A study of thirty right hepatic arteries.

Thirty right hepatic arteries discovered among 137 celiomesenteric angiographies show the high frequency (22%) of this variation. Radiologic anatomy of the right hepatic artery was discussed; with the exception of one atheromatous stenosis, the pathologic findings of the right hepatic artery and its terminal branches illustrate the development of a regional disease (12 cases or 40%). This assumed pathology is divided half in pancreatic causes (neoplasm, pancreatitis, pseudocysts) and half in hepatobiliary causes (metastatic cancer of the liver, cancer of the hilus, cirrhosis, hydatid cyst, alveolar echinococcosis or angioma). Five times the surgical technic was modified because of the right hepatic artery. Since these observations were made, we are studying the consequences of this hepatic artery over surgical technics and the approach to the various segments of this artery.

Hematoma of the iliacus muscle with femoral palsy.

A case of two simultaneous complications of anticoagulant therapy is presented: a hematoma strictly of the iliacus muscle causing femoral nerve paralysis and a retroperitoneal hematoma. The femoral nerve was trapped by the inguinal ligament to such an extent that its section was necessary to assure rapid and total nerve decompression. Evacuation and drainage of the hematoma was necessary. The favorable postoperative course encourages surgical management of this hematoma with nerve paralysis.

[Foreign bodies in the body following vascular surgery (11 cases)]. / Les corps étrangers de l'organisme après chirurgie vasculaire (11 observations).

Eleven cases of foreign body (F.B.) (3 autochthonous and 8 of other sources) demonstrate the rarity but also the persistent reality of these accidents. Incidence between 1970 and 1985 was close to one F.B. per 3,000 vascular procedures. In 4 cases the F.B. followed surgical non-reconstructive surgery and in the other 7 cases revascularization procedure, material involved being most often textile, sponges in 7 cases and towel in one case. Circumstances leading to let F.B., without disculpating the surgeon, included long and difficult operations conducted as emergencies or requiring one or more recovery operations. Clinical findings of the F.B. were of post-operative sepsis (10 cases) of varied clinical expression. General (4 cases of septicemia) and local (3 thrombosis, 1 anastomotic hemorrhage) consequences were serious. Prognosis in patients with F.B. closely follows that of vascular sepsis, with maximum seriousness after bifurcated prosthetic shunt. An essential prognostic factor is early diagnosis of F.B.: it is dependent on a series of clinical and paraclinical etiologic arguments, particularly results of radiography of the operated zone, fistulography and echography. Surgical intervention is a function of initial operation and is that proposed for all cases of vascular sepsis, with the common denominator of the total revision of the operated zone and removal of foreign bodies. Prophylaxis of F.B. in vascular surgery follows the rules for general surgery; these have been enounced for the last 50 years but have failed to prevent the postoperative F.B. This rare but always possible accident justifies its knowledge by even the most serious, experienced vascular surgeon.

[Aneurysms of the infrarenal aorta and visceral cancer. Therapeutic problems]. / Anévrysmes de l'aorte sous-rénale et cancers viscéraux. Problèmes thérapeutiques.

The association of an abdominal aortic aneurysm (AAA) and a long-standing or progressing cancer is a frequent finding: 14 cases among the 112 infrarenal aortic aneurysms treated by one of us (J.C.) are discussed in this report. The marked predominance in bronchial and ORL epithelioma (50%) is explained by the common pathogenic factors of these neoplasms and atheroma. Surgical treatment is difficult because of the potentially lethal character of the two lesions: it must allow for size and possible progressive nature of aneurysm and prognosis of the neoplasm as defined by the TNM classification. Detection of an AAA in a patient with a history of neoplasm means that the opportunity for aortic surgery is dependent of therapeutic control (or otherwise) of the neoplastic disease and therefore frequently the length of follow up period after therapy. When detection of the AAA and neoplasm is simultaneous, the aneurysm progressing or ruptured, surgical complications leave little choice with regard to operative strategy. In 3 cases, simultaneous treatment of an AAA and a neoplasm was possible, particularly in the case of Grawitz tumors of cortical development without pyelocaliceal invasion. In most patients, separate operative stages are necessary in order to ensure asepsis of AAA surgery. Aneurysmal occlusion with an extrafocal shunt can allow one-stage surgery when aneurysm and neoplasm are equally menacing.

[Epidemiology of gyneco-obstetric emergencies (within the framework of emergency medical care)]. / Epidémiologie des urgences gynéco-obstétricales (dans le cadre de l'aide médicale urgente).

