Left hepatic duct injury and thoracobiliary fistula after abdominal blunt trauma.

Thoracobiliary fistula after blunt hepatic trauma is rare. We report a case of pleurobiliary fistula after a blunt hepatic trauma leading to a left hepatic lobe laceration together with a left hepatic duct injury. The management of this traumatic lesion is discussed and related to the existing literature data. The diagnosis of traumatic thoracobiliary fistula rests upon clinical suspicion in the setting of a persistent right pleural effusion. Demonstration of the presence of bile in the pleural cavity by thoracocentesis is considered a proof of pleural biliary fistula. We think that laparotomy is an appropriate route for the treatment of pleurobiliary fistulas. However, when a bronchobiliary fistula is suspected, the patient should be treated with thoracotomy and may require pulmonary resection to remove the fistulous tracts.

[The enigma of varicocele in children]. / Les énigmes de la varicocèle de l'enfant.

After a review of the literature and their own experience, the authors relate the various dilemmas of infantile varicocele. These dilemmas are diagnostic and therapeutic. On the basis of clinical, epidemiological, etiological and pathological studies, the authors conclude that grade III and grade II varicoceles associated with testicular hypotrophy must be operated, while the others must be followed.

[How to prevent surgical morbidity after a total thyroidectomy for a multinodular euthyroid goiter?]. / Comment prévenir la morbidité chirurgicale de la thyroïdectomie totale pour goitre multinodulaire euthyroïdien?

AIM OF THE STUDY: Total thyroidectomy has been advocated for the treatment of multinodular nontoxic and benign goiter. The aim of this study, based on our experience, was to define the surgical factors which permit to decrease morbidity related to total thyroidectomy for multinodular euthyroid benign goiter. METHODS AND MATERIALS: In a retrospective study performed between January 1996 and September 2000, all records of total thyroidectomy for initial treatment of multinodular euthyroid benign goiter were reviewed. This study allowed to specify recurrent and parathyroid morbidity after surgery. RESULTS: There were 51 women and 13 men with a mean age of 47 years. Recurrent laryngeal nerve injury occurred in 2 patients. It resolved in 1 patient but was permanent in another (1.6%). Transient hypocalcemia was found in 8 patients (12.5%). One patient had permanent hypocalcemia (1.6%). CONCLUSION: The results of our serie are comparable to previous reports. Systematic identification of the recurrent laryngeal nerve, and preservation of the parathyroid blood supply permit to decrease the surgical morbidity.

[Splenectomy under celioscopy]. / Splénectomies sous coelioscopie.

Laparoscopic splenectomy has been extensively developed since its first description by Delaître in 1991. From May 1993 to July 1994, 12 patients underwent laparoscopic splenectomy in the "service de Chirurgie C" of the "CHU de Nancy". Six of them were successful. 6 women with a mean age of 27.7 years. The mean operating time was 2 h 30 min. For all cases, the indication was idiopathic thrombocytopenic purpura. No mortality and no morbidity was reported. One patient needed a blood transfusion. The postoperative stay ranged from 3 to 7 days. Splenectomy appears to be another procedure that may be successfully performed under laparoscopic guidance with satisfactory conditions of safety. The outcome evaluation should be continued in order to accurately define the real advantages and risks of this new technique.

[The role of percutaneous drainage in acute calculous cholecystitis. Apropos of 27 cases]. / Place du drainage percutané dans les cholécystites aiguës lithiasiques. A propos de 27 cas.

Surgery is the treatment of acute calculous cholecystitis. Mortality and morbidity are considerable for patients with anesthetic risk factors. In this context, ultrasound-guided percutaneous drainage seems to be a alternative to urgent surgery. The place of this technic and its results have not been determined with certainty. We report our experience of percutaneous drainage in acute calculous cholecystitis, based on a series of 27 patients treated between May 1992 and May 1996. A favorable course was observed after drainage in 26 patients, one patient was operated urgently for purulent peritonitis on D1. One drain migrated into the gallbladder and required cholecystenterostomy en D30. Seventeen patients underwent cholecystectomy after the acute episode. Surgery was contra-indicated in light patients: two presented recurrence of acute calculous cholecystitis and six remained asymptomatic. The aim of this study was to define the place of this technic in the treatment of acute calculous cholecystitis, and estimate the results in terms of mortality, morbidity and recurrence.

[Evaluation of somatostatin or octreotide efficacy in the treatment of external pancreatic fistulas]. / Evaluation de l'efficacité de la somatostatine ou de l'octréotide dans le traitement des fistules pancréatiques externes.

