BACKGROUND:Spleen-preserving distal pancreatectomy with resection of the splenic vessels (VR-SPDP) is an effective procedure. However, hemodynamic changes in splenogastric circulation may lead to the development of gastric varices (GV) with a risk of gastrointestinal (GI) bleeding. This retrospective study aimed to assess the long-term postoperative clinical follow-up of patients and review the late postoperative abdominal computed tomography (CT) or endoscopic examination.METHODS:From 1988 to 2015, 48 consecutive VR-SPDP for benign or low-grade malignant disease were included. Late postoperative follow-up was undertaken with the use of a prospective database and assessment undertaken by CT and/or endoscopy.RESULTS:The median follow-up was 76 months (range: 12-334 months). Two patients were lost to follow-up. Gastrointestinal hemorrhage occurred in one patient. Endoscopy and abdominal CT showed submucosal GV in five patients. Ten patients had perigastric varices (27%), but none developed clinical complications from their varices. All varices occurred within one year after distal pancreatectomy and remained stable during follow-up.DISCUSSION:Asymptomatic varices frequently occurred in patients who underwent VR-SPDP, but bleeding risk seemed low. Abdominal CT could identify GV and distinguish submucosal varices with a higher risk of gastric bleeding.

Les insulinomes sont des tumeurs pancréatiques rares dont les modalités de prise en charge restent discutées. Notre objectif était de réévaluer les résultats des techniques de résection chirurgicale, et de déterminer les facteurs pronostiques concernant le risque de récidive. Une analyse rétrospective a été menée sur une série unicentrique de 48 patients consécutifs opérés avec un diagnostic d’insulinome entre 1988 et 2008. Les données démographiques, radiologiques, péri-opératoires, et anatomo-pathologiques ont été analysées, de même que les résultats précoces et à distance du traitement chirurgical. La survie sans récidive a été calculée et les facteurs pronostiques ont été déterminés. Sur les 48 patients opérés, l’âge moyen était de 51 ans (22-78). Les interventions chirurgicales ont été des duodénopancréatectomies céphaliques (n = 12), des pancréatectomies gauches (n = 21), des pancréatectomies centrales (n = 5), et des énucléations (n = 7). Dans 3 cas (6 %), l’exploration chirurgicale avec échographie per-opératoire n’a pas permis de localiser la tumeur (2 cas de nésidioblastoses et 1 cas d’insulinome secondairement détecté). Les résultats anatomopathologiques étaient en faveur de tumeurs endocrines de comportement bénin (n = 30), de pronostic incertain (n = 11), et de carcinomes bien différenciés (n = 4). Avec un suivi médian de 42 mois, 9 patients ont eu une récidive de tumeur endocrine. Dans 3 cas, il s’agissait de patients porteurs d’une NEM1. Les 4 carcinomes endocrines ont récidivé, alors que 2 des tumeurs classées initialement comme bénignes ont récidivé avec des métastases hépatiques ou ganglionnaires. Un seul décès est en rapport avec une récidive néoplasique. Pour les patients réséqués, la survie sans récidive de tumeur endocrine était de 72 % à 5 ans. En analyse univariée, les facteurs de récidive identifiés ont été : la classification en carcinome endocrine (p < 0,001), l’envahissement ganglionnaire (p < 0,001), un marquage Ki67 > 1 % (p = 0,003) sur l’analyse de la pièce de résection chirurgicale, et l’existence d’une NEM1 (p = 0,04). En analyse multivariée, la classification en carcinome et l’existence d’une NEM1 ont été identifiés comme facteurs indépendants de récidive. Les insulinomes sont des tumeurs rares réputées bénignes. Dans cette série, le taux élevé de récidive (18 % à 5 ans) lié à la fréquence des carcinomes, souligne l’importance des critères anatomopathologiques dans l’évaluation du pronostic, et la nécessité d’une surveillance à long terme après résection chirurgicale.

