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Management of infected abdominal wall defects is a subject of debate, and the use of prosthetic mesh repair is not recommended due to the dramatic rate of mesh infection. The aim of this prospective study was to determine the recurrence rate and long-term outcomes of repairing infected abdominal wall defects using the Strattice porcine acellular dermal matrix reinforcement through a single-stage surgical approach. From August 2010 to May 2012, consecutive patients treated for infected abdominal wall defects using Strattice, a biologic prosthesis, were enrolled. All data were collected prospectively and all patients were followed for physical examination and CT scan evaluation. The primary outcome measure was the recurrence rate. Eighteen patients were enrolled and 14 were evaluable. Of these, eight patients had mesh infections and six had enterocutaneous fistulas. Median follow-up was 13 months (range, 3–22) and median length of hospitalization was 13 days (range, 4–56). The Strattice was placed in the intraperitoneal underlay position in 12 patients, and in the retro-rectus position for two. Post-operative complications included skin dehiscence (n = 3), wound infection (n = 2), skin necrosis (n = 1), and seroma (n = 2). At the end of follow-up, six patients (43 %) experienced abdominal wall defect recurrence. The utility of biologic prostheses to repair infected abdominal wall defects is controversial; however, currently, they remain the only alternative to a two-staged surgery. Prospective, randomized studies in larger populations of patients are necessary to fully determine the usefulness of biologic prostheses in this setting.

Le amputazioni costituiscono un gesto chirurgico frequentemente indicato nell’arteritico allo stadio di ischemia critica. Minori, esse sono limitate all’avampiede e hanno poche conseguenze funzionali. Maggiori, esse privano dei punti di appoggio del piede e mettono in gioco la prognosi funzionale e vitale del paziente. Queste amputazioni devono essere quanto piu economiche possibile e, nelle amputazioni maggiori, si privilegia l’amputazione di gamba. La scelta del livello di amputazione e clinica, ma puo essere aiutata da esami funzionali e di diagnostica per immagini. L’amputazione deve essere inquadrata da un’antibioticoterapia profilattica o curativa per ridurre il rischio di sovrainfezione del moncone, che puo richiedere secondariamente una nuova sezione. La tecnica chirurgica deve essere atraumatica, implicare la minore quantita possibile di scollamento cutaneo e muscolare, passare in tessuti sani ed essere inquadrata da una rianimazione rigorosa. Solo con queste precauzioni la prognosi di questi interventi, ritenuti, a torto, minori, puo essere migliorata.

Resume Objectif. – En 2003, 250 000 patients splenectomises ont ete recenses en France. Les patients aspleniques presentent un haut risque d'infections, en particulier vis-a-vis des bacteries encapsulees : pneumocoque, Haemophilus influenzae et meningocoque. Ces infections, caracterisees par leur rapidite d'installation et leur gravite importante, comme en temoigne une morbimortalite elevee, necessitent une prise en charge globale specifique qui a ete revue au cours d'une reunion d'experts en juin 2003 a Paris. Voici les principales conclusions concernant la periode perioperatoire. Type d'etude. – Mise au point. Synthese des donnees. – Deux vaccins antipneumococciques sont a notre disposition : le vaccin polysaccharidique (Pneumo 23®) et le vaccin conjugue (Prenevar®), propose plus recemment. Le vaccin polysaccharidique, d'efficacite variable, et qui couvre un grand nombre de serotypes, est conseille chez l'adulte. Le vaccin conjugue est preconise chez l'enfant de moins de deux ans car il est actif sur les souches resistantes aux antibiotiques et potentialise l'effet de l'antibioprophylaxie. En cas de splenectomie programmee, les vaccinations couvrant le pneumocoque (Pneumo 23®), l'Haemophilus de type b et le meningocoque de type C doivent etre realisees au moins 15 jours avant l'intervention assurant ainsi une meilleure immunogenicite du vaccin. En cas de chirurgie urgente, les vaccins doivent etre administres dans les 30 jours suivant l'intervention. Une injection preoperatoire de cefazoline est preconisee. Un relais par amoxicilline injectable peut etre entrepris jusqu'a la reprise du transit ; un traitement par penicilline V (Oracilline®) est ensuite institue pour une duree minimale de deux ans chez l'adulte et de cinq ans chez l'enfant. Cette antibioprophylaxie, complementaire de la vaccination, assure une diminution du nombre d'infection a germes encapsules.

