[Splenectomy for hematologic disease in patients over 70 years of age. Apropos of 38 cases]. / Splénectomie pour maladie hámatologique au-delà de 70 ans. A propos de 38 cas.

A retrospective series of 38 splenectomies performed in patients over 70 for haematology diseases is reported. There were no post-operative deaths and 8 patients (21%) had complications which resolved favourably. Paradoxically, mortality and morbidity were lower in elderly patients although the difference was not statistically significant. No factor predictive of post-operative outcome was found. It was concluded that age is not a contraindication although the clinical situation is a predominant factor in patient selection.

[Volvulus of the colon. Apropos of 37 cases]. / Les volvulus du côlon. A propos de 37 cas.

A retrospective study of 37 case reports of patients with volvulus of the colon was carried out to define diagnostic and therapeutic strategies. The group comprised 22 men and 15 women, mean age 69 +/- 4 years (range 26-88 years), the volvulus being located in the sigmoid colon (n = 23), ascending colon (n = 13) or transverse colon (n = 1). The diagnosis, suggested by the straight abdominal film in almost all cases, was confirmed by a barium enema in 70% of cases. Treatment was surgical in 30 patients (81%) including 12 as emergency operations. Mortality was 5.4% (2 cases), and morbidity high (43% including fatal complications) the majority of adverse reactions being respiratory. Volvulus of the ascending colon was treated by hemicolectomy in 9 cases with no mortality or relapse. In patients with sigmoid volvulus, a "medical" reduction was performed in 7 patients, with success in 5 cases, one recurrence and no mortality, ideal sigmoidectomies in 14 cases resulting in one recurrence and no mortality. Right hemicolectomy appears to be the technique of choice even for urgent cases, there being no contraindications to a one-stage re-establishment of continuity. Inversely, an urgent intervention should at all costs be avoided in cases of sigmoid volvulus, a "medical" reduction (radiology, intubation, endoscopy) allowing preparation of the patient for a deferred ideal sigmoidectomy. Obviously, failure to reduce the volvulus or signs of colon necrosis require urgent surgery and raise the problem of whether or not to re-establish colon continuity.

[Hibernoma of the axilla]. / Hibernome de la région axillaire.

Hibernomas are benign tumors derived from brown fat that most often present as painless, slowly enlarging masses in the interscapular region, the neck, the inguinal region and the mediastinum. We report one case of hibernoma of the axillary region and we review the clinical presentation, diagnostic and therapeutic of this kind of soft tissue neoplasm.

[Nodular goiter. Retrospective analysis of 608 cases]. / Goitre nodulaire. Analyse rétrospective sur 608 cas.

A retrospective study was carried out on a series of 608 patients, of whom 430 had undergone partial and 178 total thyroidectomy for single or multinodular goitre. Statistical analysis of data for the 532 women (88%) and 76 men (12%), mean age 45 and 39 years respectively, included clinical and operative features, specific morbidity of the exeresis, incidence of cancer on multinodular goitre and the frequency of recurrence of nodular lesions. The men were significantly younger at time of diagnosis (p < 0.0006). Bilateral multinodular forms (n = 577) and hypofixing lesions (n = 515) predominated. The incidence of unsuspected thyroid cancer in the multinodular cases was 3% (15/444). Carcinoma development on single nodules in our series during the same period was 8% (n = 15/195), the difference being statistically significant (p < 0.02). Mortality was nil and non specific morbidity 2% (n = 12/608). No compressive hematoma was reported and tracheotomy was never required. A clinically detectable alteration in the voice was noted in 10% (n = 67/608), this persisting in 0.5% (n = 3) beyond the 6th postoperative month. No significant difference existed between general and vocal morbidity as a function of the type of exeresis. Hypocalcemia was observed in 11% of patients (n = 67/608), 49% (n = 33/67) being asymptomatic and the anomaly spontaneously reversible. Four percent (n = 7/178) were permanent after total thyroidectomy (including 15 cancers on multinodular goitre discovered fortuitously, 8 of which received lymph node dissection) and 3% (n = 2/68) after a "wide" subtotal thyroidectomy.

[Obstruction of the small intestine caused by bridles and adherences. Analysis of 157 operated cases]. / Les occlusions du grêle par brides et adhérences. Analyse sur 157 cas opérés.