AIM OF THE STUDY: To evaluate the prevalence of pancreatic pseudocyst after persistent fistula closure with somatostatin or octreotide. To compare the patient characteristics according to the subsequent presence or absence of pseudocyst. PATIENTS AND METHODS: This retrospective study from January 1994 to August 1999 included 15 patients with an external pancreatic fistula. Fistula closure was observed for all patients with somatostatin or octreotide. CT scan was performed 66 +/- 34 days after the end of this treatment. RESULTS: CT scan was normal in 9 patients (favorable group) and showed pancreatic pseudocyst (failure group) in 6 patients. Pancreatic fistula etiologies were different between the two groups. The 5 patients presenting pancreatic fistula after duodenopancreatectomy belonged to the favorable group. Six of the 10 patients presenting pancreatic fistula after pseudocyst drainage belonged to the failure group. There were no other differences between the two groups. CONCLUSION: Persistent pancreatic fistula can be cured with somatostatin or octreotide. However, fistulas occurring after duodenopancreatectomy are more easily cured with somatostatin or octreotide than fistulas occurring after external pseudocyst drainage. Somatostatin or octreotide cannot be considered to be an effective treatment for pancreatic fistula occurring after pseudocyst drainage, despite the fact that 40% of them were permanently cured.

[Results of a controlled trial comparing 3 suture threads at slow resorption for the closure of supra-umbilical midline laparotomies]. / Résultats d'un essai contrôlé comoparant 3 fils de suture à résorption lente pour la fermeture des laparotomies médianes sus-ombilicales.

A randomized prospective trial was carried out between September 1987 and February 1989 to compare 3 different absorbable sutures (polyglactine 910, polydioxanone I, polydioxanone II) for closure of the abdominal wall after upper midline laparotomy for elective operations. The technique used to close the fascia was always a continuous suture. The criteria used to assess the results were the development of wound infection and wound dehiscence in the early postoperative period, and the development of suture sinuses and incisional hernia 1 year after operation. The early postoperative results in 235 patients revealed no wound infection and no -wound dehiscence. Suture sinuses developed in 4 patients (2%) 2 months after operation, but resolved spontaneously. We reviewed 203 patients after one year. The total number of incisional hernias detected 1 year postoperatively was 22 cases (11%), (polyglactine 910, 14.2%; polydioxanone I, 11.2%; polydioxanone II, 8.4%). The difference between the 3 groups was not statistically significant. The results of the trial indicate that absorbable sutures have a very low incidence of suture sinuses, and that polydioxanone II seems to be a good choice for closing laparotomies.

[Diagnostic imaging of idiopathic segmental infarct of the greater omentum. Diagnostic and physiopathologic considerations]. / Imagerie des infarctus segmentaires idiopathiques du grand épiploon. Apport diagnostique et physiopathologique.

Primary infarction of the greater omentum is a rare cause of acute abdominal syndrome. Rate of occurrence may nevertheless be underestimated. We report a series of six cases observed over a 30-month period with US and CT imaging. We assessed early signs and their course. CT-scans depicted fatty oval-shaped masses below the right anterior or anterolateral parietal wall, associated with a thickening of the anterior parietal peritoneum, explaining symptom pathogenesis. Torsion can be identified, but has no specific impact on prognosis. Follow-up CT scan may evidence spontaneous, but sometimes slow, resolution.

[Radiologic aspects of infarction of the appendix epiploica]. / Aspects radiologiques des infarctus d'appendices épiploïques.

Clinical, US, CT and MR findings were reviewed in 5 patients with primary epiploic appendagitis (3 men, 2 women, mean age 38 years, age range 29-62 years) seen between December 1994 and December 1997. Diagnosis was reached in all cases with CT, with US in 3 and with MR in 1. Follow-up CT was performed in 2 cases and clinical follow-up in 4. One patient underwent surgery. Initial US, CT or MR examinations revealed a fatty oval-shaped nodule located anteriorly or anterolaterally to the left colon. The greater diameter ranged from 20 to 30 mm. Perinodular lesions with strands of periappendicular fat and thickened parietal peritoneum were visualized in all cases without any other inflammatory process in the abdomen. Symptoms resolved within 4 days in all patients. Signs of fatty inflammatory processes resolved in the 2 patients who had follow-up CTs. Primary epiploic appendagitis has characteristic US, CT and MR features which help guide medical treatment.

[Cost of medical imaging practices in acute abdominal syndromes]. / Coût des pratiques d'imagerie médicale dans les syndromes abdominaux aigus.

