Prevention of secondary lymphedema.

After some preliminary remarks upon pathophysiologic and anatomo-surgical aspects, the main complications of axillary lymph-nodal dissection for breast cancer treatment are reported. The role of surgical technique is particularly underlined and also the importance of proper management of wound and surgical drainage post-operatively are pointed out. Author describes, finally, the necessity of an adequate knowledge of lymphatic drainage not only of mammary region, but also of surrounding area, in order to prevent lesions to lymphatic pathways, particularly to those draining upper arm at the same site of breast cancer.

Endoscopic management of obstructive jaundice due to portal cavernoma.

This report describes 2 cases of calcified cavernous transformation of portal vein of unknown etiology. In both cases the revealing symptom was jaundice due to extrinsic compression of the common bile duct by the cavernoma. Only 4 other cases have been previously described in the literature. The cause of the jaundice was discovered only during surgery and confirmed by arteriography. Endoscopic retrograde cholangiography allowed both the diagnosis and the palliative treatment of the stricture of the distal common bile duct. Surgical treatment could not be performed.

[The lymphatic drainage of the esophagus]. / Le drainage lymphatique de l'oesophage.

The study was carried on 65 cadavers: 50 adults and 15 newborns. The esophagus was injected at the level to the neck 16 times, in the thorax at the superior level 18 times, middle level 30 times and inferior level 21 times. The lymphatic pathways were named short when joining the nodes at the same level, half long when joining the nodes of the neighbouring level, long when joining third level, and very long. At the level of the neck were injected 24 lymph nodes chains: in 12.5% of the cases the pathways were long, joining the nodes of the arch of the Azygos vein. At the superior thorax level were injected 27 chains: half of the pathways were half-long: 7.5% long (-joining the pharynx once and the cardia once). At the middle thorax level were injected 37 chains: 27% were long and very long. At the inferior thoracic level were injected 21 chains: The pathways were half long in half cases and very long in 15% of the cases joining the cervical nodes. These results compare with experience in oncology and justify the need for total esophagectomies and nodes resection of all levels in surgical treatment of carcinomas of the esophagus.

[Clinical and surgical anatomy studies of the lymphatic circulation of the pancreas]. / Essai d'anatomie clinique et chirurgicale sur la circulation lymphatique du pancréas.

Data were collected from results of injection and dissection of 100 autopsy specimens; the examination of 34 case-reports of cancers patients; the injection of lymphatics in 14 live dogs; and the reconstruction of the mesodorsal region of the pancreas from a 30 mm embryo-using Born's technique. Anatomy of the pancreas and lymph vessels shows that the "primary mesodorsal region" of the pancreas is two-fold: a right part for the right side of pancreas, the retroportal process (RPP); a left part for the left side of pancreas, a formation not previously described, the left lateroportal process (LLPP). Whereas lymphatic drainage visible on the anterior surface of the pancreas is apparently as described, posterior drainage, which collects lymph from posterior and anterior vessels, is quite atypical. The right portion drains into the RPP and the left into the LLPP. The very rapid passage into the thoracic duct probably greatly diminishes the value of widely extended surgery. The lymphatic system acts as a "buffer system" or "safety valve", against progression to necrosis. Development and study of a lymphagogue drug for the treatment of acute pancreatitis are a justifiable project. A protocol is proposed which combines lymphagogue treatment with anti-enzymes.

[Free tumors of the peritoneum. Review of the literature apropos of a case]. / Les tumeurs libres du péritoine. Revue de la littérature à propos d'un cas.

Free bodies in the peritoneum are observed infrequently, particularly large solid tumors as in the present report. Of slightly more frequent occurrence are detached epiploic appendices or cystic tumors. Symptomatology varies greatly according to whether organs are compressed or irritated by the free body. Diagnosis is always preoperative, and the postoperative course simple because the tumor is delivered without dissection or ligature. Prognosis is good since these tumors are benign. Histopathology demonstrates origin and histologic nature of free body, and operation for a "chronic uterine fibroma" in the present case revealed a large free tumor. Operative findings (absence of right appendage) and histology suggested a diagnosis more likely to be of ovarian fibroma with a ruptured pedicle from chronic torsion. Despite the advanced age of the patient (96 years) no postoperative complications were reported.

