[Study of atrial conduction tissue in the 17 mm V-C human embryo. Morphological contribution to the pathogenesis of sinoauricular node dysfunction]. / Etude du tissu de conduction atrial chez l'embryon humain de 17 mm V-C. Contribution morphologique à la pathogénie du dysfonctionnement du noeud sinu-auriculaire.

Is there a specialised conduction pathway connecting the sinoatrial and atrioventricular nodes within the crista terminalis? As lesions of this zone can cause sinus node dysfunction and the sick-sinus syndrome, we decided to study this structure at the beginning of its embryonic development. Serial 10 micronthichness transverse sections of a 17 mm vertex-coccyx (Stage 19) human embryo were studied by light microscopy, anatomical reconstruction (Born) and morphometry. The region of the sinus venosus and venous valves, of the superior vena cava and the atrioventricular region were drawn and reconstructed with 150 X magnification by Born's method using wax plates of the following dimensions: 175 X 95X 1.5 mm. The volume of the region of the sino-atrial node was determined by multiplying the thickness of the sections by the surface of the region (measured by planimetry using the point counting method); its value was 15.4 X 10(6) microns3 with an antero-posterior diameter of 490,0 micron. These results show that this region is already proportionally larger in Stage 19 embryos. Reconstruction showed the sinoatrial node region to be a round bulge with a groove on either side: that of the sulcus terminalis and the superior vena cava on the left and the same vein with the mesocardium on the right. The right venous valve connects this zone with the interatrial septum and comprises two distinct cellular components, on derived from the atrial wall and the other from the muscle of the sinus venous. The artery fo the sinoatrial node was identified.(ABSTRACT TRUNCATED AT 250 WORDS)

[Present place of lumbar sympathectomy in arteritis of the lower limbs (author's transl)]. / Place actuelle de la sympathectomie lombaire au cours de l'arterite des membres inférieurs

A study of 75 lumbar sympathectomy helped the authors in specifying the indications of this operation for arteritis of the lower limbs. Lumbar sympathectomy is based on precise anatomical facts : para-vertebral sympathetic chain is usual but a collateral chain must be searched if the latter appears too thin. Lumbar sympathectomy can be performed alone or in association with reconstructive procedures. It is used alone in old people for its antalgic and moderately functional effect in accordance with their level of activity. Also it is used alone in cases of gangrene localized or pending or in the absence of a runoff vasculature. It is associated to repair if one wants to improve an incompetent peripheral perfusion. The authors record 79% of favourable results of which 52% were maintained when lumbar sympathectomy was used alone. In patients where direct vascular surgery is added, favorable results account for 82% of which 78% long lasting.

[Apropos of jurisprudential decisions concerning nosocomial infections]. / A propos des décisions jurisprudentielles liées aux infections nosocomiales.

Nosocomial infection is as old as cares given to patients. Doctors and hospitals are both committees. Since Cohen ruling on December 9, 1988, the "Conseil d'Etat" bases the responsibility for the public hospitals on the concept of uncompromising presumption of fault. Since Bonnici ruling on May 21, 1996 and especially since decisions known as "of staphylococcus aureus" on June 29, 1999, the "Cour de cassation" bases the civil liability for doctors and private hospitals on the principle of obligation of security of result. Such a rigor of the two high jurisdictions leads to a quasi automatic repair of any prejudice recognized as related to a nosocomial infection. The epidemiology of nosocomial infections makes it possible to assess the extent of risks at stake. This is a considerable potential contentious in process of explosion, the cost of which cannot be supported by health economy in its current state. That just shows you the extent of medical, juridical, public health, economical, social and political interests linked to nosocomial infections. It seems urgent to consider definitions that were given to this concept, and within them it will be necessary to individualize what is nosocomial infection entitled to compensation. In this matter medical opinion must prevail over law to better serve it.

[The posterior interparietoperitoneal spaces or retroperitoneal spaces. 1: Normal topographic anatomy]. / Les espaces interpariéto-péritonéaux postérieurs ou espaces rétropéritonéaux. 1re partie: Anatomie topographique normale.

The posterior spaces between the wall and peritoneum or extraperitoneal spaces are located between the visceral retrocolic and retro-duodenopancreatic fascias anteriorly and the parietalis fascia posteriorly. They were studied using an anatomic and computed tomographic comparison. The propria fascia (lateroconal fascia) divided into the anterior and posterior layers of the perirenal fascia. The fascias delimitate two anterior and posterior pararenal spaces around the kidney compartment and two anterior and posterior perirenal spaces in the compartment itself. These spaces extended above and below the renal compartment from the diaphragm to the pelvis. These large spaces composed of fat and organs can assume the guided migration of pathologic processes or their spread according to the importance of the fascias barriers. They below to the genito-urinary region. The extraperitoneal spaces are related anteriorly to the retroperitoneal alimentary organs: duodenum, pancreas, ascending and descending colon depending of the alimentary region. They are related posteriorly with the abdominal wall and its own fat. The individuality and the interdependance of these three territories (alimentary, genito-urinary and abdominal wall) and their consequences for pathologic CT scan imaging will be discussed in the second part of this paper.

