BACKGROUND:The order of revascularization in human liver grafts is still discussed. This study tries to answer this question in terms of hemodynamic data. STUDY DESIGN:Fifty-nine patients were randomized in this study to compare hemodynamic data just before and 15 minutes after revascularization of liver grafts in relation to first hepatic artery (n = 29) or first portal vein (n = 30) revascularization procedure. RESULTS:Hemodynamic variations were significantly greater in the portal vein group than in the hepatic artery group in terms of mean arterial pressure, cardiac index, central venous pressure, pulmonary capillary pressure, and systemic vascular resistance. The latter decreased from 741.8 +/- 390.3 to 659.9 +/- 411.1 dynes/ cm5 (NS) in the hepatic artery group versus 807.7 +/-336.7 to 439.7 +/- 215 dynes/cm5 (p < 0.05) in the portal vein group. Clinical results and postoperative complications, graft characteristics, patient survival, and graft survival were not significantly different between the groups. CONCLUSIONS:Initial arterial revascularization of the liver graft leads to a more stable hemodynamic profile during revascularization of the liver graft after vascular unclamping. This technique is always feasible and has become our reference procedure.

BACKGROUND:The aim of this study was to assess functional outcomes of patients who had a delayed coloanal anastomosis for a lower third rectal cancer after preoperative radiotherapy. STUDY DESIGN:From January 1988 to December 1997, 35 patients with an adenocarcinoma of the lower third of the rectum received preoperative radiotherapy (45Gy) followed by a rectal resection, combining an abdominal and transanal approach. Colorectal resection was performed about 32 days after the end of the radiotherapy. The distal colon stump was pulled through the anal canal. On postoperative day 5 the colonic stump was resected and a direct coloanal anastomosis performed without colostomia diversion. RESULTS:There was no mortality. There was no leakage. One patient had a pelvic abscess. One patient had a necrosis of the left colon requiring reoperation. Another delayed coloanal anastomosis could be performed. Median followup was 43 months (range 6 to 113 months). Functional results were evaluated with a new scoring system including 13 items. Function was considered good in 59% and 70% at 1 and 2 years, respectively. CONCLUSIONS:This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma for patients with rectal cancer of the lower third of the rectum. This technique is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results. Further adaptation could be imagined for a coelioscopic approach.

Mesenteric venous thrombosis is a rare disease with no specific signs. It's major risk is intestinal ischaemia and necrosis. We report the case of a young women who presented with unexplained abdominal pain and subnormal abdominal ultrasound. The diagnosis was made on laparoscopic exploration which allowed anticoagulant therapy followed by proximal and distal divertingostomies of the ischemic bowel. Small bowel continuity was re-established after 3 month of total parenteral nutrition. The patients is doing well 1 year after surgery. She is still under anticoagulant therapy. The etiology found was a hypermegacaryocytosis as seen in myeloproliferative disease.

AIM OF THE STUDY:The aim of this study was to assess the oncology and functional outcome after preoperative radiotherapy and delayed coloanal anastomosis for cancers of the lower third of the rectum.PATIENTS AND METHODS:From January 1988 to December 1997, 35 patients received preoperative radiotherapy (45 Gy) followed by rectal resection through a combined abdominal and transanal approach. Thirty patients had preoperative tumor staging with endorectal ultrasonography: uT1N0 = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, and uT3N+ = 14. Colorectal resection was performed on average 32 days after the conclusion of radiotherapy, and the distal colon stump was pulled through the anal canal. On postoperative day 5, the colonic stump was resected and a direct coloanal anastomosis performed.RESULTS:Pathological examination of the specimens revealed complete tumor sterilization in two cases, pT1N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, and pT3N+ = 9. There was no postoperative mortality and there was no leakage. One patient had a pelvic abscess, and another one had left colon necrosis which required re-operation. Median follow-up was 43 months (range 6-113). Two patients had locoregional recurrence, seven had distant metastasis, and 3 had both. Actuarial survival rate at 1, 3 and 5 years was 97%, 86%, and 72% respectively. The rate of local control at 5 years was 78%. Functional results were evaluated by a new scoring system. Function was considered good in 59 and 70% at 1 and 2 years respectively.CONCLUSION:This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma. It is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results.

Massive incisional abdominal wall hernias are frequent and difficult to repair, especially when they are large, multiply recurrent and when associated high with risk factors. We report the long-term results of 192 hernia repairs (in 186 patients) by non-resorbable mesh placed intraperitoneally and fixed by fascia stapler. We describe the details of the technique. There were no deaths. Early and late wound infections occurred in 11.7%, late occlusions in 6.3% and recurrence in 16%. Four percent of patients required removal of the mesh. The main caracteristic of this study was the long follow-up period (mean duration = 77 months). In view of the good results (70%), simplicity and quite execution of this technique, intraperitoneal mesh placement should be considered in the repair of large hernias when a prothesis is required.

