[Fistula-type pararectal mucinous carcinoma. A case report (author's transl)]. / Le carcinome colloïde muqueux para-rectal à forme fistuleuse. A propos d'une observation.

A case of the exceptionally rare fistula type of pararectal mucinous carcinoma is reported, the patient presenting with clinical signs of a chronic abscess in the ischiorectal hollow. The unusual gelatinous secretion suggested the need for a biopsy of the fistula cavity. Pathological examination confirmed the diagnosis, where as a barium enema and rectoscopy gave negative results, eliminating the possibility of a digestive tract origin for the tumour. Local recurrence occurred two and a half years after an abdominoperineal resection, and was treated by local excision. Aetiopathogenic hypotheses and current therapeutic procedures are discussed.

[Splanchnicectomy by Dubois' transhiatal approach. Technics, indications and results. Apropos of 25 nerve sections for visceral abdominal pain]. / La splanchnicectomie par voie trans-hiatale de Dubois. Techniques, indications, résultats. A propos de 25 sections nerveuses pour algies viscérales abdominales.

Splanchnicectomy through Dubois, transhiatal approach was performed in 25 patients with abdominal pain of mainly pancreatic origin. The four stages of the operation are described and are facilitated by the use of a Fruchaud type of retractor and rigid, long, narrow valves to enable lateral displacement of the aorta and abdominal esophagus. After dissection of the esophageal hiatus, the Xth nerves and abdominal esophagus are isolated and the pleura detached, beginning with the anterior surface of the aorta. The greater splanchnic nerves are then isolated and sectioned and a final-stage esophageal hiatus reconstruction performed. This simple, rapid technique produces immediate, total, lasting pain relief, particularly spectacular in patients with cancer of the body of the pancreas, this representing the indication of choice for this neurectomy. Splanchnicectomy does not affect survival duration but improves the comfort and quality of this period. In hyperalgic forms of chronic pancreatitis, this nerve section can be combined with conventional surgery. There was no operative mortality in this series of 25 cases.

[Firearm wounds of the lower urinary tract in men. Surgical management in emergency context]. / Les plaies par arme à feu du bas appareil urinaire chez l'homme. Prise en charge chirurgicale dans le contexte de l'urgence.

The lower urinary tract is injured in less than 1% of all firearm wounds in men. In war medicine, blast wounds occur in 75% of the cases while in civil medicine ballistic injuries are more frequent. When the bladder and the posterior urethra is involved, the projectile usually follows a path through the gluteal muscles and pelvis. A perineal genital path is usually found for injuries to the anterior urethra. This explains the frequency of associated vascular and colorectal lesions in pelvic wounds and genital injuries in perineal wounds. Bone and muscle injuries occur in both situations. A mental reconstruction of the projectile path is required for a precise diagnosis of the lesions, together with the clinical examination (urine outlet, miction impossible with or without bladder extension, urethral bleeding) and most importantly standard x-ray of the pelvis in search of bone lesions and the projectile. Urethrography should always be performed whenever the urethra is injured in all civil wounds. However, the final diagnosis of the lesions can only be made at surgery. Urology procedures, usually performed by polyvalent surgeons, should be simple, rapid and reliable. It is important to preserve urinary and genital functions in these young subjects usually under 30 years of age. Cystostomy and drainage is the strict minimum. In addition, depending on the infectious and hemodynamic status, conservative excision of damaged tissue is needed prior to primary closure. Wounds involving the bladder can be closed in 95% of the cases. Closure is simple for wounds involving the superior portion of the bladder. For deeper wounds involving the trigone endovesical suture is used after intubing the ureters. Ureteral drainage is mandatory when the bladder is highly damaged and cannot be closed. Urethro-prostato-membranous wounds should also be repaired to avoid inevitable fibrosis of fistulization. However, access to the apex of the prostate causes major bleeding and there is a risk of injuring the sphincter or erection nerves, particularly by surgeons inexperienced in urogenital surgery. When massive bleeding cannot be controlled by clamping the two hypogastrics, symphysiotomy, rather than symphysectomy, is recommended. In other cases, aligning the urethral extremities may be sufficient. Short wounds to the anterior urethra should be cleaned and the extremities spatulated and anastomosed on a guide when they can be closed. In other cases, a perineal or penile urethrostomy is created. Associated wounds involving the anus and rectum require colostomy, emptying the excluded rectum and wide pelvic-perineal drainage. An attempt should be made to repair the rectum or the sphincter. Genital lesions require early repair: tight suture of the albuginea of the cavernous bodies with or without a patch, preservation of viable testicular parenchyma and adnexal tissues (but orchidectomy is necessary in 50% of the cases).

[Our experience with reoperations in abdominal surgery. (54 reoperations in 46 patients in the last 4 years)]. / Notre expérience des réinterventions en chirurgie abdominale (54 réinterventions chez 46 malades pour les 4 dernières années)

The authors analyze 54 reinterventions in abdominal surgery in 46 patients, and present the lesions found on reintervention. In one out of two cases there is an intra-peritoneal septic focus. In more than 25 p. 100 of the cases the lesions were multiple. They oppose the localized septic foci and the occlusions which are of good prognosis, with the diffuse septic foci, acute pancreatitis and fistulae whose course is more often than not fatal.

Anatomical bases of the transhiatus approach to the greater splanchnic nerve.

