Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach

OBJECTIVES: This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate. METHODS: Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24-86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest. RESULTS: There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3-75 days). Median follow-up was 27 months (range, 2-50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years' follow-up was 86% and 83%, respectively. CONCLUSION: An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.     

A grading system can predict clinical and economic outcomes of pancreatic fistula after pancreaticoduodenectomy: results in 755 consecutive patients

Aim  

Postoperative pancreatic fistula (POPF) has a wide range of clinical and economical implications due to the difference of the associated complications and management. The aim of this study is to verify the applicability of the International Study Group of Pancreatic Fistula (ISGPF) definition and its capability to predict hospital costs.     

Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients

HYPOTHESIS: Pancreatic fistula (PF), a common and potentially lethal complication of pancreaticoduodenectomy, can be managed nonoperatively in most cases. DESIGN: Retrospective case series. SETTING: Major academic medical and pancreatic surgery center. PATIENTS: A total of 437 consecutive patients who underwent pancreaticoduodenectomy for various diagnoses between January 1, 1988, and August 31, 2004. INTERVENTIONS: Conservative management of PF with an intraoperatively placed closed-suction drain near the pancreaticojejunostomy anastomosis, computed tomography-guided percutaneous drainage, and surgery. MAIN OUTCOME MEASURES: Incidence of PF after pancreaticoduodenectomy and patient outcomes. RESULTS: Fifty-five patients (12.6%) developed a PF, which was most common after resections for ampullary tumors (21.1%) and cystic neoplasms (31.3%), and uncommon after resection for pancreatic cancer (6.5%). The mean number of complications (excluding PF) was greater in the PF group (PF, 1.24; no PF, 0.54; P<.001), but these did not prolong hospital stay (PF, 15.2 days; no PF, 13.7 days; P = .20). Biliary fistula, sepsis, reoperation, and late biliary stricture were more common in patients with PF (P<.05), but mortality rate and long-term survival in patients with either pancreatic or ampullary cancer were unaffected by the presence of PF (P>.40). Fifty-two patients (94.5%) had successful conservative management of their PF with prolonged tube drainage; 4 also required CT-guided percutaneous drainage. Three patients (5.5%) underwent reoperation and 1 died. CONCLUSIONS: Pancreatic fistula is a common problem after pancreaticoduodenectomy. It is associated with increased morbidity, but it does not affect the mortality rate. More than 90% of PF cases can be managed nonoperatively without significantly prolonging hospital stay.     

腹腔镜手术治疗219例肥胖症疗效分析

目的探讨腹腔镜下胃肠外科手术治疗单纯性肥胖症及其合并2型糖尿病（T2DM）患者的效果及安全性。方法上海第二军医大学附属长海医院微创外科2003年6月至2010年6月间对219例肥胖症患者进行了腹腔镜下胃肠外科手术,其中201例行腹腔镜下可调节胃绑带术（LAGB组）,13例行腹腔镜下改良简易型胃肠短路术（LMGB组）,5例行腹腔镜下管状胃胃切除术（LSG组）。总结分析该组患者的临床和随访资料。结果LAGB组患者体质量指数（BMI）平均37．9kg／m2,术后6个月及12个月BMI分别为平均32．4kg／mz和29．7kg／m2;43例术前合并T2DM者．11例（25．6％）术后临床部分缓解,16例（37．2％）完全缓解;有26例（12．9％）术后出现并发症。LMGB组患者BMI平均34．7kg／m2,术后6个月及12个月BMl分别为平均31．6kg／m2和26．9kg／m2：10例术前合并T2DM者,2例（20．0％）术后临床部分缓解,7例（70．0％）完全缓解;有2例（15．4％）术后出现并发症。LSG组患者BMI平均43．8kg／m2．术后6个月及12个月BMl分别为平均38．1kg／m2和34．3kg／m2;3例术前合并T2DM者,术后1例达到临床部分缓解,1例完全缓解：有1例术后出现并发症。所有术式组均无围手术期死亡。结论腹腔镜下胃肠外科手术对单纯性肥胖症有效．并能使合并的T2DM得到缓解．同时手术并发症较少。     

Thyroid carcinoma: results from surgical treatment in 211 consecutive patients.