STUDY AIM:The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery.PATIENTS AND METHODS:From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient.RESULTS:Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma.CONCLUSION:Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.

Mesenteric veinous thrombosis is a rare disease with no specific signs. It's major risk is intestinal ischaemia and necrosis. We report the case of a young women who presented with unexplained abdominal pain and subnormal abdominal ultrasound. The diagnosis was made on laparoscopic exploration which allowed anticoagulant therapy followed by proximal and distal divertingostomies of the ischemic bowel. Small bowel continuity was restablished after 3 month of total parenteral nutrition. The patients is doing well 1 year after surgery. She is still under anticoagulant therapy. The etiology found was a hypermegacaryocytosis as seen in myeloproliferative disease.

The aim of this study was to report the results of a retrospective series of 26 patients with Barrett's esophagus treated by antireflux surgery.From 1979 to 1998, 21 men and five women (mean age: 53 years) with histologically proven Barrett's esophagus underwent an antireflux procedure. The mean length of Barrett's epithelium was 5.9 cm for 19 patients (73.1%). Six patients (23.1%) had tongue lesions of Barrett's epithelium, and one (3.8%) had ectopic gastric mucosa. None of the patients had a preoperative esophageal biopsy that revealed high-grade dysplasia or carcinoma. Laparotomy was performed in 17 cases and laparoscopy in nine cases. Preoperative endoscopic local treatment with argon coagulation was performed in one patient.Clinical mean follow-up was 78 months and endoscopic mean follow-up was 59.3 months. No increase in the length of the Barrett's epithelium was observed. Seven patients (27%) had complete or partial regression (among them three patients with tongue lesions and one patient preoperatively treated by argon). No patients developed high-grade dysplasia or carcinoma.Regression of Barrett's esophagus is possible but not frequent and unpredictable after antireflux procedure. However, endoscopic and histological surveillance should be continued postoperatively.

Le but de cette étude est d'apprécier les résultats oncologiques et fonctionnels après radiothérapie préopératoire et anastomose coloanale différée pour cancer du bas rectum. De janvier 1988 à décembre 1997, 35 patients ont été traités par radiothérapie préopératoire suivie de résection rectale par une double approche abdominale et transanale permettant la conservation sphinctérienne. Trente patients ont eu une échographie endorectale: uT1N0 = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, et uT3N+ = 14. La résection rectale a été réalisée en moyenne 32 jours après la fin de la radiothérapie et l'extrémité distale du côlon gauche abaissée en position transanale. Au 5e jour postopératoire, après résection du segment colique extériorisé, a été réalisée une anastomose coloanale. L'examen anatomopathologique a trouvé deux tumeurs stérilisées, pT1N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, et pT3N+ = 9. La mortalité hospitalière a été nulle. Il n'y a pas eu de fistule anastomotique. Un patient a développé un abcès rétrorectal, un autre patient a eu une nécrose du côlon gauche nécessitant une réintervention. Le suivi moyen a été de 43 mois (6–113). Deux patients ont eu une récidive locale, sept ont eu une métastase et trois ont eu récidive locale et métastase. La survie actuarielle à 1, 3 et 5 ans était de 97 %, 86 % et 72 %. Le contrôle local à 5 ans était de 78 %. Les résultats fonctionnels évalués grâce à un système de score, étaient bons dans 59 et 70 % des cas à un et deux ans respectivement. Cette technique originale et sûre permet la conservation sphinctérienne sans colostomie de protection. Elle est parfaitement adaptée à l'utilisation de la radiothérapie avec un taux faible de morbidité locale et de bons résultats fonctionnels. The aim of this study was to assess the oncology and functional outcome after preoperative radio-therapy and delayed coloanal anastomosis for cancers of the lower third of the rectum. From January 1988 to December 1997, 35 patients received preoperative radiotherapy (45 Gy) followed by rectal resection through a combined abdominal and transanal approach. Thirty patients had preoperative tumor staging with endorectal ultrasonography: uT1 NO = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, and uT3N+ = 14. Colorectal resection was performed on average 32 days after the conclusion of radiotherapy, and the distal colon stump was pulled through the anal canal. On post-operative day 5, the colonic stump was resected and a direct coloanal anastomosis performed. Pathological examination of the specimens revealed complete tumor sterilization in two cases, pT1 N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, and pT3N+ = 9. There was no postoperative mortality and there was no leakage. One patient had a pelvic abscess, and another one had left colon necrosis which required re-operation. Median follow-up was 43 months (range 6–113). Two patients had locoregional recurrence, seven had distant metastasis, and 3 had both. Actuarial survival rate at 1, 3 and 5 years was 97%, 86%, and 72% respectively. The rate of local control at 5 years was 78%. Functional results were evaluated by a new scoring system. Function was considered good in 59 and 70% at 1 and 2 years respectively. This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma. It is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results.

