Preoperative computed tomography for transhiatal esophagectomy.

We report the results of a retrospective evaluation of preoperative chest computed tomography (CT) in 50 consecutive patients with esophageal carcinoma confirmed surgically. Forty patients underwent transhiatal esophagectomy without thoracotomy. In ten cases, blunt dissection of the esophageal carcinoma was impossible because of involvement of an adjacent organ. Transhiatal esophagectomy carries lower morbidity and mortality rates than the standard thoracotomy procedure, although long-term survival is considered to be the same with either method. The overall sensitivity of CT in detecting involvement of an adjacent organ, thus contraindicating the transhiatal procedure, was 90%, with an overall specificity of 92%. The positive predictive value was 75%, and the negative predictive value 89%. The negative predictive value of CT for tracheobronchial invasion, the main surgical risk in the transhiatal procedure, was 90%. A negative preoperative CT appears to be a reliable indicator for patients undergoing transhiatal esophagectomy.

Monocyte procoagulant activity and membrane-associated D dimer after knee replacement surgery.

We have recently shown that monocyte membrane-associated cross-linked fibrin derivatives (D dimer) can be evidenced by immunogold staining. Using this method, the procoagulant activity (PCA) expressed in vitro by endotoxin-stimulated monocytes has been found to correlate significantly with the number of D dimer-positive monocytes. The incidence of postoperative thrombosis in patients undergoing total knee replacement has been reported by Stulberg et al to be 57%. Since monocytes can play a role, via increased PCA, in the activation of intravascular coagulation, we sought to determine the level of monocyte PCA ex vivo after knee replacement surgery and its possible correlation with the number of D dimer-positive monocytes. Finally, we examined the possible link between these modifications and the occurrence of postoperative deep vein thrombosis (DVT). The PCA expressed by monocytes with or without suboptimal stimulation, the number of D dimer-positive monocytes and the plasma level of D dimer were measured pre- and post-operatively in 11 patients undergoing total knee replacement. Phlebography was performed on day 10 after surgery. A significant increase in the PCA of stimulated monocytes was observed on day 10 after surgery. Moreover, both the number of D dimer-positive monocytes and the plasma level of D dimer increased significantly post-operatively. The number of D dimer-positive monocytes correlated with both monocyte PCA and the plasma D dimer level. The relation between these parameters is discussed. However, neither monocyte PCA nor the number of D dimer-positive monocytes was found to correlate with the occurrence of deep vein thrombosis.

[Sensitivity of fine-needle puncture-biopsy in the histologic diagnosis of hepatic and pancreatic malignant tumors]. / Sensibilité de la ponction-biopsie à l'aiguille fine dans le diagnostic histologique des tumeurs malignes hépatiques et pancréatiques.

Aspiration-biopsies under ultrasound guidance, using a fine needle (external diameter inferior to 1 mm) have been performed in 61 malignant hepatic tumors (group I) and 25 pancreatic carcinomas (group II). Malignancy was diagnosed in 83 p. 100 cases; in group I, the sensitivity is 87 p. 100; the difference between hepatocellular carcinoma and liver metastases could be made in 88 p. 100 cases and in case of metastases, the site of the primitive carcinoma could be suggested in 77 p. 100 cases. In group II, the sensitivity is 72 p. 100. No complications were noted.

[Prognostic value of x-ray computed tomography in acute pancreatitis: contribution of the injection of intravenous contrast media]. / Valeur pronostique de la tomodensitométrie dans les pancréatites aiguës: apport de l'injection de produit de contraste intraveineux.

Thirty seven patients suffering from acute pancreatitis were explored using contrast-enhanced computed tomography (CT). The authors found a good concordance between the extension of the lesions on the initial CT examination, prognostic criteria on admission and the course of the disease. In addition, a new prognostic CT sign was reported in the early phase of parenchymal contrast perfusion, i.e. the lack of contrast-enhancement in a limited portion of the pancreas. This sign was present in 8 patients, all with severe clinical symptoms. These 8 patients showed the highest morbidity rate in the series with abscess-type complications occurring in all, compared with 24 p. 100 among the 29 other patients who did not exhibit this CT sign. Moreover, these 8 patients showed the highest mortality rate (25 p. 100 compared with 3.5 p. 100 among the other patients). An histological analysis of partial pancreatectomy specimens was performed in 7 out of the 8 patients. Devitalized pancreatic tissue, at the site of the parenchymal abnormalities on CT scan, was found in all cases. One false negative case was reported. Contrast-enhanced CT scan seems to be the most reliable method for diagnosing pancreatic necrosis during acute severe pancreatitis. It appears to be an useful prognostic predictor of morbidity. It can improve the outcome of the disease by depicting and guiding needle aspiration of a fluid collection, and/or surgery in case of clinical findings suggesting abscess formation.