We retrospectively studied a series of 157 patients who were operated for post-operative occlusion of the small bowel. Our aim was to analyze the clinical and operative aspects with particular emphasis of the factors predicting intestinal necrosis. We also reviewed the literature. There were 103 females and 54 males with a mean age of 61 and 51 years respectively (p < 0.01). Patients with neoplasia, hernia or irradiated bowel syndrome were excluded. Perioperative variables were analyzed and compared with the incidence of intestinal necrosis and post-operative morbidity and mortality. Data were compared with the chi 2 test. The most frequent prior surgery was appendectomy (33%) and pelvic operations (25%). The mean latency period was 15 years and 5 patients (3%) developed immediate post-operative occlusion (mean 7 days). The preoperative interval was 24 hours on the average. The pathologies involved were: bridles 48%, bridles + adherences 35%, adherences 17%. No clinical sign could distinguish between these three categories, but strangulation was more frequent in patients with bridles (p < 0.003). The following factors were significantly related to intestinal necrosis: signs of abdominal defence (p < 0.0002), white-cell-count > 16000 (p < 0.002), systolic hypotension (p < 10(-7)) and the lack of a history of occlusion (p < 0.04). Mortality was 6% (all at age > 70 years). Age was the only factor significantly related to morbidity-mortality. Emergency surgery shoulder be performed for patients at risk of intestinal necrosis, especially elderly patients.

[Acute cholecystitis in the elderly]. / La cholécystite aiguë chez le sujet âgé.

We retrospectively studied 150 patients aged over 65 years who had been operated for acute cholecystitis in order to define the surgical results and evaluate this treatment as a function of age. The patients were divided into two groups. Group I included patients between the age of 65 and 79 years, n = 99 (53 males and 46 females). Group II included patients aged 80 years and over, n = 51 (14 males and 37 females). The data were compared with the chi 2 test and the Kruskall and Wallis test. Associated affections were observed in 69 patients in group I and in 36 patients in group II (NS). The clinical picture was similar in the 2 groups with manifestations of pain in the right hypochondral region (group I, n = 97; group II, n = 50), fever (group I, n = 73; group 2, n = 38) and abdominal defence (group I, n = 62; group II, n = 35). Echography revealed the diagnosis in almost all cases in both groups. There was no statistical difference between the two groups in terms of mean operative delay and length of hospital stay. Age increased significantly the risk of exploration of the main bile duct (group I, n = 14; group II, n = 15, p < 0.05). Nevertheless, this exploration did not affect post-operative follow-up. Mortality was 6.7% with 4 deaths in group I and 6% in group II (NS). Post-operative complications were observed in 36 patients in group I and 28 in group II (p < 0.05) (43% overall including deaths).(ABSTRACT TRUNCATED AT 250 WORDS)

[Intestinal-mesenteric lesions of closed abdominal traumas]. / Les lésions intestino-mésentériques dans les traumatismes abdominaux fermés.

A retrospective series of 24 intestinomesenteric lesions after blunt abdominal trauma were investigated to determine the distribution of the lesions as a function of the type of accident and to establish diagnostic and therapeutic patterns based on observed post-operative results. The chi squared test was used for statistical analysis. There were 20 men and 4 women, mean age 39 +/- 15 years (range 17-74). Trauma was caused by a traffic accident in 16 cases (67%) including 12 victims under 40 (p < 0.01) and 14 drivers (87.5%) (12 wore a safety belt). Haemodynamic instability or generalized abdominal defense. Pneumoperitoneum was seen on only one of the 21 (5%) admission X-rays. Abdominal echography was often ordered (16 times). The mean interval between trauma and surgical intervention was 39 hours. Injury involved the mesentery (n = 15), the small intestine (n = 14), the colon (n = 7) and the colic mesenteriolum (n = 4). Lesions of the colon were observed more often in automobile accidents (p < 0.05). Injury to other abdominal organs was also observed in 12 patients: liver (n = 6), spleen (n = 5) and pancreas (n = 5). The thorax was involved in 14 patients including 11 under 40 (p < 0.01). Nine intestinal resections/anastomoses, 9 enterroaphies (including 4 colic injuries) and 1 Hartman were performed. Two patients died (8.3%) and follow-up was complicated in 14 (including the 2 deaths). Wearing the safety belt did not affect the greater number of intestinomesenteric lesions. In subjects wearing a safety belt, there were more injuries of the thorax but less neurological involvement.(ABSTRACT TRUNCATED AT 250 WORDS)

[Predictive factors of nodular recurrence after thyroidectomy for goiter]. / Facteurs prédictifs de récidive nodulaire après thyroïdectomie pour goitre.

