred and sixteen patients were operated on in a teaching hospital by 48 surgeons (six senior and 42 trainee surgeons; group I), 325 were operated on in a private center by one surgeon who had been trained in the same teaching hospital (group II). The two groups of patients and their hernias were comparable. The comparison was established on the following criteria: duration of operation, rate of conversion, length of hospitalization, morbidity and mortality rate, recurrence rate and costs. RESULTS: Operations performed by surgical trainees were associated with: (1) a mean operative time significantly (P = 0.01) longer for both unilateral (68 vs. 41 min) and bilateral (108 vs. 68 min) hernias. The operative time did not change in the teaching hospital and decreased with experience in private practice (from 62 to 25 min for unilateral hernias); (2) more frequent per-operative complications, particularly opening of the peritoneum (28% vs. 3%, P = 0.001); (3) a mean duration of hospitalization significantly (P = 0.05) longer, on average by 1.6 d; (4) a morbidity rate after 30 days significantly higher (16.2% vs. 4.9%, P = 0.01); and, (5) higher costs. There was no significant difference concerning mortality rate (nil), conversion rate (1.5%) and recurrence rate (1.3% vs. 0.6%, non significant). CONCLUSION: Surgical training for laparoscopic treatment of inguinal hernias was associated with a longer operation time and hospital stay, and with higher morbidity and costs. After a good initial training in a teaching hospital, surgeons were capable of performing laparoscopic repair of inguinal hernias with good results.

Adolescent↗
PubMed1999

[Laparoscopy in the staging of cancer of the stomach].

Prognosis of gastric carcinoma is closely related to extension. Laparoscopic staging of digestive cancers is proposed to evaluate the regional cancer spreading (TNM). The aim of this procedure is to avoid unnecessary laparotomy, and to reduce mortality and morbidity of these procedures. Laparoscopic staging can also make easier the selection of patients of preoperative treatment. In most of the series about laparoscopic staging, efficacy of the usual staging tools (computed tomography, ultrasonography, endoscopic ultrasonography) is weak and before operation 20 to 30% of the metastases, particularly peritoneal and hepatic, are missed. Laparoscopic staging is technically easy: no more than 3 trocars are necessary, laparoscopic ultrasonography may be performed during the same procedure, as well as peritoneal cytology. Feasibility is about 100%. Usual contraindications of the laparoscopy are contraindications of laparoscopic staging. The main difficulty is its utility. Staging of advanced lesions remains the best indication of laparoscopic staging in gastric cancer. Metastatic spread, particularly to the peritoneum, and resectability may be evaluated with sensitivity and specificity close to 90%. Morbidity (1 to 3%) is usually low and mainly represented by wound complications.

Carcinoma↗
PubMed1999

The effect of the learning curve on the outcome of laparoscopic treatment for gastroesophageal reflux.

The laparoscopic treatment for gastroesophageal reflux (GR) by partial (PF) or total (TF) fundoplication is the current surgical treatment of choice after failure of appropriate medical treatment. The overall results with fundoplication include the initial learning period, during which the rate of complications, conversions, and duration of surgery and hospitalization are assumed to be greater. The aim of this study was to compare the results of laparoscopic treatment for GR in three groups of consecutive patients to determine the effect of the learning period on outcome. One hundred and fifty-six patients (88 men and 68 women) with an average age of 52.3 years (range, 18-78) were included. Surgery was indicated for failure or early relapse after the end of medical treatment or a symptomatic sliding hernia. The preoperative workup (endoscopy, barium meal, or esophageal pH monitoring) was governed by the clinical picture. The choice between TF and PF was based on the results of pH monitoring. Three groups of patients were chronologically defined. The parameters that were examined were the type of preoperative exploration, the type of fundoplication, the operative technique, the conversion rate, the mortality and morbidity rates, the duration of surgery and hospitalization, and the results at short- and medium-term follow-up. The three groups were comparable with respect to patient characteristics and the nature of their GR. All patients had an endoscopy, 91% had a barium meal, 77.5% underwent esophageal manometry, and 67% had pH monitoring. One hundred and thirty-six patients had a TF and 20 had a PF. Rossetti type TF became the reference procedure (67% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between groups I and groups II and III (140, 100, 80 minutes, respectively). The rate of conversion, due to a variety of causes, decreased from 9.8% to 3.8%, and then to 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 15% to 3.8%, and then to 0%. There were seven cases of relapse (4.6%), five in group I (10%) and two in group II (4%), with no cases in group III, although the follow-up in group III was shorter. There is an effect of the learning curve on the outcome of treatment for GR, and this must be taken into account in the training of surgeons (training within experienced departments and guidance during their initial interventions) and also in publications to allow a more accurate comparison of this technique with other treatments for GR.

