Anevrisme rompu de l'artere splenique revelant un syndrome d'Ehlers-Danlos

Dans cette observation; nous rapportons un cas d'anevrisme de l'artere splenique rompu qui simulait une pseudotumeur chez une patiente porteuse d'une maladie d'Ehlers-Danlos vasculaire. La non prise en compte initiale de son terrain avait conduit a un traitement chirurgical inutilement agressif. Nous insistons sur la necessite d'une attitude prudente pour les indications therapeutiques sur ces terrains fragiles

An anatomical study of the vestibulocochlear anastomosis (anastomosis of Oort) in humans: preliminary results.

Von Oort first described the vestibulocochlear anastomosis in 1918, and there have been very few anatomical studies of it. It is located at the bottom of the internal auditory meatus and links the saccular nerve to the cochlear nerve. The aim of this study was to investigate the micro-anatomical characteristics of this anastomosis. We dissected 10 human temporal bones from five heads. We found the vestibulocochlear anastomosis in seven of the specimens, of which six were clearly visible. We were unable to uncover it in three specimens due to dissection problems. Its length was evaluated to be between 0.5 and 1 mm, with a diameter of 0.5 mm. The vestibulocochlear anastomosis could be the pathway for the nerve fibers of the cochlear efferent system, whose description remains incomplete. However, no anatomist, histologist or physiologist has demonstrated this function. From the results of this study, it seems likely that the vestibulocochlear anastomosis exists. Other studies are necessary to link it to the efferent system.

[Percutaneous ultrasound-guided drainage in the surgical treatment of acute severe pancreatitis]. / Place du drainage percutané échoguidé dans le traitement chirurgical de la pancréatite aiguë grave.

AIM OF THE STUDY: To report results of percutaneous ultrasound-guided drainage, performed by a surgeon, in the treatment of complications of acute pancreatitis (AP), and to determine the role of this technique in the therapeutic armamentarium of severe AP. PATIENTS AND METHODS: From 1986 to 2001, 59 patients were included in this retrospective study. All patients initially had severe necrotizing AP (mean Ranson score = 4.1 ; range : 2-7). Anatomical lesions included pancreatic abscess in 6 patients and necrosis in 53 (17 stage D and 36 stage E according to Balthazar's classification). Necrosis was infected in 42 and sterile in 11 respectively. Drainage was performed under ultrasound guidance and local anaesthesia using small-diameter drains (7-14 French). RESULTS: Drainage was performed on average 23 days after onset of AP. Infection was proven by fine-needle aspiration in 47 (80 %) patients (41 infected necrosis and 6 localized abscess). In one patient, culture of aspirated fluid was negative but necrosis was infected (one false negative). Culture of aspirated fluid was negative and necrosis was sterile in 11 patients. Nineteen (32%) patients healed without subsequent surgery: 7 (16%) in the infected necrosis group, 6(55%) in the sterile necrosis group, and 6 (100%) in the abscess group. Forty (68%) patients had subsequent necrosectomy including 8 (14%) who died. Twenty (34 %) digestive fistulas healed spontaneously, except one treated by diversion stomia. Of the 16 (27 %) pancreatic fistulas, 6 needed subsequent interventional treatment. CONCLUSION: In selected patients, percutaneous drainage can represent an alternative to surgery with a 14% mortality rate. The high rate of subsequent necrosectomy suggests that drains with larger diameter, possibly associated with continuous irrigation, should be used.

[Anatomohistologic study of von Oort's vestibulocochlear anastomosis]. / Etude anatomo-histologique de l'anastomose vestibulo-cochléaire de von Oort.

