[Suspected acute appendicitis. Role of enhanced helical computed tomography. Prospective study of 100 patients]. / Suspicion d'appendicite aiguë. Intérêt de l'examen tomodensitométrique hélicoïdal. Etude prospective chez 100 patients.

AIM OF STUDY: To assess the diagnosis accuracy of helical computed tomography (CT) in patients with suspected appendicitis. PATIENTS AND METHODS: This prospective study included 100 consecutive patients hospitalized for suspected appendicitis. There were 57 men and 43 women with a median age of 30 years (range: 17-91). An enhanced helical CT was performed at admission, without digestive opacification. Four criteria were interpreted as positive signs for appendicitis: appendix enlarged > or = 7 mm, right lower quadrant inflammation, stercorolith, and peri-appendicular collection. The patient was managed by the surgeon without knowing the result of CT. The final diagnosis was made pathologically. RESULTS: Eighty-one patients were operated on laparoscopically for suspected appendicitis. Intraoperative diagnosis was corrected in three cases and 78 appendectomies were performed (73 histological appendicitis, six normal appendix). Final diagnosis was a medical disease in 19 patients. The findings of 67 CT were interpreted as positive (63 true positive and four false positive) and the findings of 33 CT were interpreted as negative (24 true negative, nine false negative). Sensitivity was 87%, specificity was 86%, positive predictive value was 94%, and negative predictive value was 73%. If the nine false negative cases with minimal lesions at pathological examination were considered as true negative, the rates would be 100%, 89%, 94%, 100%, respectively. CONCLUSION: Enhanced helical CT is a good imaging diagnostic tool for suspected appendicitis. It may reduce the number of patients admitted for observation and decrease the rate of negative appendectomy.

[Laparoscopic treatment of perforated duodenal ulcer]. / Traitement laparoscopique de l'ulcère duodénal perforé.

OBJECTIVE: The aim of this study was to determine if laparoscopic simple closure for perforated duodenal ulcer is possible, efficient and safe. METHODS: Thirty-five consecutive patients with perforated duodenal ulcer and peritonitis were treated by simple closure, peritoneal lavage and omentoplasty. This treatment was performed laparoscopically. RESULTS: Diagnosis was confirmed in all cases. Conversion to laparotomy was necessary in two patients due to a technical problem and poor tolerance to pneumoperitoneum, respectively. Mean operative time was 120 min. Morbidity and mortality rates were 2.8%. Mean hospital stay was 7.8 days. No recurrence was found after eradication of Helicobacter pylori with a long-term follow-up of 38 months. CONCLUSION: Laparoscopic suture of perforated duodenal ulcer is possible and safe. It can avoid laparotomy with septic complications in peritonitis. In emergency there is no place for radical treatment of ulcer disease because of efficiency of medical treatment.

[Non-secreting pheochromocytoma of the broad ligament revealed by appendicular peritonitis]. / Phéochromocytome non sécrétant du ligament large révélé par une péritonite appendiculaire.

BACKGROUND: Non-secreting pheochromocytoma is an endocrine tumor located in the adrenal medulla in 85% of the cases. Extra-adrenal localizations account for the other 15%. A broad ligament localization related to an accessory adrenal gland is exceptional. CASE REPORT: A tumoral formation was observed during computed tomographic exploration of appendicular peritonitis in a 25-year-old patient. The tumor had developed from an ectopic adrenal gland included in the large ligament of the uterus. Pathology reported non-secreting pheochromocytoma confirmed by immunolabeling. DISCUSSION: The broad ligament localization is exceptional for pheochromocytomas and may mislead diagnosis. Resection is the only treatment. Recurrence and metastases have been reported to develop in some cases many years later, particularly after incomplete resection. Pathogenically, this tumor is remnant embryonic chromaffin tissue issuing from the parasympathetic nodes and developing in an ectopic adrenal gland.

[Laparoscopic appendectomy in the adult]. / Appendicectomie laparoscopique chez l'adulte.

AIM OF THE STUDY: The benefits of laparoscopic appendectomy remain controversial. The aim of the study was to evaluate the advantages and disadvantages of this technique. MATERIAL AND METHODS: Four hundred and forty-eight patients operated on for suspected appendicitis during a 5-year period were analysed in a retrospective study. The preoperative diagnosis was corrected in 21.4% of the cases (8.1% for males and 28.7% for females) and the conversion rate was 9.7%. There were 17 patients with generalized peritonitis and 28 with localized peritonitis. During the past year, this surgical method was introduced in another hospital and a prospective study included 92 consecutive patients operated on for appendicitis. The operating time was 53 minutes and the conversion rate was 7.6%. There were five patients with generalized peritonitis and eight with localized peritonitis. RESULTS: There were no postoperative deaths. In the first period, the morbidity rate was 2.3% in the laparoscopic group without conversion. After pathological examination, there was a 14.2% rate of normal appendix. The mean hospital stay was 4.3 days. In the second period, there were only three minor complications and the mean hospital stay was 4.19 days. CONCLUSION: The choice of laparoscopic approach is associated with some advantages: corrections of the diagnosis (mainly in young women) and simplification of the postoperative course, provided that the surgeon has sufficient experience.