Adolescent↗
PubMed1999

Does laparoscopy reduce the incidence of unnecessary appendicectomies?

The aim of this study was to evaluate the impact of laparoscopic appendicectomy on the incidence of histologically normal appendices. Between 1987 and 1997, 1,220 patients (average age 23.5 years [17-73]; 841 women [69%]) had appendicectomy due to the presence of at least one of the following three criteria: right iliac fossa guarding, fever >38 degrees C, and leukocytosis >10,000. Patients were divided into two groups: one group of 930 patients were operated on using the classic Mac Burney approach and the other group of 355 patients underwent laparoscopic exploration, with an appendicectomy performed if macroscopic abnormalities were observed (290 cases). In all cases, the appendices were examined blind and classified as normal or pathologic, with the latter divided with respect to the nature and severity of the lesions. In the Mac Burney group, the incidence of histologically normal appendices was 25.1%. In the laparoscopic group, the incidence was only 8.2% (p=0.015). The types of pathologic appendices were identical between the two groups. In 65 cases (18.3%), a macroscopically normal appendix was left in place. In 56 cases the symptoms were due to another identified cause, however, in 10 cases no cause was found. All patients were followed-up for an average of 3 years. One patient (1.8%) had a second operation (an appendicectomy), which revealed minor histologic lesions. The problem is the inability of the operator to differentiate between a healthy and a pathologic appendix on laparoscopy. The risk of false-positives and false-negatives is approximately 10%. Diagnostic difficulties usually occur in the initial phase of the disease with acute mucosal involvement in a morphologically normal appendix. At this stage the outcome cannot be predicted, although appropriate antibiotic treatment can be effective. This study shows that laparoscopy significantly reduces the number of histologically normal appendices as compared to a conventional Mac Burney operation. This can only be achieved by not removing macroscopically normal appendices, a small proportion of which (5-10%) could be cases of early appendicitis with only mucosal involvement. In the absence of other causes of the symptoms, a 3-day course of antibiotics can be tried to treat possible mucosal lesions. This approach reduces costs without having adverse consequences on the outcome.

Adult↗
PubMed1998

[Laparoscopic treatment of generalized peritonitis with diverticular perforation of the sigmoid colon. Report of 10 cases].

BACKGROUND: The classical treatment of perforated sigmoid diverticulitis with generalised peritonitis is based on the principle of two-stage surgical procedures with a temporary initial defunctioning colostomy. This approach is associated with significant morbidity, concerning mainly the abdominal wall. PATIENTS AND METHODS: Ten consecutive patients, eight female and two male, with a mean age of 54.6 years, underwent an emergency laparoscopy for generalised peritonitis secondary to perforated diverticula. Six had had previous infectious episodes; six were obese; four were diabetic and two had chronic lung disease. After exploration of the abdominal cavity and discovery of a purulent peritonitis (n = 8) or faecal peritonitis (n = 2), an extensive peritoneal lavage was performed (average 15 litres), the contaminating sigmoid lesion was covered with biological glue and a drain inserted at the site of the lesion. In some cases, drainage of dependent zones was also performed. No colostomies were performed. Antibiotic therapy instituted as soon as the diagnosis had been made was continued, on average, for 7 days. RESULTS: There was no mortality. There was a low morbidity: one case of lymphangitis on catheter and one of broncho-pulmonary infection. No cases of abdominal wall sepsis or residual deep collections were observed. The mean duration of hospitalisation was 8 days. Nine patients underwent a sigmoid resection (laparoscopic in eight cases) 3 to 4 months later, with a mean duration of hospitalisation of 6 days. One conversion to laparotomy was necessary. CONCLUSIONS: Laparoscopic treatment of generalised peritonitis secondary to perforated sigmoid diverticulitis constitutes an alternative to classical surgery. It is associated with a decreased morbidity and a marked reduction in duration of the hospitalisation. Colostomy can be avoided and the patient's quality of life is improved during the period previous to secondary colectomy, performed by laparoscopy eight times out of nine. In addition, the cost of this approach is significantly lower.

