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The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.

Background: The preoperative diagnosis of adult intussusceptions (AIs) remains difficult, and the assessment of the radiological methods has been evaluated very little in the literature. The aim of this study was to evaluate the interest of the different imaging modalities for the preoperative diagnosis of AI and describe causes of AI., Patients and Methods: Consecutive patients of 15 years and older with the postoperative diagnosis of intussusception from 1979 to 2004 were reviewed retrospectively for this multicentric study. Data concerning clinical considerations, morphological examinations, surgical procedure, histological conclusions, mortality rate and recurrence were analysed., Results: Forty-four patients with documented intussusception were included. The mean age was 51 years (15-93 years). The preoperative diagnosis of intussusception was made in 52% of the cases. The sensitivities of the different radiological methods were abdominal ultrasounds (35%), upper gastrointestinal barium study (33%), abdominal computed tomography (CT) (58%) and barium enema (73%). An organic lesion was identified in 95% of the cases. There was 29 enteric and 15 colonic (including appendicular) intussusceptions. Thirty-seven percent of the enteric lesions were malignant, and a bit less than 50% of them were metastatic melanomas. The benign enteric lesions were Meckel's diverticulum and Peutz-Jeghers syndrome in half of the cases. Fifty-eight percent of the pure colonic lesions (excluding appendix) were malignant, and 85% of them were primary adenocarcinomas. The benign colonic lesions were lipomas in 80% of the cases. All patients, except one, had a surgical treatment, and 13 of them had a complete reduction of the intussusception before resection. The mortality rate was 16% and recurrence occurred in three patients; two of them had a Peutz-Jeghers syndrome., Conclusion: Intussusception rarely occurs in adults, but nearly half of their causes are malignant. The CT scan is a helpful examination for enteric intussusceptions whether barium enema seems to be the most performing method for colonic lesions. Surgery is the recommended treatment, with or without a primary reduction of the intussusception. During the surgical procedure, this reduction can lead to a more limited bowel resection.

Objective: In Europe, until recently the standard treatment for locally advanced rectal cancer was preoperative radiotherapy (RT). The objective of this study was to evaluate the influence on survival of intervals between diagnosis and treatment., Patients and Methods: The influence on survival of intervals between diagnosis and surgery (Dg-Surg), diagnosis and initiation of RT (Dg-Rad), and completion of RT and surgery (Rad-Surg) was evaluated in a retrospective series of patients treated with preoperative RT. Between 1991 and 1998, 102 patients received treatment with preoperative RT without concomitant chemotherapy at the René Gauducheau Cancer Center. Patients generally received 45 Gy (80%) in 25 fractions over 35 days for T2-T3-T4 N0-N1 M0 rectal adenocarcinoma located mainly (62.7%) in the lower third of the rectum (< or = 5 cm from anal margin). Thirty-five pN1 patients were treated with postoperative chemotherapy. Differences between survival were assessed by the log-rank test, and prognostic factors by the Cox test., Results: Median time was 14.7 weeks for Dg-Surg, 4.6 weeks for Dg-Rad and 5.1 weeks for Rad-Surg. Median follow-up from diagnosis was 57.4 months. Five-year local relapse-free survival was 83.9%, metastasis-free survival 64% and overall survival 60.8%. No factor was predictive of tumour response to RT. Log-rank and multivariate analysis showed that overall survival was significantly influenced by lower-third tumours, pT, pN and Dg-Surg (poorer survival when > or = 16 weeks: OR = 2.59, P = 0.005). Metastasis-free survival correlated significantly with Dg-Surg (> or = 16 weeks: OR = 2.05, P = 0.05)., Conclusion: An interval of more than 16 weeks between diagnosis and surgery may reduce overall survival of patients treated with preoperative RT for locally advanced rectal cancer. Surgery should be performed shortly after completion of RT for patients with no possibility of sphincter preservation, or a minimal risk of morbidity from an abdominoperineal excision.

