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35 consecutive pancreatic trauma were operated (21 blunt trauma and 14 penetrating injuries). 30 patients were operated in emergency and diagnosis was suspected before laparotomy in only one case. 12 patients had a superficial lesion, 21 had a wirsung disruption (14 in the left pancreas, 7 in the right pancreas), 2 had a diffuse pancreatitis. For the 30 patients operated in emergency, 20 had a conservative treatment, 10 had a resection. 5 patients died (14.2%), from exsanguination (2 cases), missed diagnosis or inadequate treatment (2 cases), sepsis after adequate management (1 case). Our experience suggests that an aggressive diagnosis management in emergency, with pre or pre-operative wirsungography, could determined with precision the type of the lesion and permit an adequate management, to decrease mortality.

Between January 1, 1983 and October 1, 1990, we performed 266 surgical operations in 255 patients with human immunodeficiency virus (HIV) infection. We report the reasons for these operations and compare them with those recorded in all patients operated upon in our department between January 1, 1988 and December 31, 1989 (4,960 operations in 4,498 patients). During the 1988-89 period, 2.4 percent of these patients had HIV infection, which suggests that the proportion of patients operated upon is the same in an HIV-infected population as in the general population. The proportion of HIV-infected patients who underwent surgery for diagnostic purposes or as adjuvant treatment was 42.7 percent as compared with 37.3 percent in the general population. Among laparotomies, 37.3 percent were exploratory in the HIV group versus 7.3 percent in the control group. The emergency surgery rate was the same in both groups. In gastrointestinal surgery, proctological operations were performed in 33.5 percent of the HIV group versus 7.4 percent of the control group. Among other types of surgery, only splenectomies were more frequent in HIV-infected patients than in the general population (6.3 versus 1.7 percent).

In sigmoid volvulus, most authors recommend an emergency detorsion with transrectal intubation and delayed resection. In 25% of cases, detorsion in unsuccessful, necessitating multi-stage laparotomy. However, this approach can be harmful in these patients who are often elderly or with multiple diseases. When detorsion is impossible, we now use a one-stage resection with staplers. Using a median laparotomy, detorsion is performed and viability of the colon is confirmed; a Faucher tube placed freely in the rectum, is pushed by the nurse into the dilated colon; the colon is then deflated by applying gentle suction. After removing the tube, we perform a side-to-side anastomosis at the lower ends of both limbs with mechanical staplers, after economic resection of the mesosigmoid. We have used this procedure in five patients with a median age of 82 years; the mean operating time was 92 minutes. There was no mortality, no fistulae, or stenosis with a median follow-up of 16 months. The patients stayed in hospital for 12 to 18 days. In volvulus cases which cannot be reduced immediately, this procedure obviates multi-stage operations, often the cause of mortality, morbidity or loss of autonomy in patients who are often elderly or with multiple disease.

Although the tolerance of indwelling catheters in AIDS patients has been evaluated, the complications of implanted devices in this population are unknown. This encouraged us to compare in a prospective unicenter trial, dealing with 80 consecutive implanted devices, the complications of this kind of system in 20 AIDS patients, versus a control population. The follow-up was 10,658 days. No patient was excluded or lost to follow-up. In the control population, the infection rate was 5% (0.036 per 100 catheter days). We observed 3 thromboses (5%). In the AIDS group, the infection rate was 25% (0.21 per 100 catheter days). We observed 1 thrombosis (5%). This trial shows that implanted devices are more frequently infected in AIDS patients (p less than 0.05) than in a control population; it suggests that the infection rate in AIDS patients is not superior to the indwelling catheter rate, as reported in the literature. The precision of bacteriological tests and use of antibiotic therapy adapted to the clinical context should help to determine, in the presence of suspected infection, whether the implanted device can be maintained or should be removed in this high risk population.