Aortic anastomotic pseudoaneurysms: US, CT, MR, and angiography.

Correlation of imaging and anatomic findings in seven men with abdominal aortic graft prostheses (four "end-to-end" anastomoses and three "end-to-side" anastomoses) was done to compare the value of different imaging modalities in detecting postoperative complications, especially aortic anastomotic pseudoaneurysms (AAPs). In all cases, angiographic and CT studies were carried out. In six patients ultrasound and MR examinations were also performed. Anatomic verification was obtained by surgery in six patients and autopsy in one case. Five patients had an AAP (four at surgery and one at autopsy), one had a true abdominal aortic aneurysm above the anastomosis, and one a nondetectable abnormality of the aortic suture line. Digital subtraction angiography diagnosed one of five AAPs, missed the true aneurysm in the sixth patient, and was normal in the patient without any aneurysm. Computed tomography correctly diagnosed the five AAPs and the true aneurysm and was normal in the last patient. Ultrasound correctly diagnosed the AAPs in three of four patients, incorrectly diagnosed an AAP in the patient who had the true aneurysm, and was normal in the patient without any aneurysm. Magnetic resonance diagnosed four of four AAPs and the true aneurysm and was normal in the last patient. Computed tomography seems to be the best imaging modality with which to diagnose and evaluate an aortic AAP in patients with aortoiliofemoral graft prosthesis.

[Value of nuclear magnetic resonance in the detection of false aneurysm of the abdominal aorta]. / Intérêt de la résonance magnétique nucléaire (RMN) dans le dépistage des faux anévrysmes de l'aorte abdominale.

Among the long-term complications that jeopardize bilateral aorto-femoral prostheses, the development of a false aneurysm on the aortic suture line, is indeed one of the most severe. Its frequency, approximately 1 p. cent of cases, is probably underestimated, since its diagnosis, with usual exploration methods, is difficult. The nuclear magnetic resonance (NMR) examination is here particularly indicated and, when in doubt, must be systematically requested, especially in the presence of a false aneurysm of the femoral suture line.

[Polyaneurysmal dystrophy]. / La dystrophie polyanévrysmale.

Polyaneurysmal dystrophy (PAD) is a strange disease. It is also an uncommon disease if only strict, arteriographic and pathological criteria, are considered. True varicose disease of the arteries, this disease develops slowly and its clinical manifestations, often severe, only occur in patients over 50. The frequent association with dolichomega arteries (DMA), especially at the aorto-iliac level, is certainly not accidental. A continuous dystrophy of the media would result in the occurrence of DAM; a segmental dystrophy these diseases under a single entity: ectatic mediadystrophy. Our small personal series of 9 cases is presented to analyse the course of this disease and specify its treatment.

[Current role of partial interruption of the inferior vena cava. Apropos of 100 cases]. / Place actuelle de l'interruption partielle de la veine cave inférieure. A propos de 100 cas.

In reference to a personal series of 100 partial interruptions of the inferior vena cava (74 clips, 11 Mobin-Uddin umbrellas, 15 Greenfiled's filters), the authors analyze the criteria of choice in various procedures where the mortality, morbidity and sequellae remain low. In light of these results, the current place of surgery in the prevention of pulmonary embolism is discussed, in cases where anticoagulant therapy is contraindicated, inadequate or has failed.

[Aneurysm of the inferior mesenteric artery]. / Anévrysme de l'artère mésentérique inférieure.

Aneurysm of the inferior mesenteric artery is rare. Often unrecognized unless complicated, it is, today, demonstrated by sonography or tomodensitometry and confirmed by angiography. Usually observed in patients with atheroma, it presents a mechanical origin secondary to a "jet disorder" phenomenon occurring in an artery with a hyper-output, responsible for almost the entire gastro-intestinal vascularization. The prevention of its dangerous complications (rupture or thrombosis) justifies a systematic procedure usually requiring, in addition to the excision of the aneurysm, a revascularization of the digestive arteries, as in the case presented here.