[Clinical and surgical anatomy of the lymphatic circulation of pancreas]. / Essai d'anatomie clinique et chirurgicale sur la circulation lymphatique du pancréas.

Data was collected from results of injection and dissection of 100 autopsy specimens; the examination of 34 case-reports of cancer patients; the injection of lymphatics in 14 live dogs; and the reconstruction of the mesodorsal region of the pancreas from a 30 mm embryo using Born's technique. Anatomy of the pancreas and lymph vessels shows that the "primary mesodorsal region" of the pancreas is two-fold; a right part for the right side of pancreas: the retroportal process (RPP); a left part for the left side of pancreas, a formation not previously described: the left lateroportal process (LLPP). Whereas lymphatic drainage visible on the anterior surface of the pancreas is apparently as described, posterior drainage, which collects lymph from posterior and anterior vessels, is quite atypical. The right portion drains into the RPP and the left into the LLPP. Terminal collecting vessels of pancreatic lymphatics have only a short distance to travel before emptying into the thoracic duct. The study of lymph node metastases from pancreatic cancer appears to confirm these cadaver anatomic results but the series is too small for valid exploitation. The very rapid passage into the thoracic duct probably greatly diminishes the value of widely extended surgery, justification for the latter being exclusively to remove lymph nodes insofar as adjuvant therapy has currently failed to demonstrate absolute efficacy. Precise knowledge of the anatomy of the pancreatic lymphatics should allow development of experimental models to study lymph circulation changes during acute pancreatitis. Pancreatic edema, an enzyme-rich fluid, is an essentially "lymphatic" edema. The interstitial and lymphatic shunt pathways due to increased duct pressure were evident during the dog study. The lymphatic system acts as a "buffer system" or "safety valve" against progression to necrosis. Ligature of very proximal pancreatic lymphatic efferents (included in the bands) was followed by a fatal necrotic pancreatitis on both occasions when this was performed. Development and study of a lymphagogue drug for the treatment of acute pancreatitis is a justifiable project. A protocol is proposed which combines lymphagogue treatment with anti-enzymes, the former assists use of the enzymes by the lymphatic system. The anti-proteases prevent the onset of fatal shock caused by the outpouring of enzymes into the lymphatic system and the general circulation.

Anatomoclinical and anatomosurgical essay on the lymphatic circulation of the pancreas.

This essay is based on the injection and dissection of 100 cadaver specimens (fetuses, new borns and infants), the study of 34 case reports of pancreatic carcinoma, the injection of the lymphatic system in 14 living dogs and the reconstruction of the dorsal mesentery of an embryo of 30 mm according to Born's method. The results are as follows: the anatomy of the pancreas and of the lymphatic channels show that there are two distinct portions, one is right-sided and corresponds to the primitive ventral bud, the other is situated on the left and corresponds to the primitive dorsal bud. The primitive dorsal mesentery is formed by a double contingent: one right, for the right pancreas, this is the retroportal process (RPP). The other left, for the left pancreas. This is a formation which up until now, has never been described in the literature, the left lateral portal process (LLPP). While the anterior lymphatic drainage of the pancreas does not seem to hold any surprises, the posterior lymphatic drainage, arising from the posterior and anterior surfaces of the pancreas, is very particular. In the right side (anterior and posterior aspects), the drainage runs to the RPP, while in the left side (anterior and posterior aspects) it courses to the LLPP and here, in an exclusive manner. Only a few borderline regions, those situated precisely in the area of inosculation of the two buds, escape this systematisation. The terminal network of the pancreatic lymphatic channels have a short distance to bridge in order to reach the thoracic duct. The study of the distribution of lymph node metastases in carcinoma of the pancreas seems to confirm the anatomical results in the cadaver, but our series is too short to be of statistical value. Very early spread via the thoracic duct probably greatly reduces the value of supra-enlarged operations whose justification is precisely more complete lymph node removal. It might be useful, however, if proof could be provided that tumor reduction in the case of carcinoma of the pancreas is a necessary prelude to complementary therapeutic measures. The anatomy of the pancreas and of the lymphatic channels in mammals seems to confirm the results found in man, i.e. the division of the pancreas into a right and a left pancreas. The precise knowledge of the anatomy of the lymphatic ducts of the pancreas might be the starting point for progress in the experimental studies concerning the modifications of the lymphatic circulation during acute pancreatitis.(ABSTRACT TRUNCATED AT 400 WORDS)

[Rhexis of the small bowel by traumatism after breech hernia of particular type (author's transl)]. / Rupture du grêle après traumatisme sur hernie fessière de type particulier.