In this videoband, we present a case of hepatic hydatidosis treated by pericystectomy with the aid of the "harmonic scalpel' apparatus (Ethicon). The patient was a 47-year-old man with a computerized tomography revealed Gharbi grade Ill exophytic lesion (8 x 6 em) at segment III. At the laparoscopic exploration, the cyst was found to be covered with omental adhesions which were divided with the aid of 'harmonic shears'. The cyst was removed by cutting in the plane between the cyst and hepatic paranchyma in the coagulation mode of the apparatus at full energy. Two hepatic ven branches (1-1·5 mm) and an arterial branch (I mm) were observed as disting structures and secured with clips. At the end of the procedure. there wa~ only minimal bleeding from the liver surface and this was controlled with the argon beam coagulator. Then the cyst was placed into a plastic bag and extracted after the cyst content~ were partially removed. The postoperative course of the patient wa~ uneventful. He was discharged after two days. The harmonic scalpel greatly facilitates the procedure by sealing the 'raw' liver surface effectively. i.e. there was no leakage of bile and only minimal bleeding. With the aid of 'harmonic scalpel' or a similar apparatus. pericystectomy can be conveniently added to the armementarium of the laparoscopic surgeon. This operation should be performed in the institutions with extensive experience in both laparoscopic and hepatobiliary surgery.

Hepatic artery thrombosis after liver transplantation remains a major problem which may lead to graft loss and retransplantation. Hepatic artery diseases were compared in two matched groups of liver grafted patients. In Group I (67 patients), echodoppler examinations of the graft hepatic artery were carried out after clinical or biological abnormalities became evident. In Group II (85 patients), echodoppler examinations were systematically made during the follow-up at 2 weeks, 1, 3, 6, and 12 months after liver transplantation. In cases of an abnormal echodoppler examination, arteriography was carried out in order to confirm hepatic artery stenosis and to perform endoluminal angioplasty. In Group I, echodoppler examinations revealed no arterial blood flow in three cases and reduction of hepatic blood flow in two cases. Hepatic artery thromboses were always confirmed by angiography, in the latter two cases, a collateral arterial revascularization of the graft was developed. In this group, two retransplantations, one choledocojejunostomy, and four percutaneous radiological biliary drainages were necessary. In Group II, echodoppler results showing a resistive index below 0.5 and a systolic acceleration time above 0.08 s involved 13 arteriographies. Ten stenoses were diagnosed without any biological abnormalities. Nine endoluminal angioplasties were made without any complication. There was no recurrence of stenosis. One pseudoaneurysm of the femoral artery was cured by compression. The early and non-aggressive detection of hepatic artery stenoses after liver transplantation by echodoppler allows treatment by angioplasty in order to prevent hepatic artery thrombosis and reduce retransplantation.

Coeliac stenosis induced by arcuate ligament compression is usually asymptomatic. Current caution is advised during a supramesocolonic surgical procedure in the case of a collateral arterial system due to coeliac stenosis. 11 cases of coeliac stenosis are described. 3 patients underwent duodenopancreatic resection, 8 patients had liver transplantation. 2 patients died after complications due to celiac, stenosis. These cases are described. The authors discuss the diagnostic and therapeutic approach.

Tumoural invasion of the retropancreatic vessels and particularly of the superior mesentericoportal vein confluence (SMPV) is often considered as a contraindication to resection of malignant tumours of the pancreas. The aim of this retrospective study is to report a series of 20 patients and to demonstrate that resection of the vessels supposed to be involved is justified when it is the only barrier to a complete tumoural resection.Twenty patients, 11 men and nine women (mean age: 61.7 years) underwent a right (n = 14), left (n = 2) or total (n = 4) pancreatic resection for pancreatic adenocarcinoma (n = 19) or cystadenocarcinoma (n = 1) associated with partial resection of SMPV (n = 17), inferior vena cava (n = 1), right hepatic artery (n = 1) and common hepatic artery (n = 1). The veins were reconstructed in all cases by end to end anastomosis and the arteries by direct suture in one patient and venous or artery graft in two patients.Tumoural invasion was histologically present in the vascular wall in nine patients, in the perivascular area in six and negative in five. The in-hospital mortality was nil. One patient had an early venous thrombosis of the repaired SMPV which was reoperated and treated with success by desobstruction and venous graft. The 3-year actuarial survival rate was 16%.Segmental venous resection of the SMPV confluence can be performed safely. Localised invasion of the vascular wall, considered as the only obstacle for a complete tumoural resection, is not associated with a poor prognosis. In case of tight adhesions between tumour and SMPV (inflammatory or tumoural) the venous resection may be included in a deliberate surgical strategy. On the other hand, total obstruction of SMPV, extrapancreatic tumoural extension, tumoural invasion of superior mesenteric artery or coeliac trunk are contraindications to pancreatic resection.