The aim of this retrospective study was to evaluate the outcome and prognostic parameters of patients over 85 years of age undergoing major abdominal emergency surgery. The medical records of 45 consecutive patients aged over 85 years who underwent major abdominal emergency surgery between May 1999 and November 2001 were reviewed. The mean patient age was 88 years. Eight patients were American Society of Anesthesiologists (ASA) IV or V, 21 were ASA III, and 16 were ASA I or II. We performed 38 median and 7 right subcostal laparotomies. Perioperative mortality was 26.6% (3 times higher than that of the overall population at the same age). Perioperative complications occured in 29.5% of patients. Ten patients returned home after surgery, of whom 70% remained alive at the end of the study. Twenty-three left the hospital for a long-term care institution or post-acute care unit: of these 20% remained alive at the end of the study. Among ASA I or II patients, 43.7% remained alive at the end of the study, although 18.7% died within 1 month of the surgery. Among ASA III, IV, or V patients, only 17.2% remained alive at the end of the study, and 34.5% died within 1 month of the surgery. None of patients classified as ASA IV or V survived for more than 6 month after surgery. With an overall mortality rate of about 30%, and with the clear correlation between increased mortality and higher ASA scores, the place of palliative treatment must remain a major consideration for patients in this age group classified ASA III or higher. When surgery is performed, early return home, should be encouraged.

Resume La chirurgie des varices essentielles des membres inferieurs repose sur un bilan preoperatoire clinique et par echodoppler. Ce bilan precise le stade evolutif, la topographie des veines superficielles refluantes, les points de reflux et l'etat de la circulation veineuse profonde. Le traitement chirurgical cherche a supprimer les points de reflux et les veines superficielles variqueuses tout en epargnant les axes sapheniens non ou peu refluants. Pour les varices des territoires saphene interne et saphene externe, la technique operatoire de base est la crossectomie avec eveinage. La recherche de gestes moins invasifs, limitant les traumatismes nerveux associes, fait preferer les eveinages courts et les eveinages par invaginations quand ils sont possibles. Les gestes associes peuvent etre des phlebectomies type Muller et la ligature de perforantes. Les indications operatoires s'appuient sur des etudes prospectives qui ont montre l'importance de la crossectomie en cas de reflux ostial pathologique saphene interne ou saphene externe. L'eveinage du tronc saphene interne a ete discute. Il a semble ameliorer les resultats en cas de tronc saphene dilate et refluant. La prevention de l'apparition de neocrosse saphene interne a diminue le taux de recidive postoperatoire. Un traitement chirurgical invasif et adapte a chaque situation clinique doit etre propose pour ameliorer les resultats et diminuer les sequelles de la chirurgie des varices.

Gastritis secondary to splanchnic arterial insufficiency is rare. The diagnosis should be suspected in case of gastritis associated with occlusion of celiac axis and superior mesenteric artery. We report a patient with severe ischemic gastritis who completely healed after surgical reno-hepatic bypass. This retrograde revascularization avoids aortic clamping and was well tolerated. Ischemic gastritis belongs to the celiac-territory ischemic syndrome and cholecystectomy should be added to the revascularization to prevent post-operative acute ischemic cholecystitis.

Resume Les kystes dermoides du diaphragme sont rares et ont une symptomatologie peu specifique. La tomodensitometrie est le principal examen, bien qu’il soit parfois difficile d’affirmer leur caractere intra-, sous- ou sus-diaphragmatique. La possibilite de degenerescence de ces kystes dermoides impose leur exerese chirurgicale.

The female sex pheromone of Bonagota (=Phthteochroa) cranaodes (Meyrick) is a blend of (E,Z)-3,5-dodecadienyl ajcetate (E3,Z5-12:Ac) and (Z)-9-hexadecenyl acetate (Z9-16:Ac) according to analysis of pheromone - gland extracts and field trapping in apple orchards. This is the first time that E3,Z5-12:Ac has been identified as a lepidopteran sex pheromone. Traps baited with 100 μg E3,Z5-12:Ac were attractive over 15 weeks in the field and were as effective as traps baited with virgin females. Addition of Z9-16:Ac to E3,Z5-12:Ac at ratio of 1:10 had a significantly increase of male moths. The addition of the Z,E and Z,Z isomers to rubber septa baited with E3,Z5-12:Ac did not modify B. cranaodes male attraction, but 10% of EE enhanced trap catch.