The authors studied over a period of four years emergencies in pregnancy. These were seen in patients who were brought in from an outside hospital to a perinatal centre or when transferred from hospitals to a general maternity unit or to a high risk unit for neonatal and maternity care. 382 pregnant women needed to be looked after (293 from outside hospital and 89 transferred from another hospital). Treatment was given especially in the 3rd trimester of the pregnancy to three groups: before labour (60 cases); during labour (211 cases) and; after delivery (30 cases). There were in the same categories 37 cases before labour, 9 cases during labour and 30 cases after labour transferred from one hospital to another. The diagnosis were, in particular, 47 cases with a high risk of premature labour, 5 cases with haemorrhage and placenta praevia, 27 cases of pre-eclampsia, 211 cases in labour of which 120 were outside hospital. There were 14 cases of maternal illness, 3 cases of trauma and 4 cases of cardiac arrest. There was a high risk of prematurity in 33 cases of labour outside a maternity hospital. The neonatal mortality rate for the first six days after delivery was ten times higher than that for all neonates born in the same county in the same period of time as this series took. But the authors noted that pre-eclampsia cases received care at high risk units but premature cases did not necessarily.

[Acute postoperative arterial ischemia (author's transl)]. / Les ischémies aiguës postopératoires.

The authors analyse 16 cases of acute ischemia observed over a period of one month after an operation of general surgery. The classical cardiac origin, e.g. infarct, arrythmia, was found in only three patients. The septic etiology was predominant, septic arterial emboli but not infective or acute thrombosis during septic or post-operative shock. The clinical aspect showed no special characteristics. Surgery remains the principal form of treatment. The results are good, except in acute arterial thrombosis justifying plastic surgery which may give better results than simple thrombectomy.

[Indications for the Greenfield filter at the distal side of renal veins. 15 cases]. / Les indications du filtre de Greenfield en aval des veines rénales. 15 observations.

Analysis of results of short- and medium-term use of 15 Greenfield's filters (GF) introduced distal to renal veins confirmed the good nephrologic tolerance and efficacy of partial interruption of suprarenal inferior vena cava. The surgical technic necessarily involves use of internal jugular vein (with the exclusion of femoral vein) and it is recommended to insert the GF in the retro-hepatic vena cava at a distance from renal veins. Review of 53 cases reported in the world literature indicates cases suitable for this procedure as being patients with severe thromboembolic accidents unable to be treated by direct surgery, fibrinolysis or by effective anticoagulation. Indications for use of a suprarenal GF include suprarenal extension of a caval thrombus or lack of efficacy of an anterior caval block proximal to renal veins. In these cases, that are rare and should remain so, the suprarenal Greenfield filter is the most satisfactory solution at the present time for ensuring the very poor vital prognosis of this very particular group of patients.

[Arterio-venous fistula of the left renal pedicle after nephrectomy. Possibilities and interest of early diagnosis (author's transl)]. / Fistule artério-veineuse du pédicule rénal gauche après néphrectomie. Possibilités et intérêt du diagnostic précoce.

The authors study a new case of arterio-venous fistula of the left renal pedicle after nephrectomy for trauma. The interest of this case resides in the existence of a right para-umbilical pulsating mass which corresponds to systolic expansion of the inferior vena cava. This sign, which disappeared after corrective operation has the advantage of orienting towards an abdominal vascular condition. In fact, the diagnosis of iatrogenic arterio-venous fistula was made very early : 6 weeks after nephrectomy. The lesion was treated by the purely abdominal route, in the absence of marked peri-aneurysmal fibrosis. Complete removal of the fistula and of the afferent and efferent vessels corrects recent hypertension and prevents later heart failure.

[Haemoperitoneum due to ruptured hepatoma in a cirrhotic patient with porphyria cutanea tarda. Three years' survival (author's transl)]. / Hémopéritoine par rupture d'un hépatome chez un cirrhotique atteint de porphyrie cutanée tardive. Survie de 3 ans après hépatectomie.

A case of ruptured hepatocarcinoma of the left lobe in a cirrhotic patient with a 7 years' history of porphyria cutanea tarda (PCT) is reported. Emergency left lobectomy resulted in 3 years' survival with no sign of recurrence at present. Comments are made concerning the clinical association PCT-hepatoma: (1) either PCT is associated with a hypersecretory hepatoma and behaves as a neoplastic syndrome following the same course as the tumour; (2) or PCT is associated with a cirrhosis (usually alcoholic) which facilitates the development of a hepatoma. In such cases, PCT precedes the tumour and follows a separate course.

[Cystic lymphangioma of the spleen (author's transl)]. / Lymphangiome kystique de la rate.

A rare form of true non-parasitic cysts of the spleen, cystic lymphangiomas are seen as round calcified images in the left hypochondrium. Bidimensional ultrasonography has considerably simplified the diagnosis of splenic cysts, but modern investigations, which can usually eliminate the presence of hydatid cysts in the spleen, cannot differentiate the various types of non-parasitic cysts. Diagnosis of cystic lymphangiomas, currently made after pathological examinations, can be assisted by needle-puncture aspiration guided by ultrasonography, and the role of this investigatory method in diagnosis and therapy is discussed. The only radical treatment for splenic cysts is splenectomy, which should be conducted routinely because of the difficulty of pre-operative diagnosis and the high risk of severe complications.

[Mullerian adenosarcoma of the uterus. Review of the literature. Apropos of a case]. / Adénosarcome müllérien de l'utérus. Revue de la littérature. A propos d'un cas.

