Background/Aims: Pancreatic injury from blunt trauma is infrequent. The aim of the present study was to evaluate a simplified approach of management of pancreatic trauma injuries requiring immediate surgery consisting of either drainage in complex situation or pancreatectomy in the other cases.Methodology: From January 1986 to December 2006, 40 pancreatic traumas requiring immediate surgery were performed. Mechanism of trauma, clinical and laboratories findings were noted upon admission, classification of pancreatic injury according to Lucas' classification were considered. Fifteen (100%) drainages were performed for stage I (n=15), 60% splenopancreatectomies and 40% drainage was achieved for stage II (n=18), 3 Pancreaticoduonectomies and 2 exclusion of duodenum with drainage and 2 packing were performed for stage IV (n=7).Results: There were 30 men and 10 women with mean age of 29 +/- 13 years (15-65). Thirty-eight patients had multiple trauma. Overall, mortality and global morbidity rate were 17% and 65% respectively, and the rates increased with Lucas' pancreatic trauma stage.Conclusions: Distal pancreatectomy is indicated for distal injuries with duct involvement, and complex procedures such as pancreaticoduodenectomy should be performed in hemodynamically stable patients.

BACKGROUND/AIMS:The aim of this study was to compare post-operative outcomes of two groups of patients aged more or less than 70 years oldMETHODOLOGY:From January 1990 to January 2006, 150 patients underwent pancreaticoduodenectomy (PD) for pancreatic adenocarcinomas (PA) were reviewed at the Department of Digestive Surgery of University Hospital. Twenty five patients Group A> or =70 and Group B<70 years old, were well matched for gender, diagnosis, body mass index, American Society of Anesthesiologists (ASA) score, and texture of pancreatic parenchyma.RESULTS:There was no intraoperative death. Mean operative hospital and intensive care unit stays were in Group A, B: 21+/-9; 4.5+/-8 vs. 19+/-7; 3+/-3 NS respectively. There were four deaths in A and no death in B at three months of hospital discharge. More patients had complications in Group A (56% vs 36% NS). Medical complications seem to be more frequent in Group A (40%vs 12% NS). The median survivals were 20 and 27 months for A and B, respectively.CONCLUSION:We observed an increased rate of morbidity and mortality in patients aged more than 70 years.

