[Open versus video-endoscopic approach in the treatment of hypercortisolism by bilateral adrenalectomy]

Progress in the technique of the hypophysectomy and in the imaging procedures reduced drastically the indications of bilateral adrenalectomy (BA) in the treatment of hypercortisolism (HC). Indeed BA is indicated in 10 to 30% after failure of pituitary surgery, when HC is related to ACTH ectopic secretion, and in HC related to autonomous adrenal secretion. The purpose of this work is to demonstrate the validity of the bilateral video endoscopic adrenalectomy (BVA) in regard to open surgery. During the last 20 years, 88 patients were operated on by open adrenalectomy (Group 1), either by transperitoneal approach, or bilateral posterior lombetomy. From 1994, 62 patients (Group 2), were operated by video endoscopy. Two death occurred in group 1. The frequency of the preoperative complications were identical in each group, but postoperative morbidity were lower in the group 2. The fall in the postoperative pain, the simplicity of the follow up, the rapid hospital discharge, the low rate of parietal complications were observed in BVA. We conclude that the postoperative follow up is better after BVA a specialized training and time of adaptation are imposed to the surgeon.

[Intra-arterial fibrinolytic therapy for acute mesenteric ischemia]

We report a case of mesenteric ischemia secondary to embolic occlusion treated by percutaneous intra-arterial thrombolysis. Early initial radiographic evaluation included abdominal plain film, ultrasonography, abdominal CT, and arteriography. Only selective superior mesenteric artery angiography provided definite diagnosis. The duration of ischemic symptoms before thrombolysis was 6 hours. Post procedure angiogram at 12 hours showed complete resolution of the mesenteric arterial thrombus with clinical improvement. The most important criteria for patient survival is early diagnosis and immediate treatment. Direct infusion of urokinase into the superior mesentric artery may be an alternative to surgery in selected patients and particularly in patients without evidence of frank bowel necrosis.

Comparison of the hemodynamic parameters of open and laparoscopic adrenalectomy for pheochromocytoma

Laparoscopic adrenalectomy has gained widespread popularity for treating a variety of adrenal disorders including pheochromocytoma, but the effects of pneumoperitoneum on the hemodynamics of patients with catecholamine-secreting tumors are poorly understood. The goal of this study was to compare the effects of carbon dioxide pneumoperitoneum and tumor manipulation on the hemodynamic parameters in two groups of patients with sporadic pheochromocytomas less than 7 cm in size. Group 1 patients (n = 11) underwent lateral transabdominal laparoscopic adrenalectomy, and group 2 (n = 11) underwent adrenalectomy by the open anterior approach. The mean follow-up was 37 months in group 1 (range 26-51 months) and 52 months in group 2 (range 27-72 months). All patients undergoing laparoscopic adrenalectomy experienced intraoperative hypertension (blood pressure > or = 200/90 mmHg), as did 73% with the open approach, but the difference was not significantly different. Intraoperative hypotension (systolic blood pressure < 80 mmHg) occurred in four group 1 patients compared to six patients in group 2. Mean arterial pressure, central venous pressure, and pulmonary capillary wedge pressure were significantly higher in group 1 patients prior to tumor excision, but there was no difference in pulse, cardiac index, or left ventricle work index at any point during the procedure. There were no conversions or complications in the laparoscopic group; one patient in group 2 developed an incisional hernia. Although laparoscopic adrenalectomy for pheochromocytoma is associated with a greater increase in mean arterial pressure, central venous pressure, and pulmonary capillary wedge pressure, the creation of pneumoperitoneum does not significantly change the cardiac index or left ventricle work index. Carbon dioxide pneumoperitoneum is well tolerated in patients with pheochromocytoma.

In situ repair of a secondary aortoappendiceal fistula with a rifampin-bonded Dacron graft

Secondary aortoenteric fistulas remain challenging diagnostic and therapeutic problems. Although the duodenum is most frequently involved, other intestinal segments are possible sites for fistulization. We report here a case of graft-appendiceal fistula revealed by recurrent gastrointestinal bleeding 11 years after abdominal aortic aneurysm replacement. The preoperative diagnosis was not achieved by endoscopy or imaging assessment. Despite recommended principles of total graft excision and extraanatomic bypass, appendectomy and in situ rifampin-bonded graft reconstruction were performed because of the advanced age and poor arterial runoff. The postoperative course was uneventful and the patient remains well 17 months after operation.