[Percutaneous drainage of intra-abdominal abscesses guided by real-time ultrasonography]. / Drainage percutané des abcès intra-abdominaux guidé par échographie en temps réel.

From October 1982 to October 1984, a percutaneous drainage under realtime ultrasound guidance was performed in 53 patients with abdominal abscesses. The location of the abscesses was subphrenic (23), retroperitoneal (16), and intrahepatic (14). A safe access route was found by using ultrasound and fluoroscopy in 53 out of 55 patients (96 p. 100). Percutaneous drainage failed in 8 patients and 3 of these patients died. The causes of death were: cerebral abscess (1), renal failure after surgery for correction of a duodenal fistula (1), and pancreatic abscess (1). The other five patients were cured by surgical drainage. Two complications were observed: one case each of pneumothorax and purulent peritonitis. Forty-five patients were healed by percutaneous drainage without operation. The duration of the catheter drainage was 14 days +/- 13 (m +/- 1 SD). Our results suggest that percutaneous drainage under realtime ultrasound guidance is an efficient and safe way to treat abdominal abscesses.

D-dimer and thrombin-antithrombin III complex levels uncorrelated with phlebographic findings in 11 total knee replacement patients.

D-dimer and thrombin-antithrombin III complex (TAT) were assayed in 11 patients at various times pre- and post-operatively in order to determine the possible value of these parameters in screening for thromboembolic complications. Phlebography revealed distal thrombosis in 6 of the 11 patients. The D-dimer level, already elevated before surgery, increased at day 1 and remained high at days 5 and 10. Two methods were used for the assays and showed strongly correlated results. The TAT level increased at day 1 and then progressively returned toward basal values. No difference was observed at any time between patients with or without thrombosis. The results in surgical patients undergoing knee replacement suggest that neither D-dimer nor TAT assays are valid screening procedures for post-operative DVT. Nevertheless, in view of the small number of patient studied, further work is required to confirm these results.

[Warren's operation for distal splenorenal anastomosis. A pre- and postoperative radiological study (author's transl)]. / L'anastomose spléno-rénale distale de Warren. Etude radiologique pré- et post-opératoire.

The results of radiological examinations of 19 patients before and after Warren's operation for distal splenorenal anastomosis are reported, and compared to those of clinical and hemodynamic investigations. Good clinical results were obtained in this series in that there were no cases of relapse with hemorrhage, severe manifestations of encephalopathy, and/or hepatic insufficiency. Death occurred in 3 out of the 19 patients. Hemodynamic studies demonstrated a reduction in hepatic blood flow, persistence of a superior hepatic gradient after operation reduction in blood flow in the anastomosis after clamping of the splenic artery during operation, which demonstrates the importance of splenic artery blood flow in maintaining the permeability of the anastomosis, and persistence of high portal vein pressure during operation and after anastomosis. Radiological examination showed that the anastomosis was permeable in all the cases in this series. The hepatic portal circulation, as measured by the diameter of the portal vein and the amount of intrahepatic protal vascularization, was reduced after the operation. This diminution increased with time, as shown by studies carried out 6 months and 1 year after the operation in 3 patients. Portogastric separation was effective in only 6 cases. In the other cases, the hepatic collateral venous circulation persisted, appeared, or increased. The gastric varices were seen to be draining into the splenorenal anastomosis in 2 cases followed-up after the operation. It appears, therefore, that distal splenorenal anastomosis produces a progressive portocaval by-pass. Comparing these results with those obtained in three other series reported in the published literature (WARREN [12], MOSIMANN [8], and VANG [17], showed that they were close to those obtained by VANG, as far as reduction in intrahepatic portal circulation is concerned, but rather different from those of WARREN in respect to the efficacy of portogastric separation.

