Background: The extent of lymphadenectomy (limited vs. extended) and that of gastric resection (partial vs. total) remain controversial issues in the management of early gastric cancer (EGC). A multicentric study was performed to elucidate the appropriate gastric resection with lymph node dissection for early gastric cancer.Methods: From 1979 to 1988, 332 patients with EGC underwent surgery in 23 French centers. Clinicopathological data, the extent of resection, and the number of lymph nodes retrieved were reviewed retrospectively and screened for prognostic effect. The mean follow-up for the 332 EGC patients was 80 months.Results: Postoperative mortality was correlated to age (odds ratio [OR], 1.1) and extent of gastric resection (OR, 10.3). Examination of survival data (excluding postoperative deaths) with univariate analysis and the Cox proportional hazards model showed that the independent factors for excellent prognosis included no lymphatic involvement (P = .005), 10 or more lymph nodes retrieved (P = .003), site of the tumor in the lower third of the stomach (P = .01), and mucosal lesions (P = .04). The extent of resection did not influence long-term survival.Conclusions: Our results suggest that because of the associated good prognosis, the appropriate surgical treatment for EGC is partial gastrectomy with lymphadenectomy retrieving 10 or more lymph nodes.

Aim: Early gastric cancer (EGC) may have a 5-year survival rate of over 90% following surgery. Early multifocal gastric cancer (EMGC) accounts for between 8.3 and 17% of all EGCs. A multicenter retrospective study is reported of prevalence, characteristics, prognosis and type of resection for EMGC patients.Method: 333 patients with EGC were operated on, between January 1979 and December 1988, and followed to June 1996.Results: 33 EGC patients had EMGC. There was no significant difference in clinico-pathological features between EGC and EMGC. 21 cases of EMGC underwent a subtotal gastrectomy and 12 underwent a total gastrectomy. Recurrences after subtotal gastrectomy were, respectively, 10 and 18% for EGC and EMGC patients (p = 0.2). The cumulative 5 years specific survival rate for 298 EGC and 34 EMGC were 94 and 90%, respectively (p = 0.9). Five-year survival rates after subtotal gastrectomy were 92 and 90% for EGC and EMGC patients, respectively (p = 0.8).Conclusion: EGC and EMGC had the same clinico-pathological features and prognosis. A careful follow up of the stomach remnant is essential. (C) 2003 Elsevier Science Ltd. All rights reserved.

From 1992 to 1997, 230 patients(pts)undergoing pancreatic resection were included in a prospective, randomized trial to determine whether octreotide decreased the rate or the severity of intra-abdominal complications.Sex ratio was 1.3, mean age 56.3(16-81).177 Pancreatoduodenectomy (PD)

BACKGROUND: Factors influencing long-term survival in patients undergoing operation for adenocarcinoma of the small intestine are poorly recognized.METHODS: Retrospective study of 100 cases culled within a 10-year period by questionnaire, including 59 males and 41 females, median age 61 years (range 30 to 86). No patients were lost to follow-up (median 27 months). All patients underwent operation: curative in 65% and palliative in 35%.RESULTS: Overall actuarial 5-year survival was 38%, 0% after palliative treatment and 54% after curative resection. In patients undergoing curative resection, 5-year survival was 63% when the lymph nodes were not involved, and 52% when they were; 57% when the serosa was not involved, and 53% when it was; 56% when the tumor was well or moderately well differentiated and 40% when it was undifferentiated, Other factors influencing long-term survival were the emergency setting, the site, the multiplicity, and the size of tumor (none with statistically significant differences). Five and 10-year survival was 78% and 69%, respectively, when the patient was anemic compared with 35% and 17%, respectively when the patient was not (P<0.01). There were 14 patients with previous carcinoma, 2 with Crohn's disease, and 1 each with celiac disease and ileal tuberculosis. There were also 8 patients with associated duodenal and proximal jejunal polyps. Thirteen patients sustained a total of 14 further cancers.CONCLUSIONS: Patients should be followed up closely because the possibility of sustaining another abdominal carcinoma is high (16%). As associated polyps are nearly always duodenal or jejunal, preoperative or intraoperative endoscopy of the upper gastrointestinal tract including the initial portion of the jejunum should be able to detect their presence and reduce the risk of early recurrence. (C) 1997 by Excerpta Medica, Inc.