[Retroperitoneal gas images following subperitoneal hollow viscus rupture (author's transl)]. / Images de rétropneumopéritoine dans les ruptures d'organes creux sous-péritonéaux.

Three cases of traumatic rupture of a subperitoneal hollow viscus are reported : two duodenal lesions and one rectal wound. Early diagnosis was possible in all three cases by the recognition of retroperitoneal gas on simple radiographs of the abdomen, which was evidenced by images containing air bubbles, which were also fasciculated and fairly fixed. They were unilateral, on the right side, and usually associated with disappearance of the psoas shadow in duodenal injuries. Rectal perforation produces a bilateral distribution of the retroperitoneal gas, which extends to the subperitoneal fat and the posterior extraperitoneal space, according to the amount of effusion.

[The posterior interparieto-peritoneal or retroperitoneal spaces. 2: Pathological x-ray computed tomographic image]. / Les espaces interpariétopéritonéaux postérieurs ou espaces rétropéritonéaux. 2 Partie: Anatomie tomodensitométrique pathologique.

The old reports about the interparieto-peritoneal spaces described particularly the renal space and its environment. The CT scan has modified the in vivo study of the extraperitoneal spaces (E.P.S.) and brought the question of the acquired knowledge up again. An anatomical research was performed in the first part of this study which describes the structures limited between the parietalis fascia and visceral peritoneal fascias. These are the true EPS which the main element is the propria fascia of Sappey (lateroconal fascia) and its anterior and posterior renal double layers. All these lamellar structures limits spaces variably infiltrated with fat tissue: the anterior pararenal space almost virtual, the posterior pararenal space which continues till the Bogros space and the anterior and posterior renal spaces of the renal compartment which the fat continues till the bladder and accompanies the ureter. The second part of this study precises some notions of general topography which are necessary for reading abnormal CT scan images. This part reminds the aortic and arterial general organization of the vertebrates as described by Mackay. It underlines the architectural importance of the three areas so defined: parietal or peripheral, intermediate or mesoblastic genitourinary and deep lateral or digestive endoblastic. These three areas corresponds to the three vascular aortic circles. It emphasized the importance to accept in practice the notion of visceral joining fascia which has been proved in adult people. The longitudinal architecture of the compartments is precise with respect to their appartenance to one among the three arterial arches of Mackay. What the anatomy suggest, the pathology can prove. Several pathological processes are studied on CT scan: large hemorrhagic or necrotic collections in acute pancreatitis, abnormalities or diseases of renal or adrenal compartments, extraperitoneal mesenchymomas, diseases of the psoas compartment. All these observations are analysed in order to explain anatomical and CT scan findings. This study refers not only to the oldest researches which are still valuable but also to the most recent controversies. All the questions are not solved using the clearest schemes.

[Surgical approach to the 3rd segment of the vertebral artery by a paramedian posterior route]. / Abord chirurgical du troisième segment de l'artère vertébrale par voie postérieure paramédiane.

Following an anatomical study of the lateral suboccipital region, the authors have devised an approach to the third segment of the vertebral artery, from C2 to the foramen magnum, which enabled them to treat an arteriovenous fistula in C1 while preserving the vertebral artery. The different operative stages and anatomical features are described. The simplicity and safety of this approach should encourage surgeons to use it.

[Interprostatorectal dissection: value of Denonvilliers' fascia]. / Clivage inter-prostato-rectal: intérêt du fascia de Denonvilliers.

We demonstrate that the Denonvilliers' fascia is attached to the prostatic gland and suggests that it is of Wolffian origin. The dissection plane between prostate and rectum therefore lies between the fascia and the rectum.

[Aorto-iliac microbridge by continuous suture in the rat]. / Micro-pontage aorto-iliaque par suture continue chez le rat.

We have performed micro-anastomoses by continuous suture technic: --circular suture of an aorta with 9/0 and with 10/0 Vicryl three (90% permeability); --next we performed an aortic-iliac bypass thanks to a carotid graft (70% permeability). The verification was carried out by injection of the complete arterial system with solidifying agent, and we obtained an arterial fitting after corrosion by the mean of hydrochloric acid.