[Videolaparoscopic excision of insulinoma. A study of 5 cases]

STUDY AIM

Evaluation of the feasibility of the videolaparoscopic resection in pancreatic insulinomas, and reporting of five cases.

PATIENTS AND METHOD

From 1996 to 1998, a videolaparoscopic resection was attempted in five patients with sporadic, unique and benign insulinoma. The insulinoma was recognised and localised by preoperative ultrasonography in the pancreatic head (n = 1), body (n = 3) or tail (n = 1). For the videolaparoscopic procedure, three to five trocars were necessary. Cephalic and corporeal insulinomas were approached through an opening of the gastrocolic ligament and caudal insulinoma required mobilisation of the splenic flexure of the colon and dissection of the splenic pedicle. Peroperative ultrasonography was not used.

RESULTS

Four resections were exclusively performed with videolaparoscopy: three enucelations and one distal pancreatectomy with splenic preservation. The cephalic insulinoma could not be found by laparoscopic exploration and required a laparotomy to be recognised and enucleated; it was located further down than expected. There were no postoperative complications in four patients. One enucleation was complicated by a pancreatic fistula that required reoperation. All the patients were cured with a 6- to 16-month follow-up.

CONCLUSION

Selected insulinomas may be operated on with videolaparoscopy. Preoperative endoscopic ultrasonography is necessary for this selection. Videolaparoscopic approach is contraindicated in multiple insulinomas, in insulinomas located on the posterior wall or deeply located in the head of the pancreas, and in malignant tumors. Videolaparoscopic resection is mainly indicated in unique and benign insulinomas, superficially located on the anterior wall of the pancreas, to be resected by enucleation or distal pancreatectomy. Disadvantage of laparoscopic approach compared to conventional approach is the absence of palpation and difficulty to explore the whole pancreas; advantage is the lack of parietal incision and the good postoperative comfort.

[Pancreatic echo-endoscopy and preoperative localization of insulinomas]

Preoperative localization of insulinomas often fails because of the small size of these tumors. The aim of this study was to analyse the value of endoscopic ultrasonography of the pancreas in comparison with them to those of conventional localization procedures.

PATIENTS AND METHODS

From 1983 to 1997, 32 patients, operated with a preoperative diagnosis of insulinoma, underwent one or more localization procedures: ultrasonography (US) (n = 31), computed tomography (CT) (n = 31), magnetic resonance imaging (MRI) (n = 10), angiography (ANG) (n = 6), transhepatic portal venous samplings (THPVS) (n = 3), and/or endoscopic ultrasonography (EUS) (n = 25). More recently, 4 patients had scintigraphy with labelled octreotide. During surgery, intraoperative palpation and ultrasonography of the pancreas, performed in all but one cases (laparoscopy), allowed the localization of 29 solitary tumors and 2 multiple tumors (one of which in a case of a MEN II). A malignant tumor was found in 6 patients.

RESULTS

The sensitivity of the localization procedures was as follows: US = 19%, CT = 39%, IRM = 30%, ANG = 33%, THPVS = 0%, EUS = 96%. Labelled octreotide scintigraphy was positive in 3/4 cases. Surgical procedures included: 15 enucleations or partial resections, 14 left pancreatectomies (5 of which with splenectomy), 3 duodenopancreatectomies. In one case the tumor was resected laparoscopically (distal pancreatectomy).

CONCLUSION

EUS was the best preoperative localization procedure in this study. It may avoid the need for other imaging procedures. Combined with intraoperative ultrasonography, EUS could allow laparoscopic resections in selected cases.

