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In 1990 Scopinaro's technique of biliopancreatic diversion with distal gastrectomy (DG) and gastroileostomy was modified. A sleeve gastrectomy with duodenal switch (DS) was used instead of the distal gastrectomy; and the length of the common channel was made 100 cm instead of 50 cm. A questionnaire and a prescription for blood work were sent to 252 patients who underwent DG a mean 8.3 years ago (range 6-13 years) and 465 patients who underwent DS 4.1 years ago (range 1.7-6.0 years). The questionnaire response rate was 93%, and laboratory work was completed for 65% of both groups. The mean weight loss after DG was 37 +/- 21 kg and after DS 46 +/- 20 kg. There were fewer side effects after DS: The number of daily stools was lower (p < 0.0002), as was the prevalence of diarrhea (p < 0.01), vomiting (p < 0.001), and bone pain (p < 0.001). Greater benefits related to several aspects of life were reported after DS than DG (p < 0.0001). The mean serum levels of ferritin, calcium, and vitamin A were higher (p < 0.001), and parathyroid hormone was lower. The yearly revision rate for excessive malabsorption was 1.7% per year after DG and 0.1% per year after DS. The two procedures were equally efficient for treating co-morbid conditions such as diabetes, hypertension, and hypercholesterolemia. Biliopancreatic diversion with sleeve gastrectomy/duodenal switch and a 100-cm common limb was shown to produce greater weight loss with fewer side effects.

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OBJECTIVE: To evaluate the long-term clinical outcome and compare the rupture rate of the two generations of the silicone Angelchik antireflux prosthesis. DESIGN: A cohort study. Follow-up ranged from 61 to 119 months. SETTING: A university teaching hospital. PATIENTS: Sixty-three patients: 33 patients received the first generation Angelchik device (group 1) and 30 patients received a second generation design (group 2). The two groups were comparable for sex ratio, mean age and duration of symptoms. INTERVENTIONS: Implantation of the Angelchik prosthesis. MAIN OUTCOME MEASURES: Comparison of the rupture rate and migration of the prosthesis as assessed by patient questionnaire, telephone interview and radiography of the abdomen. RESULTS: The prosthesis remained in a good position in 53% of group 1 patients and 93% of group 2 patients. The prosthesis was removed in 40% of group 1 patients, most often for rupture, and in only 7% of patients in group 2, to relieve dysphagia (p < 0.01). Grading on a Visick scale demonstrated a good result in 37% of group 1 patients and 69% of group 2 patients. Long-term dysphagia was the most prevalent adverse effect, seen in 45% of patients whose prosthesis was in a good position, and symptomatic reflux recurred in 8%. CONCLUSIONS: The second generation of the Angelchik prosthesis, resulted in a reduced rupture rate of the prosthesis. Nevertheless the high complication and the failure rates militate against continued implantation of the prosthesis.

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In 1980 Scopinaro described biliopancreatic bypass for the treatment of obesity. This procedure was aimed at selective malabsorption. The authors used Scopinaro's procedure in 33 patients, but in 17 they modified it by doing selective vagotomy with closure of the duodenum in continuity instead of a subtotal gastrectomy. Eighteen months after the operation, 88% of the patients had what the authors considered was a good to excellent result, that is a loss of more than 25% of the patient's initial weight. Morbidity of many kinds was encountered but most was self-limiting or easily corrected by medical means. From their experience the authors conclude that biliopancreatic bypass as a procedure for the treatment of morbid obesity should continue to be performed and evaluated.

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Although considered by many as the operation of choice in the treatment of duodenal ulcer, hyperselective vagotomy without drainage is not unanimously accepted because little is known about its long-term efficiency in preventing ulcer recurrence. The long-term results of 203 patients with duodenal ulcer, treated by hyperselective vagotomy between 1974 and 1983 at the Hôpital Laval, are reported. Patients were followed at yearly intervals and questionnaires were used to determine whatever benefits they perceived. The procedure was found to be a safe one with an uncomplicated postoperative course. The overall recurrence rate was 12% over a mean follow-up of 64 months. Recurrences may occur 5 or more years after surgery. The operative technique is important in preventing recurrence. Dissection of the last 6 cm of esophagus lowered the recurrence rate at 5 years from 21% to 9%. Only four patients required reoperation. The majority of recurrences consisted of a single episode, the ulcer being easily controlled by short-course medical treatment. The authors found that 94% of patients were satisfied with the results of the operation.

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The combination of cefotaxime and metronidazole has been suggested for the treatment of peritonitis. We compared their effectiveness with that of tobramycin and clindamycin. Since antibiotics have most of their beneficial effect within a few days a four day course was used and a randomized trial was undertaken. The effectiveness of the 4-day course was 86% and no difference was seen between the two groups of the study.

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The presence of a pleural effusion in patients with pancreatitis is a common marginal occurrence. On rare occasions the pleural effusion not only is abundant, recurrent, hemorrhagic and contains a high concentration of amylase, but presents as the only manifestation of an otherwise undiagnosed or obscure pancreatitis. Thus it presents a difficult diagnostic and therapeutic problem. The authors report such a case and review the literature in which 49 cases have been reported in the past 10 years. Pancreatomediastinopleural fistula is usually visualized and seems to be the basic fault in most cases. Thoracic drainage will relieve the patient and dry up the effusion in one third of cases. Otherwise pancreatic resection is usually required. Internal or external drainage of the mediastinopleural component by laparotomy is not difficult. Pleural sequelae are minimal in most cases.

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Hyperselective vagotomy is a relatively recent surgical procedure used for the treatment of duodenal ulcer. We report excellent results in 98 consecutive patients during the last four years. After a mean follow-up period of 2.2 years, the results, according to the classification of Visick, are excellent in a large number of patients. There was a significant gain in body weight in a majority of the patients. The recurrence rate for an ulcer is only 4.5 per cent. There is a significant reduction of basal acid output of 63 per cent, maximal acid output of 46.8 per cent and postinsulin acid output of 73.7 per cent.

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