BACKGROUND: This study was done to determine if certain criteria could predict the presence of common bile duct stones in patients with symptomatic gallstones. It was hoped that patients could be identified in whom intraoperative cholangiography was unnecessary.STUDY DESIGN: One hundred seventy-five patients, from 15 surgical centers, were prospectively enrolled, For each patient, the preoperative score (Huguier score) previously published was calculated according to clinical and ultrasound data: age, diameter of the common bile duct, diameter of the smallest gallstone, history of biliary colic, and acute cholecystitis. All patients underwent an open cholecystectomy and an intraoperative cholangiography. The absence or presence of a common bile duct stone was evaluated during the operation, if necessary, after an instrumental investigation of the common bile duct.RESULTS: Ultrasound was not interpretable in eight (5 percent) of 175 patients. Final analysis was; made from the charts of the 167 remaining patients, Thirty (18 percent) had common bile duct stones, When the score was equal to or greater than 3.5, the risk of having a common bile duct stone was 24 percent (27 of 111), When the score was less than 3.5, this risk was 5 percent (three of 56),CONCLUSIONS: Huguier's score is well assessed and can be safely used. Intraoperative cholangiography could be avoided in 33 percent of patients when the score is less than 3.5 (56 of 167).

BACKGROUND:This study was done to determine if certain criteria could predict the presence of common bile duct stones in patients with symptomatic gallstones. It was hoped that patients could be identified in whom intraoperative cholangiography was unnecessary.STUDY DESIGN:One hundred seventy-five patients, from 15 surgical centers, were prospectively enrolled. For each patient, the preoperative score (Huguier score) previously published was calculated according to clinical and ultrasound data: age, diameter of the common bile duct, diameter of the smallest gallstone, history of biliary colic, and acute cholecystitis. All patients underwent an open cholecystectomy and an intraoperative cholangiography. The absence or presence of a common bile duct stone was evaluated during the operation, if necessary, after an instrumental investigation of the common bile duct.RESULTS:Ultrasound was not interpretable in eight (5 percent) of 175 patients. Final analysis was made from the charts of the 167 remaining patients. Thirty (18 percent) had common bile duct stones. When the score was equal to or greater than 3.5, the risk of having a common bile duct stone was 24 percent (27 of 111). When the score was less than 3.5, this risk was 5 percent (three of 56).CONCLUSIONS:Huguier's score is well assessed and can be safely used. Intraoperative cholangiography could be avoided in 33 percent of patients when the score is less than 3.5 (56 of 167).

Potentiated local anaesthesia has been generally used for repair of inguinal hernia since the Shouldice technique was first introduced in France in the early 80s. The technique requires a correct understanding of inguinal innervation and the properties of the local anaesthetic. The local anaesthetic is injected into the abdomino-genital and genito crural nerves and at the line of incision allowing smooth surgical repair. Potentiation releaves patient apprehension. This method can be used for all types of inguinal hernia, whether simple or complicated and in all patients. There is no limitation for age or general condition. Contraindications are rare and include allergy or uncontrolled (no pacemaker) arrhythmias.

