[Acute pancreatitis: prognostic value of early x-ray computed tomography coupled with Ranson's criteria and its role in surveillance of the course]. / Pancréatites aiguës: valeur pronostique de la tomodensitométrie précoce couplée aux critères de Ranson et son rôle dans la surveillance de l'évolution.

Fifty nine patients suffering from a first attack of acute pancreatitis were investigated during the first ten days of illness with computerized tomography (CT scan) and biological signs of Ranson. The prognostic value of the combination of these two classes of signs was evaluated. The grading of initial CT scan findings was accorded to the Ranson and Balthazar classification. In addition, the authors evaluated the presence and extent of necrosis and studied phlegmonous extrapancreatic spread. A high risk group of patients was determined: grade C, D, E, with at least three prognostic signs. Twelve of these high risk patients with grade D and E had a glandular necrosis as detected on initial contrast enhanced CT scan. This was an important prognostic value sign (sensibility 100 percent; specificity 92 percent) as all morbidity was 100 percent compared with 8.5 percent among the 47 other patients who did not exhibit this CT sign; mortality was 25 percent compared with 0 percent among the other patients. Phlegmonous extrapancreatic spread in three or more areas also influenced the prognostic but to a lesser extent (sensibility 100 percent; specificity 62 percent). Forty-four patients among the fifty-nine had a morphologic follow-up of the course of lesions by repeated CT scan. Local complications occurred only in patients at high risk: 9 pancreatic abscesses (20.4 percent) and 6 pseudocysts (15 percent). One-third of the twenty-one grade D and E patients had spontaneous resorption of the phlegmonous extrapancreatic areas.(ABSTRACT TRUNCATED AT 250 WORDS)

[Contusions of the liver in adults. Initial non-operative management with computerized tomography follow-up is a reasonable therapeutic option. Report of 16 cases]. / Contusions du foie de l'adulte. L'abstention opératoire initiale sous contrôle tomodensitométrique est une option thérapeutique raisonnable. A propos de seize observations.

Nonoperative management of blunt liver injury in adults still remains controversial. From February 1985 through September 1989, 27 patients were treated for blunt hepatic trauma: 11 required immediate operation and 16 (59%) were initially managed nonoperatively after evaluation of intraabdominal injury by computerized tomography. All of these 16 patients were hemodynamically stable and had no significant peritoneal signs. CT criteria for nonoperative management included subcapsular and intrahepatic hematoma, capsular tear or unilobar fracture, absence of large hemoperitoneum, absence of large devitalized liver and absence of other intraabdominal organ injuries. Clinical follow-up, repeated radiologic examinations and surgery confirmed the accuracy of CT. Only 2 patients required delayed operation (12.5%). Serial abdominal CT studies are an integral part of the conservative treatment of blunt hepatic injuries and showed complete resolution of hepatic injuries in the fourteen nonoperated patients in less than six months. No death and no delayed septic or biliary complications were noted. Mean hospital stay was seventeen days for all of the patients (multiple injuries or not) and only ten days for isolated blunt liver injury. These good results depend on identification of candidates for nonoperative management on strict clinical and CT criteria. Nonoperative management of adult blunt liver injury based on these findings is a useful alternative in a selected group of hemodynamically stable patients and decreases the rate of non-therapeutic coeliotomy.

[Rupture of aneurysm of the splenic artery during the first three months of pregnancy]. / Rupture d'un anévrysme de l'artère splénique pendant les trois premiers mois de la grossesse.

A rare but dramatic case of haemoperitoneum of non-gynaecological origin which occurred during pregnancy is reported. Obstetrical causes of shock having been excluded, laparotomy made it possible to discover an aneurysm of the splenic artery and treat it by resection-ligation and splenectomy. In such cases, the uterus is spared before the 6th month of pregnancy, and beyond that data caesarean section is mandatory. The pathogenesis of such arterial ruptures during pregnancy is unknown. The abrupt collapse accounts for the high maternal and foetal mortality. Prevention can only be achieved by surgical treatment of all uncomplicated aneurysm of the splenic artery in young women.

[Hydatid cysts of the liver appearing late (10 to 22 years) after surgical treatment of pulmonary hydatidosis. Physiopathologic problems]. / Les kystes hydatiques du foie de révélation tardive (10 à 22 ans) après traitement chirurgical d'une hydatidose pulmonaire. Problèmes physiopathologiques.