[Possibilities and limits of surgical treatment of malignant adrenal cortex carcinomas. Apropos of a series of 74 cases]

The aim of this study was to report our experience of 74 patients operated on for adrenocortical carcinomas in the last 15 years with particular reference to survival rate and prognostic factors. The tumors were secreting in 78% of the cases and non secreting in 22% of the cases, encompassing stade I: 7%, stade II: 43%, stade III: 21%, stade IV: 29%, according to the MacFarlane classification. All patients were operated on whatever the stade. Adrenalectomy with regional lymphadectomy was performed in 50% of the cases. Other procedures included extended adrenalectomy with nephrectomy (n = 27), hepatectomy (n = 7), and desobstruction or resection of inferior vena cava (n = 13). The resection was curative for 66% of the patients and palliative in 34% of the patients. Local recurrences were operated on in 13 patients. Operative mortality was 4%. Stade I and II had significantly the best actuarial survival rates (78 and 62% at 5 years, respectively), when compared to stade III (27%). Extension to the vena cava was not considered as a contra indication even in cases of massive extension. The survival rate of patients with local recurrences was the same as patients wich stade III: 32% at 5 years. Stade IV tumors had the poorer prognosis with a survival rate of 5% at 3 years. In this group, some patients may have benefited from mitotane. Further studies are mandatory to appreciate the benefit of adjuvant therapy with mitotane and palliative chemotherapy.

[Bilateral video-endoscopic adrenalectomy in Cushing's disease. Experience in 24 patients]

The purpose of this study was to compare the results of bilateral laparoscopic adrenalectomy (BLA) to bilateral open adrenalectomy (BOA) in the treatment of Cushing's disease. Twenty-four patients (23 Cushing's disease, 1 congenital adrenal hyperplasia) were divided into 3 groups. Group 1 patients (n = 15) underwent BCA using the lateral transabdominal approach, Group while 2 patients (n = 9) underwent laparoscopic adrenalectomy on one side and conventional open adrenalectomy on the contralateral side. Groups 1 and 2 were compared retrospectively to 15 patients (Group 3) who underwent BOA as part of larger series of 61 patients. There was no difference in the degree of hypercortisolism in the 3 groups. At the beginning of the experience, the duration of surgery was longer in Groups 1 and 2 compared to the open surgery group, but this difference subsequently decreased during the study. There was no difference in intraoperative blood loss or transfusion rate. Group 1 patients experienced fewer wound and intraabdominal complications and less postoperative pain, shorter hospitalization, and quicker recovery than groups 2 and 3 patients. Technically obesity and tissue fragility are easily overcome by the laparoscopic approach. BCA also achieves success rate of hypercortisolism correction. In conclusion, BLA is the surgical procedure of choice for the treatment of Cushing's disease when surgical therapy is indicated.

Common bile duct stenosis caused by chronic pancreatitis after liver transplantation for alcoholic cirrhosis

BACKGROUND

The prevalence of chronic pancreatitis in patients with alcoholic cirrhosis ranges from 7% to 11% and is not considered a contraindication for liver transplantation.

METHODS

Among 59 liver transplant recipients grafted for alcoholic cirrhosis, we report two observations of common bile duct stenosis due to chronic pancreatitis.

RESULTS

In both cases, pretransplant work-up disclosed no clinical or radiological evidence of chronic pancreatitis. The diagnosis of common bile duct stricture was made 6 and 60 months after liver transplantation. One patient was reoperated upon, and his choledochocholedochostomy was converted into a Rouxen-Y choledochojejunostomy. The second patient experienced metastatic laryngeal carcinoma and died before reoperation.

CONCLUSIONS

These observations suggest that common bile duct stricture caused by chronic pancreatitis may occur after liver transplantation for alcoholic cirrhosis, even after a long-standing history of abstinence.

