Biomedical subjects
J Moreaux
Publications and source records attributed to J Moreaux.
["La Grande Chirurgie" by Guy de Chauliac restored by Laurent Joubert].
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[Diaphragmatic hernias in adults].
The sliding hiatal hernias are the most usual diaphragmatic hernias in adults. Their recognition and the survey of their complications are performed with esophagoscopy. Antisecretory drugs are efficient in case of esophagitis. Indications for surgery are discussed in young patients with a long-term medical treatment. The paraesophagal hernias even with a total intrathoracic volvulus of the stomach are operated through abdominal approach. The Morgagni hernias are uncommon and rarely symptomatic. The Bochdaleck hernias are exceptionally revealed at adult age. Traumatic hernias occur after penetrating injury or blunt diaphragmatic rupture in automobile accident victims. Association of serious injuries and difficulty to identify the diaphragmatic injury may explain the delay in the diagnosis. Optimal management consists of early repair of the diaphragmatic injury through an abdominal approach, to avoid strangulation of the herniated organs.
[Carcinoid tumors and neuroendocrine carcinomas of the stomach. Prognosis and therapeutic management. Study of 6 cases].
UNLABELLED: The six reported cases were separated into 2 groups: 1) the tumors of sporadic type, carcinoids (n = 2) and neuro-endocrine carcinomas (n = 2); 2) the gastrin-promoted tumors (n = 2). The purpose of this retrospective study was to review for each group of tumors, the clinicopathologic characteristics, prognosis factors and optimal management. In the first group, patients with a small and well differentiated tumor revealed by digestive bleeding, were treated by wedge excision and are alive and well 24 and 22 years later; the patients with large, invasive and poorly differentiated tumors were treated by subtotal (n = 1) and total (n = 1) gastrectomy, and died 1 year and 3 years later with metastases. In the second group, one patient with a small asymptomatic carcinoid tumor revealing chronic atrophic gastritis, was treated by endoscopic resection, without recurrence 3 years later; another patient with asymptomatic multifocal carcinoid tumors (about 100) associated with Zollinger-Ellison syndrome and multiple endocrine neoplasia type 1, was treated by total gastrectomy and is alive and well 7 years later. No patient had carcinoid syndrome. Synaptophysin was the most sensitive marker and secretion of serotonine was detected in 2 tumors. CONCLUSION: Sporadic carcinoids serotonin and neuro-endocrine carcinomas are life-threatening tumors and need aggressive surgical therapy: their prognosis depends on tumors size, histological differentiation and mostly on tumor extension. In contrast, gastrin-promoted carcinoids do not result in disseminated disease and death, and a rather conservative approach seems appropriate.
[Diagnostic pitfalls of complicated colonic diverticulosis].
Irritable bowel syndrome and (or) non complicated diverticulosis, associated with fever, could simulate diverticulitis. Cancer of the sigmoid colon appears the main differential diagnosis, when diverticulitis is associated with an atypical or complete colonic stenosis on opaque enema, with a vesicoenteric fistula or with a peritonitis due to a colonic perforation. Even at laparotomy, a pseudotumoral diverticulitis cannot easily be differentiated from a colonic carcinoma. Acute diverticulitis of the caecum or ascending colon is usually mistaken for acute appendicitis. When massive and life-threatening bleeding occurs, the diverticular origin is difficult to assess. Bleeding due to peptic ulcer disease and thermometric ulceration being precluded, arteriography performed on emergency is necessary to differentiate between diverticular bleeding and angiodysplasia.
Traditional surgical management of common bile duct stones: a prospective study during a 20-year experience.
PURPOSE: To analyze the operative findings and evaluate the hospital morbidity and mortality. This experience is documented in order to provide a basis for comparison with therapeutic alternatives. PATIENTS AND METHODS: Prospective data were collected on 579 patients who underwent elective (n = 443) or emergent (n = 136) operations between 1970 and 1990. Their mean age was 60.1 years. Prior biliary symptoms were present in 96% and suggestive of choledocholithiasis in 69%. Acute pancreatitis was associated in 3%. RESULTS: Cholecystectomy was performed with intraoperative cholangiography in 85% of cases. Stones were extracted via the cystic duct in 18%, through a choledochotomy in 79%, and through an additional sphincterotomy in 3%. Cholangioscopy has been routinely used since 1977. The incidence of extraction of the stones via the cystic duct increased and the incidence of biliary-enteric bypass decreased significantly during the second decade. Complications occurred in 24.5% of the patients. General complications were significantly fewer in the second decade than in the first (6% versus 15%). The main biliary complications were related to biliary tubes (5%) and retained stones (5%). Ten patients (2%) required early reoperation. The overall mortality rate was 0.3%. Mortality was 1.4% after emergency operations and zero after elective operations and in patients under 60 years of age. The mean stay was 16.6 +/- 7.2 days, decreasing with time. CONCLUSION: Traditional open surgery is an effective and safe option for the management of cholelithiasis with choledocholithiasis. The choice between open surgery, laparoscopic surgery, and endoscopic sphincterotomy should be made for each patient according to the local availability and efficacy of these methods.