A retrospective study was undertaken of 211 patients who were operated on for thyroid carcinoma. The revised histological diagnoses were papillary (n = 167), follicular (n = 26), medullary (n = 9) and undifferentiated (n = 9). No patient was lost to follow up (mean 10 years). In 162 patients a palpable neck mass was the only clinical presentation of disease (76%). Fine needle aspiration cytology was increasingly used throughout the period. Total thyroidectomy was done in 167 (79%), hemi or subtotal thyroidectomy in 22 (10%), the remaining received palliative treatment. Accidental unilateral vocal cord paralysis occurred in 3 (1.4%). Total thyroidectomy was followed by permanent hypoparathyroidism in 19 (11%). The tumour recurred in 37 (19%), and 23 of the patients died thyroid cancer (11%). The disease specific mortality for patients with undifferentiated tumours was 77% compared with 8% for patients with differentiated tumours. In the latter group, death of cancer was correlated significantly with age, sex, tumour size, presence of regional metastases, and palliative treatment.     

Compression anastomosis (AKA-2) in colorectal surgery: results in 442 consecutive patients

BACKGROUND: The morbidity and mortality associated with colorectal surgery results partly from anastomotic leakage. Animal experiments have shown some advantages of sutureless anastomosis over conventional colorectal anastomosis. Compression anastomosis follows the same biological principles as sutureless anastomosis. METHODS: The compression anastomosis AKA-2 was evaluated in a prospective consecutive audit of 442 patients between September 1989 and August 1998. RESULTS: Anastomoses were performed in 372 elective and 70 emergency situations. The indication for operation was colorectal cancer (56.3 per cent) and diverticulitis (23.5 per cent). A defunctioning colostomy was performed in 110 patients (24.9 per cent). Fourteen patients died (3.2 per cent). Death was related to anastomotic complications in three patients (0.7 per cent). Twenty-four patients (5.4 per cent) developed intra-abdominal complications. There were 11 symptomatic (2.5 per cent) and six asymptomatic (1.4 per cent) leakages. Anastomoses that were more than 10 cm from the anal verge leaked in seven (2.4 per cent) of 291 cases, while anastomoses between 5 and 10 cm leaked in three (2.6 per cent) of 116 cases and those less than 5 cm from the anal verge leaked in one (3 per cent) of 35 cases. CONCLUSION: The low incidence of anastomotic complications demonstrates good biological healing of compression anastomoses. The compression anastomosis AKA-2 is safe in both high and low anterior resection and can therefore be recommended for use in colorectal surgery.     

Nephrolithiasis after bariatric surgery for obesity

Surgical intervention has become an accepted therapeutic alternative for the patient with medically complicated obesity. Multiple investigators have reported significant and sustained weight loss after bariatric surgery that is associated with improvement of many weight-related medical comorbidities, and statistically significant decreased overall mortality for surgically treated as compared with medically treated subjects. Although the Roux-en-Y gastric bypass (RYGB) is considered an acceptably safe treatment, an increasing number of patients are being recognized with nephrolithiasis after this, the most common bariatric surgery currently performed. The main risk factor appears to be hyperoxaluria, although low urine volume and citrate concentrations may contribute. The incidence of these urinary risk factors among the total post-RYGB population is unknown, but may be more than previously suspected based on small pilot studies. The etiology of the hyperoxaluria is unknown, but may be related to subtle and seemingly subclinical fat malabsorption. Clearly, further study is needed, especially to define better treatment options than the standard advice for a low-fat, low-oxalate diet, and use of calcium as an oxalate binder.     

Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure. METHODS: We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery. RESULTS: The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically. CONCLUSION: Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.     

