Mattress suture for pancreatic closure and anastomosis.

The vertical mattress suture is described as used during pancreatic surgery. This method of closure enhances the security of anastomoses and minimizes the likelihood of leakage or sepsis.

Pancreatic insulinomas.

We report a series of 30 patients with pancreatic insulinoma treated from 1967 to 1990. Twenty-nine patients underwent surgery. In 24 patients, the lesion was a benign adenoma. The pancreatic lesion was localized preoperatively in 59% of cases (94% since 1980), and all lesions that were identifiable histologically were palpable intraoperatively. Endoscopic pancreatic ultrasonography, performed twice, appeared to be a very promising method of investigation. In the 24 patients with adenoma, 14 enucleations and 10 pancreatic resections were performed, with the enucleation rate increasing over time. One patient died during the postoperative period. Pancreatic fistulas (43%) were the most common cause of morbidity and were more common after enucleation (57% versus 29% after pancreatectomy). The mean follow-up period was 7 years. Excluding the patients with adenocarcinomas, the recovery rate was 92% (23 of 25 among whom 2 patients had transitory recurrent hypoglycemia), 2 patients who underwent corporeo-caudal pancreatectomy being diabetic (8%).

[Trauma emergency care]. / Les urgences traumatologiques.

The organization of trauma care within the country is essential. Hospitals able to provide optimal care for the injured patient must be selected. Every hospital have to evaluate its capabilities and resources and its places in the emergency medical services system. The number of hospitals defined to take care of severely injured patient should be defined by many factors: geography and population density, capable personnel immediately available priority of access to sophisticated laboratory and radiologic services, operative rooms and intensive care units. University Hospitals should have a trauma service connected with the department of surgery to take care of severely injured patients. General hospitals are an important resource to take care of others trauma patients.

[A case of papillary disinsertion during gastro-duo-denectomy for ulcer of the second part of the duodenum and its repair by a "physiological" reconstruction (author's transl)]. / A propos d'un cas de désinsertion papillaire au cours d'une gastro-duodénectomie pour ulcère du deuxième duodénum et de sa réparation par un montage "physiologique".

The authors report a personal case of repair of papillary disinsertion. They emphasise the risk of retrograde dissection of an old stenosing duodenal ulcer, the importance of peroperative recognition of this accident by cholangiography, the interest of sphincterotomy to attempt to prevent secondary stenosis of the papilla, the absolute necessity of an anastomosis preventing anastomotic ulcer by contact between the mouth of the gastro-enterostomy and the alkaline secretions. Vagotomy seems to them a useful complementary procedure but, associated with a drainage procedure, they believe it might have avoided this severe complication.

[Value of duodenostomy in cases where duodenal stump closure is difficult following gastrectomy for ulcer (author's transl)]. / L'intérêt de la duodénostomie en cas de fermeture difficile du moignon duodénal dans les gastrectomies pour ulcère.

The authors report 3 cases of gastrectomy with terminal duodenostomy in patients which were operated on in emergency for large duodenal ulcers. They outline the history of this method, which seems to be seldom used in France. Technic and results are presented. This procedure is advised when closure of the duodenal stump is difficult and may lead to postoperative leakage : it is therefore advocated in large perforated ulcers involving the anterior wall of the duodenum.

[Vater's ampulla neoplasms. Diagnostic and therapeutic approach. Apropos of 18 cases]. / L'ampullome vatérien. Approche diagnostique et thérapeutique. A propos de 18 observations.

Diagnostic and therapeutic aspects of neoplasms of the ampulla of Vater are discussed in relation to a relatively small but homogeneous series of 18 cases. The presenting sign is almost always jaundice, with or without associated manifestations of the angiocholitic type, sometimes regressive but recurrent. A rapid diagnosis should now be possible by ultrasound imaging of the dilated intra- and extra-hepatic biliary pathways, complemented by either fibroscopy with or without retrograde catheterization or trans-parieto-hepatic-cholangiography. The most effective therapy appears to be cephalic duodeno pancreatectomy, pathologic examination of fresh specimens of possible adenopathies being of doubtful interest since the presence of N + lymph nodes does not prevent prolonged life expectancy. The principal technical problem is related to the pancreatic stump, since this is formed of healthy parenchyma capable of provoking a fistula whether or not a pancreatico-digestive anastomosis has been performed. It might be possible in the future to use substances blocking the external secretion of the pancreatic stump left in place, in order to diminish the risk of fistula and its well-known consequences. Tumors of the ampulla of Vater have a relatively favorable prognosis when compared with that of other neoplasms in the biliopancreatic intersection zone, and an aggressive attitude to their therapy is therefore fully justified.