Prospective study of open cholecystectomy for calculous biliary disease.
Data of 5000 consecutive patients with biliary lithiasis operated on between 1970 and 1990 were recorded prospectively. There were 476 emergency procedures and 125 reoperations. Concomitant abdominal operations were performed in 504 patients. The mean(s.d.) age was 54.7(14.2) years. Cholecystectomy was performed in 4872 patients (97.4 per cent) and intraoperative cholangiography in 4400 (88.0 per cent). There were 612 operations for acute cholecystitis, 579 for common bile duct stones, 50 for acute pancreatitis and 29 reoperations following injury to the bile duct. Complications occurred in 527 patients (10.5 per cent). There was one injury (0.02 per cent) to the hepatic duct. The complication rate was 7.0 per cent following elective cholecystectomy and 17.4 per cent after emergency surgery. The mortality rate was zero after elective procedures and 0.8 per cent after emergency surgery; the mortality rate after concomitant abdominal operations (1.0 per cent) was unrelated to the biliary procedure. The mean(s.d.) hospital stay was 12.8(5.2) days.
[Current aspects of stomach cancer. Surgical experience].
The incidence of gastric carcinoma is variable through the world. This incidence has significantly decreased during recent decades, in France and in industrialized countries. The decline of gastric carcinoma is attributable to changes in the living habits and mostly to preservation of foodstuffs by refrigeration; it is explained by the decrease in number of intestinal or differentiated histologic type carcinomas according to the Lauren's classification; on the contrary, diffuse or poorly differentiated histologic type carcinomas became more common in France and in low-risk areas, but is it a relative or an absolute increase? There has been also an unexplained change in location of the tumor with a decreasing incidence in the cancers occurring in the prepyloric area and an increasing incidence in those occurring in the gastric cardia area. Early gastric carcinoma should be really a precursor of the invasive gastric carcinomas. Diagnosis of gastric carcinoma is now based on gastroscopy and biopsy of the lesion. Tumoral extension through the gastric wall and nodal involvement can be appreciated by endoscopic sonography. The procedure (subtotal versus total gastrectomy) depends on the site and extent of the lesion. Elective total gastrectomy is not advocated in patients with carcinoma of the antrum. The value of extended lymph node dissection commonly performed in Japan, is still controversial in Western countries. In patients with carcinoma of the gastric cardia, there is controversy concerning the approach and type of resection, in relation with the frequent esophageal and mediastinal extension of the tumor. In a global series including 408 operated patients, the 5-year survival rate was 51% after resection with curative intent and the overall 5-year survival was 28%.(ABSTRACT TRUNCATED AT 250 WORDS)
Limy bile. A surgical experience in 16 patients.
OBJECTIVES: This study is a retrospective analysis of clinical symptoms and operative findings in 16 patients with limy bile (mean age: 47.3 years, M/F ratio: 1/7) operated on over a 25-year period. METHODS: The patients were separated into two groups: patients with limy bile limited to the gallbladder and those with limy bile extending to the common bile duct. RESULTS: In the group of patients with limy bile in the gallbladder (n = 11), previous attacks of biliary pain were present in 9 and the gallbladder was entirely inactive in 9; an elective cholecystectomy was performed; an impacted stone was found in the neck of the gallbladder (n = 5) or in the cystic duct (n = 6), and the intraoperative cholangiogram was normal. The material deposited in the gallbladder was characteristically creamy or dense, white or yellow-brown, and consisted of calcium carbonate. The patients with limy bile extending to the common duct (n = 5) were admitted with acute pain and jaundice, and operated on a few days later. In the common bile duct, limy bile was associated with small stones (n = 4). CONCLUSION: Abdominal radiographs are sufficient to identify limy bile. The presence of this condition in the gallbladder is always associated with biliary lithiasis and the obstruction of the cystic duct. The presence of limy bile in the common bile duct is due to the migration of impacted stone and calcareous material deposited in from the gallbladder. Surgical treatment is only necessary in patients with specific biliary symptoms.