Off-line calculation of the pulse pressure variation (PPV(ref)) has repeatedly been shown to be a reliable predictor of fluid responsiveness in mechanically ventilated patients. This study was designed to assess the ability of two algorithms for automated calculation of PPV (PPV(auto)) (Intellivue MP 70) and stroke volume variation (SVV(auto)) (FloTrac/Vigileo) to predict fluid responsiveness during abdominal surgery.We conducted a prospective study of 56 fluid challenges given for haemodynamic instability in 11 patients undergoing major abdominal surgery. Fluid responsiveness was defined as an increase in stroke volume index (SVI)10%. PPV(ref), PPV(auto), SVV(auto), and SVI (oesophageal Doppler) were recorded simultaneously before and after each fluid challenge.PPV(auto) and SVV(auto) both correlated with PPV(ref) [r(corr)=0.87 (P0.0001) and 0.84 (P0.0001), respectively; n=77]. All three indices measured before fluid challenges were higher in responder (n=32) than in non-responder (n=24) fluid challenges (Por = 0.02). The mean areas under the receiver operating characteristic curves were 0.96 (PPV(ref)), 0.96 (PPV(auto)), and 0.95 (SVV(auto)), and the optimal threshold value for each variable was 13%, 13%, and 12%, respectively. All indices correlated with the fluid challenge-induced changes in SVI (PPV(ref): r(corr)=0.65; PPV(auto): r(corr)=0.58; SVV(auto): r(corr)=0.58, P0.001 for all).PPV(auto) and SVV(auto) predict fluid responsiveness as accurately as off-line PPV(ref) in patients with haemodynamic instability during major abdominal surgery.

Dermoid cysts involving the diaphragm are rare and their symptomatology is non-specific. CT is the principal diagnostic tool, but it may fail to distinguish whether a cyst is located above, below, or within the diaphragm. Surgical excision of dermoid cysts is recommended because of the possibility of malignant degeneration.

The aim of this study was to assess outcome after surgical revascularization for chronic intestinal ischemia (CII).From 1980 until 2003, 34 patients underwent revascularization for CII. Records were reviewed for operative technique, perioperative mortality and long-term outcomes. CII was diagnosed on the basis of clinical, arteriographic and angio-magnetic resonance imaging (MRI) criteria. Revascularization patency was monitored by arteriography, color duplex ultrasound scanning (CDS), computed tomography (CT)-scanning or angio-MRI.The celiac artery (CA) was severely diseased in 26 cases and the superior mesenteric artery (SMA) in 30 cases. Four patients presented single-vessel, 15 patients two-vessel, and 15 three-vessel involvement. Revascularization was performed by either simple (N=15) or double (N=19) bypass grafting. In 2 patients bypass grafting was combined with reimplantation. One patient underwent reimplantation alone. Median follow-up was 45 months. The 30-day mortality rate was 3%; there were 22 late death (64%). Primary revascularization patency was 94% at 1 month and 79.4% at 4 years. Clinical success rates were 85% and 70% respectively at 1 month and at 4 years.To choose the most suitable intervention, the Authors distinguished isolated CII treatable by single SMA revascularization from the digestive arteritis affecting the supramesocolic level of the abdomen, which requires double CA and SMA revascularization.

The aim of our study was to evaluate and compare short- and long-term outcomes of percutaneous angioplasty and open revascularization for chronic intestinal ischemia. Twenty-nine consecutive patients undergoing percutaneous angioplasty (n = 14) or open revascularization (n = 15) for chronic intestinal ischemia were prospectively studied from 2000 to 2006. All patients were symptomatic with at least thrombosis or 80% stenosis of superior mesenteric artery. No patient was lost to follow-up. Patients were older in percutaneous angioplasty than in the open revascularization group (p = 0.0009). Open revascularization allowed to revascularize more vessels (1.4 versus 1, p = 0.01). There was no difference between groups regarding major complications, mortality, hospital length of stay, and symptomatic recurrence. Primary re-stenosis was only observed in three patients (21.4%) in the percutaneous angioplasty group. Survival at 2 years estimated by the Kaplan–Meier method was 58% in the percutaneous angioplasty group and 70% in the open revascularization group (p = NS). Percutaneous angioplasty should be preferentially offered to older patients and those unable to undergo open revascularization.

The aim of this retrospective study was to evaluate the efficacy of bypass in patients with endstage renal disease (ESRD) and to determine predictive factors and precise bypass indications.Forty one patients with ESRD underwent 50 bypass, 6 limbs were stage II and 44 stage III or IV according to Leriche and Fontaine classification. Revascularisations procedures were 47 infrainguinal bypass and 3 miscellaneous. Median follow up was 17,0+/-15,7 months.Perioperative mortality rate was 12% (n = 6). Morbidity was as follow : 1 perioperative major imputation and 8 secondary ones. There were 26 secondary death (12 from cardiac events), cumulative survival rate declined to 42,9+/-7,7% and limb salvage rate to 77,2+/-7,5% at 2 years. Primary and secondary potency rates were 53,5+/-10,4% and 70,6+/-10%. Quality of life was good in 28% of revascularised patients. Among risk factors, myocardial events showed a statistical significance in predicting survival, good runoff and bypass occlusion showed a statistical significance in predicting limb salvage.Revascularisation can be performed in ESRD patients. However to improve the results full evaluation of myocardial risks, skin lesions and infection of the feet, available autologous vein and nutritional status may be needed in those patients.