OBJECTIVES: To describe the costs of medical imaging practices in the diagnosis management of acute abdominal pain (AAP). METHODS: Medical imaging techniques until decision for treatment were prospectively recorded in patients presenting with AAP. Direct costs used hospital analytic accountability. Time of human resources involved was also surveyed prospectively. RESULTS: In 122 adult patients (2.3 examinations on average) before treatment decision making, the more frequent practices were: initial plain abdomen x-ray followed by tomodensitometry (36.8%), by echography or endoscopy (17.2%), plain abdomen solely (19.6%) or initial abdominal tomodensitometry (12.3%). Direct costs ranged from 977 to 1073 FF for practices with initial plain abdomen x-ray, and from 996 to 1150 FF with initial tomodensitometry. It ranged from 808 to 880 FF when the treatment decision was surgery, and 300 FF higher when it was medical. CONCLUSION: Differences in costs assessed for practices were very narrow. Such information should be taken into account to determine cost-effective strategies, and to built up reference guidelines.

[The mesorectum: improvement and anatomy of a semantic error]. / Le mésorectum: mise au point et anatomie d'une erreur sémantique.

AIMS: The cancer of the rectum touches 10,000 patients per year in France. Its treatment is mainly surgical. 50% of the treated patients will die of their cancer, either by loco-regional recurrence, or by metastatic disease. The rates of local recurrence vary from 10 to 40%. Heald is first who brought back recurrence rates lower than 4%, results obtained by the only surgical treatment. This treatment included the total exeresis of cellulo-fatty tissue surrounding the rectum, tissue which was baptized mesorectum. The aims of this work is to define and describe this space, and to discuss its Christian name. MATERIAL AND METHODS: The anatomical study carries on the dissection of 2 frozen pelvis of fresh man, one cut transversely on the level of L4, the other half-compartment sagittaly, then defrosted for the dissection. RESULTS: The mesorectum is defined and its various structures, fascia, vessels and nerves, are detailed. CONCLUSION: The mesorectum is an anatomical and surgical structure individualisable. Its recognition and its importance were born from the understanding of the fascia and the rectal anatomy. Its exeresis decreases the rate of the local recurrence (18). The technique of exeresis of the mesorectum must be validated, standardized, in order to be reproducible in the treatment of the cancer of the rectum.

[Intestinal resection in the treatment of Crohn disease. Retrospective study of a series of 106 cases]. / Résection intestinale dans le traitement de la Maladie de Crohn. Etude rétrospective d'une série de 106 cas.

Crohn's disease needs medical and surgical management. Most patients are operated and surgical procedure the most often realised is intestinal resection. The authors report their experience of 106 intestinal resection performed between 01/01/1980 and 31/12/1992, in the "service de Chirurgie C" of the "CHU de Nancy" for patients operated for the first time for Crohn's disease. They were 54 men and 52 women with an average age of 31.7 years at operative time. The following clinical patterns were established: small intestine 36, colonic 10 and ileocolic 60 patients. The average length of evolution before surgery was 4.5 years. The main indication was intestinal obstruction in small intestine patterns (91%) and poor response to medical therapy in colonic patterns (30%). Usual surgical procedure was to remove all visibly diseased bowell with healthy margin of resection, as judged by gross examination, of 3 to 5 cm. Postoperative morbidity was low (17.9%) with 3 anastomotic leakages. Postoperative morbidity was 1.9% (2 patients). The average duration of follow-up was 4 years. Among the 106 patients operated for the first time for their Crohn's disease, 19 (18%) were operated again, at least one time, during the follow-up. The quality of life of operated patients is considered as good with only one patient very invalidated by a short small bowel syndrome. According to the data of their series and the literature, the authors conclude that in Crohn's disease, excisional surgery is able to improve patients clinical status account to a low morbidity and mortality, with a low risk of short small bowel syndrome as clinical course but it does not avoid recurrence.

[Adrenalectomy by posterior approach for benign adrenocortical tumors. Apropos of 12 cases]. / Surrénalectomie par voie postérieure pour tumeurs bénignes cortico-surrénaliennes. A propos de 12 cas.

The posterior extra-peritoneal route is usually preferred for exeresis of benign tumors of the adrenal glands measuring less than 5 cm. We examined the hospital reports for patients in which Young access was used since 1985. From December 1985 to December 1994, 12 patients underwent surgery for benign tumor of the adrenal gland. There were 9 women and 3 men (mean age 49.4 years, range 29-67). In all patients, the tumor was localized pre-operatively on a CT-scan. There was a unique tumor in each case. There were 11 adrenal adenomas including 10 Conn tumors and 1 secreting tumor (Cushing's syndrome). The last case was a cortical cyst. One patient died in the post-operative period, probably due to massive pulmonary embolism although necroscopic evidence was not obtained. Parietal infection occurred in one case and a spontaneously regressive hematoma in another. Mean duration of hospitalization was 7.0 days. At follow-up, 1 patient suffered deinnervation of the oblique muscles of the abdomen which did not require reoperation. Two months after surgery, clinical signs and hormone disorders related to the Conn adenomas had regressed in 7 of the 9 patients. In summary, the posterior route is perfectly adapted to the treatment of benign tumors of the adrenal glands when the exact localization can be identified on pre-operative imaging. This access should be considered as the reference route of evaluating laparoscopic procedures.