Early gastric cancer. A 25-year surgical experience.
OBJECTIVE: Special emphasis has been placed on pathologic features, survival after surgical treatment, and prognostic factors. SUMMARY BACKGROUND DATA: Incidence is much lower in Western countries than in Japan. All degrees of tumor differentiation met in invasive cancer may be found. Prognosis is remarkably good, compared with advanced gastric cancer. METHODS: After reexamination of the pathologic specimens of 115 patients, 101 patients were included in this study; 58 were male. Mean age was 60.7 years. Preoperative biopsies were positive in 88%. The lesion was located in the antrum in 78 patients. Subtotal gastrectomy was performed in 85 patients and total gastrectomy in 13 patients with a RI lymph node resection. RESULTS: Cancer was extended to submucosa in 68.3%, poorly differentiated in 48.5%, and multifocal in 12.9% of patients. Lymph node involvement was present in 18.8%. Secondary deaths (n = 25) were in relation with the cancer in 6 patients only. The 5-, 10-, 15-, and 20-year actuarial crude survival rates were 88, 65, 58, and 51%, respectively. The survival rate was significantly higher for mucosal lesions than for submucosal lesions (p < 0.01). Survival showed no significant correlation with lymph node involvement, tumor size, and differentiation. CONCLUSIONS: Subtotal gastrectomy is recommended, except for proximal lesions, with survey of the gastric stump. Prognosis is significantly better for cancers limited to mucosa. Early gastric cancer is not a specific entity. Transitions between early and advanced carcinomas, especially observed in the poorly differentiated carcinomas with signet ring cells, suggest that this type of cancer should be a precursor of the invasive gastric carcinomas.
Biliary tract reconstruction after injury of the main hepatic duct.
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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.
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.
Gastric adenocarcinoma in the gastric stump after partial gastrectomy.
Carcinomas of the gastric stump are divided into two types. In the main group of patients (n = 18), carcinoma developed after resection for benign ulcer disease, and in the second group (n = 4) after resection for early gastric carcinoma. In the first group, the mean age of the patients was 63, and the male-to-female ratio of 17:1. The mean interval between the primary operation and the diagnosis of cancer was 27 years. Biopsies were positive in 16 out of 18 patients. The resectability rate was 72%, resection being performed with curative intent in 50%. Total gastrectomy was performed in 50% of the cases. There were no postoperative deaths. The 5-year survival rate was 33% for all patients and 50% after tumoral resection. Early detection was achieved by means of an endoscopic survey of the gastric stump. A comparison between gastric stump carcinomas and other gastric carcinomas in our series fails to reveal any major differences. Gastric stump carcinoma is not specific. In the second group, the mean age of the patients was 72.5 and the sex ratio 1:1. The mean interval between the two operations was 5 years. The resectability rate was 100%, and all the patients survived with follow-up ranging from 2 to 10 years. The second lesion could be considered a metachronous cancer, but it may have been present and overlooked at the time of the initial gastrectomy. Differentiating between synchronous and metachronous lesions is quite difficult.
[Diverticular sigmoiditis: surgical treatment].
From 1966 to 1990, 226 consecutive patients were operated on electively for diverticular disease of the sigmoid colon. The indications for surgery were colovesical fistula or suspicion of residual abscess, existence of two or more previous attacks of acute inflammation, existence of chronic symptoms and suspicion of colonic carcinoma. Colonic resection with primary anastomosis was performed in 217 patients with a covering colostomy in 1 case only. The Hartmann procedure was performed in 9 patients with extension of the lesions to the rectum and/or high operative risk. One or more abscesses were found by the surgeon or the pathologist in 50% of the patients. There were no postoperative deaths, no clinical anastomotic leakages. Long-term results were evaluated for the patients operated on before 1987, with a follow-up from 2 to 22 years. 85% of the patients had no more symptoms, 11% complained of persistent symptoms and 3% had recurrent attacks of pain and fever. Colonic barium enema is the best examination for diverticulitis and chronic abscesses. Surgical treatment is easier for abscesses located within the colonic wall and mesentery, than for extracolic abscesses with local peritonitis. Correlations between preoperative symptoms and operative findings are often not good. The good results obtained in 82% of the patients operated on for chronic symptoms suggest that chronic symptoms should be part of the indications for elective surgery. The low incidence (3%) of recurrent attacks of pain and fever is in favour of a resection limited to the sigmoid colon even when diffuse colonic diverticula are present.(ABSTRACT TRUNCATED AT 250 WORDS)
Elective resection for diverticular disease of the sigmoid colon.