[Anatomical study of different modes of anastomosis between the facial artery and ophthalmological artery at the medial angle of the orbit (author's transl)]. / étude anatomique des différents modes d'anastomose entre l'artère faciale et l'artère ophtalmique à l'angle interne de l'orbite.

In 21 autopsy specimens, we performed latex injection, and studied the rate and the diameter of the anastomosis between the ophthalmic artery and the facial artery: we find 26 cases in 42 face-sides, 60 %; which can supply rapidly a circulatory insufficiency. The anastomosis which go to the ophthalmic artery from the others branches of the external carotid are less frequent.

[Reflections on surgery of high lesions of the internal carotid. Experimental study of the floating endarterial graft]. / Réflexion sur la chirurgie des lésions hautes de la carotide interne. Etude expérimentale de la greffe flottante endo-artérielle.

The use of a floating graft is proposed in order to attempt resolution of surgical problems raised by distal internal carotid artery lesions located high in the neck. Surgical treatment is essential, but vascular suture is impossible below the petrosa and ligature of internal carotid artery is often the only solution. The floating graft, which is fixed proximally only and is allowed to float in the circulation, allows exclusion of the lesion and maintenance of the carotid vascular axis. Preliminary experimental studies in the rat have provided satisfactory results and research should be continued in larger animals prior to possible clinical use.

[Nosocomial infection: medical responsibility regarding the law]. / L'infection nosocomiale: la responsabilité médicale face au droit.

The nosocomial infection, infection transmitted to a patient at the time of medical care, constitutes a complex nosological framework. The knowledge of the risk factors is essential to their good management. It underlies all the lawful texts concerning the fight against the nosocomial infections. These texts propose to us definitions established in a context of public hygiene and health. The complexity and the cost of the management of all these risks can only be compared with jurisprudential simplification, which results from this in responsibility matters. In a pro indemnity concern, the position of the "Cour de Cassation" is closely akin to the rigor of the "Conseil d'état", which imposes the uncompromising presumption of fault against supposed guilty, persons or entities. It is necessary to redefine the risks towards praetorian right. It is the role of the legal expert, auxiliary of the judge, to provide in equity an informed opinion on the facts. The factual criteria must allow a modulation of responsibility concerning the fault, the serial risk or the medical risk.

[Home enteral nutrition: functional partnership experience in the network of care of the Centre Médical de Forcilles, 1990-1999]. / Nutrition entérale à domicile: expérience de partenariat fonctionnel en réseau de soins du Centre Médical de Forcilles de 1990 à 1999.

Since 1990, the home enteral nutrition (HEN) has been experienced by the Centre Médical de Forcilles (CMDF), according to the 1988 and 1993 instructions. This service has a regional vocation and forms an integral part of a partnership system in care including: the prescribing hospital, the usual physician and various specialists. We have a triple objective: 1) To define the structure and the action of this medical service, the only one in France. 2) To appreciate the 9 years experience with 4297 patients: Medical interest, with the nutritional care of patients suffering of heavy diseases, more particularly ORL cancers and neurological troubles disturbing deglutition. The use of regulating flow pumps, care avoid "Mendelson syndrome". Repercussion on patients quality of life, who stays in a family environment. This seems to be beneficial for 58.9% cases. More over, 95.8% patients prefer this solution instead an hospitalization. The permanent communication between the members of this plural disciplinary team guarantees safety, comfort and relief. Economical benefit with a computerized management, recovering of the products and reduction in purchase (large quantities). This allows a very reasonable "price per day" (120.38 F in 1999), to wit a thrift of 95% in comparison with a classical hospitalization. 3) To propose, according to the CMDF example, a quality charter for a HEN centers regional organisation, and the valuation of their activity. According to the fact that the HEN has to be legally realized all over the national territory, the CMDF exemplary fitted to local needs, should allow an appropriate solution, with a control of the costs, thanks to a real partnership in network of care, for this public health problem.

[Hepatic adenoma and oral contraceptives (author's transl)]. / Adénome hépatique et contraceptifs oraux.

The authors report a new case of hepatic adenoma apparently related to oral contraception continued for more than 9 years with a pill containing mestranol. The clinical presentation suggested an attack of hepatic colic with swollen gall bladder. The preoperative diagnosis of a tumour of segment VI of the liver was made by radiological examination of neighbouring organs. Hepatic arteriography, hepatic radioisotope scan using technetium phytate and echotomography. Surgical removal of segment VI confirmed by histological study showed that it was an adenoma with multiple foci, associated with hepatic involvement. One of the tumours was the site of central included hemorrhage, responsible for the clinical syndrome. In connection with this case the authors review the possible relationship between hepatic adenoma and oral contraception.

[Four original cases of splenic venous infarction during pancreatic disease (author's transl)]. / Quatre observations inédites d'infarctus veineux splénique au cours des atteintes pancréatiques chroniques.