Since the end of the nineteen-nineties, cannabis is not only incriminated in the onset of thromboangiitis obliterans but also in inducing artheromatous lesions in young subjects.A young, Caucasian, 18 year-old man was referred for cannabis withdrawal in the treatment of arteritis of the left leg.Cannabis is by far the illicite psychoactive substance most consumed by the 15-25 year-olds. Data in the literature, notably since the end of the nineteen-nineties, show that cannabis is accused of provoking arterial disease similar to that which is found in Buerger's disease (or thromboangiitis obliterans) in young subjects of whichever sex.

In 2003, asplenia had involved 250000 patients in France. These patients are at risk of severe infection, mostly with capsulated bacteria as pneumococci, meningococci and Haemophilus. The higher mortality and morbidity due to infection in asplenic patient led in June 2003 a French expert committee to propose preventive management based on vaccination and antibioprophylaxis.Update article.For vaccination, two vaccines against pneumococci are available. The first one, the antipolysaccharide (Pneumo 23) is recommended for adults. It is effective for the majority of the serotypes even if its efficacy can be variable. The second one a conjugated pneumococcal vaccine (Prenevar) is used for children under two years because it has higher activity on antibiotic resistant strains therefore increasing antibiotic prophylaxis efficiency. When splenectomy is required, vaccination against pneumococci, Haemophilus (b type) and C meningococci must be performed at least 15 days before surgery, in order to get better immune stimulation. In case of emergency, vaccines have to be administrated within 30 days after surgery. Antibioprophylaxis is based on cefazolin injection before splenectomy and by postoperative intravenous amoxicillin administration. As soon as oral intake is allowed, antibioprophylaxis is continued for at least two years in adults and five years in children. Both antibiotic and vaccination have been reported to reduce pneumococcus infections.

To review our global management of duodenal adenomas in patients with familial adenomatous polyposis and report the results of different therapeutic approaches. To present the outcome and possible sequels of pancreaticoduodenectomy.We identified five cases of duodenal adenomas in patients with familial adenomatous polyposis over a period of 10 years (1992-2001), we followed the progression of their Spigelman score. Results of conservative and surgical treatment were collected.Duodenal adenomas were discovered 5-33 years after the first operation for colonic polyposis. The score of Spigelman was as follows: 2, stage 2; 3, stage 3; 1, stage 4. Endoscopic laser therapy followed by Sulindac prescription was proposed in three cases, with only one success. Duodenopancreatectomy was performed in four patients: once the diagnosis of adenoma was made in one patient, due to Spigelman stage 4 with severe dysplasia, because development of intramucosal carcinoma under surveillance in one patient, and after failure or complication of conservative treatment in two others. Worsening of Spigelman score was observed in two out of four patients submitted to conservative therapy. Correlation between Spigelman score and final examination of the specimen was correct in two cases. There was neither significant morbidity nor long-term nutritional sequel after pancreaticoduodenectomy.Duodenal adenomas may recur or progress into malignant degeneration under conservative treatment. The pancreaticoduodenectomy is an acceptable solution for stage 4 of Spigelman, especially when severe dysplasia is present.

Cancer of the gastric stump is a classical late complication of gastrectomy for benign lesion. This tumor is defined by various criteria, including a minimal delay of 5 years since the initial gastrectomy and the benignity of the initial lesion. Early diagnosis is difficult since suggestive clinical signs are usually associated with advanced tumors. Prognosis is globally bad and theoretically justifies routine endoscopic screening. For tumors which can be radically resected, completion gastrectomy with lymphadenectomy is indicated and allows a 40% 5-year survival. In other cases, palliative treatment remains a major concern.

To determine the outcome and the place of transluminal angioplasty (ATL) in the treatment of severe limb ischaemia.Seventy two legs at stage III and IV of Fontaine's classification have been exclusively treated by endoluminal procedures. The success was valued both on the haemodynamic post-operative improvement of the run-off flow and on the clinical statut leading to the conservation at mid-term of a functional limb. Patency and survival rate had been valued by actuarial method.Seventy percent of the limbs were haemodynamically improved. For the global population, a 48% clinical success rate was obtained at 6 months but 30.5% of limbs were loss. Primary patency rate was respectively 79, 71 and 68% at 6, 12 and 24 month. The quality of the run-off arteries has been the most influential factor.Endoluminal treatment of chronic limb ischaemia had lead to a clinical improvement in 48% of cases. Multi-stages and distal atherosclerotic disease of this patients limits ATL indications which results depend of run-off quality.

To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries.Among 40 patients with severe caustic gastric burns (IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation.Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality.Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.

