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Cystic tumors of the Pancreas (CTP) are rare (less than 5% of all pancreatic tumors). We have limited our study to CTP of epithelial origin which represent 90% of all CTP. These can be divided into three subgroups: (1) Benign tumors with no risk of malignant progression (serous cystadenoma). (2) Tumors with risk of malignant degeneration (mucinous cystadenoma, intraductal papillary mucinous tumors (IPMT), and pancreatic solid-cystic papillary tumor. (3) Malignant tumors (cystadenocarcinoma, IPMT with malignant degeneration). The latter two groups of CTP require radical resection while serous cystadenoma does not require surgical intervention unless symptomatic. The ability to determine preoperatively the exact nature of a CTP is of tremendous importance; cytologic examination and biochemical assays of cyst fluid aid greatly in this determination. Better understanding of the biologic evolution of CTP has increased the indications for surgical resection but the risks of postoperative morbidity and mortality in these patients must not be underestimated.

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Neuroendocrine tumors are slowly growing and carry a high risk of recurrence. Somatostatin receptor scintigraphy is considered as the gold standard for preoperative evaluation and postoperative follow-up. The use of an intraoperative detection probe makes easier a complete resection of abdominal residual or recurrent tumor. These resections may be incomplete because of the small size of the tumor and the postoperative adhesions. Radio-guided surgery is recommended in order to reduce the need for reoperation.

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STUDY AIM: The aim of this retrospective study was to report an original technique for heterotopic liver transplantation with the graft in the left hypochondrium, and to discuss the indications and limitations of this technique. PATIENTS AND METHOD: Over the past ten years, four patients were treated by this technique; this constitutes 2% of all liver transplantations carried out during this period. RESULTS: No immediate per- or postoperative mortality related to the surgical procedure was noted. Moreover, no severe hemodynamic complications occurred during the per- or postoperative period. In three out of four cases, hepatic function was fully restored within 48 hours. Long-term survival (50 and 97 months) was observed in two patients. CONCLUSION: Heterotopic liver transplantation in the left hypochondrium is an alternative to orthotopic liver transplantation; it is a technique that is easy, non-aggressive, and with good long-term results. It is indicated in cases where the main portal vein is non-functional (following total thrombosis or porto-caval shunt), and orthotopic liver transplantation is therefore not possible.

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Propósito: Evaluar la eficacia de la biopsia del ganglio centinela (BGC), sin utilizar colorante azul, en pacientes con melanoma cutáneo. Material y métodos: Estudio prospectivo llevado a cabo sobre 42 pacientes consecutivos con melanomas primarios en estadio I-II según la AJCC. La BGC ha sido realizada mediante la combinación de linfogammagrafía preoperatoria y localización intraoperatoria del GC usando exclusivamente un detector manual de rayos gamma. Resultados: Se extirparon un total de 43 melanomas primarios en 42 pacientes. De los 46 GC identificados mediante la gammagrafia preoperatoria se consiguieron encontrar 45 durante la intervención, alcanzando un éxito en la técnica del 97,8 por ciento . Entre las 36 regiones ganglionares con BGC negativa ha aparecido una recidiva local, la cual ha sido considerada como un probable falso negativo (2,7 por ciento). Conclusiones: 1 ) La BGC es útil en el estadiaje y como factor pronóstico del melanoma cutáneo. 2) La inyección de colorante azul perdesional podría llegar a ser innecesaria en la BGC si se obtienen buenos resultados con la linfogammagrafía + detector manual de rayos gamma (AU)