The authors report a case of müllerian adenosarcoma in an 86 year old woman. This tumor is characterized by the association of proliferative benign epithelium with a sarcomatous mesenchyma. It was described for the first time in 1974 by Clement and Scully. It is a cancer of decreased malignancy, revealed either by isolated metrorrhagias, or by an increase of the size of the uterus in a post-menopausal woman. Its course shows the occurrence of local recurrences and pulmonary or peritoneal metastases. The only appropriate treatment is total abdominal hysterectomy with salpingo-oophorectomy.

Iliocaval venous compression due to aneurysm of the abdominal aorta: report of ten cases.

Ten patients with symptomatic venous compression secondary to aneurysm of the infrarenal abdominal aorta are reported. Compression was responsible for edema of the lower extremities in seven cases, and, in three instances, for venous thromboembolic disease. The incidence of venous complications secondary to aneurysm (8.8% in our series) is close to that of urologic complications (10%), but their respective pathogeneses are different. Mechanical compression (nine patients) was the predominant mechanism and was due to retroperitoneal hematoma (two patients) and left-sided (three patients) or right-sided (four patients) development of the aneurysm. Noninvasive imaging, including computed tomographic scan and sonography, have replaced the more conventional invasive methods of diagnosis. The large diameter of the aneurysms generally found in these cases mandates rapid surgical treatment in order to avoid rupture and aortocaval fistula. Because of venous collateral circulation, caution must be exercised when working on the left side of the aorta above the aneurysm and at the level of the iliac vessels. Treatment consists of the inclusion prosthetic replacement. The insertion of a Greenfield filter is needed only when pulmonary embolism occurs or in the case of recent or life-threatening caval thrombosis.

Unusual approaches for insertion of the Greenfield vena cava filter: the value of its approach through the jugulosubclavian junction.

During the last four years, we have attempted 249 insertions of the Greenfield inferior vena cava filter using the right internal jugular vein. This approach was impossible in 31 patients (12.5%). Our first alternative was the insertion of the filter through the venous junction between the right internal jugular and right subclavian veins. If this latter technique was not possible we attempted the insertion of the Greenfield filter through the left internal jugular vein before using the retrograde femoral route which is associated with high morbidity. By these techniques we have been able to reduce the number of patients in whom it is impossible to achieve mechanical endocaval partial interruption to 2.4%.

Diagnosis of splenosis: the advantages of splenic scintiscanning with Tc 99m heat-damaged red blood cells.

We present one case of peritoneal splenosis, which was not confirmed by the splenic scintiscan with 99mTc-sulphur colloid, but whose diagnosis, carried out during a second scintiscan with 99mTc-heat-damaged RBC, was confirmed by laparotomy and histology. This case confirms that, for the diagnosis of splenosis, heat-damaged RBC scintigraphy must be used rather than either sulphur colloid scintigraphy or computed-tomography.

[Parenteral use of a solution-emulsion following digestive surgery]. / Utilisation parentérale d'une solution-émulsion dans les suites de chirurgie digestive

A post-operative use of the calorico-nitrogenous mixture: Trivé 1000 was carried out in 25 patients after digestive surgery. The prescribed dose of this lipidic emulsion was 1,36 1 for an average period of four days. A study of the results led to establish the following facts:--a 55 p. cent increase in the nitrogen retention in comparison with a control series of ten patients and from (J o) the day of the intervention to (J F) the day when the treatment was stopped. Besides, the duration of the treatment did not seem to modify this balance, at least within the limits of the period of use. On the other hand, the quantity of EB 51 was a determining factor since 2000 ml were necessary to obtain a positive nitrogen balance (+ 0.96 g).--a very small rise in the amino-acid serous rate. It appeared in 14 patients and, supplied by EB 51, 3 other amino-acids increased their proportion spontaneously (Asp.--Gluc.--Tau.).--a reduction of the rate of 5 amino-acids, one of which, however, (Arginine) was being supplied by the drip. The variations were never statistically significant but for the Phenylalanine rate increase.--a non-systematic variation in the blood proteids that decreased as far as total proteids and albumin were concerned and that increased as far as globulins alpha1 and alpha2 were concerned.--Finally, no variations in the serous graphic record of lipid levels were noted, neither in the average of figures, nor in the analyses carried out after each bottle. Besides, it must be added that the tolerance of the product was excellent both on a general level (very few cases of intolerance: 4) and on the level of the plasma turbidimetry which did not reveal and chylomicrons except in one case. Therefore Trivé 1000 proved to be an interesting nutrient combinatin quite suited to a parenteral feeding because of its high caloric power. The necessity of a calories/g/nitrogen ratio from 100 to 200 corresponding to 2000 ml of EB 51 was once more evidenced. Therefore such a dose (for lack of a protein assimilation) allows for a nitrogen retention important enough to prevent an excessive consumption of the body proteinic reserves. Such doses are perfectly tolerated both on the general and metabolic levels (mainly on the lipometabolic one).