Appendectomy is the most current digestive surgical procedure in France. Ascending prevalence of infection by HIV, invites us to report 19 documented cases of appendicular syndroma in a population infected by HIV, within 13 cases who required criteria for AIDS. In 31.5% of cases, operation discovered infection by HIV or AIDS. 10 patients had an abscess or gangrenous appendicitis. Furthermore, a tumoral, inflammatory of infectious associated disease which required a treatment was found in 5 others patients. 2 patients died. In all cases, histologic, bacteriologic, virologic and parasitologic samps are warranted to discover current associated diseases.

From 1978 to 1988, we performed 110 laparotomies for hepatic metastases. With 41 resections for colorectal metastases, the survival was 34% at 3 years. The operative mortality was 7%. With 25 resections for non colorectal liver metastases, the survival was 42% at 1 year, 12% at 3 years. The results, compared with those of literature justify, in the absence of any other potential curative treatment, to remove colorectal liver metastases. For metastases from other tumours, results of resection for endocrine tumours and few sarcomas invite us to an aggressive approach.

We report a case of necrotic collection in the head of the pancreas infected by Salmonella typhimurium. Treatment associated necrosectomy and antibiotic therapy without cholecystectomy. The course of pancreatic disease was uneventful. Complete sterilization was obtained with quinolone antibiotic therapy.

38 cases of primary gastric non-Hodgkin malignant lymphoma operated on between 1961 and 1978 are reported. They note two changes in the study of this localisation of malignant lymphomas: a diagnostic difference as the latter is more and more often made with certainly although histological difficulties persist, and a therapeutic difference as surgical removal is now associated with radiotherapy and chemotherapy. The relative importance of these three methods depends on each case, and in the future will depend on careful assessment of the lesions, of which classification is now accepted by everyone.

A patient with typical clinical and biochemical features of a glucagonoma also presented obvious signs of hypokalemia, indicating combined secretion of renin by the tumor. The latter was voluminous, was located in the tail of the pancreas and was of a malignant nature as shown by the development of secondary hepatic metastases. Syndromes associated with glucagonoma and mixed or combined insular tumors are reviewed in detail.

Different surgical models are used in the dog for studying gastric secretion: gastric fistula, denervated Heidenhain pouch, innervated Amdrup pouch and cervical esophagostomy. The surgical procedures are described as well as the care and the monitoring allowing long-term survival of the animals. The association of gastric fistula - Heidenhain pouch has been assessed 30 times and 8 times with cervical esophagostomy. The death-rate was been 7% and the morbidity 24%. Three dogs were provided with an Amdrup pouch. Calibration of the animals allowed the acid and pepsin secreting dose-response to be platted and translation according to lineweaver-Burk or Dowd and Riggs is used to calculate the efficient dose (ED 50) and the maximal response (maxR). Pharmacological or physiological effects might be analyzed in regard to the modification of these parameters in response to a pharmacological agonist or antagonist substance. Some physiological studies could be made using sham-feeding on dogs fitted with a cervical esophagostomy.

In the technique described, the area of granulation tissue is first separated from the small bowel from which it originates and entirely removed. The internal borders of the rectus abdominis sheath are then brought together after being released by a wide lateral dissection of the skin and by a long counter-incision in the anterior surface of the sheath. The presence of a fistula or an enterostomy does not preclude the operation : indeed, they can be suppressed at the same time. Eight patients were treated by this simple technique which does not require prosthetic material. The results were satisfactory, with a durably strong abdominal wall.

Between 1980 and 1985, the authors have treated 26 recurrences of a colon or rectal cancer in patients in whom the sphincter apparatus was preserved. In 9 cases only a curative repetitive excision was possible with 3 patients currently alive, without recurrences (8 months, 12 months, 50 months). 11 patients underwent another excision, which was only a palliative one. When no surgical procedure is feasible, the evolution is rapidly fatal. According to the literature, the capabilities of "curative" excision vary between 16 and 47% with often disappointing results. Prevention of these recurrences does not depend probably on the extension of the first excision but on a much earlier screening process. The treatment is surgical and only complete excision may let hope for an adequate survival. The surgical approach depends on the site of the recurrence in relation to the upper pelvic strait and the invasion of peritumoral structures.