Rationale and technical constraints of a tertiary liver transplantation

Because of the current shortage of donor organs, the routine performance of tertiary liver transplantation (LT) may be questioned. In this study, the indications of tertiary LT are discussed, paying particular attention to intraoperative technique. Of 501 LTs performed from 1986 to 1995, eight (1.6%) were tertiary LTs. Three patients underwent an emergent third LT because of associated hepatic artery and portal vein thromboses (n = 2) or hyperacute rejection (n = 1). Five patients had an elective third LT for ischemic cholangitis (n = 4) or chronic rejection (n = 1). The 3 patients who underwent retransplantation emergently died early from multiple-organ failure. Because of previous surgery and subsequent technical difficulties, the third LT in the remaining 5 patients required unroutine surgical procedures including the following: intrapericardial control of the suprahepatic vena cava (n = 1), "en bloc" clamping of both the infrahepatic vena cava and the hepatic pedicle (n = 1), arterial reconstruction onto the aorta via an aortoiliac conduit (n = 5), and aortic resection with aortoaortic prosthetic reconstruction (n = 1). Of these 5 patients, 4 required reoperation because of bowel perforation (n = 5) or intraperitoneal bleeding (n = 1). The 5 patients (62%) who were regrafted electively are alive and well after a median follow-up of 45 months. A third LT can be reasonably offered to selected young recipients if performed electively. Tertiary LT may require unroutine surgical procedures and may lead to severe morbidity.

[Role of selective venous catheterization with assay of parathormone 1-84 in the treatment of persistent hyperparathyroidism]

From March 1993 to October 1994, 12 patients operated for persistent hyperparathyroidism had preoperative catheterization of large cervical and mediastinal veins (CLCMV) with determination of serum concentration of intact parathyroid hormone. Other localization procedures included: ultrasonography (US, n = 9), computed tomography (CT, n = 8), magnetic resonance imaging (MRI, n = 5), and sestamibi radionuclide imaging (MIBI, n = 9). A (1-84 PTH) gradient of 1-84 PTH was demonstrated in all patients, localizing a lesion in the neck (n = 9) or in the mediastinum (n = 3). An adenoma was found in nine patients either in the neck (n = 6) or in the mediastinum (n = 3), and 2 patients had glandular hyperplasia. Two patients remained hypercalcemic despite the removal of parathyroid tissue during CLCMV-guided reexploration. An other patient underwent unsuccessful neck reexploration. The sensitivity of other procedures was lower: US: 22%, CT: 50%, MRI: 60%, and MIBI: 66.5%. After a median follow-up of 13 months, 9 patients were cured of their hyperparathyroidism (75%) and 3 had persistent hypercalcemia. Our results suggest that CLCMV with 1-84 PTH measurement is the most accurate localization procedure in persistent hyperparathyroidism.

Laparoscopic splenectomy versus open splenectomy: a comparative study

BACKGROUND/AIMS

In 1993, we reported a new technique for laparoscopic splenectomy, namely the "hanging spleen" technique. The patient was placed in a right lateral supine position with the operator being located on the right of the patient. We herein report the results of 28 laparoscopic splenectomies performed with this technique until January 1996.

MATERIAL AND METHODS

From 1993 to 1996, the results were compared with those of 28 patients operated on by open splenectomy from 1988 to 1995. The two groups were similar in terms of age, sex-ratio, and physical condition (ASA classification). Indications for splenectomy were the following in each group: idiopathic thrombocytopenic purpura (ITP) (n = 26 and 27, respectively) and hemolytic anemia (n = 2 and 1, respectively).

RESULTS

Accessory spleens were found in 3 patients of the laparoscopic group and in 5 patients of the open group. Three conversions to open procedure were necessary in the laparoscopic group, but two conversions might have been avoided. We have observed significant advantages in the laparoscopic approach: shorter ileus and postoperative stay. On the other hand, the procedure was longer than with open splenectomies. Three patients had postoperative complications in the laparoscopic group, whereas nine patients had complications in the open group. Recurrence of ITP was observed in 2 patients of the laparoscopic group and in 4 patients of the open group.

CONCLUSION

Our results suggest that laparoscopic splenectomy may be considered as a safe alternative to open splenectomy in patients with hematological diseases such as ITP and hemolytic anemia.

Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism

Unilateral neck exploration (UNE) is a controversial approach to the treatment of primary hyperparathyroidism (PHP), and most surgeons favor bilateral neck exploration. The aim of this study was to assess the value of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of urinary cyclic AMP (UcAMP) or 1-84 PTH in 200 patients undergoing unilateral neck exploration under local anesthesia. Conditions for UNE were (1) a presumed solitary adenoma detected by ultrasonography, (2) no thyroid disease, and (3) no family history of PHP or multiple endocrine neoplasia. Patient's consent was obtained for conversion to bilateral exploration according to surgical and biologic findings. Sensitivity of ultrasonography was 92.5%. Sestamibi scintigraphy, performed in 70 patients, was less sensitive than ultrasonography (80%). Persistent PHP was accurately detected by intraoperative measurement of UcAMP or 1-84 PTH in all cases. At follow-up, 96.0% of the patients were cured either after unilateral neck exploration only (90.5%), or after conversion into bilateral exploration. Ultrasonography and intraoperative measurement of 1-84 PTH allow unilateral neck exploration with excellent results in a selected group of patients with PHP.

Metastatic endocrine tumors: medical treatment, surgical resection, or liver transplantation

We reviewed our experience with 34 patients with metastatic endocrine tumors (METs) who were treated by different modalities. Eight patients were treated by chemotherapy or chemoembolization because of stable disease or surgical contraindications. Seventeen patients underwent curative or cytoreductive surgical resection. Nine patients received grafts based on the following criteria: no extrahepatic spread on imaging workup and nonresectable symptomatic metastatic disease. Of the eight medically treated patients, the five patients with initial stable clinical condition are alive 32 to 56 months after referral. Of the 17 patients treated by liver resection, 13 are alive 6 to 108 months after surgery, and 7 are disease-free. After curative resection, the 5-year actuarial survival and disease-free survival rates were 62% and 52%, respectively. Of the nine grafted patients, three patients grafted for carcinoid tumor are alive at 15, 24, and 62 months, one of whom has a late recurrence. Our results indicate that therapeutic indications for METs should be based on age, clinical symptoms, histologic type, and tumor extension: Patients with stable MET may benefit from surgical restraint; liver resection in patients with aggressive MET may provide good long-term palliation and possibly cure one-third of the patients; liver transplantation should be restricted to young patients with nonresectable carcinoid MET but remains a high-risk operation because of previous surgery and chemoembolization.

Role and operative risk of bilateral adrenalectomy in hypercortisolism

Transsphenoidal pituitary surgery has radically modified the management of pituitary-dependent hypercortisolism (Cushing's disease). Bilateral adrenalectomy may, however, represent the ultimate treatment in some cases of hypercortisolism. In the present study we report our experience of bilateral adrenalectomy in 82 patients operated on during the last 15 years. The causes of hypercortisolism were Cushing's disease (n = 78), ectopic ACTH syndrome (n = 3), and primary adrenocortical nodular dysplasia (Carney-Meador syndrome) (n = 1). Before operation 37% of the patients had severe symptoms of hypercortisolism. A bilateral posterior approach was undertaken in 58 patients, whereas 18 patients had an anterior transabdominal approach and 6 patients a laparoscopic approach. There were two operative deaths (2.4%). Postoperative complications occurred mostly in cases of advanced disease and were observed in 14 patients (17%), among whom 4 had severe complications. At long-term follow-up, one recurrence of hypercortisolism and 12 Nelson syndromes (15%) were observed. In conclusion, bilateral adrenalectomy carries an acceptable operative risk, and we recommend bilateral adrenalectomy rather than long-term suppressive therapy in patients requiring prompt and definitive control of their hypercortisolism or after pituitary surgery failure.

Endoscopic ultrasonography for the preoperative localization of insulinomas

Preoperative radiological localization of insulinomas often fails because of the small size of the tumors. We studied retrospectively the value of different procedures in preoperative localization of insulinomas in 18 patients. Radiological assessment included transabdominal ultrasonography, computed tomography, angiography, magnetic resonance imaging, transhepatic venous sampling, and endoscopic ultrasonography (EUS) for the last 11 patients. During surgery, the association of palpation and intraoperative ultrasonography localized 16 solitary tumors and two multiple tumors (mean size, 1.8 +/- 1.1 cm). There insulinomas were found to be malignant. Conventional preoperative methods correctly localized the tumor in seven of 18 cases (38%), whereas the sensitivity of EUS was 10 of 11 cases (90%). Surgical procedures involved eight enucleations, nine distal pancreatectomies, and one total pancreatectomy. Because of its high sensitivity and safety, EUS was found to be the best method for preoperative localization of insulinomas, and we recommend that EUS replace conventional methods for the majority of cases.