OBJECTIVES: The vestibulocochlear anastomosis was first described in 1918 by von Oort. It is situated deeply at the bottom of the internal acoustic meatus, and spreads from the saccular nerve before its terminal ramifications, to the cochlear nerve before its penetration into the cochlea. Nerve fibers of the cochlear efferent system are thought to pass through it. The aim of our study was to investigate the anatomy of the vestibulocochlear anastomosis and characterize its histological features. METHOD: [corrected] Ten human temporal bones were dissected. Serial sections were obtained for histological evaluation. RESULTS: The vestibulocochlear anastomosis was found in seven of the specimens, perfectly visualized in six. Average diameter was 0.5 mm with lengths varying from 0.5 to 1 mm. Serial histological sections demonstrated the nervous nature of the anastomosis and its relations with the saccular and cochlear nerves. The epinevrium of the saccular nerve was continuous with the supposed anastomosis in five of the specimens, demonstrating the distinct nature of the anastomosis from the saccular and cochlear nerves. We did not find any evidence linking these fibers to the cochlear efferent system. DISCUSSION: The vestibulocochlear anastomosis was found in seven of our ten dissections. The anastomosis is probably an anatomic reality composed of nerve fibers. The efferent function of these fibers remains to be demonstrated.

[Arterial blood supply and innervation of the rectus muscles of the eyeball]. / Vascularisation artérielle et innervation des muscles droits du bulbe de l'oeil.

UNLABELLED: The authors report on the arterial blood supply and the innervation of the rectus muscles of the eyeball from human orbital dissections. MATERIAL AND METHODS: Hundred human orbits were dissected using a superior approach after arterial injection with colored latex. The different arterial pedicles for each muscle were noted and the nervous supply was studied. RESULTS: The arterial blood supply of the rectus muscles comes from different branches of the ophthalmic artery, usually the inferior muscular artery, the lacrimal artery, the superior muscular artery when it exists, and by small branches arising from the ophthalmic artery. The superior rectus is supplied by branches of the ophthalmic artery and the lacrimal artery (1 to 5 pedicles). The medial rectus is supplied by branches of the ophthalmic artery and the inferior muscular artery (5 to 9 branches). The inferior muscle rectus is principally supplied by the inferior muscular artery (4 pedicles) and the lateral muscle is supplied by the lacrimal artery or the lateral muscular artery (3 to 6 branches). For innervation, the abducens nerve supplies the lateral rectus; the other muscles are supplied by the oculomotor nerve whose superior branch supplies the superior rectus and whose inferior branch, supplies the inferior and medial rectus. DISCUSSION: The arterial blood supply is variable. The arteries which lie near the rectus muscles usually supply one or more branches to the muscles. The arteries go into the muscles through their conal side. This arterial supply is at the posterior part of the muscle. Innervation, in contrast, is very constant and fixed. CONCLUSION: The arterial blood supply to the rectus muscles is variable but always substantial. The pedicles are numerous, often 3 to 5 for each muscle. Innervation is fixed and constant.

The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications.

No significant difference has been found between early and new diagrams of the posterior anatomy of the inguinofemoral area from a laparoscopic standpoint because anatomy is unique to each individual. But new dangers can arise from new approaches, even if the anatomic structures are well known, so anatomic research is still useful. It provides, relative to new surgical techniques, new vision of structures known for centuries.

The inguinal rings.

The inguinofemoral area constitutes the frontier between the abdomen and the lower limb. Because of the human standing position, the inguinal region is a zone supporting the abdominal thrust, and is weakened by the orifice of the inguinal and femoral passages. Peritoneal diverticula may externalize into these orifices, leading to the formation of hernias. This article reviews the anatomic constituents of the inguinofemoral region and the anatomic basis for the treatment of hernias.

Ampulla of Vater. Anatomic, embryologic, and surgical aspects.

The region of the ampulla of Vater constitutes a complex anatomic and functional entity, the biliopancreaticoduodenal confluence, of which the essentials of this rapid review are the: Variation in site of implantation of the greater duodenal papilla, whereas the relations between the common bile duct and the main pancreatic duct are relatively constant Presence at this site of a weak point in the duodenal wall, commonly the site of mucosal diverticula Interdependence of the parietal duodenal mucosa and the sphincteric system of Oddi Existence of an extramural zone of this sphincter, which should be the only one involved in sphincterotomy Danger of wide excisions of the papilla, which, apart from the risk for hemorrhage, cause a breach of the digestive barrier The ampulla of Vater corresponds to the dilated junction of the common bile duct and main pancreatic duct, if present. The ampulla is an extensive anatomic and functional region that includes not only the choledochopancreatic junction but also the sphincter of Oddi, the whole traversing the duodenal wall to open at the greater duodenal papilla. The chief anatomic features of this biliopancreaticoduodenal junction have been reviewed, forming the basis of techniques of surgical or endoscopic sphincterotomies and localized excisions of vaterian tumors.