The level of origin and mode of constitution of the greater splanchnic nerve and its relations in the posterior mediastinum were studied. The aim of this work was to identify the anatomical basis of the transhiatus approach to the right and left greater splanchnic nerves. The azygos venous system was seen to be the main anatomical relation of these nerves. The results of this study should allow the surgeon to perform total bilateral neurotomy.

[Phlegmon of the fore arm succeeding to a dog-bite : respective role of the miscellaneous bacteria involved in this mixed infection (author's transl)]. / Phlegmon de l'avant-bras après morsure de chien : rôle respectif des diverses bactéries impliquées dans cette infection mixte.

The authors report a case of a severe mixed infection (phlegmon of the fore arm) succeeding to a dog bite. A complex flora has been isolated from this phlegmom : Pasteurella multocida, Pasteurella pneumotropica, Streptococcus mitis, Actinomyces sp., Bacteroides melaninogenicus, and a Gram- bacteria related to group II j. The pathogeny of such diseases is discussed, dwelling in one hand on the part of synergistic development of these various germs and in the other hand on the part played by saliva in the severity of animal or human bites. This kind of wound requires careful disinfection and radical debridment without omitting a preventive broad-spectrum antibiotherapy.

Comparison of concentrations of sulbactam-ampicillin administered by bolus injections or bolus plus continuous infusion in tissues of patients undergoing colorectal surgery.

The concentrations of sulbactam and ampicillin were determined in sera and different abdominal tissues of 16 patients who underwent elective colorectal surgery. Patients were randomly allocated to two groups. At the time of induction of anesthesia, patients in group 1 (eight patients) were given 1,000 mg of sulbactam with 2,000 mg of ampicillin by intravenous bolus injection (3 min). This dose was administered again after 2 h by bolus injection by the same route. Patients in group 2 (eight patients) were given the same initial dose of sulbactam-ampicillin by bolus injection (3 min). Then, a continuous infusion of 1,000 mg of sulbactam with 2,000 mg of ampicillin in normal saline was immediately started and was administered over a 4-h period. Blood samples were collected to determine peak (10 min) and trough (end of surgery) antibiotic levels. Serial blood samples were also collected at predetermined periods (at the time of opening and closing of the abdominal cavity and at the time of surgical anastomosis). Abdominal wall fat, epiploic fat, and colonic wall tissue samples were collected simultaneously. Antibiotic concentrations were determined by high-performance liquid chromatography. Similar levels of the drugs in serum were observed for the two regimens of administration, with trough sulbactam levels of 33 +/- 16 and 37 +/- 22 microg/ml in groups 1 and 2, respectively, and trough ampicillin levels of 72 +/- 55 and 79 +/- 47 microg/ml in groups 1 and 2, respectively. Similar sulbactam concentrations were observed in abdominal tissues whichever regimen of administration was used; in fatty tissues the sulbactam concentrations ranged from 2.7 to 3.8 microg/g for group 1 and from 1.7 to 4.0 microg/g for group 2, and sulbactam concentrations in the colonic wall were 5.6 +/- 7.7 and 6.8 +/- 3.2 microg/g in groups 1 and 2, respectively (not significant). Again, no influence of the regimen of administration was observed on tissue ampicillin concentrations; in fatty tissues ampicillin concentrations ranged from 4.1 to 5.4 microg/g for group 1 and from 3.2 to 5.8 microg/g for group 2, and sulbactam concentrations in the colonic wall were 7.0 +/- 2.8 and 11.0 +/- 4.7 microg/g for groups 1 and 2, respectively (not significant). In most patients, the concentrations of ampicillin-sulbactam were greater than the MIC at which 50% of isolates are inhibited (MIC50) for Bacteroides fragilis in the fatty tissues. In the colonic wall, for most patients the concentrations of ampicillin-sulbactam were greater than the MIC90 for B. fragilis. No influence of the regimen of administration was observed on the ratio of the two components in the tissues investigated and in sera. In conclusion, a second intraoperative bolus injection or a continuous infusion were equally effective in maintaining sulbactam-ampicillin concentrations in abdominal tissues. The first method of administration can be recommended since it is easier to handle.

Macroscopic study of the adult thymus.

The dissection of 48 cadaveric specimens has been compared with operative findings for a review of the shape, size and site of this gland in the adult. The structure of the thymic compartment and the relations of the thymus, particularly with the vessels of the superior mediastinum and the base of the neck, were studied. The relative positions of the inferior parathyroid glands and the thymus were identified, with respect to the influence of this topography on the surgery of these glands. The arterial suply to the thymus, which is still very abundant in the adult, presupposes a functional organ whose physiologic involution is slow.

[Anatomical studies of Luschka's gland]. / Recherches anatomiques sur la glande de Luschka

In that work, the authors determine precisely the classical outlines relating to the formation described by LUSCHKA in 1859. The morphology, the situation in relation with the medium sacral artery, the exact topography of what is wrongly called "gland of Luschka" are successively analysed. Otherwise, notions which emerge about is histological conformation are referred to.

Anatomic basis of the liver for the development of a perihepatic prosthesis.

We studied specimens from 50 cadavers (27 men and 23 women) to obtain anatomical data concerning the liver and its attachments. The results allowed us to develop a polyglactin perihepatic prosthesis for compression of the injured liver. The falciform ligament and a narrowing of the hepatic parenchyma at this level allow attachment of the prosthesis. Separate prostheses were designed for each lobe. Clinical use has demonstrated that our prosthesis can be used to achieve effective control of haemorrhage and bile leakage.