[Attempt at preventing hyperacute xenogenic rejection by isotopic suppression of IgM in the recipient]

Hyperacute xenogeneic rejection is partly initiated by the binding of performed natural antibodies on the recipient's vascular endothelium. In this study, isotypic suppression of IgM in the recipient was conducted in the guinea pig-to-rat combination. Anti-IgM HIS 40 and 56 monoclonal antibodies were injected intraperitoneally in rats (n = 3) (Group 1). Control animals were rats (n = 13) treated by PBS (Group 2). Guinea pig hearts were implanted heterotopically in all rats. Depletion of circulating IgM in the recipient was assessed by ELISA. The circulating and splenic B-lymphocyte population was scanned by FACS analysis. Isotypic suppression was very effective for the depletion of circulating IgM in Group 1 rats (alpha < 0.01) as assessed by ELISA. Similarly, the rate of circulating and splenic B-lymphocytes was significantly decreased in treated animals (alpha < 0.01). However, the graft survival in Group 1 (14 +/- 6.9 min) was not different from that observed in Group 2 (15.4 +/- 5 min). Isotypic suppression of IgM in the recipient did not delay hyperacute xenogenic rejection in the guinea pig-to-rat combination. The prevention of hyperacute rejection must therefore be based on the various mechanisms of this phenomenon.

How valid is emergency liver transplantation for acute liver necrosis in patients with multiple-organ failure?

Multiple-organ failure (MOF), defined as the failure of initially uninvolved organs, is the final step of definitive and massive liver necrosis. Emergency liver transplantation (ELT) has radically modified the outcome of acute liver failure and early primary graft failure, but the results of ELT in cases of MOF are unknown. From May 1988 to June 1993, 243 patients underwent a liver transplantation (LT). Thirty-seven patients (15.2%) who had an acute liver necrosis complicated by a MOF underwent an ELT. Twenty-one patients were children. An emergency retransplantation was performed in 16 patients. Three or 4 organ-system failures (OSF) were present in 13 patients. Before ELT, the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 26.3 +/- 5.1. Six-month and 1-year survival rates were 37.8% and 25.9%, respectively, after ELT complicated by MOF, and 78% and 73.5%, respectively, in other cases of LT. Twenty-six patients had surgical complications (70%), whereas thirty-one patients had medical complications (84%). Twenty-two patients died during the postoperative period (60%). Before ELT, infection (P < .05), cardiovascular failure (P < .03), and more than two OSF (P < .05) were more frequent in patients who died after intervention. The APACHE II score (P < .05) and the length of stay in the intensive care unit before ELT (P < .05) were lower among survivors. In the context of liver allograft shortage, our results suggest that an ELT should not be performed in patients with cardiac failure, more than two OSF, or an APACHE II score higher than 30.

Extrafascial hyper-reduction of the hepatic graft

The technique and limits of graft reduction in orthotopic liver transplantation (OLT) are not well-defined, especially for small recipients. To reduce the hepatic graft to the left lateral segment (segments II and III), the authors have used an extrafascial hepatectomy without any dissection of the hepatic hilum. Among 165 pediatric OLT, 22 procedures using such hyper-reduced hepatic grafts were performed upon 21 children of median age 2.6 years between 1988 and 1992. These 22 hyper-reduced hepatic grafts were transplanted orthotopically with conservation of the inferior vena cava of the recipient. The three-year patient survival rate was 66 percent (80 and 50 percent for those patients undergoing elective and emergent procedures, respectively). The main postoperative complications were: primary graft nonfunction (n = 1), arterial complications (n = 2), portal vein thrombosis (n = 1), intra-abdominal bleeding (n = 2) and biliary complications (n = 2). This technique is useful in instances of a large size discrepancy between the donor and recipient. However, it does not increase per se the absolute number of hepatic grafts available for transplantation.