The authors report a new case of biliary cancer occurring in a 23 year old asiatic girl with congenital cystic dilatation of the common bile duct. After a review of the world literature, the authors recall the principal features of this congenital disease, which is becoming more common in France with the influx of Asian refugees. They stress the risk of malignant degeneration which is related to irritation of the mucosa and biliary stasis. Ideal treatment involves complete excision of the cyst.

In the light of their personal experience of 1,036 splenectomies, the authors review the hematological diseases which still require surgery, viz. certain hemolytic anemias, idiopathic thrombocytopenic purpura, Hodgkin's disease under certain conditions, and sometimes the splenic lesions in certain malignant blood diseases; they analyse their results. Thanks to close collaboration between hematologists and intensive care specialists, the mortality has been reduced to 1.35 p. cent and the morbidity to 3.46 p. cent which leaves 95.19 p. cent without any immediate postoperative complications. The late results depend on the initial disease process.

Following technical consideration on the use of Mikulicz's drain, with emphasis on introduction and irrigation with hydrogen peroxide, the authors describe its advantages: wide drainage, extraperito-nealization of the septic focus and removal without general anaesthesia. Such advantages clearly overcome the drawbacks which are now reduced by a strict and well codified application of this type of drain: prolonged purulent discharge, fistulae and incisional hernias are rare. Nowadays, the Mikulicz's drain is mainly indicated in diffuse peritonitis (notably post-operative) difficult bleeding control, pelvectomy and hepatectomy.

Since July 1st, 1958, we have operated 1095 patients with some hematological disease. We review the chief currently accepted surgical indications for splenectomy (Hodgkin's disease no longer being one of them, or seldom so), and we communicate our results pertaining to the immediate postsurgical period. Mortality and morbidity have been 1.36% and 3.28%, respectively. In over 95% of cases, there have been no complications. The low incidence (1.36%) of infection-related complications was partly due to the important number of splenic drains placed. High quality results can only be achieved when tight collaboration exists between hematologists, radiologists and surgeons.

This syndrome, also known under the initials W.D.H.A., is due to a single or multiple pancreatic tumour or to micropolyadenomatosis consisting of non-beta islet cells. Malignancy is found in about two-thirds of the cases. The other endocrine glands are rarely involved. The syndrome is more frequent in women than in men. It is characterized by liquid diarrhoea, marked hypokalaemia and absence of gastric hyperacidity. The tumour is mainly diagnosed by echotomography, computerized tomography and arteriography. It can also be located by staged collections of blood along the portal system for hormonal assays. The nature of the tumour can only be ascertained by demonstrating the presence of the responsible hormone, usually the "vaso-intestinal peptide". Treatment is primarily surgical. Adjuvant treatments include streptozotocine and embolization by superselective catherization in cases of hepatic matastases. The prognosis is sombre since in spite of the various treatments cure can only be achieved in 50% of the patients.

In 1974, cephalic duodeno-pancreatectomy was performed in a 48-year old patient with papillary adenocarcinoma within the pancreatic duct. The patient is still alive without overt recurrence. The authors emphasize the rarity of such lesions (8 cases published to date), the diagnostic value of retrograde contrast radiography of the main pancreatic duct, the need for wide pancreatectomy, the quality of survival and the possibility of cure.