One case of a rhexis of the small bowel by traumatism on the breech is related. It concerns a 80 years woman operated 17 years before: removal of rectum for cancer and coloanal anastomosis by the transcoccygeal route. The anatomical alterations, consequence of the removal of coccyx and the abdominal hyperpressure explain probably the mechanism of the lesions.

[The metastatic meningoradiculitis. An exceptional detection of a gastric cancer. Review of the literature about one case (author's transl)]. / La méningoradiculite métastatique: un mode de révélation exceptionnel de cancer gastrique. Revue de la littérature à propos d'un cas.

The authors relate a case of gastric cancer on a 47 years woman, revealed by the presence of nerve roots metastasis whose evolution was fatal in 13 months. They are pointing out the singularity of this pathology as only 29 cases have been published to date. The clinical and radiological diagnosis must cancel the existence of paraneoplasic polyradiculoneuritis, only by histological examination of the roots. The primary cancer concerns often the breast, the lungs and the stomach. But 25% of cases remain unknown. Among the various terms proposed to define this neurological complication of visceral neoplasms, the authors are selecting the expression of "metastatic meningoradiculitis", as the best reflecting of the anatomical scheme.

[The injection of the lymphatic system of the stomach during surgery by vital staining dye: an anatomical or surgical interest? (author's transl)]. / L'injection per-opératoire du système lymphatique de l'estomac par colorant vital. Intérêt anatomique ou intérêt chirurgical? A propos de 20 cas.

The authors present the report of their experience of 20 injections of the lymphatic system of the stomach during surgery by vital staining dye: 19 times by Pontamine sky blue 6 BX, 1 time by patent blue violet. The results of this study are analysed; the anatomical interest is specified. Nevertheless, this technique presents no surgical interest concerning the stomach, in spite of many authors' opinion.

[Bilateral lobular in situ carcinoma discovered by sub-cutaneous mastectomy (author's transl)]. / Carcinome lobulaire in situ bilatéral découvert par mastectomie sous-cutanée.

The authors relate the observation of a 42 years old woman with antecedents of mastodynia from several years and numerous operations for fibroadenoma. During the follow-up a sub-cutaneous mastectomy is realized owing to the discovery of clustered calcifications on mammographic study, which reveals a bilateral lobular in situ carcinoma. They talk over surgical procedures in this form of carcinoma.

[Strangulated retrocostoxiphoid hernia. Review of the published literature and report on two cases (author's transl)]. / Les hernies rétro-costo-xiphoïdiennes étranglées: Revue de la littérature à propos de deux cas.

Two cases of strangulated retrocostoxiphoid hernia (Morgagni-Larrey hernias) are reported. This is a relatively rare complication, as only 66 cases have been reported, and it has a poor prognosis. The clinical picture includes three main symptomatological groups: occlusion of the colon, gastric volvulus, and small intestine occlusion. Radiological examination of the lungs by frontal and profile films is usually sufficient to establish the diagnosis rapidly, and whether surgery is indicated. In some cases, however, the symptoms are such that opacification with water soluble agents is required. Reduction of the visceral hernia and closure of the orifice is carried out after laparotomy, resection of viscera being rarely required.

[The lymphatic drainage of the stomach (author's transl)]. / Le drainage lymphatique de l'estomac.

The authors became interested in the lymphatic drainage of the stomach in order to attempt to determine for each region the type of drainage and the risk of cancer spread. They studied 132 dissections including 97 injections, 210 cases records of gastric carcinoma, 8 lymphographies by ultrafluid Lipiodol and 17 peroperative injections of vital staining. The system of drainage proposed by Rouvière was on the whole confirmed; however, one should emphasise the doubling of the hepatic chain, the existence of long collectors which bypass a relay in the left gastric artery, the importance of the posterior gastric artery which transmits the lymphatics of the splenic chain. Finally, the authors emphasise the existence of 3 longitudinal areas on the stomach where the presence or agsence of valvules in the subserous collectors orients the lymph towards the lesser or greater curvature of the stomach, which easily explains the onset of isolated carcinomatous adenopathy, situated on the curvature opposite the neoplasm.