[Echography of tumors with multiple localizations in the urinary tract. Apropos of 2 cases]. / Echographie des tumeurs à localisations multiples de la voie urinaire excrétrice. A propos de deux observations.

The authors report 2 cases of unilateral non functioning hydronephrotic kidney, associated with homolateral bladder tumoral filling defect. Cystoscopy and histology showed a non infiltrating tumor. In one case, sonography showed a diffuse tumoral proliferation from the renal pelvis to the bladder and in the other case revealed a tumor located in the lower ureter prolapsed into the bladder. Both were non infiltrating ureteral tumors on histologic examination. These sonographic features, suggesting that the level of obstruction was not the bladder, accounted for the contradiction between urographic findings and lack of histological infiltration.

[Real time echographic study of the normal Wirsung duct. Comparison with retrograde catheterization]. / Etude du canal de Wirsung normal en échographie temps réel. Confrontation avec le cathétérisme rétrograde.

An ultrasonogram (US) of the pancreatic duct was performed in 59 patients prior to a retrograde pancreatography (ERCP). In 41 patients with normal ERCP, the pancreatic duct in the body of the pancreas was found to be on US less than 2 mm. The diameter measured on ERCP on the same portion of the pancreas was found to be 2,5 larger. On 18 abnormal ERCP, 3 patients had normal US defined by a pancreatic duct less than 2 mm in internal diameter and a normal pancreatic parenchyma. These 3 patients had mild ductal abnormalities of chronic pancreatitis on ERCP, undetectable by US. These 3 false negative cases give to a normal pancreatic US a negative predictive value of 93%. The injection of 5 normal autopsy pancreas, combined with US of the pancreatic duct, showed that neither the radiological magnification nor the pressure of injection accounted for the discrepancy between US and ERCP in the measurement of the pancreatic duct diameter. It is thought to be due to an underestimation of the internal diameter of the duct which may be related to an apparent thickening of its highly echogenic walls.

[Abdominal echography in the diagnosis and monitoring of retroperitoneal fibrosis. Apropos of 2 cases]. / Echographie abdominale dans le diagnostic et la surveillance des fibroses rétropéritonéales. A propos de 2 observations.

The authors report 2 new cases of unilateral ureteral obstruction due to a retroperitoneal fibrosis diagnosed by ultrasound examination. Retroperitoneal fibrosis presents as a hypo-echogenic, homogeneous mass, anterior to the sacral promontary, extending more or less cranially or caudally around the aorta and the iliac vessels where it gets a circumferential appearance. The complete regression of the mass has been followed by ultrasound on one patient. The authors underline the diagnostic problem posed with the R.P.F. secondary to metastatic neoplasm and discuss the place of ultrasound guided fine needle biopsy performed on one patient for the diagnosis of the affection.

[Diagnostic value of arteriography in a case of splenomegaly of unknown origin (author's transl)]. / Apport de l'artériographie dans un cas de splénomégalie inexpliquée.

A 32 year-old patient was found to have a tender enlarged spleen with hardly any other signs apart from transient fever and moderate hepatomegaly. Coeliac arteriography was performed to eliminate the possibility of a splenic tumor. The splenic arteriography showed the presence of a great number of lacuna dispersed throughout the parenchyma and measuring 0,5 to 1 cm. Histopathological examination of samples of the spleen, removed by operation, and biopsies of the liver and lymphnodes confirmed the diagnosis of sarcoidosis of the liver, spleen and lymphnodes.

[Real-time echography of the parathyroid glands]. / Echographie en temps réel des glandes parathyroïdes.

Real time ultrasonography of the neck, using a sectorial scanner with an ordinary 5 MHz transducer, was performed on 24 patients with hypercalcemia. 21 of them were suffering from primary hyperparathyroidism and 3 from a severe paraneoplasic hypercalcemia. There were 18 true positive, 3 false positive, 1 false negative and 2 true negative. The sensibility and the negative predictive value of the method are 83%. The specificity and the negative predictive value are 95%. The accuracy is 91%. Real time ultrasonography of parathyroid glands is possible with a sectorial scanner using an ordinary 5 MHz transducer and is systematically done, in our institution, before cervicotomy.