The metastasis of testicular choriocarcinoma are often hemorrhagic, primarily of cerebral or pulmonary seat. The secondary digestive localizations are rare and of bad forecast when they bleed. The surgical operation by laparotomy allows the topographic diagnosis and the treatment, but was made responsible for hemorrhagic decompensation of other metastatic localizations engaging the vital forecast.

Decompensation of lower limb arteritis after bone and joint surgery is an unusual finding compared with the large number of procedures performed in both emergency and controlled settings. There is however a functional and limb-threatening risk that must not be overlooked.We report a series of 9 patients followed in our department over the last 3 years. Emergency surgery had been required in 6 patients after trauma and 3 had undergone a planned orthopedic procedure. All the patients had at least one vascular risk factor, and 7 of them had a cardiovascular history. The inaugural sign was a trophic disorder due to a grade IV decompensated arteritis in 8 patients, including 2 with nonunion. Delay to treatment ranged from 1 to 3 months. Acute embolic ischemia required emergency care in 1 patient.A revascularization procedure was performed on 6 limbs and was successful in 3. There were also 6 amputations, three initially, 1 after septic shock and 2 because revascularization was impossible. Three of the amputations were required after failed revascularization. Prosthesis wearing and walking was possible in only two amputated patients. Overall rate of successful salvage was 33% (3 successful revascularizations among 9 limbs). One of the nonunions healed after revascularization; the limb was amputated for the other one. One patient died from septicemia.Our series further illustrates the severity of decompensated arteritis after bone and joint surgery, emphasizing the importance of searching for cardiovascular risk factors and functional signs suggestive of a vascular disorder. Arterial duplex Doppler and if necessary arteriography of the lower limbs should be obtained in case of doubt. Two different situations can be distinguished depending on the predictable vascular risk and the localization of the planned bone reconstruction. If the patient has an asymptomatic proximal arteritis and bone and joint surgery is planned above the knee, a revascularization procedure would not appear necessary prior to bone surgery. In other cases, it may be more advisable to treat the arteritis before attempting bone surgery. For trauma victims, the osteosynthesis technique depends greatly on knowledge of the vascular risk.

The aim of this retrospective study was to report on seven blunt fractures of the pancreas and to emphasize the difficulties of their diagnosis and treatment as well as their severity.From October 1995 to March 2000, seven cases of blunt fracture of the pancreas were observed. The diagnosis was immediate in two cases, due to an emergency abdominal CT scan, and for the five other patients it was postponed by 4 to 12 days because of the frequency and severity of the associated lesions present in five cases out of seven. A left splenopancreatectomy was performed in four patients; a late necrosectomy with external drainage in two patients; and one patient was not operated on.There was one postoperative death due to associated cerebral lesions. After left splenopancreatectomy a pancreatic fistula dried up in less than a week in two patients. After necrosectomy and drainage, the operation was complicated in the two cases because of repetitive abscesses and a large and long-lasting pancreatic fistula.Blunt fractures of the pancreas are rare and serious lesions. The diagnosis is often made during an emergency laparotomy for hemoperitoneum or peritonitis. The existence of a canal rupture confirmed by transpapillary wirsungography, or better by wirsungo-MRI, is a strong arguing point for a left splenopancreatectomy when the patient's state allows it. Simple external drainage is only justified when the left splenopancreatectomy isn't possible.

We evaluated the value of dynamic transcutaneous oxygen tension measurement in 15 patients with Leriche stage II intermittent claudication treated with vascular bypass procedures. Fifteen men, median age 60 years (range: 37-72 years), were studied during six months; 19 limbs were revascularized: eight by angioplasty, 11 by patent graft. Claudication perimeter and dynamic transcutaneous oxygen tension measurement were evaluated before and after revascularization. The TcPO2 was continuously measured with a multimodular Kontron Supermon at seven different sites simultaneously: precordium (reference probe), thighs, calves and feet, in the dorsal recumbent position after 30 minutes rest, during a standardized exercise stress test at 50 W and during the recovery phase. The results were expressed as index of surface defect (ISD). After revascularization, the duration of significant ischemia was significantly reduced (P0.001 thigh, calf, foot) in 14 patients. Dynamic transcutaneous oximetry therefore seems to be a useful method in assessing stage II occlusive peripheral arterial disease and the topography of tissue hypoxia. Dynamic transcutaneous oximetry is helpful in the surveillance after revascularization and guides the choice of specific treatment (angioplasty or patent graft) especially for multiple lesions.

Lumboscopy is an endoscopic surgical technique providing direct visualization of the retroperitoneal space from the kidney hilium to the iliac bifurcation. We report our 10-year experience with this technique used to diagnose masses in the retroperitoneal space. This method is not very invasive and the morbidity is low. The sensitivity is greater than needle biopsy under CT guidance.