[Treatment of sub-levator rectocele by transrectal approach. Value of the automatic stapler with linear clamping]. / Traitement des rectocèles sus-lévatoriennes par voie endorectale. Intérêt de la pince automatique à agrafage linéaire.

Surgical treatment of rectocele causing outlet blockage is still a subject of controversy. A retrospective study of eight rectocele repairs endorectally using a surgical stapling device done over a two years period was performed. The most common indication was constipation. All patients underwent in the preoperative period complete physiologic examination including defecography, anorectal manometry, electromyography and colonic transit studies. All patients underwent colonoscopy to exclude an obvious physical disorder. There was no postoperative morbidity and the mean hospital stay was four days. Good functional results were obtained in seven patients with a one year follow-up. Endorectal resection using a stapling device is both a simple and effective technique to treat rectocele associated with difficulty in evacuation.

Early postsplenectomy arthritis caused by penicillin-resistant Streptococcus pneumoniae.

The first case of early-onset postsplenectomy arthritis due to intermediately penicillin-resistant Streptococcus pneumoniae is reported. After initial parenteral vancomycin and rifampin followed by oral prystinamycin-rifampin, the patient recovered without any sequelae. This case should increase awareness of the risk of invasive disease caused by penicillin-resistant Streptococcus pneumoniae in the early postoperative period after splenectomy.

What are the small bowel obstructions to operate and how to do it?

Small bowel obstruction is one of the main surgical emergencies. CT scan is today the best exam to detect occlusions requiring an urgent surgical procedure. It also specify the cause of the obstruction. Post-operative adhesions are the first etiology and justify 3.5%-5% of laparotomies in Western Countries. Recently, small bowel obstructions due to adhesions could be treated by a laparoscopic procedure. The authors report a series of 35 patients presenting an acute small bowel obstruction treated by laparoscopy. The laparoscopic procedure was successful in 70% of cases when occlusion was due to acute adhesions. Compared with open procedure, coelioscopy had an immediate benefit on intestinal mobility re-establishment and hospital stay. The morbidity was 4.5% with no mortality. CT has to be part of pre-operative check-up in front of a small bowel obstruction in order to propose a laparoscopic procedure when postoperative adhesions are suspected.

Solitary rectal ulcer syndrome: a series of 13 patients operated with a mean follow-up of 4.5 years.

Solitary rectal ulcer syndrome (SRUS) is an infrequent pathology often associated with pelvic floor disorders. The aim of this retrospective study was to review the long-term results of a surgical series of SRUS. Between 1988 and 1998, 13 patients were operated on for SRUS. Seven patients had associated internal rectal prolapse (58%), two had associated total rectal prolapse (15%), and two had associated mucosal prolapse (15%). We performed simple resection of the SRUS in one case (8%), a stoma as primary operation in one (8%), three rectopexies according to Orr-Loygue (23%), and eight Delorme's operations as modified by Berman (62%). Mean follow-up was 57 months (range 15-112). Simple resection of the solitary rectal ulcer syndrome did not improve symptoms. Colostomy permitted relief of symptoms and healing of the SRUS. Two of the three rectopexies achieved good results, and the third patient relapsed at the 6th postoperative month. A secondary modified Delorme's operation permitted relief of symptoms and healing of the SRUS. Five of the eight patients (62.5%) who received modified Delorme's operations had improved at a follow-up of 46 months. We conclude that, considering the high failure rate after surgery, operations should be performed only in patients with total rectal prolapse or intractable symptoms not amenable to behavioral therapy. Delorme's operation and abdominal rectopexy help in about 60% of cases.

Actinomyces naeslundii, acute cholecystitis, and carcinoma of the gallbladder.

This report describes the first case of biliary actinomycosis associated with an adenocarcinoma of the gallbladder. Actinomyces naeslundii was encountered as a pure isolate after a precise and careful identification. Although, in diagnosis, cancer and actinomycosis are often confused, the simultaneous occurrence of actinomycosis in cancer lesions can happen. This case illustrates the diagnostic challenge of actinomycosis.