Aneurysms of the visceral and renal arteries.

Visceral aneurysms represent a rare clinical entity; however, 10-20% will rupture and this is accompanied by a significant mortality rate of 20-70%, depending on the location of the aneurysm. The incidence, pathogenesis and clinical aspects of splanchnic and renal artery aneurysms are reviewed from the available literature and the problems of diagnosis and treatment are discussed. Their incidence is increasing and controversy still exists regarding their treatment. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, surgery is advisable. An alternative treatment is the use of endovascular techniques, ie embolisation, or graft stent insertion.

[Treatment of caustic burns of the esophagus with interferon gamma. Comparison with epidermal growth factor. Experimental study in rats]. / Traitement des brûlures caustiques de l'oesophage par l'interféron gamma. Comparaison avec l'epidermal growth factor. Etude expérimentale chez le rat.

OBJECTIVES: Effects of sequential use of epidermal growth factor followed by interferon gamma on healing response after severe oesophageal corrosive burns has been demonstrated. This sequential treatment improves the inflammatory response of the initial phase and prevents residual stenosis. The aim of this study was to evaluate the use of interferon gamma alone in the same condition. METHODS: The study was performed in 5 groups (n = 15) of Wistar rats: control, placebo, epidermal growth factor alone, interferon gamma alone and epidermal growth factor for 5 days followed by interferon gamma from the 6th to 20th day. The last 4 groups had an oesophageal injury caused by a solution of 2.5 N NaOH. The efficacy of treatment was assessed on days 2, 5 and 20 on: weight gain, oesophageal internal lumen, stenosis index: wall thickness/lumen diameter, collagen production. RESULTS: Interferon gamma significantly reduced residual stenosis frequency while it did not improves the initial healing process. A complete effect on the two healing phases was only observed in animals having the sequential treatment. CONCLUSIONS: These results could lead to clinical trial in man to evaluate efficacy of sequential treatment with epidermal growth factor-interferon gamma in oesophageal corrosive burns.

[Prolonged survival in peritoneal mesotheliomas. Apropos of a case]. / Survie prolongée des mésothéliomes péritonéaux. A propos d'une observation.

A case of peritoneal mesothelioma discovered during laparotomy for ascites is reported. A long-term survival of 5 years was observed with combined treatment: surgery and chemotherapy. Peritoneal mesothelioma is a rare neoplasm often related to asbestos exposure and its prognosis is poor. No laboratory test other than histologic examination is specific for the diagnosis. Combined treatment with radiotherapy and chemotherapy seems to improve the survival rate.

[Cystic lymphangioma of the adrenal gland. Three misleading cases]. / Lymphangiome kystique de la surrénale. Trois observations trompeuses.

Three cases of adrenal cystic lymphangioma are reported. In 1 patient the lesion was complicated by intracystic haemorrhage. The remaining 2 patients had a hepatic lesion which was treated in the same surgical operation as the adrenal cyst. Ultrasonography and computerized tomography play a major role in the exploration of these cysts. Their unexpected discovery has become more frequent since these methods have multiplied, and this raises therapeutic problems. The nature of adrenal cysts is determined at histology. In asymptomatic cysts percutaneous needle aspiration can only have an indicative value.

[A rare form of internal hernia: hernia of the sigmoid mesocolon]. / Une forme rare de hernie interne: la hernie du mésocôlon sigmoïde.

An internal hernia of sigmoid mesocolon provoking an occlusive syndrome is described, and the different types of hernia of sigmoid mesocolon analyzed and discussed. The diagnosis of these rare (5% of cases) internal hernias is established frequently at operation only, their treatment, always surgical, being simple when instituted in their early stages.

[Current indications and results of elective truncal portacaval shunt. Apropos of 97 cases]. / Indications actuelles et résultats de l'anastomose porto-cave tronculaire en période élective. A propos of 97 observations.

The authors analyse the results of a series of 97 cases of elective porto-caval anastomoses for ruptured oesophageal varices and compare them with those of the literature. Elective porto-caval anastomosis satisfactorily prevents haemorrhagic recurrence (3%) at the cost of an operative mortality of 10% (nil over the last five years). Porto-caval encephalopathy was observed in 36% of cases with an incapacitating form (stage II or III) in 21% of operated patients and always represented the major disadvantage of surgery. However, the place of truncal porto-caval anastomosis is still intact in the prevention of recurrent haemorrhage from ruptured oesophageal varices. Warren's operation, the reference surgical technique, cannot be performed systematically because of technical reasons and/or because of rigorous selection. Endoscopic sclerotherapy represents a fundamental therapeutic procedure during the haemorrhagic period. Permanent haemostasis is more difficult to obtain and requires surgery in about 25% of cases. The mortality and morbidity associated with the endoscopic method are compared with the surgical results in two series of patients belonging to Child's groups A and B.

[Place of the splanchnic nerves in the pathogenesis of shock due to retroperitoneal hematoma (author's transl)]. / Place des nerfs splanchniques dans la pathogénie du choc par hématome rétro-péritonéal. Etude expérimentale.

The clinical picture of retroperitoneal hematoma includes usually a state of shock. The author's experiment implies that the splanchnic nerves are directly involved in the pathogenesis of this fall in blood pressure. Simple therapeutic implications result from this.

[Treatment of pancreatic fistulas with somatostatin]. / Traitement des fistules pancréatiques par la somatostatine.

Four cases of pancreatic fistula were treated with somatostatin. Two cases occurred after caudal pancreatectomy and the other 2 after duodenopancreatectomy. Somatostatin rapidly reduced fistula flow by 50% 48 hours after treatment. The shorter hospital stay and reduced morbidity underline the importance of somatostatin in the treatment of pancreatic fistulae.