Intrinsic brainstem tumours in adults: results of microneurosurgical treatment of 16 consecutive patients

Intrinsic brainstem tumours in adults have a poor prognosis and surgical resection is rarely performed. Encouraged by successful operations on children performed in our department, we began a more aggressive strategy of open operations. Between 1986 and 1997, we operated upon 16 consecutive patients over 16 years of age (five female, 11 male, mean age 36.9 years) who were suffering from intrinsic tumours located in the pons and/or medulla oblongata. The extent of first open resection was 80 - 100% in two of the cases and more than 50% in nine cases. The mean survival time after the first occurrence of symptoms was 88.1 (median 34.5) months, and 39.9 (median 11) months after the first open operation. The rate of 5-year survival from the first occurrence of symptoms was 37.5% (25% after the first open surgical procedure). Thirteen out of 16 patients died within the follow-up period of at least 6.3 years, two of them within the immediate postoperative period. Eleven patients experienced a postoperative deterioration of symptoms from which only four recovered. Eight patients had from WHO grade II astrocytoma and a similar course as patients with higher-grade gliomas (n = 4). Our results indicate that open microneurosurgery for intrinsic brainstem tumours is of questionable benefit for the patient. Although surgery offers the advantages of reliable confirmation of histopathology and may be associated with prolonged survival, neurological deterioration was common and, unlike in paediatric patients, often irreversible.     

Atrial fibrillation after esophageal cancer surgery: an analysis of 207 consecutive patients

Purpose

The aim of this study was to identify perioperative risk factors that are associated with postoperative atrial fibrillation (AF) and the outcomes of different pharmacological interventions in esophageal cancer patients who underwent transthoracic esophagectomy.

Methods

This study included 207 patients who underwent a transthoracic esophagectomy for esophageal cancer resection by a single surgeon from January 1, 2004, through December 31, 2010.

Results

Postoperative AF occurred in 19 patients (9.2 %), all of whom received antiarrhythmic drug therapy at the early stage. Antiarrhythmic treatment was effective in 12 cases (63.2 %). In this study, landiolol hydrochloride, an ultrashort-acting β₁-selective β-blocker, was the first-line therapy for postoperative AF. A multivariate logistic regression analysis showed that postoperative AF was significantly associated with the use of an ileo-colon for reconstruction after esophagectomy (P = 0.0023, odds ratios [OR] = 13.6) and with the presence of tachycardia with a heart rate of >100 bpm on postoperative day (POD) 1 (P = 0.0004, OR = 18.4).

Conclusions

Postoperative AF is associated with the use of a colon conduit for reconstruction after esophagectomy and with tachycardia with a heart rate >100 bpm on POD 1. Identifying patients at high risk for postoperative AF will allow for more direct application of pharmacological methods of prophylaxis.     

Routine immediate extubation after off-pump coronary artery bypass surgery: 514 consecutive patients

OBJECTIVE: The purpose of this study was to evaluate the feasibility of routine immediate extubation in patients undergoing off-pump coronary artery bypass surgery. DESIGN: Case series. SETTING: Private hospital. PARTICIPANTS: Five hundred forty-eight consecutive patients undergoing off-pump coronary bypass surgery, representing 5 years of a single anesthesiologist's practice, were evaluated for routine immediate extubation. Thirty-four patients were excluded because they were already intubated, in preoperative cardiogenic shock, or converted to on-pump during the procedure. INTERVENTION: Patients received general anesthesia or general anesthesia plus thoracic epidural analgesia (25%) and underwent off-pump coronary bypass surgery. MEASUREMENTS AND MAIN RESULTS: All 514 patients who were intended to be immediately extubated were expeditiously extubated in the operating room. The numbers of reintubations, morbidity, and mortality were low. CONCLUSIONS: Routine immediate extubation of most off-pump coronary artery bypass patients appears feasible and most probably safe.     