Adult↗
PubMed1998

[Evaluation of pancreatic cancer by combined laparoscopy and echolaparoscopy].

STUDY AIM: This prospective study was undertaken to evaluate the efficiency of staging laparoscopy associated with laparoscopic ultrasonography in the assessment of tumoural extension and surgical resectability in patients with carcinoma of the pancreatic head. PATIENTS AND METHODS: From June 1995 to March 1997, 26 consecutive patients (11 male and 15 female patients), with a mean age of 62.5 years, were included in this study. The lesion was located in the pancreatic head with jaundice. Four staging methods were used: percutaneous ultrasonography (n = 26) computed tomography (n = 26), endoscopic ultrasonography (n = 26). The assessment of resectability by each procedure was verified by surgical exploration and histologic examination. RESULTS: Results of percutaneous ultrasonography and computed tomography were similar, predicting unresectability in 50% of the patients. Endoscopic ultrasonography performed in the 16 patients without visible metastases according to the previous procedures predicted surgical resectability in seven patients only. With staging laparoscopy associated with laparoscopic ultrasonography, undiscovered metastases were found and unresectability was predicted in 21 patients out of 26; the sensitivity was 100% for liver metastases, peritoneal metastases and vascular involvement, 90% for lymph node involvement and 88% for diagnosis of the primitive lesion. A Whipple procedure was performed in five patients and a palliative bypass in all the other patients except one. An unnecessary laparotomy was avoided in 12 patients. CONCLUSIONS: Staging laparoscopy associated with laparoscopic ultrasonography is superior to all other staging methods. It should be the first step of a potentially curative surgical treatment (five cases only in this series) or of a palliative bypass. Laparotomy was avoided in 12 cases.

Adult↗
PubMed1998

[Videolaparoscopic treatment of splenic injuries. A study of 5 cases].

BACKGROUND: When splenic trauma does not require an emergency splenectomy in order to achieve hemostasis, the current policy is either observation under close surveillance, with transfusions if necessary, or conservative surgical procedure through laparotomy. Videolaparoscopic approach has the advantage of achieving in the same procedure, complete evacuation of the hemoperitoneum, full investigation of the abdominal cavity and repair of the damaged spleen. PATIENTS AND METHODS: Over a 4-year period, five patients aged 27.3 years on average, with severe splenic trauma but no major hemodynamic disturbance, were operated on by emergency laparoscopy. The diagnosis of splenic lesion had been confirmed preoperatively by ultrasonography. The procedure performed by open laparoscopy included evacuation of the hemoperitoneum and blood clots and splenic hemostasis which was achieved by the use of electrocoagulation and biological glue, associated in three cases with omentoplasty. Drains were inserted systematically. RESULTS: The average length of operation was 75 min. There were no cases of conversion, nor mortality, no morbidity. The average duration of hospitalization was 10 days. No blood transfusions were required. A CT-scan was performed immediately in the postoperative course and served as the baseline for comparison during the follow-up. There were no reinterventions. The longest follow-up was 4 years and the mean follow-up 2.5 years. Laboratory tests or isotopic imaging did not detect any change in splenic function. CONCLUSION: In specific defined circumstances, videolaparoscopic repair of splenic trauma is justified provided that careful attention is paid to the patient's condition.

Adult↗
PubMed1998

[Video-parietoscopic surgery of the abdominal wall. A study of 15 cases].

AIM: The aim of videoparietoscopic surgery is to repair an abdominal wall weakness or defect without affecting the overlying skin, mainly for cosmetic reasons, and especially in young women. PATIENTS AND METHOD: A supra-pubic or umbilical approach was used, depending on the site of the lesion to be repaired. A 10 mm trocar with a sponge mandrin was placed in contact with the aponeurosis. After an initial dissociation of the cellular tissue, progressive insufflation with CO2 produced extensive detachment of the cutaneous plane upwards and laterally. Using one or two 5 mm trocars, the aponeurotic plane was progressively freed and the pathological zones were identified and repaired with standard endoparietal sutures or with percutaneous sutures using a Reverdin needle. Fifteen patients (14 females, one male) with a mean age of 30 years (19-36), were treated by parietoscopy for a diastasis of the rectus abdominis (five cases), an eventration (three cases) or an epigastric or linea alba hernia (seven cases). RESULTS: A conversion to a classical technique was necessary in one man with a diastasis of the rectus abdominis, due to fibrous tissue which did not allow a subcutaneous plane of detachment to be obtained. Successful repair was possible in 14 cases. The mean operating time was 1 h 20 min; the mean duration of hospitalisation was 2 days (1-3). There was no mortality or morbidity. With a mean 18-month follow-up (range: 4-40), cosmetic and functional results were excellent. CONCLUSION: Abdominal videoparietoscopy allows repair of minor parietal pathologies while preserving the overlying skin. It is indicated for cosmetic reasons in young women with normal skin overlying a localised abdominal wall defect or weakness.