A prospective multicenter study was done concerning the use of 29 vocabulary terms to determine whether: (a) these terms can be equated with specific percentages; (b) observer assessment varied with time; (c) teachers and students used the same words with the same meaning; (d) certain words were more discriminant than others; (e) terms corresponding to numbers were the same in French as in English. Three hundred and thirty medical doctors, coming from general and digestive units of 45 university, regional or private institutions, were asked to answer three types of questionnaires pertaining to the same 29 words, but in a different order. One to three months later, 170 of them were asked to fill in the same questionnaire with the same words but in a different order from the first. Sixteen percent were university professors, 15% were hospital or private surgeons, 19% were senior residents, 29% were interns or junior residents and 21% were medical students. In all cases, the adjective and corresponding adverb were listed side by side, except for "normal" and "normally". The 27 other terms were "absent", "exceptional", "occasionally", "sometimes", "inconsistent", "readily", "possible", "commonplace", "often", "ordinary", "common", "usual", "generally", "in most cases", "invariable", "always", "never", "almost never", "rare", "fairly rare", "frequent", "not frequent", "infrequent", "fairly frequent", "very frequent", "consistent", and "almost always". Ah participants were asked to express their answers either as sensitivities or the probability of being present in disease. Results were expressed as means +/- 1 SD, mode, median, 25th and 75th percentiles and range. Comparisons were made according to the Student's t-test and variance analysis. Results were as follows: (a) There was a vocabulary gap for values situated around 50% (between 31 and 59%). This gap can be filled by using a fractional quantitative expression such as "one of two". (b) The form (adjective or adverb) or the order of terms in the questionnaire did not significantly influence the results; there was no intraobserver variation. (c) Excepting nine terms, teachers and students use the same language; they attribute the same percentages to the same terms. (d) Of the 29 terms proposed, 11 words and their synonyms are enough to cover the entire range of percentages. (e) In 9-13 cases of 15, the French- and English-speaking doctors did not use the same percentages to express the same words. When writing or discussing frequencies, it seems preferable to use precise percentages when these details are not repeated too often. When required, words often used should be chosen according to a correspondence scale.

The current randomized study was done to compare the results of choledochoduodenostomy (CD) and choledochojejunostomy (CJ) for choledocholithiasis, with special reference to long term results and the risk of ascendant cholangitis. From january 1978 to January 1990, 130 patients were included in the study-64 with CD (side to side, in all patients) and 66 with CJ (side to side in 25 patients and end to side in 41). No significant difference was observed between the CD and CJ groups for postoperative mortality (3.8 percent) and morbidity rates. One hundred and twenty patients (58 CD and 62 CJ) were available for long term follow-up evaluation (mean follow-up period of 29+/-11 months). One hundred and seven patients had no symptoms attributable to biliary disease or operation. Five patients in this group died of unrelated causes. Thirteen patients experienced biliary symptoms suggestive of cholangitis, or at least related to the bilioenteric anastomosis-six patients in the CD group and seven in the CJ group. Cholangitis was observed in the first postoperative year in eight of these 13 patients and during the second year for the five others. In the CD group, cholangitis was the result of sump syndrome (n=3), anastomotic stricture (n=1) and unknown causes (n=2). In the CJ group, cholangitis was die result of anastomotic stricture (n=3), residual intrahepatic stones (n=1) and unknown causes (n=3). The results of the current study confirm the good long term results of both procedures. However, it suggests that CD is preferable for choledocholithiasis for two reasons-it is technically easier and faster to perform than CJ and, unlike CJ, CD permits easy access to further endoscopic exploration or treatment if necessary.

The feasibility of discharge within 48 h of surgery was evaluated in 500 consecutive men with unilateral uncomplicated non-recurrent inguinal hernia. Eighty-nine [corrected] patients were unsuitable for short-stay surgery on medical or social grounds. Of 411 patients suitable for early discharge, 107 stayed longer than 48 h. Early discharge was declined by 84 otherwise suitable patients and contraindicated because of local or general complications in 42. A total of 304 patients were discharged within 48 h; 1-day surgery was performed in 51 patients. Employment, low physical requirements, a lower age and fewer than two medical risk factors were associated with feasible and successful short-stay surgery. These factors may not be independent variables.

