A new technique for closing abdominal incisions in patients with poor wound healing.

A new procedure is described for closing the abdominal wall in patients expected to have poor wound healing. The technique uses rigid steel wires passed through both abdominal thicknesses perpendicularly to the incision with an extraperitoneal course and passed through a large Silastic tube laid on the skin surface parallel to the incision. This method considerably reduces the two detrimental effects of one layer stitches: sawing of tissues by the thread and ischemic compression of the abdominal wall. We have used this procedure in 33 patients, with 31 satisfactory results. In 10 eviscerations that occurred after other methods of closure, only 1 recurrent evisceration was observed.

[Esophageal intramural bronchogenic cysts (author's transl)]. / Les Kystes bronchogéniques oesophagiens intramuraux.

The authors report two cases of bronchogenic cysts of the esophagus. The first description of an intramural double bronchogenic cyst of this organ is published. These cysts are uncommon and result from an aberrant cleavage of the primitive gut. They are characterized by the presence of a ciliated cylindric epithelium of the respiratory type, bordering the intern side of the tumor. The symptomatology is not specific. The diagnosis of benign tumor is based on the roentgenologic picture. The thoracotomy is necessary and the best treatment is enucleation of the tumor.

[Paraduodenal hernia: 3 cases and revue of the literature (author's transl)]. / Les hernies paraduodénales. Revue de la littérature à propos de 3 cas.

Three cases of surgically treated para-duodenal hernia are presented. The literature is reviewed. Several modalities of this entity are described as well as the embryological hypotheses to explain their genesis. The diagnosis is usually made at the time of a laparotomy for bowel obstruction. The surgical manipulations to reduce the hernia content (one or several loops of small bowel) are discussed.

[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.

[Bacteriological aspects of acute cholangitis with gallstones]. / Aspects bactériologiques des angiocholites aiguës lithiasiques.

The bacteria found in the bile and blood of 45 patients (27 men, 18 women; mean age 69 years) suffering from acute cholangitis with gallstones were studied in order to determine the appropriate antibiotic therapy. Before any antibiotic was prescribed, a series of haemocultures was performed under aerobic and anaerobic conditions, and later gallbladder bile samples were taken during the operation. Blood cultures were positive in 55 percent of the cases and bile cultures in 84 percent. The bacteria most frequently encountered in blood were Escherichia coli, Klebsiella spp. and Bacteroides fragilis. The frequency of bacteria passage from bile to blood was studied and clearly showed a predominance of E. coli, Klebsiella and anaerobes. Enterococci passed into the blood stream only in very special circumstances, such as endoscopic sphincteromy or inadequate antibiotic therapy. To be effective, the antibiotic treatment should cover enterobacteriaceae, anaerobes and, if required, staphylococci. Enterococci can be ignored in most cases.

[Peritoneal actinomycosis. A rare disease. 2 cases]. / L'actinomycose péritonéale. Une affection rare. 2 observations.

We report two cases of peritoneal actinomycosis, a rare localization of an uncommon disease (27% of the 212 cases previously published). The disease presents with tumoral symptoms. It is exceptionally diagnosed before surgery which usually consists of a safety excision. The true nature of the tumour is revealed by pathological examination, and its consequence is an antibiotic treatment. In the 2 cases reported here the patients had an old, uncontrolled intra-uterine device which might have been the portal of entry of the infection.

[Crohn's disease. The indications for surgical treatment (author's transl)]. / A propos des indications du traitement chirurgical dans la maladie de Crohn.

On the basis of immediate and long term results obtained by surgery in a consecutive series of 46 patients with Crohn's disease (1968-1978), the authors establish the salutory efficiency of a therapy which is often too delayed. Some of the patients could have advantage of an earlier resection complications occur. Thus the rate of mortality and morbidity could be lowered. This principle may become of great interest in opposite to the feebleness of the actual medical treatment.

[Rectal metastasis of breast cancer. Apropos of 2 cases]. / Métastases rectales du cancer du sein. A propos de 2 cas.

2 cases of rectal metastatic breast carcinoma were treated by an abdomino-perineal resection. The rectal involvement is quite uncommon, and only 6 others cases treated with surgery have been described in the international literature. We think that only radical surgery can give a good palliation.

[Surgical treatment of villous tumors of the rectum and sigmoid. Apropos of 79 cases]. / Traitement chirurgical des tumeurs villeuses du rectum et du sigmoïde. A propos de 79 observations.