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OBJECTIVE: To compare surgical treatment (ST) with endoscopic management (EM) in patients with suspected common bile duct stones. PATIENTS: Two hundred twenty eligible patients originating from 18 surgery units. Patients enrolled in this multicenter randomized study had clinical symptoms that included jaundice, mild pancreatitis (Ranson score < or = 2), or mild acute cholangitis; biliary colic (with increased alkaline phosphatase levels); and common bile duct stones or a common bile duct diameter of 1 cm or larger on ultrasonography. METHODS: Two hundred two patients were randomly assigned to either ST (n=105) or EM (n=97) during a 5-year period. Both groups were comparable with respect to age, sex, American Society of Anesthesiologists score, and clinical presentation. MAIN OUTCOME MEASURES: The rates of early postoperative additional procedures necessary to deal with the impossibility to perform the initial procedure, complications, and retained stones after ST or EM. Subsidiary endpoints were intention-to-treat analyses of mortality and of major complications and the duration of hospital stay. RESULTS: Surgical treatment was associated with a significantly (P<.001) lower rate of 1 or 2 additional procedures (8% vs 29%) due to a significantly lower rate of the impossibility to perform the initial procedure (0% vs 5%) (P<.05), major complications (4% vs 13%) (P<.05), and retained stones (6% vs 16%) (P<.04). Minor complications occurred more often in patients having ST (4%) than in those having EM (0%) (P<.01). Cholecystectomy was performed routinely in 102 patients having ST and electively in 36 patients having EM. There was 1 death in each group initially. On an intention-to-treat analysis, 3 deaths (3.1%) occurred after EM and 1 (0.9%) after ST; this difference was not statistically significant (P=.56). Major complications occurred in 4% of patients having ST compared with 1 1% of patients having EM (P<.002). The median duration of hospital stay was 16 days in patients having ST and 12 days in those having EM; this difference was not statistically significant (P=.09). CONCLUSION: Whether an additional cholecystectomy is performed routinely or electively, the high risk of additional procedures after EM precludes its use as the optimal therapy in patients with symptomatic common bile duct stones, except in those with severe cholangitis.

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BACKGROUND/AIMS: Currently, surgical treatment of hepatocellular carcinoma in patients with cirrhosis is not clearly defined. The objective of this study was, in patients with cirrhosis with hepatocellular carcinoma, to compare liver resection to transplantation assessed by patient survival and to determine whether the tumor recurrence might be influenced by prognostic factors. METHODS: We have gathered all the available data from six French Medical Universities, for 215 patients with cirrhosis with hepatocellular carcinoma surgically treated either by liver resection (102) or by transplantation (113). RESULTS: The overall 5-year survival rate was similar in the transplantation group and in the resection group (32% vs. 31%, p=0.7). However, the 5-year survival rate without recurrence was higher in the transplantation group than in the resection group (60% vs. 14%, p<0.001). Three independent prognostic factors influenced significantly the survival without recurrence: the surgical treatment by transplantation (p<0.001), the number of tumors (p<0.01) and the tumor size (p<0.001). With these factors we defined a prognostic index (Ip) which allowed assessment of the probability of survival without recurrence: Ip= (Xie. x 1.41)+(Nbr T. x 0.19)+(Size TV. x 0.16); Xie=surgical treatment (Xie=0 if transplantation, Xie=1 if resection), Nbr.T. and Size TV.=number of tumors and size of the most voluminous tumor, respectively, according to the histologic study. CONCLUSIONS: These results and this prognostic index are encouraging for liver transplantation as treatment of hepatocellular carcinoma in selected patients with cirrhosis.

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UNLABELLED: The aim of this study is to characterise benign from malignant breast lesions by using 99mTc-Tetrofosmin. MATERIALS: Fifteen female patients with suspected breast lesions and ten normal controls underwent breast scintigraphy with 99mTc-Tetrofosmin. All patients had conventional mammography. Breast imaging begun 20 minutes after i.v. injection of 740 MBq 99mTc-Tetrofosmin. Patients were imaged in supine and prone position. Results of the 15 patients with suspected breast lesions, 13 showed breast uptake, and 6 of them had suspicious lesions on mammography. Surgery confirmed 10 carcinomas and 3 benign lesions. Two patients demonstrated no abnormal accumulation or suspicious findings in mammography. None of the normal controls had breast uptake or mammographic abnormalities. Our study has a sensibility of 100% and 60%, and a specificity of 80% and 100% in scintigraphy and mammography respectively. CONCLUSION: Our findings suggest that 99m Tc-Tetrofosmin may play a role in evaluating breast masses and that can differentiate benign from malignant lesions.

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A case of Splenic Spontaneous Rupture (SSR) due to Infectious Mononucleosis is presented, occurring after a slight clinical course without significative abdominal pain. The SSR was recognized by ultrasonography and CT, with free intraperitoneal liquid. The evolution was successful with non operative management. The Medical literature concerning SSR is comment, enhancing the possibility of non operative management of SSR associated to infectious mononucleosis.

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A total of 196 records of colonoscopic surgical complications were reviewed during a 12-year period. Perforation (183 patients) and haemorrhage (11) were the two main complications. Diagnosis of perforation was delayed in 58 per cent of patients. The sigmoid colon was the site of perforation in 72 per cent with evidence of peritoneal contamination in 59 per cent. Postoperative mortality rate of perforation was 12 per cent and was significantly related to a past history of medical disease and size of perforation. Postoperative morbidity rate was 43 per cent. There were two deaths after colostomy closure. The overall mortality rate of colonoscopic perforation requiring an emergency surgical procedure reached 14 per cent. Haemorrhage always occurred after endoscopic polypectomy; the postoperative course was uneventful in these patients.

