AIM OF THE STUDY: This prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseases. MATERIAL AND METHODS: The study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectability or potential resectability (n = 34) and irresectability (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy. RESULTS: For endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar. CONCLUSIONS: Imaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.

Adenocarcinoma↗

PubMed1998

Treatment of local recurrence of rectal cancer.

BACKGROUND: Treatment of local recurrence of rectal cancer remains a challenge. Preoperative irradiation and total mesorectal excision halve the risks of local failure, but increase morbidity and even mortality. The results of re-resection of recurrent rectal cancer suggest need to reexamine therapeutic strategies for initial treatment. METHODS: Seventy-one patients operated on for rectal carcinoma without radiotherapy developed local recurrence (29 with metastatic disease). Thirty underwent a curative re-resection (8 had combined resection of metastases). RESULTS: The incidence of asymptomatic recurrence was higher after anterior resection (38%) than after abdominoperineal resection (16%). The actuarial 5-year survival rate was 19%; 28% in asymptomatic patients and 8% in symptomatic (P = 0.04). CONCLUSIONS: Early detection of recurrence of rectal cancer leads to an improved re-resection rate and survival. In patients who did not undergo radiotherapy at the time of the original resection, re-resection can be achieved safely. The place for radiation in the treatment of rectal cancer must be redefined.

Aged↗

PubMed1998

5-Fluorouracil and cisplatin as palliative treatment of advanced oesophageal squamous cell carcinoma. A multicentre randomised controlled trial. The French Associations for Surgical Research.

OBJECTIVE: To compare chemotherapy with no chemotherapy as palliative treatment for oesophageal squamous cell carcinoma. DESIGN: Randomised study. SETTING: Multicentre trial in France. SUBJECTS: Of 161 patients with histologically confirmed oesophageal squamous cell carcinoma located more than 5 cm from the mouth of the oesophagus, five were withdrawn because of protocol violation. The remaining 156 patients, 149 men and 7 women, mean (SD) age 58 (9) years range 36 to 77, were randomly allocated to either a control group without chemotherapy (n = 84) or a group treated by chemotherapy (n = 72). Patients were divided into four strata: I = complete resection of the tumour but with lymph node involvement (n = 62); II = incomplete resection of tumour leaving gross tumour behind (n = 58); III = no resection because of local or regional invasion (n = 22) ; and IV = no resection because of distant metastasis (n = 14). Exclusion criteria were histologically confirmed tracheobronchial involvement, oesophagotracheal fistula, Karnosky score < 50, cerebral metastases, or hepatic metastases occupying more than 30% of the liver, peritoneal carcinomatosis, associated or previously treated ear-nose-throat carcinoma, or complete resection of tumour without lymph node involvement. INTERVENTIONS: 5 fluorouracil (5FU) and cisplatin (CDDP) were given in 5-day courses, once every 28 days, for a maximum of eight cycles. 5 FU, 1 g/m2, was infused for 24 hours after a water overload, during five days. Cisplatin was given either in one dose of 100 mg/m2 at the beginning of the cycle or 20 mg/m2/day over three hours for five days. Duration of treatment ranged from 6-8 months. OUTCOME MEASURES: Median and actuarial survival. The subsidiary endpoint was quality of survival judged by complications of treatment, swallowing disorders, and the duration of ability to feed normally. RESULTS: There was no difference in survival, either overall (median = 12 months) or in any of the strata. There were however significantly more patients with neurological (p < 0.003), haematological (p < 0.0001), and renal (p < 0.0002) complications in the treated group compared with the control group. Four patients (6%) died of complications of chemotherapy. The course of swallowing disorders did not differ between the two groups. The duration of autonomous oral feeding was exactly the same in both groups (median = 10.5 months). CONCLUSION: The results suggest that 5FU and CDDP do not help in patients with squamous cell carcinoma of the oesophagus whether or not the tumour has been resected.

Adult↗

PubMed1997

Computed tomography in acute left colonic diverticulitis.

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Diverticulum, Colon↗

PubMed1997

Sphincter-saving resection, or not, for cancer of the midrectum.

BACKGROUND: The purpose of this study was to compare the time to pelvic recurrence and survival after sphincter-saving resection (SSR) or abdominoperineal resection (APR). METHODS: Out of the 119 patients with a cancer of the midrectum, 43 had undergone a SSR and 76 an APR for cure. To eliminate bias of a nonrandomized retrospective comparison, an adjustment for baseline prognostic covariates was used. RESULTS: Pelvic recurrence rates and survival distribution according to the type of resection did not differ significantly, with P values of 0.31 and 0.95, respectively, by the log-rank test. The Cox regression model incorporated nine binary covariates and the treatment group. Given these nine covariates, treatment did not influence either pelvic recurrence (adjusted P value = 0.62, relative risk = 0.78) or overall survival (adjusted P value = 0.89, relative risk = 1.05). CONCLUSION: These results suggest that, in patients with cancer of the midrectum treated by SSR or APR, recurrence and survival rates are similar.

Adenocarcinoma↗

PubMed1997

[Surgically treated esophageal cancers: predictive model of survival].