The very late observation of an hydatid cyst of the liver, after clinical or fortuitous signs (intraoperative, ultrasound, CT) is a highly underestimated possibility. From 4 cases of hydatid cysts of the liver which were removed 10 to 22 year after a pulmonary hydatidosis, any possibility of parasitic reinfestation during this time being excluded, the authors propose a physiopathological explanation to an often very long clinical latency period of the liver hydatidosis. Indeed the pulmonary location of the hydatid disease means that the hepatic filter did not properly operate or was bypassed, but it does not exclude a simultaneous intrahepatic graft. The literature study shows a 4 to 8.4% rate of concomitant liver-lung location according to the statistical data provided by thoracic and digestive surgery departments. The percentage reaches 25% when ultrasounds and abdominal computed tomography are systematically used. The rapid growth of the hydatid cyst in the lung can be explained by the low resistance of the lung parenchyma and vasculo-bronchial structure to the intracystic pressure, whereas in the liver, the hydatid cyst growing is stopped by a dense parenchyma and the hepatobiliary capsules. When fissuring or large opening in the biliary tract occurs the intracystic pressure drops, the pericyst becomes sclerotic, calcified. The combination of these different factors all the more contributes to the cyst involution since it presents a central topography.

[Idiopathic segmental infarction of the greater omentum]. / Infarcissement segmentaire idiopathique du grand épiploon.

Segmental infarction of the omentum is a rare disease, with about 150 published cases, and an unusual cause of "pseudoacute" abdomen. The preoperative diagnosis is difficult because of the rarity and lack of specificity of the syndrome, and it is established after laparotomy, with a few exceptions. The authors report on a personal case and emphasize the importance of systematic exploration in spite of the "innocence" of the organ initially involved, and they describe the few signs that are nontheless suggestive of this provocative and puzzling entity.

[Single-lobe Caroli's disease. Anatomoclinical aspects. Diagnostic and therapeutic procedure. Apropos of 3 personal cases and 101 cases in the literature]. / La maladie de Caroli unilobaire. Aspects anatomocliniques. Démarche diagnostique et thérapeutique. A propos de 3 observations personnelles et de 101 observations de la littérature.

On the basis of 3 personal cases of single-lobe Caroli's disease and of 101 cases in the literature, the authors have observed that biliary-type pain was the most constant presenting symptom (85%), in association with fever (72%), while angiocholitis was observed in only 44% of all cases. The preoperative diagnosis of the disease and of the hepatic and extrahepatic lesions is aided by the noninvasive techniques of morphological exploration such as ultrasound and computed tomography, which must be proposed in first intention as they clearly demonstrate the cystic nature of the intrahepatic lesions, the associated biliary lesions [choledochal cyst (30%), lithiasis (37%)]. However, the cystobiliary communication and the definition of the type of biliary dilatation can be demonstrated only by transhepatic percutaneous cholangiography, endoscopic retrograde cholangiography, the injection of a contrast medium with biliary elimination, and quite often by intraoperative cholangiography only. The 4 types of single-lobe Caroli's disease distinguished by the authors, ie: type I: racemose biliary dilatation, type II: digitiform biliary dilatation, type III: large cystic biliary dilatation, type IV: choledochal cyst associated to the intrahepatic biliary disease, require a particular surgical treatment, which must also take account of the operative risks and of all the associated lesions (lithiasis, choledochal cyst, congenital hepatic fibrosis (5 cases), neoplastic degeneration (8 cases)]. External biliary bypass no longer has any use for treatment as it constantly fails. First-intention hepatic resection is the ideal treatment is all anatomical forms of single-lobe Caroli's disease as it treats all the hepatic lesions with no mortality. It is therefore indicated whenever the general conditions do not produce an excessive risk, when the controlateral liver is normal and when resection will not injure the bile duct of the remaining liver. If an associated choledochal cyst is present, it must be resected at the same time. Hepatic resection also is the best second surgery to propose when the other methods have failed. Hepaticojejunal anastomosis is the therapeutic solution every time hepatic resection cannot be performed.

[External fixation of comminuted fractures of the distal extremity of the radius : technical details (author's transl)]. / Précisions techniques sur l'utilisation du fixateur externe dans les fractures comminutives de l'extrémité distale du radius.

Experience gained by the authors in the use of external metacarpo-radial fixation for compound fractures of the lower extremity of the radius has led to their proposal of a technique that is less aggressive to the soft tissues. They employ a systematic approach to the radius and second metacarpal, followed by the use of atraumatic plates applied by means of a simple screw.