Functional anatomy of the gastroesophageal junction.

The study of the functional anatomy of the gastroesophageal junction allows for the demonstration of a double mechanism that combats the conflict of pressures that tends to lead to gastroesophageal reflux. On one hand, the LES, an intrinsic structure, is directly related to the muscle fibers of the organ and responds to a neurohormonal physiologic command. On the other hand is an anatomic entity, centered by the crura of the diaphragm, closely related to the movements of respiration. These structures constitute a second, extrinsic sphincter that gives rise to the zone of high pressure in the terminal esophagus. This role is difficult to assess, and its importance is underestimated. The proper functioning of these two mechanisms implies that the gastroesophageal junction remains in place within the diaphragmatic channel of the esophagus. Also important are the postural phenomena associated with the sloping position of the fundus. In patients with gastroesophageal reflux, the decrease of the pressure measured in the terminal esophagus accounts for the occurrence of reflux. Investigators concede that, under the influence of abdominal straining, the gastroesophageal junction tends to ascend into the diaphragmatic channel. The results are twofold: (1) the muscle fibers of the lower esophagus relax, explaining the incompetence of the intrinsic sphincter, and (2) the sphincteric zone is withdrawn from its muscular diaphragmatic environment. Physicians should consider these structures as a whole in approaching the surgical treatment of reflux. The construction of a periesophageal valve has no anatomophysiologic basis. A gastropexy procedure must be added to replace the gastroesophageal junction in its anatomic setting and keep it there. This procedure also allows retightening of the muscle fibers of the esophageal wall, which is essential in long-term surgical correction.

Anatomic basis of hepatic surgery.

Modern hepatic surgery is based on precise anatomic foundations. The importance of this information applies to all levels of the diagnostic and therapeutic chain. Modern methods of imaging--CT scanning, MR imaging, and preoperative sonography--help physicians to detect variations and plan surgical excision.

Surgical anatomy and embryology of the adrenal glands.

Gross anatomy explains the different surgical approaches to adrenalectomy and the difficulties encountered by surgeons during this procedure. Development of the adrenal glands explains the location of the ectopic sites and excess hormone production by adrenal tumors. The choice of a surgical approach is sometimes difficult and is dependent on (1) the morphology of the body; (2) the volume of the tumor, which necessitates immediate vascular control; and (3) the type of disease, which may necessitate a complete exploration of the abdominal cavity.

Right nonrecurrent inferior laryngeal nerve and arteria lusoria: the diagnostic and therapeutic implications of an anatomic anomaly. Review of 17 cases.

The authors report 17 cases of a right non-recurrent inferior laryngeal n. (NRILN) observed during 15 years of practice of thyroid and parathyroid surgery. In their last two cases, the existence of an aberrant right subclavian a., constantly associated with NRILN, was confirmed by MRI angiography. On the basis of the literature and their own experience, the authors review the incidence of this double anomaly, its embryologic explanation and its anatomic and surgical importance. They stress the diagnostic factors and the therapeutic implications, very different in children and adults, of a particular vascular anomaly whose outcome is little understood.

[Anatomy and mechanism of inguinal hernias]. / Anatomie et mécanisme des hernies de l'aine.

Anterior abdominal wall presents a weak point between the pelvic bone and the muscular arch of transverse and internal oblique muscles. This myo-pectineal orifice, crossed by the inguinal ligament is closed by the transversalis fascia. All groin hernias, inguinal directs, indirects or femoral, result from a defect of the transversalis fascia. They have two causes. Congenital hernias result from a persisting peritoneo-vaginal canal. Acquired hernias result from a progressive weakening of the transversalis fascia depending on connective tissue insufficiency and increase of intra-abdominal pressure.

