Circular anastomosis stapler. An alternative to pursestring suture.

When used with the circular anastomosis stapler, the pursestring suture (PSS) is not always secure, primarily due to esophageal fragility and secondarily due to poor operative exposure. This problem prompted us to develop a simple, rapid technique to replace the PSS. It consists of a total circular ligature of the esophageal wall, which is tightened around the axis of the stapler between the anvil and cartridge. Exposure of the esophagus and introduction of the device are easily done. Anastomosis reliability was shown by the absence of postoperative complications caused by anastomotic leakage in more than 200 consecutive patients.

[Asymptomatic cystic dilatation of the choledochus in an adult]. / Dilatation kystique asymptomatique du cholédoque chez un adulte.

A congenital choledochal cyst, type Ia according to Todani's classification, was discovered fortuitously in a 54-year old man by abdominal sonography. The patient had no biliary symptoms, and liver tests were normal. Excision of the cyst was performed because of the theoretical risk of cholangiocarcinoma. Recovery was uneventful.

[Last recourse reconstruction of the cervicothoracic esophagus: the free jejunal transplant]. / Reconstruction de dernier recours de l'oesophage cervico-thoracique: autotransplant jejunal libre.

Free intestinal autograft has been recommended for oesophageal reconstruction following total circular pharyngolaryngectomy for cancer. Coloplasty or gastroplasty are commonly used for reconstruction of cervical and thoracic oesophagus. Necrosis of the plasty or anastomotic leakage can occur and may require the resection or reintegration of the pedicled graft into the abdominal cavity. For later reconstruction another pedicled graft may not be feasible and interposition of a free intestinal autograft can be a helpful method. The authors report a case of successful reconstruction of the cervical and thoracic oesophagus by a free ileal autograft, after the initial failure of a right coloplasty in a patient with previous gastrectomy. The free ileal autograft was interposed between the cervical oesophagus and the previous coloplasty repositioned in the lower part of the anterior mediastinum. The vessels of the graft were implanted onto the left common carotid artery and the innominate venous confluent.

[The presence of an ovarian granulocytic sarcoma concurrent with a type M2 acute myeloblastic leukemia: a case]. / Localisation ovarienne d'un sarcome granulocytaire contemporain d'une leucémie aiguë myéloblastique type M2: un cas.

The authors report a case of granulosa cell tumor principally located in the ovary associated with M2 type acute myeloblastic leukemia (AML) in a trisomy 22 patients. Surgery and chemotherapy were combined with a bone marrow allograft. Frequency of granulosa cell tumor is 8 percent or less of AML cases. Diagnosis is particularly difficult when haematologic expression occurs late in the disease course. An immunohistochemical work-up is required in these cases. Aetiopathogenesis is discussed. Treatment relies essentially on chemotherapy. The prognostic is variable according to different case reports in the literature.

[Pheochromocytoma of the broad ligament]. / Phéochromocytome du ligament large.

The authors report a rare case where a pheochromocytoma which was not in the adrenal gland occurred in the broad ligament. A review of the literature resulted in only three published cases being found. When the symptomatology suggests that there may be a pheochromocytoma in the body one has to research where it is sited and one has to think of such a possibility if a tumour in the broad ligament is found during an operation, so that the risks of operating on these tumours can be lessened.

[Metastasis of breast cancer to a uterine leiomyoma]. / Métastase d'un cancer du sein dans un léiomyome utérin.

The authors report a case of metastasis of cancer from the breast in a uterine leiomyoma. The metastases into the body of the uterus from extragenital cancers are rare. If they occur they are usually in the myometrium where they are asymptomatic and where the diagnosis is difficult, or in the endometrium where the diagnosis can be made by biopsy after curettage. A few rare cases of metastases in uterine leiomyoma have been reported in the literature. They can be the cause of very sudden increase in size of fibroids with compression of the pelvic organs.

[Hepatic insufficiency and nutritional problems after major hepatobiliary surgery]. / Insuffisance hépatique et problèmes nutritionnels après chirurgie majeure hépato-biliaire.

Problems raised by major hepatobiliary surgery affect the total economy of the human body. The liver is implicated in all body metabolism processes and possible problems during partial or total hepatectomy can only be solved by a knowledge of liver physiology. The liver plays a major role in the metabolism of products of digestion, whether these are carbohydrates or amino acids arriving in the portal blood. The most important activity of the liver is the preservation of a constant level of glucose by ensuring a fixed and predictable concentration to extrahepatic tissues. It ensures a very precise control of plasma and tissue flow of amino acids and thus protein synthesis and neoglycogenesis. Synthesis and degradation of non-esterified fatty acids, ketogenesis, cholesterol synthesis and triglyceride production result from the action of the liver on lipid metabolism. Free cholesterol is the precursor of bile acids and steroid hormones, but esterified cholesterol is not synthetized in the liver. Apart from its role in bilirubin metabolism, it has a key role to play in correct functioning of most endocrine systems: many are catabolized in the liver. But one of the most interesting properties of the hepatic tissue, as far as the surgeon is concerned, is liver regeneration, which combines hypertrophy with hyperplasia. This is dependent on age, hepatotrophic factors of portal blood, and extraportal factors. A study of hepatic metabolic processes allows assessment of the consequences of partial hepatectomy. Postoperative hypoglycemia, in the absence of a continuous infusion of glucose, is easily explained by the weakness of hepatic reserves in glycogen. Albumin levels fall during the first 7-10 days after liver resection, but this hypo-albuminemia is often marked by the need to infuse large quantities of frozen fresh plasma to try to avoid lesions of the other specific proteins, which are coagulation factors. Lipid metabolism disorders are of little clinical consequence. Hepatic resection is being alarming when it involves 80 to 90% of the hepatic mass and menaces the life of the patient. The existence of a previous liver alteration worsens the consequences of major hepatobiliary surgery. Indications for hepatic resection must be weighed carefully in patients with cirrhosis, liver regeneration being totally absent after resection. Metabolic consequences of total hepatectomy followed by transplantation are identical in kind to those of partial hepatectomy but are increased in frequency and start during operation. Postoperative surveillance must be strict to avoid marked variations in glycemia with the risk of hypoglycemia, and variations in kaliemia.(ABSTRACT TRUNCATED AT 400 WORDS)

[Primary retroperitoneal mucinous cystadenoma: a case treated by celioscopic surgery]. / Cystadénome mucineux rétropéritonéal primitif: un cas opéré par coelioscopie.

We used laparoscopy to treat a case of primary retroperitoneal mucinous cystadenoma. This tumours is rarely encountered and has been reported in 22 cases in the literature. The histogenesis is uncertain. Diagnosis is never made preoperatively since primary retroperitoneal mucinous cystadenomas are usually mistaken for cystic lymphangiomas of the retroperitoneum. Surgery is the only treatment. Laparoscopic surgery can be used only if the cystadenocarcinomatous nature of the tumour is ruled out.