[Treatment of hydatid cyst of the liver. Our present attitude (author's transl)]. / Traitement du kyste hydatique du foie. Notre attitude actuelle.

From 1968 to 1978 the authors treated 60 hydatid cysts of the liver. Echotomography and computerised axial tomography showed the topography of the cyst. However, coelio-mesenteric arteriography and cavography are essential before any kystectomy. In spite of its simplicity, resection of the salient dome of the diaphragm is less often used, owing to the risk of bile leakage and recurrence. Pericystectomy fulfils better our therapeutic objectives. It is more difficult to carry out for there is a risk of hemorrhage. Marsupialisation and hepatectomy are exceptional. Since 1974, 13 pericystectomies out of 15 patients have been carried out, whereas resection of the salient dome was previously the most commonly used procedure (40 out of 45 cases). Only regular immunological follow up is a reliable test of lasting cure.

[Surgical treatment of hemorrhagic gastritis]. / Traitement chirurgical des gastrities hémorragiques.

The authors report a review of the literature concerning an observation of rebleeding hemorrhagic gastritis which needed a total hemostasis gastrectomy. 479 interventions are analysed, with all surgical procedures combined. The surgical mortality is 28% and rebleeding reaches 30%. These figures express the evolutive gravity and the difficulty in choosing a treatment for hemorrhagic gastritis. Numerous techniques exist with varying results: the simple gastrotomy with ligations gives 58% rebleeding and 50% mortality. The subtotal Gastrectomy presents a non perfect control of hemorrhage (48% rebleeding, 30% mortality). Among the conservative procedures the choice can be either truncular-vagotomy-pyloroplasty (28% rebleeding, 24% mortality) or vagotomy-resection (18% rebleeding, 34% mortality). All these methods are not perfect and present a rebleeding risk. Only the total gastrectomy provides a definitive cure when the patient can resist the operation. Total gastrectomy was previously considered to be impossible during hemorrhage. However it represents the only way to save patients who continue to bleed following conservative surgery. Total gastrectomy represents a logical technique and should be reconsidered as a second procedure. As first procedure total gastrectomy is debatable. If systematic, it could lead to abusive intervention. If refused, there is a risk of mortal bleeding. Where elderly patients are involved the decision seems to be clear due to the risks of multiple transfusions or second interventions.

[Treatment of caustic stenoses of the upper digestive tract]. / Traitement des sténoses caustiques du tractus digestif supérieur.

Stenosis of the upper digestive tract developed in 22 patients with stage IIB or stage III caustic burns due to massive ingestion of an alkaline substance in 18 cases and an acid substance in 4 cases is analysed. Emergency oesogastrectomy without thoracotomy was performed in emergency situations in 10 patients in whom mortality reached 30%. For the remaining 12 patients with minimal stage IIB lesions, a jejunostomy was opened for enteral nutrition. After three months, stenosis developed in 10 cases and required surgical treatment in 7 after failure of endoscopic dilatations. Surgery included retrosternal coloplasy with oesophagectomy for 3 patients. There were no deaths. Two patients with a stenosis of the cervical anastomosis were treated endoscopically. These results suggest that the use of the endoscope in the acute phase can help ascertain the best management technique and confirms that stage IIB stenosis can develop a tight stenosis in 50% of the cases. This situation requires surgical treatment in 70% of the cases.

[Intestinal obstruction caused by Meckel's diverticulum in adults]. / Occlusion intestinale par diverticule de Meckel chez l'adulte.

The diagnosis of intestinal obstruction caused by Meckel's diverticulum is difficult. The clinical evolution of the condition is subacute, with painful bouts occurring over several years and puzzling the clinicians. As a first step, explorative laparotomy solves the problem. Two cases show how difficult this decision is. Celioscopic surgery may be chosen in the future.

[Spontaneous perforation of the hepatic duct during biliary lithiasis complicated by acute pancreatitis]. / Perforation spontanée du canal hépatique au cours d'une lithiase biliare compliquée de pancréatite aiguë

The association of perforation of the common bile duct, cholecystitis and acute pancreatitis, should be emphasized. Physiopathology of perforation of the bile duct may be compared with that of pancreatitis. Repair of the bile duct may be delicate requiring hepatico-jejunostomy on an isolated loop.

[Late ileal metastases from a skin melanoma with mainly hemorrhagic symptoms. Report of one case (author's transl)]. / Métastases iléales tardives d'un mélanome cutané périphérique. Manifestations hémorragiques prédominantes. A propos d'un cas.

Intestinal metastase from a malignant melanoma are rare and raise difficult diagnostic problems especially when far from the initial tumour. Although acute intussusception is the usual clinical presentation, one should recognise the possibility of atypical symptoms: e.g. repeated digestive hemorrhage or resistant anemia. A sutdy of past history may lead to the discovery of a malanoma. Treatment is unfortunately surgical and palliative to releave the complication.

[Hepatic tumoral form of bacterial infections. Diagnostic and therapeutic considerations apropos of 3 cases]. / Forme tumorale hépatique des affections bactériennes. Considérations diagnostiques et thérapeutiques à propos de 3 cas.

When the clinical picture and complementary tests reveal a tumoural formation in the liver suggesting cancer, it is often difficult to diagnose such formations resulting from bacterial infection without surgical exploration. The diagnosis is particularly difficult since exclusive hepatic formations are extremely rare, the latency period is often long and specific markers are often lacking. We observed 3 such cases with local hepatic tumour-like formations due to tuberculosis, brucellosis and actinomycosis. Pathology examination of a liver biopsy can contribute to the diagnosis and avoid unnecessary exploratory laparotomy allowing successful medical treatment.