Between January 1982 and 1987, 772 consecutive endoscopic retrograde cholangiopancreatographic examinations (ERCP) were performed in 673 consecutive patients suspected of having biliary tract lithiasis (mean age: 62.1 +/- 18.2 years). Two hundred and thirty-two were emergency procedures (30 %). Endoscopic sphincterotomy was performed for common bile duct stones (CBDS) in 257 cases (38.0 %), of whom 143 (55.6 %) had undergone previous cholecystectomy. In 17.2 % of cases, ERCP was either a complete (7.8 %) or partial (9.4 %) failure. In 124 patients for whom microlithiasis was not identified by sonography and who underwent operation, sensitivity and specificity of ERCP was 70 % and 87 %, respectively. Of 266 patients in whom ES was attempted, 96.6 % were achieved and the common bile duct was cleared of stones in 72 % of cases. Nineteen percent of patients required two or more attempts at extraction. After ERCP without ES, mortality and morbidity rates were 0.96 and 3.6 % respectively. After ES, complications followed in 12.1 % of patients and 3.9 % died. Mortality and morbidity directly related to ES were 3.1 % and 11.3 % respectively. The most common complications after ERCP were acute cholangitis and pancreatitis, whereas after ES, acute cholangitis was the most common complication, followed by hemorrhage and duodenocholechocal perforations. These complications occured independently of age and previous cholecystectomy but was closely related to stone clearance (P < 0.05). Seventy-one patients (10.5 %) required operation. Twenty-nine patients underwent emergency surgery for complications with a mortality rate of 17 %. Forty-two patients underwent elective surgery for retained CBDS after ES without any mortality. ES is efficient in the treatment of CBDS, but the morbidity and mortality rates are often underestimated. Prospective, cooperative studies are needed to define the respective indications of endoscopic and surgical treatments of CBDS.

Individual medical and social factors associated with the acceptance and success of short stay surgery for unilateral, uncomplicated inguinal hernia were looked for in 500 consecutive unselected patients. The mean duration of postoperative hospital stay was 3.4 days. Sixty percent of the patients were discharged within the first 48 hours following surgery, including 10 percent who left the hospital in the evening of the operation day. Twenty-two percent of the patients who could have left during these 48 hours refused to do so. The most predictive variable for acceptance and success was a profession requiring little physical activity. Local anaesthesia has been associated with success in the so-called ambulatory surgery, but the methodology of the present study did not permit to establish a cause-effect relationship.

One hundred and ten distal splenorenal anastomoses (DSRA) were performed between 1976 and 1988 for gastrointestinal haemorrhages secondary to portal hypertension. Thirty five patients underwent DSRA (Warren's operation) followed by a mesenteric disconnection procedure. Eleven patients (10%) died (nine Child B and two Child A), including two after an emergency shunt. The mortality was influenced by age (p less than 0.01) and by the number of previous episodes of ictero-ascitic decompensation (p less than 0.02). A single anastomotic thrombosis was observed; the high flow rate of the anastomoses (mean: 1200 +/- 650 ml/min) explains the high patency rate (more than 90%). Eleven patients developed partial or total thrombosis of the portal trunk less than 6 weeks after the operation. The quality of hepatic perfusion was not significantly influenced by the mesenterico-splenic disconnection and this was omitted in 75 patients. The mesenterico-splenic collateral venous circulation was more developed in the absence of disconnection (p less than 0.05). The long-term actuarial survival was 83% at one year, 53% at five years, 47% at eight years and 28% at ten years. Survival was not influenced by the disconnection. Warren's operation is more difficult to perform than a porto-caval or mesenterico-caval shunt. DSRA appears to have three advantages: 1) a high flow rate as it is arterialised by the splenic artery, 2) hepatopetal portal perfusion maintained for several days, weeks or months, possibly reducing the risk of encephalopathy, 3) the absence of dissection of the hepatic pedicle preserves the possibilities of liver transplantation.

A prospective multicenter study concerning 30 vocabulary terms was undertaken to determine if: 1) these terms could be equated with specific percentages; 2) observer assessment varied with time; 3) teachers and students used the same words with the same meaning; 4) certain words were more discriminant than others, and 5) terms corresponding to numbers were the same in French as in English. Three hundred and thirty medical professionals, coming from general and digestive units of 45 University, regional, or private institutions, were asked to answer three types of questionnaires pertaining to the same 30 words, but in a different order. One to 3 months later, 170 of them were asked to fill out the same questionnaire with the same words but in a different order. Sixteen percent were University professors, 15 percent were hospital or private surgeons, 19 percent were senior residents, 29 percent were interns or junior residents and 21 percent were medical students.(ABSTRACT TRUNCATED AT 250 WORDS)