Management of true aneurysms of the splenic artery.

BACKGROUND: Splenic artery aneurysms (SAA) are detected with increasing frequency but their management still remains controversial. This paper relates our experience in the outcome and management of ruptured aneurysms of the splenic artery. METHODS: Between 1977 and 1996, 8 patients presented to our institution with a ruptured SAA. Their ages ranged from 25 to 72 years (mean 55 ys). RESULTS: All patients presented with rupture as the first sign of SAA. One patient was at 32 weeks of gestation and rupture suggested placental abruption. Three patients required cardiopulmonary reanimation prior to surgical procedures. Splenopancreatectomy (n = 4), splenectomy (n = 2), and ligation of the splenic artery (n = 1) were performed. Seven of the 8 patients survived. Size of aneurysms ranged from 2 cm to 3.5 cm (mean 3 cm). CONCLUSIONS: SAA may rupture at any age. Diagnosis during pregnancy rests upon a high index of suspicion. The mortality rate remains low if immediate resuscitation is performed and an aggressive surgical approach is taken.

[Multicentric intestinal angiosarcoma. Report on a case]. / Angiosarcome multicentrique intestinal. A propos d'un cas.

The authors describe the case of a seventy-four year old female with no past medical history, in whom a duodenal angiosarcoma was found during investigation for anemia. Despite adequate surgical excision, hemorrhage persisted and the patient died. Autopsy disclosed multiple angiosarcomatous tumours in the colon and pulmonary micrometastases. Angiosarcoma is a rare tumour in the digestive tract. Multiple tumors occur but are often difficult to detect. In the present case, radiologican and angiographic investigations did not confirm the diagnosis, which was made on endoscopic and surgical findings and substantiated by histological examination of the surgical specimen.

Thirty-year experience of surgery for breast carcinoma in men.

OBJECTIVE: To present the long-term outcome after surgery for breast carcinoma in men. DESIGN: Retrospective study. SETTING: University Hospital, Switzerland. SUBJECTS: 37 consecutive men who were operated on for breast carcinoma between 1968 and 1998. RESULTS: The mean age was 67 years (range 41-89). The delay between the first clinical presentation and operation ranged from 1 month to 3 years (median 3.5 months). Operations included modified radical mastectomy (n = 19), radical mastectomy (n = 12), simple mastectomy (n = 3), Halsted procedure (n = 1), and conservative resection (n = 1). One patient had only a biopsy and was excluded from survival analysis. There were 30 infiltrating ductal carcinomas, 4 in situ ductal carcinomas, 2 papillary carcinomas, and 1 adenoid cystic carcinoma. Most tumors (n = 25, 68%) were in the subareolar region. The overall survival at 10 years was 44%, but it was significantly influenced by the stage of disease, ranging from 57% in stage I (n = 12), to 26% in stage II (n = 15), and 0 in stage III (n = 8). CONCLUSION: Although the long term survival in stage I and II is similar in men and women, the rarity of breast carcinoma in men and its location in the subareolar region may delay diagnosis and treatment.

Spontaneous hemopneumothorax--results of conservative treatment.

Spontaneous hemopneumothorax is a serious condition complicating spontaneous pneumothorax. Early stage thoracotomy has been advocated to stop the bleeding and evacuate the coagulated blood from the pleural cavity. The present review was undertaken to emphasize the potential life-threatening condition of spontaneous hemopneumothorax and reassess the benefit of conservative treatment with chest tube drainage. Out of six patients, five patients were treated conservatively and one required an emergency thoracotomy because of cardiovascular collapse. Although three patients still had minimal residual hemopneumothorax on discharge, none of them developed empyema or trapped lung. In conclusion, conservative treatment is efficient and should be performed if bleeding persists for less than 24 hours after chest tube placement.

Comparison of transanal and external perineal ultrasonography.

Anal endosonography with rotating endoprobes provides state-of-the-art imaging of sphincter integrity; however, the technique is not widely available and requires expensive equipment. Since pelvic anatomy permits the use of standard external ultrasound probes, we tested the feasibility, tolerance and reproducibility of uniplanar perineal sonography, with respect to visualisation of the anal sphincter, using both convex and linear 3.5- to 7.5-MHz and 360 degree rotating 7-MHz probes. Twenty healthy nulliparus female volunteers were investigated. Two operators performed endosonography and perineal sonography in duplicate, each blinded to the findings of the other. We then used this technique to examine 20 postpartum primiparus patients. The examination was well tolerated by all subjects. The internal anal sphincter appeared in perineal sonography as a hypoechogenic ring surrounded by an echogenic ring representing the external anal sphincter. Endosonography revealed six sphincter tears, four external and internal sphincter tears, one isolated external tear and one isolated internal tear. Perineal sonography recognised in all cases external sphincter tears. In one case the internal sphincter defect was missed. Perineal sonography appears to be a feasible alternative to anal endosonography in female patients and provides good information on external sphincter defects suggesting that this procedure might be particularly useful in incontinence screening. Perineal sonography gives a good image of internal sphincter. The lack of an isolated internal defect cannot be considered as relevant to our study.