From January 1993 to August 1995, we performed 60 revascularizations of the lower limb using 65 bypasses in 55 patients (32 men, 23 women, mean age 66.6 yars) with diabetes. Trophic lesions of the foot existed in 57 of the revascularizations, and in 3 cases pain was provoked by the supine position. Supra-articular femoropopliteal bypass was performed in 8 cases, subarticular femoropopliteal bypasses in 25, femorotibial bypasses in 14 and paramalleolar bypasses in 18. There were 6 post-operative deaths. Six major amputations were required including 2 despite patent bypasses. Twenty-nine minor amputations were required for trophic disorders. There were 5 deaths after the postoperative period in which 4 major amputations were required despite patent bypasses in 2 cases. Retarded cicatrization was seen in 13 of the amputation stumps of areas of atrophism. Actuarial survival at 2 years was 77 +/- 6% with primary patency of 53 +/- 9.5% and secondary patency of 74 +/- 7%. The rate of success in saving the lower limb was 80.5 +/- 5.6%. Bypass revascularization has been effective in the treatment of the diabetic ischemic foot. Operative mortality was high, resulting from associated cerebral vascular events and coronary heart disease.

Isolated iliac aneurysms are often discovered when they rupture, sometimes into a neighbouring organ. We report 2 cases of aneurysm of the common iliac artery, one which ruptured into the right common iliac vein and the other in to the sigmoid. Diagnosis was made at laparotomy in the first case and on the CT-scan of the pelvis in the second. The first case was treated with an exclusion graft using ilio-iliac bypass with suture of the venous breach via the aneurysm. In the second case, the aneurysm was excluded by ligature of the iliac arteries with extra-anatomic crossed femoro-femoral bypass, sigmoid colostomy and drainage of the pelvis. These two cases illustrate the importance of digital examination of the pelvis and CT-scan for the diagnosis of complicated aneurysms of the iliac vessels. Rapid surgery is a determining factor in prognosis.

The decision to perform protectomy must be considered very seriously in the course of Crohn's disease. The objectives of this study were to evaluate the consequences of this procedure: healing, sexual disorders, quality of life and the subsequent course of the disease. From 1981 to 1993, we performed 24 proctectomies: 15 females, 9 males, mean age: 39 years (18-76), mean preoperating time: 9 +/- 4 years. Rectal and anoperineal lesions were always accompanied by pancolitis; ileal involvement was observed in 11 cases (45%) at the time of diagnosis of Crohn's disease, and in 4 cases at the time of proctectomy. Proctectomy was performed after a period of rectal exclusion in 19 patients, while the rectum was not isolated for 5 others, including 2 patients after total colectomy. The indication for surgery was based on the coexistence of a microrectum (n = 16), anal stenosis (n = 15), rectovaginal or complex fistulas (n = 15). Technical features were: close rectal dissection (n = 19), levator muscle preservation (n = 7), wall effraction (n = 8), primary closure (n = 6) or perineal wound packing (n = 8). Mean follow-up: 44 +/- 24 months, statistical analysis: Fisher's test, Wilcoxon's test and Kaplan-Meier method. No perioperative deaths were observed. An intraperitoneal collection required drainage. Mean hospital stay was 21 days. Sexual complications were: dyspareunia (n = 3), ejaculation failure (n = 1), not correlated to the type of dissection. Perineal wound healing was considered to be normal when it took less than 6 months (n = 14).(ABSTRACT TRUNCATED AT 250 WORDS)

The adequate treatment of gastrointestinal tract carcinoma requires accurate preoperative staging. Laparoscopy has been advocated for this purpose. We reviewed the data of 12 patients and the literature to compare the results of laparoscopic staging to those of conventional imaging (ultrasonography-CT scan). Laparoscopy was more sensitive in the diagnosis of peritoneal and lives metastases. It was inadequate for the diagnosis of lymph node metastases. Laparoscopy was especially useful in patients with esophagus, stomach, pancreas and liver cancers. Laparoscopic ultrasonography improved the staging of pancreatic carcinoma and the diagnosis of liver metastases.