The authors report 4 cases of splenic complications occurring during chronic pancreatic disease and emphasize the vascular origin of the lesions observed in the spleen whether rupture, pseudo-cysts, hematic cysts, infarction or necrosis. The symptoms in each case seemed identical in their pathogenesis and linked to trunkular or radicular splenic venous thrombosis.

[The subscapular combined free flap. Original technique]. / Le transplant libre combiné sous-scapulaire. Technique originale.

Combinations of subscapular pediculated flaps have been used in recent years. These single pedicle flaps include the latissimus dorsi, the serratus, the scapular crest and the ortho and para-scapular skin flaps. Together these flaps comprise a combined subscapular transplant. This combined flap is particularly important since the different components provide great spatial flexibility. Complex and massive pluri-tissular substance losses can thus be reconstructed. We report our work in anatomy and techniques. We found variations in the origin of the subscapular pedicle in 25% of the cases in our anatomy study (50 cases). We recommend dissection of the vascular pedicle via the axillary route first. Thus necessary adaptations can be made as a function of the variations observed. This combined flap can be removed with the patient in supine position. The fact that the position of the patient does not have to change is essential for cervicofacial surgery performed by two teams. The pedicle of the cutaneous scapular flaps is dissected starting ventrally. Since 1990, we have performed 15 combined subscapular transplantations for cervicocephalic reconstructions.

[Peptic oesophagitis and carcinoma of the lower third of the oesophagus: report of 7 cases (author's transl)]. / Oesophagite peptique et cancer du tiers inférieur de l'oesophage. A propos de sept observations.

The authors report seven cases of carcinomas of the lower third of the esophagus developed on lesions of peptic esophagitis. These lesions precede the carcinoma. They can be real precancerous states and even in situ carcinomas whose evolution over several years could be proved indeed. They argue about the therapeutical indications in peptic esophagitis considering not only that such a cancerous transformation is always possible but also the fact that a surgical ablation is always serious.

[Sclerodystrophy of the sphincter of Oddi (author's transl)]. / La sclérodystrophie oddienne.

Among 1,645 biliary operation carried out between 1952 and 1974, the authors count 177 organic stenoses of the Oddi region. They recall the authenticity of chronic odditis, the pathological substratum of which is Oddi sclerodystrophy, a primary and progressive lesion. They emphasise the radiomanodebimetric criteria. The risk of an error of interpretation was 2% in this series. After discussing the etiopathogenesis and the physiopathological consequences of Oddi sclerodystrophy, they discuss the therapeutic choice between sphincterotomy and choledoco-duodenostomy. Temporary gall bladder drainage is only of interest in inflammatory labile manifestations without sclerodystrophy. The interest of diagnosis and initial surgical treatment of the lesion is that the classical post-cholecystectomy syndrome almost disappears.

[Vascular problems in gastric esophagoplasty after esophagectomy or circular pharyngolaryngectomy]. / Etude des problèmes vasculaires dans les oesophagoplasties gastriques après oesophagectomie ou pharyngolaryngectomie circulaire.

Gastric oesophagoplasty (GOP) after total oesophagectomy or circular pharyngolaryngectomy is complicated by an average anastomotic breakdown or fistula rate of 15%, and a stenosis rate of 8%. Ischemia related to the actual procedure itself undoubtedly plays a role in the production of such complications in spite of the rich vascular supply to the stomach. The authors report the results of an anatomical study involving 24 stomachs from non-embalmed adults studied by various forms of arteriography depending in the GOP technique employed. For healthy normotensive gastric arteries, they demonstrate the principal elements likely to influence the vascularisation of the graft and propose a provisional vascular score for ischemia. Based on this, they discuss the vascular risks associated with GOP techniques in general.

[Comparative study of vascularization of the stomach after hyperselective vagotomy and anterior seromyotomy]. / Etude comparée de la vascularisation de l'estomac après vagotomie hypersélective et séromyotomie antérieure.

Based on a Micropaque arteriography study of 21 stomachs from non-embalmed adults, the authors compare the ischemic consequences of highly selective vagotomy (HSV) with those of anterior seromyotomy (ASM) combined with posterior trunk vagotomy. HSV inevitably produced an avascular band 2-4 cm wide in the lesser curve region. ASM, to be total and effective, needs to produce hemostasis of the submucosal plexus thereby also producing ischemia of the denuded mucososubmucosal band. It is however possible to avoid the submocosal plexus by remaining more superficial; however, it is then necessary to combine an additional neurotomy otherwise the procedure is likely to fail. In any event, the partial ischemia associated with ASM is much less serious than that noted after HSV.