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We report the case of a 57-year-old woman with celiac disease of long standing, who developed episodes of intestinal obstruction during two months. They were misdiagnosed as intestinal obstructions caused by adhesions. The barium meal and follow-through examination disclosed several jejunal stenoses. Therefore, the patient underwent early surgery where an intestinal resection was carried out. The histological examination showed the presence of benign ulcers at the stenoses. After surgery, the patient began to gain weight and her nutritional state improved remarkably.

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The treatment of common bile duct stones is controversial. The objective of our study was to report the results of choledochotomy, rigid choledochoscopy and systematic external biliary drainage in the treatment of stones of the common bile duct. Over a 15-year period, 555 patients were operated in our department according to a precise surgical protocol. 14% of these patients were operated as an emergency and 11.8% were operated immediately after endoscopic sphincterotomy. One third of patients suffered from cholangitis. The endoscopic investigation of the common bile duct was positive in 81.5% of patients. The investigation was negative in 18.5% and negative choledochotomy was significantly more frequent in patients operated for acute pancreatitis (p < 0.05). External biliary drainage was performed in 95.7% of patients. When necessary, a bilioenteric anastomosis (3%) or a surgical sphincterotomy (1.9%) was also performed. The postoperative mortality rate was 4.8% significantly higher in patients over the age of 70, in patients operated as an emergency and in patients operated immediately after endoscopic sphincterotomy (p < 0.05). The morbidity rate was 8.4%. Residual stones were diagnosed in 4.4% of the patients. The presence of residual stones was significantly more frequent in patients with multiple stones of the common bile duct (p < 0.05). Long-term follow-up was available for 89% of patients, 95% of whom were asymptomatic. These results, based on a homogeneous therapeutic protocol, can be used as a reference for the evaluation of other techniques, especially endoscopic and laparoscopic techniques.

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PURPOSE: A multicentric randomized study that compared patients who received intrahepatic arterial infusion (HAI) to a group of patients who did not receive HAI (control group) was performed for unresectable hepatic metastases from primary colorectal carcinoma. PATIENTS AND METHODS: One hundred sixty-six patients were assigned randomly to HAI of floxuridine (5 fluoro-2'deoxyuridine [FUDR]) 0.3 mg/kg/d for 14 days every 4 weeks or to the control group; this latter group, depending on the investigator's choice, was either under observation or received systemic fluorouracil (5-FU). The same regimen of systemic 5-FU also was administered to the HAI group in the event of extrahepatic progression. No crossover from the control group to the HAI group was permitted. The mean duration of follow-up was 54 months (range, 31 to 72), and 163 patients were analyzed. RESULTS: A significant improvement was observed in the survival rate for the 81 patients assigned to HAI group (P less than .02) with a 1-year survival rate of 64% versus 44% in the control group (82 patients). The 2-year survival rate was 23% versus 13%. The median survival was 15 months versus 11 months for the HAI group and the control group, respectively. Survival was better for patients with a less than 30% liver involvement, and for those treated in more specialized centers. The hepatotoxic effects of HAI were observed in 47 patients (chemical hepatitis [n = 28], and biliary sclerosis [n = 19]). The 1-year rate of sclerosing cholangitis was equal to 25%. Gastrointestinal toxicity was infrequent and consisted of gastritis or diarrhea. CONCLUSIONS: Therapy with HAI of FUDR improves the survival of patients with liver metastases over colorectal carcinoma. However, the methods that are used to diminish the toxicity of HAI and efficient systemic chemotherapy, such as a combination of 5-FU and leucovorin, are required to prevent extrahepatic metastases.

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Appendicectomy is a century old. McBurney's incision is the oldest but still most frequently used approach. This well-codified surgical procedure can be made difficult by anatomical variations in the situation of the caecum within the peritoneal cavity or by variations in winding of the appendix around the caecum. In uncomplicated appendicectomy abdominal drainage must be installed only when the base of the appendix is of poor quality. Complicated forms of appendicitis (with peritoneal abscess, appendiceal mass, appendicular peritonitis) have their own specific treatment. Laparoscopic surgery has a role to play among the appendicectomy techniques, and this role seems to be particularly interesting in appendicular peritonitis.

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