From 1966 to 1987, 177 consecutive patients were operated on electively for diverticular disease of the sigmoid colon. The indications for surgery were: colovesical fistula (n = 12), suspicion of residual abscess (n = 39), two or more previous attacks of acute inflammation (n = 52), chronic symptoms (n = 72) and suspicion of carcinoma (n = 2). An abscess was found at operation in 76 patients (43 per cent) and this was extracolic with local peritonitis in 52 patients (29 per cent). An unsuspected abscess was found in 25 of the 72 patients operated on for chronic symptoms. Colonic resection with primary anastomosis was performed in 95 per cent of the 177 patients and in 94 per cent of those 52 patients with an extracolic abscess. There were no postoperative deaths and no clinical anastomotic leakages. Long-term results were very good in 85 per cent of the 177 patients and in 82 per cent of the 72 patients operated on for chronic symptoms. The results of this series suggest that a one-stage procedure can be safely performed with some technical precautions in most patients operated on electively for diverticular disease, even if an extracolic abscess is found. The good long-term results in patients operated on for chronic symptoms suggest that such symptoms should be taken into account with respect to surgical indications.
[Surgical treatment of common bile duct calculi. Results and outcome in a series of 707 cases].
From 1965 to 1990, 707 patients (22 p. cent aged between 70 and 80 and 6% over 80) were operated on for common bile duct (CBD) stones, with intraoperative cholangiography and endoscopic control of the duct patency since 1977. Before 1981, all patients were operated on (n = 546). After 1981, 161 patients were operated on, 30 had an endoscopic sphincterotomy (ES) and the operation was completed by an ES in 9 patients for retained stones voluntarly (n = 5) or unvoluntarly (n = 4). Before 1981, there were no postoperative deaths. One patient died during the anesthetic induction and was not operated on. After 1981, there were 3 deaths: no death after surgery, 1 after surgery + ES from acute cholangitis with multiple hepatic abscesses and 2 after ES in high risk patients. After 1981, there were no biliopancreatic postoperative complications. The incidence of operations for CBD stones has decreased in our series (400 between 1970 and 1979, 190 between 1980 and 1989) and the proportion between operations for CBD stones and operations for gallstones has decreased from 14% before 1981 to 8% after 1981. The declining of surgery is in relation to the increasing of ES. Many factors may influence the choice between surgery and ES: 1--age and general health problems, 2--complicated (jaundice, acute cholangitis, acute pancreatitis) or non complicated lithiasis, 3--gallbladder in situ with or without stones, or anterior cholecystectomy, 4--predictive difficulties for ES or for extraction of stones through ES, 5--predictive difficulties for surgery or extraction of stones through hepaticotomy, 6--experience of the endoscopic and surgical teams.(ABSTRACT TRUNCATED AT 250 WORDS)
[Extracorporeal lithotripsy in experimental vesicular lithiasis in pigs].
Experimental extracorporeal shock wave lithotripsy of gallstones was performed with the EDAP LT 01 piezoelectric lithotripter. Fragmentation of biliary stones was evaluated after implantation of human stones inside the gallbladder in 10 pigs. Lithotripsy was performed with a firing frequency of 2.5 shots per second during a mean time of 50 min. Zero to 18 days after lithotripsy, complete fragment clearance was seen in 6 cases, fragments less than 2 mm were found in 2 cases and fragments larger than 2 mm with only 1 non fragmented stone in 2 cases. There were no stone fragments in the cystic and common ducts. Damage to gallbladder and adjacent organs was appreciated after lithotripsy to the empty gallbladder of pigs with firing frequencies from 40 to 1.25 shots per second. Perforation of the gallbladder was observed in both pigs treated with a firing frequency of 40 shots per second and in 1 pig out of 3 treated with a firing frequency of 20 shots per second. With 10 shots per second and lower firing frequencies, mild histological changes of the gallbladder walls were only observed in 3 cases reoperated on the 2nd day after lithotripsy. The gallbladder wall was normal in the 5 cases reoperated on the 15th day and there were no hepatic, duodenal and pancreatic lesions. These experimental results are consistent with utilization of this machine in the treatment of gallstones in man; low firing frequencies are effective for fragmentation of gallstones without any adverse effects.