The authors analyse a series of 79 villous tumors of the rectum and sigmoid. These tumors are observed more often in men at an average age of 65. They distinguish benign tumors (44 cases), premalignant (21 cases) and malignant tumors (14 cases). The histology of the whole piece has a greater value than a preoperative biopsy. There are many clinical symptoms and the forms with electrolyte depletion are not rare (6 cases). Tumors with wide implantation need a surgical treatment. It will be conservative in benign cases, but the excision will be wide in cases of invasive malignancy. The indication are based upon the localisation of the tumor on the rectum. Mortality of wide excision is quite important (10) because of the bad general feature of the patients. Recurrences must be detected early by regular endoscopic follow-up.

[Remaining pancreas after cephalic pancreaticoduodenectomy. Development and treatment]. / Le pancréas restant après duodénopancréatectomie céphalique. Son devenir et son traitement.

The authors relate a series concerning 123 cephalic pancreatico-duodenectomy cases for chronic pancreatitis and pancreatic tumors. Post surgical complications due to pancreatico jejunal anastomosis and those appearing later on in relation with residual parenchyma have been studied; so were described the different therapeutic proceedings remedying to them. The obstruction of Wirsung's duct in the tall of Pancreas with some acrylate glue seems interesting in limiting the post surgical complications if the risk of pancreatic fistula can be prevented while preserving the endocrine function.

[Prognosis and surgical indications in acute pancreatitis. Contribution of abdominal x-ray computed tomography]. / Pronostic et indications chirurgicales dans les pancréatites aiguës. Apport de la scanographie abdominale.

The authors have retrospectively studied 17 patients with acute pancreatitis to see if computed tomography (CT) findings were correlated with the clinical type of acute pancreatitis. This study permit to say that a normal CT scan is possible with an edematous pancreatitis. There is no necrotizing pancreatitis with normal CT scan. But, in 11 CT scan with severe appearance, 6 patients had an edematous pancreatitis of good prognosis. Several explanations are given, but the important thing is the lack of correlation that make CT scan of a bad prognosis value. Any way, CT scan is still the best examination for diagnosis of acute pancreatitis.

[Emergency surgery in colonic obstructions. Retrospective study of 70 cases]. / Chirurgie d'urgence face aux occlusions coliques. Etude rétrospective de 70 cas.

70 patients with complete colonic obstruction requiring emergency surgery were treated at the "Clinique Chirurgicale C" between 1977 and 1984. Carcinoma was the cause of obstruction in 65 cases. Obstruction was situated on the right colon 8 times, on the splenic flexure 13 times, and on the left colon 49 times. In emergency obstruction of the right colon was treated by right hemicolectomy in 6 cases with 0 death. Obstruction of the splenic flexure was treated in 10 cases by simple loop colostomy, twice by resection with ileo-sigmoid anastomosis, 1 by resection without anastomosis with 5 deaths. Obstruction of the left colon was treated by simple loop colostomy in 46 cases. Of the 34 patients who survived after loop colostomy, 26 were reoperated and in 23 cases a resection could be performed with 2 deaths and the colostomy could be closed in a third stage in 20 cases without death. 5 years survival of curative resection was 57%. It is concluded that primary resection is the best treatment for obstruction of the right colon and of the splenic flexure. But three stage resection seems to be a good procedure for obstruction of the left colon with low mortality, low morbidity and good 5 year survival.

[Toxic megacolon and its surgical treatment. Results in 21 cases (author's transl)]. / Le mégacôlon toxique et son traitement chirurgical. Analyse d'une série de 21 cas.

The authors present their experience of the toxic colonic dilatation after 21 cases. The frequency of this serious syndrom seems to be in augmentation, and is not any more exclusive of the ulcerative colitis. Actually, pathogeny is not yet known. Diagnosis is established by the standard abdominal X Ray. A continuous clinical, radiological and biological survey is essential, in order to avoid perforation, that is the main complication of the toxic dilatation. The surgical treatment becomes imperative as soon as the failure of the limited medical management is recognized. In this series, total colectomy with or without ileo-rectal anastomosis has been considered as the best surgical operation. Ileo-rectal anastomosis would be possibly protected by a temporary ilestomy.

[Retrospective study of a series of 62 cases of hydatid liver cysts]. / Etude rétrospective d'une série de 62 cas de kystes hydatiques du foie.

Sixty-two cases of hydatid cyst of liver were treated and followed up between 1968 and 1982. Current pre-operative investigations include immunologic tests (immunoelectrophoresis, tests for hemagglutination inhibiting antibodies) and medical imaging (ultrasound, scanner). Vascular exploration is now very rarely performed. Surgical treatment is mainly by pericystectomy and was conducted in 90% of cases with a postoperative mortality of 5,2%. Chemotherapy with Albendazole was combined routinely.

[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.