STUDY AIM To evaluate symptoms and results of the treatment of aneurysms of digestive arteries. PATIENTS AND METHOD Retrospective study of 23 patients (14 male and 9 female, mean age = 51 years) treated in two departments of academic hospital. We studied the aneurysms characteristics (location, number, size, etiology) the type of treatment, and occurrence of post-operative complications. RESULTS The aneurysms involved the splenic artery in 13 patients (56%), the superior mesenteric artery in 5 patients (22%), the hepatic artery in 3 patients (13%), the gastroepiploic artery in 2 patients (9%). There were thirty-one aneurysms (24 true aneurysms and 7 pseudo-aneurysms) in 23 patients. Diagnosis was mainly done by the CT-scan. An aneurysm rupture occurred in 7 patients (30%). Treatment was surgery for 26 aneurysms (84%) or a radiological embolization in 3; abstention was decided for 2 aneurysms (6%). No death was observed. CONCLUSION The bad prognosis after rupture, the lack of predictive factors of rupture combined with the good results of surgical treatment suggest to prefer a surgical treatment at first. Embolization could be reserved for the contra-indication of surgery and when aneurysms are poorly accessible to surgery.

But de l’étude : Évaluer la symptomatologie et les résultats du traitement des anévrismes des artères digestives.

Study aim: The aim of this retrospective study was to compare a group of patients who underwent resection for gastric adenocarcinoma (cancer of cardia excluded) and to assess the influence of radical lymphadenectomy on postoperative mortality and morbidity and 5-year survival rate.Patients and method: One hundred and six patients were operated on from 1975 to 1985 and 99 from 1986 to 1995 for gastric adenocarcinoma located in the distal portion of the stomach in 56 % and 61 % respectivaly and, undifferenciated in 56 %. Gastric resection was a subtotal gastrectomy for cancers of the lower third and total gastrectomy for cancers of the middle and superior thirds. In the first group (1975-1985), a D1 lymphadenectomy was performed in all patients. In the second group (1986-1995) a D1.5 lymphadenectomy without systematic splenectomy and pancreatectomy was applied to 49 patients.Results: In the second group, the proportion of curative resection was higher (85 % versus 75 %) along with a higher rate of total gastrectomy (42 % versus 17 %). The postoperative mortality rate was 2 % in the first group and 1 % in the second group. The morbidity rate was 33 % in the first group and 15 % in the second group with a rate of anastomotic leak of 11 % and 2 % respectively. Among the second group, the morbidity rate was 20 % after D1,5 lymphadenectomy versus 10 % after D1 lymphadenectomy. The overall 5-year survival rate was 29 % in the first group versus 38 % in the second group. In this latter group, the overall 5-year survival was 32 % after D1 lymphadenectomy and 46 % after D1,5 (p = 0,038).Conclusion: Radical lymphadenectomy without associated splenic or pancreatic resection in good general status patients may provide a better staging of resected gastric cancer without increase of the postoperative mortality. However, the influence of radical lymphadenectomy on long-term survival remains to be proven. (C) 2000 Editions scientifiques et medicales Elsevier SAS.

Diffuse esophageal leiomyomatosis is a rare disorder which may be found in association with leiomyomas in other locations or with other disorders. We report two cases in men, one with associated tracheobronchial involvement, which illustrate the value of imaging in differentiating this entity from other causes of dysphagia and in establishing a diagnosis.

STUDY AIM:The aim of this retrospective study was to compare a group of patients who underwent resection for gastric adenocarcinoma (cancer of cardia excluded) and to assess the influence of radical lymphadenectomy on postoperative mortality and morbidity and 5-year survival rate. PATIENTS AND METHOD:One hundred and six patients were operated on from 1975 to 1985 and 99 from 1986 to 1995 for gastric adenocarcinoma located in the distal portion of the stomach in 56% and 61% respectively and, undifferenciated in 56%. Gastric resection was a subtotal gastrectomy for cancers of the lower third and total gastrectomy for cancers of the middle and superior thirds. In the first group (1975-1985), a D1 lymphadenectomy was performed in all patients. In the second group (1986-1995) a D1.5 lymphadenectomy without systematic splenectomy and pancreatectomy was applied to 49 patients. RESULTS:In the second group, the proportion of curative resection was higher (85% versus 75%) along with a higher rate of total gastrectomy (42% versus 17%). The postoperative mortality rate was 2% in the first group and 1% in the second group. The morbidity rate was 33% in the first group and 15% in the second group with a rate of anastomotic leak of 11% and 2% respectively. Among the second group, the morbidity rate was 20% after D1,5 lymphadenectomy versus 10% after D1 lymphadenectomy. The overall 5-year survival rate was 29% in the first group versus 38% in the second group. In this latter group, the overall 5-year survival was 32% after D1 lymphadenectomy and 46% after D1,5 (p = 0.038). CONCLUSION:Radical lymphadenectomy without associated splenic or pancreatic resection in good general status patients may provide a better staging of resected gastric cancer without increase of the postoperative mortality. However, the influence of radical lymphadenectomy on long-term survival remains to be proven.