A very rare diagnosis before a terminal hemorrhagic accident, aorto-esophageal fistula (FAO) is almost always fatal. Three cases of this exceptional lesion are reported. The first patient died within a few minutes of admission from a cataclysmic hematemesis. This 52 year old man had a recurring adenocarcinoma of the cardia that had been treated by laser. A "premonitory hematemesis" of bright red blood had occurred eight hours before admission. In the two other cases the problem arose with an "open abdomen" in exsanguinated patients operated upon as emergencies for massive hematemesis. In both cases, an intra-esophageal balloon catheter and controlled hypotension allowed performance of a left thoracotomy and aortic clamping. One patient had a cancer of middle third of esophagus that had perforated into the descending aorta. A resection-graft of the aortic isthmus and a retrosternal gastric esophagoplasty was successfully carried out at the time of exploration. The other patient had an FAO in the aortic isthmus region probably due to a foreign body. Operation involved an esophagectomy with cervical esophagotomy and gastrotomy combined with a resection-graft of aortic isthmus using a Dacron prosthesis. This patient died on the 21st postoperative day from rupture of the brachiocephalic trunk over a tracheotomy tube. In both of these patients a "premonitory hematemesis" with dysphagia had preceded the severe hemorrhagic accident. Successful treatment is rarely obtained with such lesions, since difficulties in ensuring rapid hemostasis in exsanguinated patients operated upon usually without diagnosis and for massive hemorrhage only, are associated with the risks of aortic repair surgery in a hemorrhagic field and with a mediastinum infected from the esophageal wound.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors describe the case of a 16-year-old African woman presenting with a cystic dilatation of the common bile duct associated with a dilatation of the left intrahepatic bile duct, hepatic fibrosis and portal hypertension. The disease was revealed by a non-infectious cholestatic syndrome. The diagnosis was made before the intervention by abdominal ultrasonography and computed tomography. A choledococyst-jejunostomy was performed which led to progressive normalisation of liver function. This report emphasizes the possibility of simultaneous lesions at different levels of the biliary tree in patients with choledocal cysts. The prognosis depends upon the state of the liver. A liver biopsy is therefore mandatory when an operation is performed. In the present case, the follow-up is too short to assess the regression of the biliary cirrhosis as described in the literature.

The authors report a case of hemo-lymphangioma from the body and the tail of the pancreas. Through a review of the literature, the histological, histogenetical and clinical features of this disease are recalled and the diagnostic and therapeutic modalities are considered. These are benign tumors and their treatment must be surgical and radical. Two operative attitudes are possible: the tumoral enucleation and the partial pancreatectomies.

A case of isolated rupture of the gallbladder following a closed injury to the abdomen is reported. Various anatomical forms of this very rare lesion have been described. The mechanism, diagnosis, and treatment of this traumatic lesion are discussed, based on a review of the published literature.

We report the case of a 43 year old man with multiple endocrine neoplasia (Zollinger-Ellison syndrome-hyperparathyroidism) diagnosed during investigations for a severe ulcer with diarrhoea. The history suggested Zollinger-Ellison syndrome, especially as basal acid production and blood gastrin levels were high. Hypercalcaemia and low blood phosphate levels suggested hyperparathyroidism, which was confirmed by ultra-sound of the neck, showing two parathyroid adenomas. The aim of treatment was two-fold: suppress the hyperparathyroidism and treat the Zollinger-Ellison syndrome. The approach is surgical in most cases, but the tumour is often impossible to remove and total gastrectomy has become rare with the progress in anti-secretory therapy. When the tumour behind a case of Zollinger-Ellison syndrome cannot be found, complementary chemotherapy is indicated. Other endocrine lesions must always be sought and the family investigated to exclude Wermer syndrome.

The case reported is that of a young woman who underwent a termino-terminal jejno-ileal by-pass procedure for obesity which was refactory to usual forms of treatment. Eight months later, a cholecystectomy was carried out for lithiasis, presenting with abdominal pain. At the time of operation, lesions of cystic pneumatosis were discovered on the excluded length of small bowel. This complication frequently manifests itself in the form of pseudosurgical abdominal pain, or as diarrhoea. More rarly, it is a radiological finding. The pathogenesis remains a subject of discussion. The mechanical theory would seem the most logical, since colonic intraluminal pressure is higher than that in the intestine excluded from the circuit. Bacterial proliferation, classical in blind loops, would be a farourising factor.