To the Editor: Stercoral perforation of the colon is rarely reported in the surgical literature. Infrequently, a stercoral disease or ulceration with perforation may represent the underlying etiology. Age, comorbidity, systemic disorders, reduced “functional reserve,” and poor tolerance to repeat surgical stresses are some of the medical factors that can lead to the high mortality rate (32–57%) related to this condition.1 In the present study, we reported on the surgical management of eight stercoral perforations and indicate the importance of preventive treatment. We retrospectively reviewed the medical records of eight patients operated on for peritonitis due to perforation of a fecaloma in two hospitals between 2004 and 2006. The demographic, operative, pathological, and outcome details were recorded to assess the conditions of colonic perforation due to fecaloma.2 The mean age of the eight patients (5 women and 3 men) was 81±5. Two patients came from a chronic nursing home or similar environment. All of the patients had a long history of chronic constipation preceding the stercoral perforation. Three patients were taking amitriptyline or others constipation sedatives, and two patients were in chronic renal failure. Three patients had neurological antecedents (1 psychotic, 1 depression, 1 dementia). Five patients had a lack of mobility. A diagnosis of acute abdomen was readily made with general peritonitis in five cases and local peritonitis in two. In four cases, a palpable impacted fecal mass was found on rectal examination. In one case, x-ray of the abdomen showed free air at; in another case, a pneumomediastinum was observed on the chest x-ray. In only five cases was observed pneumoperitoneum on a computed tomography scan. In all cases, the perforation occurred in the sigmoid. All patients were operated on through a median incision. Hartman's procedure, which involves resection of the diseased rectosigmoid colon at the level of the peritoneal reflection, with creation of proximal end colostomy and suture of the distal rectal stump, was the standard technique used. This surgical approach was applied in the case of five patients. Exteriorization of perforation without resection was carried out in two cases; in the last case, a resection of the colon with double colostomy was achieved. Three patients died (33%) in the early postoperative course. All patients with exteriorization of perforation died. Five patients were alive, but four patients had a colostomy. The profiles of morbidity and mortality are shown in Table 1. Observations reported in the present study underline the difficulty of determining precisely the true incidence of stercoral perforation. An explanation for the rarity of the disease is not apparent but almost certainly is underreported.1, 2 The first step of this pathology began by constipation that often pass unperceived, asymptomatic stercoral ulcer appeared in the second step (rarely they can lead to intestinal bleeding),3 and in the final step, perforation of the colon occurred. The mean age of the patients in this study explains the greater rate of mortality than in Mauer's report.2 Data reported in a French multicentric study showed that four independent preoperative risk factors of mortality exist: emergency surgery, loss of more than 10% of weight, neurological comorbidity, and age 70 and older.4 Moreover, six independent risk factors for morbidity were found: age 70 and older, neurological comorbidity, hypoalbuminemia, cardiorespiratory comorbidity, long duration of surgery, and peritoneal contamination.4 The study presented here is the anecdotal concept that stercoral ulceration and perforation are complications that develop in older individuals or in those with chronic pathologies (e.g., neurological and cardiorespiratory comorbidity). The perforation may have an atypical presentation (e.g., asthenic peritonitis) or result in few laboratory abnormalities (e.g., acute renal failure, hyperleukocytosis).5 Moreover, an empty rectal fecaloma does not exclude perforation by fecaloma, although the most appropriate approach would be a preventive policy with active treatment of terminal constipation and fecaloma. Chronic constipation with fecal impaction is a mundane problem. Clinical symptoms such as anorexia, nausea, vomiting, abdominal pain, paradoxical diarrhea, and incontinence are among the most common symptoms in patients in institutions and should be carefully taken into account.6 Although most impactions are in the rectal vault, the absence of palpable stool on rectal examination does not rule out a fecal impaction.7 Although enemas and suppositories alone may eliminate the impaction, the manual fragmentation and extraction of the fecal mass is almost always indicated first.6 Extraction of fecal mass may be made under local or general anesthesia.6 The evolution of a bad extraction may continue to ischemic colitis and perforation. Surgical treatment of a perforation of fecaloma must be done with resection and proximal colostomy. Exteriorization of perforation is not recommended, because sepsis of ischemic colon is not controlled. However, the best treatment would be prevention. Institutionalized, neurological, or elderly patients may be carefully observed and constipation taken into account and treated. After constipation and incontinence signs, a rectal examination may often be made to treat early fecaloma. Financial Disclosure: None. Author Contributions: Study concept and design: M. Ouaïssi, I. Sielezneff, S. Benoist, B. Sastre, B. Nordlinger. Acquisition of data: M. Ouaïssi, N. Pirrò, S. Benoist, E. Cretel. Analysis and interpretation of data: M. Ouaïssi, S. Benoist, I. Sielezneff, E. Cretel. Drafting of letter: M. Ouaïssi, E. Cretel, J. B. Chaix, F. Peschaud. Critical revision of the letter for important intellectual content: B. Sastre, B. Nordlinger, R. Malafosse, B. Consentino, C. Penna. Statistical analysis: M. Ouaïssi, S. Benoist. Study supervision: S. Benoist, B. Nordlinger, B. Sastre. Sponsor's Role: None. The authors wish to thank Dr. Ali Ouaissi, Head of Research at INSERM for his precious help and advice.

Paragangliomas are rare tumors arising from extraadrenal chromaffin cells. These tumors are most commonly found in the adrenal gland but other locations are possible. A 79-year-old woman with abdominal pain underwent computed tomography (CT scan). Surgery was indicated because of the increase in the size of the tumor. Histopathological examination revealed a non secreting paraganglioma in the left retroperitoneum. Paragangliomas are rare neuroendocrine tumors. They have a greater potential for malignancy than pheochromocytomas due to metastases or local recurrence making surgical excision the treatment of choice.