[Spontaneous rupture of a neurogenic bladder. Report of a new case]. / Rupture spontanée d'une vessie neurologique. Présentation d'un nouveau cas.

The authors report a new case of intra-peritoneal spontaneous rupture of the bladder, which was observed during a voiding urethro-cystography. Urodynamic studies on this patient showed a neurologic bladder which was due to a diabetic neuropathy.

[Renal malacoplakia. A report of a case and discussion]. / La malakoplakie du rein. Etude d'un cas et discussion.

A woman of 40 years of age without any past history of urinary affections was discovered to have malacoplakia of one kidney, demonstrated by a mass in the right flank, fever, and a coliform urinary infection. No secretion from the affected side was observed on intravenous urography. Renal arteriography showed an inflammatory mass affecting mainly the lower half of the kidney. Histological examination of a nephrectomy specimen led to a diagnosis of a malacoplakia. The authors review the clinical, radiological, and pathological features of renal malacoplakia, which is an inflammatory condition of the renal parenchyma very similar to xantogranulomatous pyelonephritis. The pathogenesis is completely unknown, but the lesion probably arises from a disorder of macrophage function, and renal malacoplakia should be a differential diagnosis of inflammatory renal masses.

[X-ray computed tomography in the course of mediastinitis after sternostomy for heart surgery]. / Apport de la tomodensitométrie dans l'évolution des médiastinites après sternotomie pour chirurgie cardiaque.

Results are reported of a prospective study of 79 CT scan examinations in 50 patients who had undergone sternotomy for cardiovascular surgery. In 69 cases the examination was conducted during the course of a progressive postoperative mediastinitis treated surgically. Mediastinitis was confirmed in 13 cases, including 12 relapses. In 2 cases the CT scan image was normal (2 false negatives) whereas mediastinal drains had been inserted. The CT scan image of mediastinitis shows mainly hypodense fluid collections (0 to 16 UH) in anterior mediastinum or between sternotomy borders (8 of 13 cases). But this type of image, detected 11 times in the absence of recurrence (favorable course), can result from a residual serous collection after ablation of drains. In 8 cases, a CT scan-guided puncture (7 cases) or one under ultrasound control (1 case) eliminated recurrence. The CT scan imaging also allowed diagnosis of 5 cases of osteitis, confirmed surgically. These findings indicate the definite interest of CT scan imaging in postoperative follow-up review of median sternotomies. It appears to be particularly indispensable for surveillance of surgically treated mediastinitis, because of the serious consequences of relapses and the often clinically silent chronic bone lesion. However, the possibility of residual serous collections emphasizes the importance of the clinical context and should lead to guided puncture investigation in doubtful cases.

[Muscle metastases: ultrasonic and x-ray computerized tomographic aspects. Apropos of 9 cases]. / Les métastases musculaires: aspects échographiques et tomodensitométriques. A propos de 9 observations.

Clinical, ultrasound and CT scan examinations were carried out in 9 patients with secondary muscle lesions. All muscles can be affected but there was a marked predominance of psoas lesions (6 of the 9 cases). Two contrasting clinical pictures are seen. Secondary muscle tumors can occur during evolution of a known treated cancer (5 of the 9 cases), revealed usually by large, rarely painful, mass. CT scan imaging shows a heterogeneous mass taking up contrast and often partially necrotic, the lesions appearing hypoechogenic or heterogeneous on ultrasound examination. Certain lesions can be totally necrotic. In some cases (4 of the 9 patients) the muscle metastases revealed the presence of a tumor. Symptomatology may be atypical and lead to a delay in diagnosis. Fine needle puncture biopsy can detect the secondary origin of the muscle lesion and also the primary tumor site (4 out of 9 cases), bronchopulmonary and colon cancer predominating. Images are however non-specific and in the absence of NMR imaging the muscle or lymph node metastases can be confused, although this has no practice consequences since treatment is identical.

[Diagnosis of glucagonoma. Value of scanning, echography and arteriography. Apropos of 2 cases and a review of the literature]. / Diagnostic du glucagonome. Intérêt du scanner, de l'échographie et de l'artériographie. A propos de deux observations et revue de la littérature.