Abdominal Muscles↗
PubMed1998

[Port site metastasis. Prospective study of 131 cases].

Laparoscopic staging and laparoscopic treatment of gastrointestinal malignancy is still controversial because some studies report port sites metastases. The aim of the study is to determine in 131 patients, with prospective follow-up, after laparoscopic staging or laparoscopic treatment, the incidence of port site metastases. 131 patients with localized a gastrointestinal malignancy or other advanced malignant tumors were included. In 57 cases only laparoscopic staging was performed, in 25 cases the laparoscopic staging was followed by a laparoscopic resection and in 49 cases after laparoscopic staging a traditional laparotomic treatment was performed. In 57 cases (43.5%) the tumor invaded the serosal layer. The median follow-up was 17.7 months (3 to 62 months). 502 port-sites were controlled. One patients (0.7%) presented one port site metastases after right colectomy for carcinoma with local carcinomatosis. This study confirm that port sites metastases are rare, and that are favorised by serosal invasion and support the laparoscopic staging of malignant abdominal tumors in order to recognize occult lesions which are not detected by conventional preoperative clinical, biological and radiological explorations (44.2% in this study). In addition, selected patients can be submitted to laparoscopic treatment of the disease (20%).

Adult↗
PubMed1998

Evaluation of the biliary tree during laparoscopic cholecystectomy: laparoscopic ultrasound versus intraoperative cholangiography: a prospective study of 150 cases.

From November 1994 to March 1996, 150 patients treated by laparoscopic cholecystectomy were included in a prospective study, to compare intraoperative cholangiography (IOC) and laparoscopic ultrasonography (LU). The biliary tree was successively explored by these two methods in the routine detection of common bile duct stones. The feasibility of LU was 100%. Cholangiography was performed only in 125 cases (83%). The time taken for LU was significantly shorter (11.6 vs. 17.6 minutes, p = 0.0001). In this study, common bile duct stones were found in 14 cases (9%). For their detection, results were comparable to LU and IOC. For LU, sensitivity was 80% and specificity 99%; and for IOC, 78 and 97%, respectively. Both examinations combined had a 100% sensitivity and specificity. Laparoscopic ultrasonography failed to recognize the intrapancreatic part of the common bile duct in 25 cases (17%) and did not show anatomic abnormalities detected by IOC. It did, however, detect other unsuspected intraabdominal abnormalities. Although LU is safe, repeatable, and noninvasive, a considerable learning curve is necessary to optimize its efficacy. Comparison of relative cost must be undertaken.

Adult↗
PubMed1998

[Laparoscopic treatment of pancreatic pseudocyst. 3 cases].

Three patients with pancreatic pseudocysts were treated laparoscopically by cysto-enteric by pass. Two developed a large cyst in the course of acute biliary pancreatitis. The third patient had chronic pancreatitis of unknown etiology. The mean size of the collection was 12 cm (8-20). Treatment was performed with a delay of 80 days (30-300) after the onset of the disease. Two patients underwent laparoscopic cysto-gastrostomy using laparoscopic ultrasound. Stapling anastomosis appears easy and safe. The third patient underwent operating laparoscopically assisted cysto-jejunostomy with an-Y loop. Mean time was 120 minutes (90-200) and hospital stay was 7 days (5-8) without morbidity. The follow-up was 18 months without radiological recurrence and with excellent clinical results.

Adult↗
PubMed1998

[Inguinal hernia. 4-year follow-up of 2 comparative prospective randomized studies of Shouldice and Stoppa operations with pre-peritoneal totally laparoscopic approach (461 patients)].