We report a retrospective series of 44 recurrences of nodular goitre following 430 partial thyroidectomies over a 10 years period. There were 40 women and 4 men with a mean age of 43 and 37 years respectively. Twenty-four recurrences were from our institution (6%) and 20 were referred to us. The median follow-up of primary thyroidectomies was 8.5 years for patients with recurrence and 4 years for patients free of recurrence (p < 10(-6)). The incidence of recurrence was analysed in a statistical and actuarial model considering clinical intra-operative and post-operative variables. The following risk-factors for recurrence were found: age < 50 years (p < 0.01), family history of goitre (p < 0.04), unilateral multinodularity (p < 0.0002), diffuse and bilateral distribution of nodules (p < 0.02), atypical resections with conservation of isthmus (p < 0.0001), scintigraphically "warm" nodules (p < 0.001). Interestingly, sex, heterogeneous thyroid parenchyma without macroscopic nodules and the use of post-operative levothyroxine did not modify the risk of recurrence. Thirty-three patients were non symptomatic. Thirty-four patients underwent re-operation. Three primary non suspected carcinomas were found. There was no mortality related to re-operation. There were not definitive vocal cord paralysis or hypocalcemia. There was no significant difference in vocal or parathyroid morbidity when total thyroidectomy for primitive goitre was compared to total thyroidectomy as re-operation. Long-term and periodic follow-up is necessary to detect non-symptomatic recurrences in a high-risk population. Total thyroidectomy is the treatment of choice for bilateral multinodular goitre.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cholelithiasis in patients over 75 years of age. Apropos of 147 cases]. / La lithiase biliaire des sujets de plus de 75 ans. A propos de 147 cas.

The authors perform a retrospective study of a series of 147 patients aged 75 and more, who were treated for gallstone. AMong them, 104 had conventional surgery and 43 a nonsurgical treatment. The noticeable elements produced by this analysis are: the frequency of common bile duct lithiasis and of severe septic complication in elderly patients, the frequency of previous gallstone, sometimes remote in time, a significantly higher mortality when the treatment is non-surgical (p less than 0.001), mainly due to the septic complications of the lithiasis. the influence of the diathesis on mortality, and finally, the greater inocuity of the right infracostal approach in view of respiratory complications.

[Sigmoido-uterine fistula of diverticular origin. Review of the literature apropos of a case]. / Les fistules sigmoïdo-utérines d'origine diverticulaire. Revue de la littérature à propos d'un cas.

The authors report one case of sigmoid-uterine fistula of diverticular origin with a favorable outcome after an ideal colectomy associated with subtotal hysterectomy. They emphasize the rarity of this complication, due to the resistance of the uterine tissue. Its diagnosis is primarily clinical, and other examinations are required only to establish the etiological diagnosis. Surgery must be curative, ideally in one stage including the treatment of the diverticular disease and that of its gynecological consequences, which may vary according to the local conditions.

[Restoration of colonic continuity after Hartmann's operation]. / Rétablissement de la continuité colique après intervention de Hartmann.

A retrospective analysis of data from 69 patients treated by Hartmann's operation between 1981 and 1991 determined prognostic factors for colon continuity re-establishment and the mortality of this second intervention. The 15 patients who died during the first month after the Hartmann's operation were excluded from the study, the 54 survivors including 32 men and 22 women, mean age 68 +/- 12 years (range 19 to 87 years). The initial indication for surgery was: complicated sigmoid diverticulis (n = 26), cancer of colon (n = 14) or other site (n = 14). Colon continuity was re-established in 23 patients (42.6%), including 15 men and 8 women, mean age 60 +/- 10 years (range 38 to 78 years). In this latter group, 82.6% of the patients were under 70 years of age, indicative of a significant effect of age (p < 0.001) on re-establishment of continuity. Secondary anastomosis was obtained in 65.4% of cases of complicated sigmoid diverticulitis, whereas re-establishment of continuity was possible in only 7.1% of colon cancer patients (p < 0.001). The mean duration prior to re-establishment was 4.8 +/- 1.6 months (range 2.5 to 9 months). Morbidity was high (47.8%) and mortality 4.3% (1 patient). Hartmann's operation remains indicated for stages III and IV of complicated sigmoid diverticulosis, as well as for other benign affections (volvulus of sigmoid, perforation of sigmoid following injury), although it must be recognized that the possibilities of re-establishment are limited more in elderly patients and that fewer patients with colon cancer can benefit from the procedure. A period of 3 to 4 months appears sufficient to allow healing of the inflammatory phenomena of the initial operation, without the development of excessive retraction of the rectal stump.

[Mesenteric-portal thrombosis after hematologic splenectomy]. / Thrombose mésentérico-portale après splénectomie hématologique.