The authors report 2 cases of congenital mesothelial cyst of the diaphragm diagnosed in adults. The differential diagnosis will be discussed and the literature reviewed.

Surgical resection is currently the only potentially curative treatment for gastric cancer. Nodal extension, present in 3/4 of the patients, is related to topography and penetration of the tumor and is progressive, beginning by the perigastric proximal lymph nodes N1 to the perivascular distal nodes N2. A subtotal gastrectomy is possible for distal cancers and total gastrectomy is necessary for cancers of the middle and upper portions. D1 lymphadenectomy is the resection of the N1 perigastric nodes (> 15) and D2 lymphadenectomy is the resection fo the N2 perivascular nodes (> 25). In Japan, 5 year survival after D2 resection is very high, around 60%, but all the series are retrospective with a high proportion of superficial cancers. In several recent European controlled studies, D2 resection is responsible for a high mortality rate (> 10%) and the reported 45% survival is not statistically different from the D1 resection. In Western patients an "in-between" lymphadenectomy without spleno-pancreatectomy can be recommended with analysis of at least 15 nodes, and with a mortality lower than 5%. Pathological analysis of the operative specimen allows to use the new TNM classification where the number of positive lymph nodes is the main independent prognostic factor.

AIM OF THE STUDY:To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series.PATIENTS AND METHODS:Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration.RESULTS:Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enterococcus, staphylococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical procedure including two necrosectomies was necessary in six patients.CONCLUSION:This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.

L'objectif de cette étude rétrospective est de décrire une technique de drainage percutané par radiologie interventionnelle pour nécrose pancréatique infectée, et de rapporter les résultats de cette technique comparés à ceux des techniques opératoires classiques et à ceux d'autres séries de drainage percutané. Entre 1992 et 1997, cette étude a porté sur 32 malades ayant une pancréatite aiguë nécrosante grave (score moyen de Ranson de 4,6), dix au stade D (une coulée de nécrose) et 22 au stade E (plusieurs coulées) selon la classification de Balthazar. Le drainage percutané a été effectué sous contrôle tomodensitométrique avec des drains modifiés de Van Sonnenberg: drains de gros calibre 24 F, à double courant, avec système de connexion élargi pour permettre un lavage continu et une aspiration continue du liquide et des débris nécrotiques. Chez ces 32 malades, 49 drainages ont été réalisés pour 41 nécroses infectées et huit collections abcédées. La preuve de l'infection a été obtenue chez 26 malades par ponction à l'aiguille fine et examen bactériologique montrant une majorité d'entérocoques, de staphylocoques et de Pseudomonas. Le drainage a été effectué en moyenne au 23e jour. La durée moyenne du drainage a été de 43 jours, avec en moyenne trois drains par malade. Cinq malades (15%) sont décédés et parmi les survivants, 16 (59%) ont présenté 21 complications dont 14 fistules entérocutanées ou pancréatiques. Une intervention secondaire dont deux nécrosectomies a été nécessaire chez six malades (18%). Cette étude montre que le drainage percutané avec un taux de succès de 70% et une mortalité de 15% constitue bien une alternative à la chirurgie dans les nécroses pancréatiques infectées. To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series. Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration. Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enteroccus, staphy-lococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical 11procedure including two necrosectomies was necessary in six patients. This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.

Les auteurs rapportent 2 cas de malformation congenitale mesotheliale kystique du diaphragme, decouverts chez l'adulte. Ils en discutent le diagnostic et rappellent la rarete des tumeurs et des malformations diaphragmatiques dans la litterature.