We examined the records of 12 patients operated for lesions of the inferior vena cava, the iliac vein, or the common femoral vein were examined. The results of venous grafts, treatment of the lesions of the posterior inferior vena cava or the supra hepatic vena cava and the permeability after repair of these large vessels was studied. Treatment included simple suture (n = 9), venous patch (lateral iliac vein, n = 1), and venous autografts (common femoral veins, n = 2). For 3 lesions of the posterior or supra-hepatic inferior vena cava, haemostasis was obtain by double clamping (n = 2) or four-way clamping (n = 1) with right hepatectomy. In 9 cases, the patients were followed-up for a mean of 59 months. Morphologic exploration with phlebography (n = 1) or echo-Doppler examination (n = 7) was performed during the follow-up period. There were no post-operative deaths. There were no functional sequellae affecting the lower limbs. In one case, the echo-Doppler examination revealed repermeabilization of a thrombosed lateral iliac vein after simple suture. Lesion repair of large diameter veins with autografts using the internal jugular or internal saphenous vein gave good results. Haemostais of posterior or supra-hepatic lesions to the inferior vena cava was obtained with clamping. In cases with associated hepatic involvement, haemostasis was controlled with a four-way clamp and trans-hepatic access or digitoclasty. Long-term permeability of venous repair was good.

One case of hemobilia, revealing a right hepatic aneurysm, following a hepatic biopsy for active chronic hepatitis B, is reported. The diagnosis established by computed tomography and arteriography. Because of chronic hepatitis and the high localization of the aneurysm, surgery was not performed. A direct percutaneous thrombin injection was performed, owing to the fact that arterial catheterization was unsuccessful, and was followed by a decrease in volume of the aneurysm, but definitive recovery was achieved secondarily by arterial embolization (coil). This case illustrates the therapeutic alternative biopsy in intrahepatic arterial aneurysm treatment.

Acute necrotic pancreatitis was diagnosed in two patients treated with asparaginase for, in the first case a highly malignant lymphoma and in the second an acute lymphoblastic leukemia. The diagnosis on clinical findings and amylase assay results was confirmed by LDH and/or C reactive protein values and abdominal CT scans. Both patients recovered after drainage of peripancreatic fluid collections, in the first patient by surgical followed by cutaneous drainage and in the second by cutaneous drainage of a pancreatic pseudocyst. In addition to the frequent pancreatic reaction observed during asparaginase treatment, signs of pancreatic necrosis requiring urgent treatment have to be identified. The necrotic nature of the pancreatitis was confirmed by clinical examination, assay to biologic markers and abdominal CT scans, eliminating other causes of the pancreatitis.

Indications for surgery in Crohn's disease were studied in 100 consecutive cases. Cases included emergency situations (n = 22) complicated forms (n = 55) and chronic forms (n = 23). Lesions were located in the small bowel alone (n = 43), small and large bowel (n = 16) and in the colon and rectum (n = 16). During the same period, 26 reoperations were performed, there was no operative mortality and no short bowels were observed. A stomy was required in 30 cases and could be removed in 19. For lesions involving the small bowel, resections were limited to symptomatic lesions; long and short plasties were performed with no complications. For the colon, total and segmentary colectomy was performed for 18 cases and ileorectal anastomoses in 13. Five proctectomies were required. Rectal exclusion was considered as a wait and see solution which was long in several cases with severe rectoperineal lesions. In these cases, secondary proctectomy should be widely proposed. For emergency situations, it would be prudent to use a safe operative technique with wide indication for stomies. For complicated forms, careful preparation allows for complete procedure with one operation. For chronic forms resistant to medical treatment, the decision can be rather difficult, but the fact that recurrences do exist should not mask the long-term remissions obtained in half the cases with surgery.

The authors describe a technique of laparoscopic gastrostomy and jejunostomy, which has been used in 23 patients between May 1991 and August 1992: 13 laparoscopic gastrostomies (LG) and 10 laparoscopic jejunostomies (LJ), all performed under general anaesthesia. There were no operative deaths, one intraoperative complication and 3 postoperative complications. Twelve patients had died by the end of the study, 7 patients were still using their feeding tube and 4 patients ate normally. The mean duration of use of the feeding tubes was 4 months for LG and 43 days for LJ. The secondary complications consisted of 3 tube obstructions and one case of pyloric obstruction. Laparoscopic gastrostomy and jejunostomy, performed according to the method described, constitute an effective and reliable alternative to open operations. They can be performed in cases in which endoscopic gastrostomy is impossible. Due to its technical simplicity, laparoscopic jejunostomy should be preferred to gastrostomy whenever there is a risk of inhalation.

Between January 1986 and January 1991, 52 femoropopliteal shunts were carried out in 51 patients for lesions defined by the Ad Hoc Committee as grade III in 36 cases, grade II in 10 and grade I in 6. The shunt graft used was the internal saphenous vein in situ in 34 cases, inversed in 13 cases, and a PTFE prosthesis in 5 cases. The postoperative course included 12 complications and one death. At the end of the study, 10 shunts had thrombosed and 4 patients had required a major amputation. Actuarial analysis at 5 year follow up showed primary permeability of 56% and secondary permeability of 60%. Statistical analysis of secondary permeability as a function of the distal bed, an associated diabetes or the in situ or inversed venous shunt, failed to demonstrate any significant difference. These femoropopliteal venous shunts in critical ischemias reduced the incidence of major amputations, the proportion of limbs saved being higher than that for shunt permeability from the 6th postoperative month. Poor results were recorded for femoropopliteal shunts using prostheses.