Venous thrombosis of the portal system following splenectomy for haematological diseases is uncommon, being reported with an incidence of 0.2 to 6%. Diagnosis may be difficult and the clinical presentation varies greatly. We report 4 cases, included in a consecutive series of 350 splenectomies for hematological diseases. Case 1: a man of 22 years, operated on for autoimmune hemolytic anemia developed severe and generalized abdominal pain 20 days after splenectomy. The coeliac arteriography showed a thrombosis of the portal system. The laparotomy revealed segmentary small bowel necrosis. Outcome after intestinal resection was uneventful. Case 2: a man of 56 years, operated on for essential thrombocythemia had the laboratory findings of acute hepatic failure 28 days after splenectomy. Doppler ultrasonography revealed a portal vein thrombosis. He was treated with heparin. Case 3: a man of 69 years, operated on for acquired idiopathic anemia, developed asthenia and fever 23 days after splenectomy. The ultrasonography showed a portal vein thrombosis. He was successfully treated with heparin. Case 4: a man of 20 years, operated on for Minkowsky-Chauffard hemolytic anemia developed a severe and generalized abdominal pain and fever 13 days after splenectomy. The CT-scan showed a thrombosis of the portal system. Outcome after thrombectomy and regional thrombolysis was uneventful. The aim of this presentation is to review the pathophysiological diagnosis, therapeutic and prophylactic aspects of this serious complication of splenectomy.

[Rupture of the diaphragm in closed traumas: apropos of 28 cases]. / Rupture du diaphragme lors des traumatismes fermés: à propos de 28 observations.

Twenty-eight cases of ruptured diaphragm due to blunt trauma are reported, including three with rupture on the right. Most of the patients were young men and rupture was an isolated lesion in only 6 patients, all others having multiple trauma. One patient died during surgery (3.6%) and complications, mostly respiratory, occurred in 17 patients (60.7%). Mid-term functional digestive and respiratory sequellae were evaluated. The gravity of ruptured diaphragm is basically related to the severity of the trauma and associated lesions. The diagnosis remains unrecognized in an important number of cases emphasizing the importance of repeated chest X-rays.

[Prognostic factors for peritonitis in elderly patients. Multifactorial statistical analysis apropos of 216 cases]. / Facteurs pronostiques des péritonites du sujet âgé. Analyse statistique multi-factorielle à propos de 216 observations.

The aim of this paper is to analyse retrospectively the data of our patients over 60 years old who had an acute peritonitis, localized or diffuse, to establish prognostic factors. They were 216 patients, who underwent surgical treatment between 1971 and 1990. We observed 243 variables and its significance using the chi 2 test. We divided our study in two stages: from 1.10.71 to 30.09.80 (group I = 93 patients) and from 1.10.80 to 31.01.90 (group II = 123 patients). Group I was composed by 51 men and 42 women with a mean age of 71.9 +/- 5.3 years. General mortality of this group was 36% (33 patients). Group II corresponded to 55 men and 68 women with a mean age of 74.26 +/- 7.1 years. Mortality was 23% (28 patients). Age, sex and associated clinical disorders were not significant on prognosis, meanwhile the clinical and biological form of presentation were not adequate to establish a severity index. The most common ethiologies were: biliar (24 patients = 26%) in group I and appendicular (41 patients = 32.2%) In group II. Significant factors on mortality rates in group II were: delay between onset of symptoms and surgical treatment (over 96 hs, p less than 0.05), generalized or purulent peritonitis operated after 96 hs from onset of the attack (p less than 0.05) and malignancy (p less than 0.01).

[Surgical treatment of colonic diverticulosis: results of a series of 70 cases]. / Traitement chirurgical des diverticuloses coliques: résultats d'une série de 70 observations.

Results are reported on a series of 70 patients operated upon for colon diverticulosis, surgery being elective in only 23 (32.9%) cases. Global mortality (12.9%), was higher in patients over 70 years of age (P < 0.01) and for emergency cases (17% against 4.3% (NS) after cold surgery). Global morbidity was 20%, the onset of septic complications being influenced (p < 0.01) only by treatment with antiinflammatory drugs. Despite the absence of precise factors predictive of the course of diverticular disease, it should be possible to further improve the very poor prognosis in patients with serious septic complications (Hinchley's stages I to IV) by: prophylactic colectomy in symptomatic diverticulosis, improved evaluation by complementary examinations, notably the scanner, of localized septic complications (stages I and II), with the possible association of guided puncture to avoid the septic areas and to allow performance of a cold colectomy without the need for colostomy. Certain severe septic complications may still develop and these cannot be totally prevented by any therapy. In these cases preference is given to resection of the septic focus using mainly Hartmann's operative techniques. Further studies are needed to evaluate those cases where protected anastomotic resection provides the best results, since in the long term the incidence of re-establishment is higher.

Transiliac hernia after bone graft.

Lumbar hernias, namely transiliac hernias, are not frequent events and are almost always associated with bone graft harvesting from the iliac crest. We describe a case of transiliac hernia 10 years after bone graft harvest, the patient presenting with right colon incarceration. Diagnosis was made by CT scan. The hernia was repaired with a composite polypropylene-PTFE mesh (Bard(®)).