The authors report two cases of glucagonoma, a rare endocrine tumor of the pancreas, and describe the data currently found in literature. Glucagonoma is a single and usually large tumor, which develops in the alpha cells of the islets of Langerhans and evolves slowly. The combination of characteristic skin lesions, diabetes and weight loss should lead to searching for hyperglucagonemia and for the pancreatic tumor. The diagnosis is usually made rather late, average evolution is five years before diagnosis when it is detected. Imaging, in particular ultrasound and computed tomography (CT), proves to be necessary for the positive diagnosis of glucagonoma as it localizes the pancreatic mass and plays a role in local assessment, thus providing guidance for surgery. The role of imaging is also fundamental for the detection of metastases, which are the only sign of malignancy as no criterion of benignity is found for this tumor.

[Imaging of external instabilities of the patella. State of the art]. / Imagerie des instabilités externes de la rotule. Mise au point.

External femoropatellar instability is a dynamic abnormality from various origins: osseous, cartilaginous or musculotendinous; X-rays films cannot give a precise enough description of this phenomenon. Attention is drawn by anterior pain or a sensation of instability. Clinical analysis distinguishes between permanent, traumatic or transient dislocations which are now more frequently discovered as part of a femoro-patellar syndrome with or without cartilage involvement. Conventional imaging, CT-scan and MR imaging are based on faultless techniques. Lateral views precisely report femoropatellar architectural abnormalities and patellar instability. Skyline views are able to quantify the various parts of the dysplasia. Dynamic tests increase the sensitivity of the plain films. But the main shortcoming of these techniques is the lack of visualization of the initial patellar engagement in the trochlea. The femoropatellar component of the knee arthrography visualizes rather large cartilaginous lesions. CT-scan, better than skyline views, allows examining the patellar bone without interference with the trochlea (extended knee), during the engagement (15 degrees flexed knee) and after the engagement (30 degrees flexed knee). However, the examination technique varies from one author to another according to his own pathophysiologic understanding. With the bicondylar plane reference, the reliability of the CT-scan measurements are better than skyline views. Like the dynamic tests during the beginning of the patellar engagement at 15 degrees, flexion is more sensitive than those at 30 degrees. Finally, CT-scan arthrography demonstrates thinner cartilaginous lesions than conventional arthrography. Presently the main contribution of MR imaging consists of detecting transient patellar dislocation that a single clinical examination cannot differentiate from other internal knee disorders. MR imaging is more precise in analyzing the cartilaginous structure. Kinematic MR imaging, still in an experimental stage, offers a new approach to the dynamic study of the patellar tracking.

[Value of ultrasonography in the diagnosis of carcinoma of Vater's ampulla. Apropos of 9 cases]. / Intérêt de l'échographie dans le diagnostic des ampullomes vatériens. A propos de 9 cas.

In ten patients where ampullary carcinoma was proved, ultrasonography has been performed in 9 cases and failed in 1 case. The results reported, could be put into two different groups. In 7 cases out of 9, sonogram did not show any specific signs: In 3 of these cases, it mimicked a pancreatic carcinoma; in the other 4 cases, dilatation of biliary and/or pancreatic ducts has only been evaluated. In the 2 remaining cases (20% of the 10 patients of the series) the diagnosis of ampullary carcinoma could be suggested on sonographic features. It showed the "double duct sign" and a bulging mass filling the lumen of the distal common bile duct. In one of these 2 cases, the mass was also detectable in the second duodenum, previously filled with water. Endoscopy with biopsy is the most reliable procedure in the diagnosis of ampullary carcinoma but the interest of ultrasonography is: 1 degree to show suggestive findings when the tumor bulges in the common bile duct and the duodenum; 2 degrees to evaluate the tumor extension in the pancreatic parenchyma.

[Osseous hydatidosis of the pelvic girdle. Contribution of computerized tomography and ultrasonics. Apropos of 3 cases]. / Hydatidose osseuse de la ceinture pelvienne. Apport de la tomodensitométrie et de l'échographie. A propos de 3 observations.

Three cases of bone hydatidosis of pelvis with invasion of soft tissues provided data on the effectiveness of CT scan and ultrasound imaging for diagnosis, evaluation of extension and follow up surveillance of this affection. Two of the three patients treated medically were followed up by review CT scan and ultrasound examinations. The two techniques were found to be effective for detecting recurrence and for surveillance of hydatid lesions of soft tissues during medical therapy.