Transcutaneous oximetry has been used to define the level of amputation in arteritic patients, with discrepant results. We have studied preoperative statix oximetry in 33 arteritic patients at the Leriche-Fontaine Stage IV, who underwent 36 amputations (thighs = 6, Legs+Symes = 14, transmetatarsal = 7, toes = 9). Oximetry included the measurement, at the level of amputation, of the transcutaneous partial oxygen pressure (tc pO2), of the tissue oxygenation ratio (TOR), preferably with a precordial electrode, of the tc pO2 gain after oxygen inhalation and of the gain ratio with the reference electrode. Two patients died postoperatively, the amputation stump did not heal in another 8 patients. The tc pO2 value was 36.6 +/- 16.2 mm Hg in the healed group and 21.1 +/- 19.9 mm Hg in the non healed group. The TOR respectively was 71.2 +/- 32.7% and 38.6 +/- 29.9% in these two groups. These differences were statistically significant. The difference between the two groups in the measurements made after the oxygenation test was not statistically significant. With a tc pO2 threshold at 26 mm Hg, the sensitivity was 73% and the specificity 75%, the positive predictive value 90%, the negative predictive value 46% and the value of the test 73.5%. The thresholds calculated to be 56% for TOR, 11 mm Hg for the gain and 32% for the gain ratio, did not improve the performances of oximetry. In our study, the tc pO2 was the parameter that best allowed predicting healing was obtained with smaller values than the threshold. Other elements such as the general condition and diabetes have played a role in the prognosis.

Pericardoscopy (PCS) is an original method of examination of the pericardial cavity. Its principle is derived from pleuroscopy and the apparatus is derived from mediastinoscopy. The main indication for this technique is the diagnosis of pericardial effusions. Sixty-five PCS were performed for this purpose, allowing an accurate etiological diagnosis in 35 cases. The etiological diagnosis was based on the clinical and paraclinical context in 4 other effusions, considered to be idiopathic after PCS. In 23 cases, the etiology remained uncertain, but a tuberculous or neoplastic etiology was ruled out after PCS. Three false negative results were obtained. Complete cleaning of the pericardial cavity allowed favorable immediate and mid a term outcome, avoiding possible constriction. Finally, PCS established the operability of two bronchial cancers, located in the hilar area and suspected of intrapericardial extension (PCS was performed in these cases in absence of pericardial effusion).

Between 1983 and 1990, 95 patients with abdominal injury and splenic damage underwent surgery. Conservative treatment was performed in 34 cases (group I) and splenectomy was performed in 61 cases (group II). In group I, one patient died and post-operative complications occurred in 18 patients (53%). In group II, 3 patients died (of a 0hrenic abscess for one of them), and postoperative complications occurred in 38 patients (62%). There was no significant difference between group I and group II in terms of length of hospital stay and operation time; but a greater number of red cell concentrates was required during the operation in group II. No patient of group I developed post-operative infection during the mean interval of 18 months. This experience confirms that the conservative treatment of splenic contusions does not worsen the prognosis of abdominal injuries. Medium and long term infectious complications might be prevented by the conservative treatment but it is still too early to assess the real benefit of this option.

The emergent treatment of gastrointestinal hemorrhage caused by the rupture of esophageal varices in cirrhotic patients is based on sclerotherapy. The prevention of frequent recurrence may be an indication of portocaval shunting. Over an 8-year period, 72 patients were operated with a distal splenorenal shunt without deconnection aimed at preventing gastrointestinal rebleeding. This was non-emergent surgery. The Child-Pugh grade was 41 A and 31 B. All patients had an angiography, which demonstrated the lack of arterioportal reflux. Operative mortality was 2.7%. Actuarial survival at 5 years was of 67%, respectively 71% for grade A and 60% for grade B. Patency of the shunt was estimated to be 90%. Persistence of hepatopetal flow on control arteriography has been established in 65% of cases. Rebleeding was observed in 10% of cases, and episodes of encephalopathy in 10% as well out of 60 studied cases, 29 presented with a chronic increase in ammoniemia (48%). Two risk factors of mortality have been demonstrated: age higher than 60 years, and relapse of ethylic intoxication, which has been observed in 40% of cases. Later hepatic transplantation has been performed in one case, without success. These results are similar to those obtained with Warren's procedure. Further development of hepatic transplantation may limit its indications.