[Surgical treatment of Basedow's disease. Study of a homogenous series of 105 cases]. / Traitement chirurgical de la maladie de Basedow. Etude d'une série homogène de 105 cas.

Basedow's disease was the indication for surgery in 105 of 3000 operations on the thyroid performed over the last 15 years. The choise of operative therapy was based on age of patient, size of thyroid, and the failure of medical treatment to provide more than partial improvement or to prevent recurrence. Pre-operative preparation must follow a strict procedure. Surgery was initially by bilateral subtotal lobectomy, soon modified to include a left total combined lobectomy with a right subtotal lobectomy (25 p. 100 of operations). Postoperative complications among the first patients treated, in 1966, included one death from an acute toxic reaction, three lesions of the recurrent nerves (only one was permanent) and four cases of hypothyroidism (three were transient). A one to 15 years follow up was possible in 80 p. 100 of the patients. Recurrence was noted in 9 cases, two of these developing after a long period (6 and 10 years respectively). These recurrences appear to be related the sex (males), age (under 40 years), weight of goitre (50 g and over), and the type of excision (bilateral subtotal as against unilateral total lobectomy). Of the 74 patients failing to develop a relapse, 80 p. 100 were normothyroidal and 20 p. 100 hypothyroidal, while 91 p. 100 were sujectively with the results of their operation.

[The place of intrahepatic peripheral anastomoses in neoplastic obstruction of the upper bile duct junction. Report of 20 cases (author's transl)]. / La place des anastomoses intrahépatiques périphériques dans les obstructions tumorales du confluent biliaire supérieur. A propos de 20 observations.

In 32 patients with carcinoma involving the bifurcation of the hepatic ducts 17 intrahepatic cholangiojejunostomies and 3 intrahepatic gastrotomies were performed. The post-operative mortality rate is high (35%), the median survival time is 9 months. These results suggest that resection should by attempted when possible or dilatation used rather than by-pass of the tumor.

[Acute amebic abscess of the liver followed by colonic ulcers. Report of 2 cases]. / Abcès amibiens suraigus du foie suivis d'ulcérations coliques. A propos de deux cas

Two unusual cases of ruptured acute amebic liver abcess are presented one with inferior vena caval compression. Surgical drainage was followed by the development of colonic complications (haemorrhage and perforation) although the patients were under specific therapy. After a new surgical operation both cases were cured. The relation with amebiasis is discussed. The possibility of such an association must always be kept in mind. The value of immunofluorescence test in the diagnosis is emphasised.

[Results of resection in cancers of the pancreatic head]. / Les résultats des exérèses dans les cancers de la tête du pancreéas.

50 patients with a carcinoma of the head of the pancreas have been treated wether by duodenopancreatectomy (38 cases) or by total pancreatectomy (12 cases). Post operative mortality was 23.6% and 25%, mean survival 18 months and 9 months. Analyzing these results reviewing the literature the authors conclude that in limited tumors resection is preferable to palliative surgery. The choice between duodeno pancreatectomy and total pancreatectomy remains difficult and it will only be analysis of more extensive series which might give the answer.

[Cystadenoma and cystadenocarcinoma of the pancreas. Apropos of 7 new cases]. / Les cystadénomes et cystadénocarcinomes du pancréas. A propos de 7 nouvelles observations.

Cystadenomas and cystadenocarcinomas of the pancreas are tumours which remain poorly known because of their relative rarity. They are seen essentially in women aged between 40 and 60 and involve the left half of the pancreas more often than the right. The symptomatology remains latent for a fairly long time, which explains the fact that they are most often discovered only at the stage of a palpable tumour. Recent methods of investigation--echotomography and computed tomography--are of very great value in preoperative diagnosis. It is extremely important to draw the distinction within the group of benign cystadenomas between microcystic forms and macrocystic forms or mucinous cystadenomas, the latter having a definite potential for malignant change, possibly explaining the link with certain cystadenocarcinomas. As a result, excision surgery is always preferable, when possible, to bypass surgery, at least in caudal or corporeo-caudal lesions, since excision surgery is usually easy. For cephalic lesions, if excision surgery seems difficult, it may be conceivable, using modern techniques of investigation, to adopt a conservative attitude when there are no features suggestive of potential malignant change.