Anatomic study of the pre- and neonatal hip. Physiopathologic considerations on dysplasia and congenital dislocation of the hip.

Therapeutic success in dysplasia and congenital dislocation of the hip depends on an early diagnosis. The physiopathology remains very debatable and several concepts are propounded. For a better physiopathologic understanding, the authors have carried out a study of the morphology and development of 22 pre- and neonatal hips. At first, the acetabulum is cartilaginous and distorted by the moving femoral head; this acetabulum is histologically affected by the femoral pressure. The pathologic hip is characterized by defective posterior bony coverage of the femoral head by the acetabulum. The acetabulum ossifies during the 3 months following birth, forming a cup-like cavity under the pressure of the femoral head. Therefore, neonatal screening tests such as sonography must take place in the first weeks of life.

[Comments on emergency treatment of biliary lithiasis in patients over 75 years of age. Apropos of 157 cases]. / Réflexions sur le traitement des urgences de la maladie biliaire lithiasique chez les sujets de plus de 75 ans. A propos de 157 observations.

Surgery remains the ideal emergency treatment for biliary lithiasis in elderly subjects despite perioperative morbidity and mortality. Minimally invasive techniques appear promising but require assessment. The aim of this work was to determine the usefulness of these techniques and evaluate outcome in a series of 157 patients over 75 years of age who were hospitalized in an emergency setting of complicated biliary lithiasis from January 1990 to December 1996. There were 103 women and 54 men, mean age 82 years. The patients' general status was evaluated according to the ASA classification; 66% of the patients were ASA III, IV or V. Diagnoses at admission were acute cholecystitis (n = 71, 45%), angiocholitis (n = 50, 31%) subintrant hepatic colic (n = 17, 10.8%), pancreatitis (n = 10, 6%), isolated jaundice (n = 2), peritonitis (n = 2) and occlusion (n = 5). Within 24 hours of admission, 7 patients underwent emergency surgery, and the 150 others were given medical treatment. Among these 150 patients, cure was considered to have been achieved with medical treatment alone in 41 (subsequent surgery being required in only one 6 months later), semi-emergency was performed in 17, and a minimally invasive procedure was performed in the 92 others (echo-guided percutaneous cholecystostomy in 42, endoscopic sphincterotomy in 50) followed by a subsequent operation in 29. In the 103 patients (65.5%) in this series who did not undergo surgery, mortality was 3.8% and in the 54 patients (34.5%) who did, mortality was 15%, but this rate was only 6.9% when the open procedure followed a minimally invasive technique. Surgical treatment of complicated biliary disease remains the ideal therapy but indications should be carefully weighed in these elderly fragilized subjects. Under surgical observation, abstention from surgery or use of minimally invasive techniques can play an important role in the therapeutic strategy aimed at lowering perioperative mortality.

[Ultrasound-guided percutaneous drainage in the treatment of retentional pseudocysts of chronic pancreatitis]. / Drainage percutané échoguidé dans le traitement des faux kystes rétentionnels de la pancréteate chronique.

25 to 35% of the patients with calculous chronic pancreatitis will develop a pseudocyst in the course of their disease. Up to recent years pancreatic pseudocysts were treated surgically most of the time by internal drainage (cysto jejunostomy). More recently, it was proved that percutaneous drainage could collapse pseudocysts if aspiration was maintained within 3 to 4 weeks. From January 1986 to December 1994, 22 patients with Wirsung communicating pseudocysts were treated percutaneously. Total recovery was achieved in 11 patients (50%). In these cases the pancreatic out flow towards the duodenum was always restored. There were 8 recurrences, always in relation with persistent or recurrent obstruction of the pancreatic main duct. Modern procedures, associating extra corporal lithotripsy and transpapillary endoscopic management should allow to reduce the failure rate of percutaneous drainage. According to their results, the authors state that an unuseful operation can be avoided in 50% of the patients with percutaneous drainage only. This success rate could probably be increased with association of other non invasive procedures aiming at the permeability of pancreatic duct.