The aim of this study was to evaluate the late (4 years) recurrence rate after laparoscopic totally preperitoneal (TPP) approach, to Shouldice and Stoppa procedures. All patients were reviewed at one, six months, one year and yearly there after. The mean follow-up was 4 years: the follow-up was 100 per cent at one month, 98 per cent at 6 months, 95 per cent at one year, 91 per cent at 2 years, 84 per cent at 3 years, 79 per cent at 4 years and 61 per cent at 5 years. At one year, the recurrence rate was 2.2 per cent in the laparoscopic group, 1.2 per cent for Shouldice and 0 per cent for Stoppa procedure (ns). At 3 years, the recurrence rate was comparable and 3.6 per cent for laparoscopy, 5.1 per cent for Shouldice and 5.2 per cent for Stoppa respectively (ns). At 4 years, the recurrence rate was lower (but ns) for the laparoscopic group 7.4 per cent versus 12.5 and 10.5 per cent. Two predictive factors for recurrence in laparoscopic treatment were the size of the mesh and the surgeon's experience.

Adult↗
PubMed1998

[Is laparoscopic evaluation of digestive cancers legitimate? A prospective study of 109 cases].

UNLABELLED: This aims of this study is to evaluate after laparoscopic exploration or treatment in digestive cancers, the incidence of port site metastases and the incidence of unnecessary laparotomy in advanced disease. PATIENTS: 109 patients were included in this study: 91 had localized digestive cancers and 18 had disseminated disease with hepatic and/or peritoneal metastases. METHODS: All the patients underwent a laparoscopy and a laparoscopic ultra-sonography under general anesthesia prior to a definitive decision on therapeutic management. Depending on the circumstances, histological or cytological biopsies were performed. The puncture sites of the trocar were examined clinically and, if required, by ultrasonography, monthly through out the course of the disease. Chemotherapy was instigated in 60.5 per cent of patients. RESULTS: 35 patients (32.1 per cent) only had one laparoscopic examination with a mean survival of 4.8 months, 22.9 per cent of patients had laparoscopic treatment of their lesion and 44.9 per cent had conventional treatment. Laparoscopic exploration allowed the detection of 52 lesions that had not been identified by conventional imaging techniques and thereby avoided 35 laparotomies (32.1 per cent). Tumor invasion of the peritoneum was present in 46 per cent of cases, most notably in the cases of pancreatico-biliary cancers. The overall mean survival was 32.7 months while it was 9.8 months in cases of palliative treatment. In total, 436 trocars were used. There was one case (0.9 per cent of patient or 0.02 per cent of port) of a metastasis occurring at the site of the trocar following treatment by right-sided, laparoscopic colectomy in a patient with disseminated cancer. Two factors seem to be involved peritoneal spread of the tumor and manipulation of the tumor. CONCLUSIONS: Laparoscopic exploration for digestive cancers is a legitimate technique. It allows the detection of lesions that are not identified by conventional imaging techniques, permits a more accurate assessment of the resectability of a tumor and reduces the number of unnecessary laparotomies. The incidence of metastases at the site of the trocar is low and is closely linked to the presence of disseminated disease and manipulation of the tumor.

Adult↗
PubMed1998

[Risk factors and prevention of thromboembolic risk in laparoscopy].

The aim of this prospective study was to assess the clinical thrombo-embolic risk in laparoscopic digestive surgery. The study prospectively included 2384 patients, who underwent surgery between April 1991 and June 1997. All patients received peri-operative Low Molecular Weight Heparin (LMWH) thromboprophylaxis. This regimen was administered until the patients resumed normal ambulatory activity. Eight cases of phlebitis were observed (3.36/1000), but no pulmonary embolism was noted. In six out of eight cases, the diagnosis of deep vein thrombosis was established after cessation of LMWH delivery, after the patients were discharged home, and before day postoperative 10. Pneumoperitoneum predisposes to deep vein thrombosis formation. Long operations, and reverse Trendelenburg are aggravating factors. In laparoscopy, heparin thromboprophylaxis has to be identical to that of open conventional surgery; i.e. appropriate for the potential risks and must be delivered for a duration of 7 to 10 days. We recommend the use of graduated compression stockings, to reduce intra-abdominal pressure and the duration of reverse Trendelenburg, and to perform intermittent exsufflation.

Adolescent↗