[Traumatic lesions of the anorectum]. / Lésions traumatiques de l'anorectum.

Injuries of the colon and rectum are common surgical problems. Lesions can be classified into four groups according to the site of damage and the presence of sphincter tears: 1. intraperitoneal perforation without sphincter damage 2. intraperitoneal perforation with sphincter damage 3. extraperitoneal perforation without sphincter damage 4. extraperitoneal perforation with sphincter damage From 1990 to 1998, 11 patients, 7 males and 4 females presenting an anal and/or rectal trauma were admitted in Geneva University Hospital. 8 patients were admitted as an emergency, the 3 others had been transferred to correct an incontinent post traumatic pathology. No mortality. A terminal colostomy was performed in all patients with intraperitoneal injury and in 5 patients with combined extraperitoneal and anal sphincter injury. All sphincter lesions were sutured as an emergency (6 cases). In 3 patients we performed an overlapping sphincteroplasty. 2 patients with persisting incontinence were cured by a dynamic stimulated graciloplasty. The choice of treatment of anorectal trauma includes broad spectrum antibiotherapy, cleaning of the rectum, sphincter repair. A terminal diverting colostomy and laparotomy must be achieved in case of intraperitoneal injury, large extraperitoneal lesion, severe perineal laceration with or without pelvic fracture.

Management of true aneurysms of the pancreaticoduodenal arteries.

OBJECTIVE: To review the authors' recent experience and that of the literature since 1973 and to provide management guidelines for true aneurysms of the pancreaticoduodenal arteries (PDA). SUMMARY BACKGROUND DATA: True aneurysms of the PDA are rare, with a total of only 52 cases reported since 1973. METHODS: Six patients were admitted to the authors' institution between 1985 and 1995 for rupture of a true aneurysm of the PDA. They were analyzed with regard to the mode of presentation, preoperative workup, management, and outcome. RESULTS: All patients had severe epigastric pain from retroperitoneal hemorrhage. Computed tomography scanning and angiography were performed in all cases. Aneurysms ranged from 0.7 to 1.2 cm (median 0.9 cm). The celiac axis was stenotic or occluded in five cases. Three patients underwent emergency pancreatoduodenectomy. Two of them survived. In one case, section of the median arcuate ligament was associated with the procedure, and the patient died from an aortic dissection. Embolization was performed in the last three patients. The procedure was definitive in two cases. In one, hemorrhage recurred 8 days later and required surgical ligation of the bleeding artery. CONCLUSIONS: The authors recommend rapid treatment of all true aneurysms of the PDA. Because most of these aneurysms result from a stenosis of the celiac axis, selective embolization may help to preserve patency of the PDA and should, therefore, be the primary therapeutic choice in ruptured aneurysms. Close follow-up is mandatory because of possible recurrent bleeding. Appropriate and expeditious management of true PDA aneurysms should help reduce the mortality rate.

Formaldehyde application for haemorrhagic radiation-induced proctitis: a clinical and histological study.

OBJECTIVES: Haemorrhagic radiation-induced proctitis is a serious complication of radiotherapy of pelvic organs. In severe cases, massive haemorrhage may necessitate hospitalization and repeated transfusions. Application of formaldehyde under direct vision is one of the most efficient treatments. The aim of this study was to evaluate the results of this treatment as well as the histological changes induced by formaldehyde on the rectal mucosa. MATERIAL AND METHODS: From January 1991 to September 2001, 13 patients who presented a haemorrhagic radiation-induced proctitis have been treated in our outpatient clinic with 4% formaldehyde cotton soaked applications. They were followed up to one year after the treatment. Endoscopic biopsies were performed before, immediately after the application, 1 month later, as well as at the one-year follow-up. RESULTS: In eight cases bleeding stopped after the first application. In two patients a second application was necessary to control the haemorrhage and in two other patients bleeding ceased definitively after the fourth application. Follow-up evaluation at 12 months showed no sign of acute proctitis or rebleeding. One asymptomatic patient had a mild stenosis of the rectum. Baseline biopsies showed signs of acute inflammation. Those performed after the application of formaldehyde showed fresh thromboses of the vessels of the mucosa. Biopsies at 1 month and 1 year showed only chronic changes secondary to the radiotherapy. CONCLUSION: Local application of 4% formaldehyde for the treatment of haemorrhagic radiation-induced proctitis gives good results, is well tolerated and easy to perform. Formaldehyde applied selectively causes thromboses of the bleeding vessels, without deep lesions or extended necrosis.