[Hepatocellular carcinoma on cirrhosis. Resection or transplantation]

In cirrhotic patients who develop hepatocellular carcinoma the only hope of prolonged survival is surgery. A review of the literature was carried out in order to determine precisely the indications for surgical treatment and the choice between liver resection and transplantation. With a low post-operative mortality rate, the survival rate 3 years after liver resection is almost 50 percent. The most favourable cases are tumours smaller than 5 cm, uninodular and well encapsulated, but intrahepatic recurrences are almost constant at 5 years. Liver transplantation does not improve the long-term survival. Its best indications are the same as those of liver resection. Because of graft scarcity and rapid tumoral progress in patients on the waiting list, liver transplantation must be reserved for unstable cirrhosis. In the other situations, liver resection must be considered in priority.

[Resection of hepatocellular carcinomas. Analysis of prognostic factors of a multicenter series of 153 patients]

In order to identify the prognostic factors of the resection of hepatocellular carcinoma, the results of 153 resections performed between January 1984 and December 1988 in 18 French centers were analysed. Cirrhosis was present in 76% of the patients. Among the postoperative complications (61%), the most frequent were ascites (35.3%) and liver failure (19%). Operative mortality was 20%. One-, 3- and 5-year survival rates were 52.7, 30.1, and 17.9%, respectively. The survival rate was significantly higher in patients with a curative resection, Pugh's class A or with a tumor less than 3 centimeters in diameter. After curative resection, actuarial survival rates without recurrence were 65, 24.4, and 16.7% after, 1, 3, and 4 years respectively. In this case, the survival rate was significantly related to the number of resected nodules and the size of the tumor but not to the presence of a capsule surrounding the tumor.

Controlled liver splitting for transplantation in two recipients: technique, results and perspectives

A technique of controlled liver splitting for transplantation in two recipients is proposed, based on a full anatomical assessment of the graft including arteriography and cholangiography on the back-table. Using eight livers, 16 patients received a graft: right liver (eight patients), left lobe (four) or left liver (four). Twelve patients required urgent or very urgent transplantation. Anatomical assessment of the graft demonstrated a portal bifurcation in all cases, a common trunk of the left and middle hepatic veins in five, a right biliary duplication in three and duplication of the left branch of the middle hepatic artery in one. After revascularization of the graft, bleeding was greater in patients with a right graft, particularly if the middle hepatic vein had been ligated. The main postoperative complications were hepatic artery thrombosis (four cases), biliary complications (four), portal vein thrombosis (two), haematoma (two) and abscess (two). No primary non-function of the graft was observed. The postoperative survival rate was 75 per cent. The four patients in whom transplantation was not considered urgent are still alive. The immediate survival rate of the grafts was 69 per cent. These results compare favourably with those in the literature. In spite of the technical, logistical and ethical problems raised by this technique, the results suggest that controlled liver splitting for transplantation in two recipients may in the future significantly improve the feasibility of liver transplantation.

[Benign non-parasitic splenic cysts. 9 cases]

Benign non-parasitic splenic cysts are uncommon. Their diagnosis can benefit from ultrasounds and computed tomography. However, it may be difficult, before surgery, to distinguish between true cysts, which are congenital with epidermal lining, and false cysts, which are consecutive to a trauma, inflammatory or degenerative, without epidermal lining. We report nine cases of non-parasitic splenic cysts and try to determine the preoperative diagnostic approach. To prevent the overwhelming post-splenectomy infection syndrome, conservative surgical treatment is mandatory. Various surgical methods are discussed.

[Peritoneal puncture dialysis in the monitoring and treatment of hemoperitoneum of traumatic origin?]

The great diversity of injuries after abdominal wound, need an adapted treatment. When laparotomy is indicated in uncontrollable hemorrhage, peritoneal lavage associated with C.T. scan seems to be interesting in the management of hemoperitoneum with a moderate injury severity score and stable arterial and venous pressures. Three patients were recently managed non operatively with good results. The authors draw up these three cases with inclusion criterias and limits of the method.