OBJECTIVES: The aim of this study was to identify prognostic factors in patients with esophageal cancer after curative resection, and to establish a predictive model of their long-term prognosis. PATIENTS--METHODS: Eighty-nine patients operated on for neoplasia of the esophagus, who underwent a curative resection, an who did not die within one month or during the hospital stay, were included in this study. Twenty-one variables were studied by univariate analysis. The variables linked with survival were include in a Cox model. Regression coefficient of independent prognostic factors allowed to compute a score. RESULTS: Life table analysis of the entire population, showed 2 and 5 year survival rates of 48% and 28%, respectively. In univariate analysis, 5 out of 21 factors were statistically linked with survival. In multivariate analysis (Cox model), 4 independent factors were linked with survival: age (P = 0.02), the American Society of Anesthesiologist classification (P = 0.01), parietal invasion (P = 0.03), and lymph node invasion (P = 0.009). The score established with these 4 factors allowed to distinguish 3 sub-groups, discriminated by their long term prognosis. Life table analysis of the 3 sub-groups were at 2 and 5 years 83%, 55%, 20% and 60%, 32%, 0%, respectively. CONCLUSION: This model may be useful for the assessment of prognosis in patients with esophageal cancer after curative surgical treatment.

Adenocarcinoma↗

PubMed1997

[Remarks on the update titled: adjuvant treatment of rectal cancer].

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Humans↗

PubMed1997

[Surgical activity in health care facilities].

Surgical activity for 144,000 beds in 1605 health care facilities in France in 1992 are reported. Both public (49%) and private (51%) hospital beds were studied. There were 2456 surgical theaters and a representative sample of 450,000 operations was examined. There were 4723 authorized beds which were not installed and 1168 non-authorized beds which were installed. The number of authorized beds per 10,000 inhabitants ranged from 16.1 (Picardie) to 33.2 (Corsica). Operations per 10,000 inhabitants ranged from 568 (Picardie) to 992 (Languedoc-Roussillon). The most frequent operations were adenoidectomies-amygdalectomies, cataract, appendectomy, herniacure, varicose veins of the lower limbs. Among the emergency operations, 91% of the operations were performed in 1156 permantly operating theaters. In these theaters, there was, on the average, one night operation every 4 nights. Regional variations in the number of beds demonstrate the need for improvement in organization. For operations, migratory flow and age differences cannot explain all the differences observed. Medical management varies greatly suggesting that more rigorous methodology and clinical training are needed.

France↗

PubMed1997

[Control of hospital expenditures].

Hospital expenditures in France (300 billion francs in 1995) comprise half of the expenditures of the Health Care Assurance system. The government directive dated 24 April 1996 created a national accreditation and evaluation agency. The effectiveness of the agency will largely depend on the ability of the experts to create a pragmatic system. The 5-year maximum delay for an accreditation request can be explained by the fact that the system is new, but will nevertheless delay hospital closure decisions and thus prolong the function of hospitals with reduced activity and thus less medical experience, leading to extra cost for the society. The directive also created regional hospitalization agencies which are to develop a regional health care policy, analyze and coordinate hospital activity and determine hospital resources. It is hoped that these agencies will be more effective than the former health care and social organization committees. The necessary decisions for hospital closures will be difficult due to the opposition of both the populations and elected officials. Finances for public facilities will continue on the basis of a global budget, an attempted macro-economic cost-containment policy which has had only limited effect. For private facilities, use of medicalization data systems could have unfavorable effects if the data is too approximative and could cause undue increase in cost over benefit if the data is too exhaustive. The directive does not appear to modify the authorization system for major equipment expenditures. There is no mention of the increasing size of hospital administration staffs. Finally, the directive does not address the fundamental question of medical behavior: a modification of medical training which would place more emphasis on clinical training and reasoning.

Financial Management, Hospital↗

PubMed1997

[Laparoscopic cholecystectomy. Vascular and biliary complications].

The aim of this study was to analyse the vascular and biliary complications on the first 361 laparoscopic cholecystectomies performed in a university digestive surgery unit. The rate of laparoscopic cholecystectomies increased from 17% in 1991 to 65% in 1995. The conversion rate was 18%. Laparoscopy was almost always converted for cholecystitis. Nine operative complications were observed, 6 hemorrhages, and 3 biliary complications with section of the common bile duct in one case. All these lesions were treated by laparotomy with good results. Six postoperative biliary complications were observed. Symptoms were pain (n = 6), fever (n = 2), jaundice (n = 1), and a choleperitoneum at ultrasound examination (n = 4). In one case a choleperitoneum was drained with an uneventful course. The other patients were reoperated (3 bile leakage of the cystic duct or the gallbladder plate, and 2 partial injuries of the common bile duct) with good results. Complication rates were higher in cholecystitis (P = 0,02) but were similar according to the experience of the surgeon. These results, similar to those of a British independent audit suggest than conversion and complication rates are higher than those reported in most of the multicentre studies. However, in all but one of the patients, the lesions were benign. The only common bile duct section was recognized at laparoscopy and repaired by open operation with a good result.

Adolescent↗