Laparoscopic gastric banding: a minimally invasive surgical treatment for morbid obesity: prospective study of 500 consecutive patients

OBJECTIVE: To evaluate early and late morbidity of laparoscopic adjustable gastric banding for morbid obesity and to assess the efficacy of this procedure by analyzing its results. SUMMARY BACKGROUND DATA: Laparoscopic adjustable gastric banding is considered the least invasive surgical option for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. It is potentially reversible and safe; major morbidity is low and there is no mortality. METHODS: Between April 1997 and June 2001, 500 patients underwent laparoscopic surgery for morbid obesity with application of an adjustable gastric band. There were 438 women and 62 men (sex ratio = 0.14) with a mean age of 40.4 years. Preoperative mean body weight was 120.7 kg and mean body mass index (BMI) was 44.3 kg. m. RESULTS: Mean operative time was 105 minutes, 84 minutes during the last 300 operations. Mean hospital stay was 4.5 days. There were no deaths. There were 12 conversions (2.4%), 2 during the last 300 operations. Fifty-two patients (10.4%) had complications requiring an abdominal reoperation. Forty-nine underwent a reoperation for minor complications: slippage (n = 43, incisional hernias (n = 3), and reconnection of the catheter (n = 3). Three patients underwent a reoperation for major complications: gastroesophageal perforation (n = 2) and gastric necrosis (n = 1). Seven patients had pulmonary complications and 36 patients experienced minor problems related to the access port. At 1-, 2-, and 3-year follow-up, mean BMI decreased from 44.3 kg. m to 34.2, 32.8, and 31.9, respectively, and mean excess weight loss reached 42.8%, 52%, and 54.8%. CONCLUSIONS: Laparoscopic adjustable gastric banding is a beneficial operation in terms of excessive weight loss, with an acceptably low complication rate. It can noticeably improve the quality of life in obese patients. Half of the excess body weight can be effortlessly lost within 2 years.     

Factors affecting erectile function after radical retropubic prostatectomy: results from 1620 consecutive patients

OBJECTIVE

To report the return of erectile function in 1620 consecutive men after radical retropubic prostatectomy (RRP), chosen by half of men diagnosed with clinically localized prostate cancer, and the goal of which is to completely excise the tumour while preserving continence and erectile function.

PATIENTS AND METHODS

From January 1992 to October 2006, one surgeon performed RRP with a nerve‐sparing technique where feasible. Men with erectile dysfunction before surgery, salvage RRPs, those not having a nerve‐sparing procedure, neoadjuvant or adjuvant therapy within 6 months of RRP and a follow‐up of <6 months were excluded from the analyses. Erectile function was evaluated by the surgeon when possible or by an annual questionnaire. Potency was defined as erectile function sufficient for intercourse with or without a phosphodiesterase‐5 inhibitor.

RESULTS

Of 619 men who had a bilateral and of 178 who had a unilateral nerve‐sparing RRP, 72% and 53%, respectively, were potent. When stratifying by age groups (≤49, 50–59, 60–69 and ≥70 years) potency rates were 86%, 76%, 58% and 37%, respectively. Potency was more common after bilateral than unilateral nerve‐sparing RRP in all age groups (P < 0.001). Age, bilateral nerve‐sparing (odds ratio 2.9) and surgeon experience were associated with potency in a multivariate analysis.

CONCLUSION

Careful patient selection and meticulous surgical technique are essential to achieve the right balance between cancer control and morbidity. The patient’s age, nerve‐sparing RRP and the surgeon’s experience were the significant predictors of return of potency after RRP.     

Trachea-innominate artery fistula: successful management of 3 consecutive patients.

Trachea-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Three successive patients who developed this complication while receiving ventilatory assistance through a tracheostomy tube were successfully managed, with long-term survival. Bleeding was controlled by direct digital pressure on the innominate artery or by hyperinflation of the balloon cuff of the tracheostomy tube. In 2 patients, replacement of the tracheostomy tube with an orotracheal tube improved direct access to the innominate artery for digital compression. Late follow-up examination of the right carotid circulation revealed complete reversal of flow in the right internal and common carotid arteries in the 2 patients studied.     

Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients

BACKGROUND: Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population. METHODS: Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible. RESULTS: Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis. CONCLUSIONS: Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.     

Curative surgery for gastric cancer: Study of 166 consecutive patients

From January 1980 to December 1991 we operated on 295 patients with a gastric carcinoma. In 166 cases (56.3%) surgery was performed with curative intent. In 93 patients (56%) a subtotal gastrectomy was performed, and in 73 cases (44%) a total gastrectomy. In all the cases a D-2 type lymphadenectomy was used. The global morbidity rate was 23%, and in-hospital mortality was 3.6%. The morbidity and mortality rates of these two operations were statistically different. Global 5-year survival estimate for the whole series is 61.3%. Univariate and multivariate analysis according to T and N (TNM classification), the number of positive nodes resected, and the relation of positive per resected nodes, revealed statistically different outcomes. This kind of quantitative classification allowed identification of high risk groups irrespective of site of nodal involvement. Tumors classified as intestinal or diffuse type by the Lauren classification had similar survival curves and 5-year survival estimates (p=0.834). By univariate and multivariate analysis this classification did not reveal a prognostic value in this group of patients. In our opinion, tumor penetration and lymph node involvement are at present the most reliable prognostic factors available.

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Resumen En el período enero 1980 a diciembre 1991 se operaron 295 pacientes con carcinoma gástrico. En 166 (56.3%), la cirugía fue realizada con intención curativa; en 93 (56%) se realizó gastrectomía subtotal y en 73 (44%) gastrectomía total. En la totalidad de los casos se realizó linfadenectomía D-2. La mortalidad global fue 23% y la mortalidad hospitalaria 3.6%. Las tasas de mortalidad y morbilidad de estas dos operaciones aparecieron significativamente diferentes. La sobrevida global a cinco años estimada para la totalidad de la serie es de 61.3%. Los análisis uni y multivariables de acuerdo con la clasificación TNM, el número de ganglios positivos resecados y la relación positivos/resecados revelaron resultados estadísticamente diferentes. Este tipo de clasificación cuantitativa permitió la identificación de Grupos de alto riesgo independientes del lugar de la invasión ganglionar. Los tumores clasificados como intestinales o difusos (clasificación de Lauren), registraron similares curvas de sobrevida y de sobrevida estimada a cinco años (P=0.834). Mediante el análisis univariable y multivariable esta clasificación no demostró tener valor pronóstico en nuestro Grupo de pacientes. En nuestra opinión, el grado de penetración del tumor y la invasión ganglionar son los factores de pronóstico más confiables.

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Résumé Entre Janvier 1980 et Décembre 1991, nous avons opéré 295 patients ayant un cancer gastrique. Chez 166 (56.3%), l'exérèse a été jugée curative. Chez 93 (56%) des cas, il s'agissait d'une gastrectomie subtotale alors que dans 73 (44%) cas, une gastrectomie totale a été pratiquée. Dans tous les cas une lymphadénectomie du type D-2 lui a été associée. La morbidité globale a été de 23% et la mortalité hospitalière de 3.6%. La morbidité et la mortalité des deux types d'intervention différaient de façon statistiquement significative. La survie à 5 ans de la série en entier a été de 61.3%. Une analyse uni et multifactorielle a pu mettre en évidence une différence statistiquement significative en ce qui concerne la survie par rapport à la classification T-N (TNM), le nombre de ganglions réséqués et le nombre de ganglions envahis/nombre de ganglions enlevés. Cette analyse a permis d'identifier les malades à haut risque, indépendamment du site de l'envahissement lymphatique. La courbe de survie et la survie estimée à 5 ans étaient identiques selon que la tumeur a été classée intestinale ou diffuse selon Lauren. Cette classification n'a pas, pourtant, de valeur pronostique d'après les analyses uni et multifactorielle. A notre avis, la pénétration tumorale et le degré d'envahissement lymphatique sont les deux facteurs pronostiques les plus constants.