Background and Aims: Achalasia is a disease of unknown aetiology. An immune mechanism has been suggested on the basis of previous morphological observations. The objective of this study was to test whether the serum of achalasia patients could reproduce the phenotype and functional changes that occur with disease progression in an ex vivo human model., Methods: Specimens of normal human fundus were maintained in culture in the presence of serum from patients with achalasia, gastro-oesophageal reflux disease (GORD), or healthy subjects (controls). Immunohistochemical detection of choline acetyltransferase (ChAT), neurone specific enolase (NSE), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), and substance P was carried out in whole mounts of gastric fundus myenteric plexus. In addition, the effects of achalasia serum on electrical field stimulation (EFS) induced contractions were measured in circular muscle preparations., Results: Serum from achalasia patients did not affect the number of myenteric neurones. Tissues incubated with serum from achalasia patients showed a decrease in the proportion of NOS (-26% of NSE positive neurones; p=0.016) and VIP (-54%; p=0.09) neurones, and a concomitant increase in ChAT neurones (+16%; p<0.001) compared with controls. In contrast, GORD serum did not modify the phenotype of myenteric neurones. Area under the curve of EFS induced relaxations (abolished by N-nitro-L-arginine methyl ester) was significantly decreased following incubation with serum from achalasia patients compared with controls (-7.6 (2.6) v -14.5 (5.0); p=0.036)., Conclusions: Serum from achalasia patients can induce phenotypic and functional changes which reproduce the characteristics of the disease. Further identification of putative seric factors and mechanisms involved could lead to the development of novel diagnostic and/or therapeutic strategies in achalasia.

The major functions of the stomach are under the control of the enteric nervous system (ENS), but the neuronal circuits involved in this control are largely unknown in humans. Enteric neurones can be characterized by their neuromediator or marker content, i.e. by neurochemical coding. The purpose of this study was to characterize the presence and co-localization of neurotransmitters in myenteric neurones of the human gastric fundus. Choline acetyltransferase (ChAT), neurone-specific enolase (NSE), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), substance P (SP) were detected by immunohistochemical methods in whole mounts of gastric fundus myenteric plexus (seven patients). Antibodies against ChAT and NOS labelled the majority of myenteric neurones identified by NSE (57.2 +/- 5.6% and 40.8 +/- 4.5%, respectively; mean +/- SD). The proportions of VIP- and SP-immunoreactive neurones were significantly smaller, constituting 19.6 +/- 6.9% and 16.0 +/- 3.7%, respectively. Co-localization studies revealed five major populations representing over 75% of the myenteric neurones: ChAT/-, 30.1 +/- 6.1%; NOS/-, 24.2 +/- 4.4%; ChAT/SP/-, 8.3 +/- 3.1%; NOS/VIP/-, 7.2 +/- 6.0%; ChAT/VIP/-, 4.9 +/- 2.6. Some similarities are apparent in the neurochemical coding of myenteric neurones in the stomach and intestine of humans, and between the stomach of humans and animals, but striking differences exist. The precise functional role of the neurochemically identified classes of neurones remains to be determined.

Metastasis within the buccal cavity is a relatively uncommon finding observed in about 1% of malignant tumors in this region. Mandibular or maxillary bones are usually involved as well as soft tissues. Tongue involvement is rare. Secondary localizations arising from the esophagus are exceptional. These metastatic disseminations occur at advances stages. We report a case of tongue metastasis from an esophageal adenocarcinoma in a 73-year-old man who had undergone surgery for lower esophageal adenocarcinoma a few months earlier. The clinical presentation in this context was suggestive of a metastatic process confirmed at histology. Careful pathology examination is required to distinguish primary from secondary localizations and establish the diagnosis of metastasis.

Aims: To study the clinical outcome of 82 cases of pancreatic neuroendocrine tumours classified according to the recent histological and prognostic classification of Capella., Methods and Results: Eighty-two surgical cases of pancreatic neuroendocrine tumours were examined histologically with immunohistochemical staining of paraffin sections using streptavidin-biotin complex and application of antibodies against chromogranin A and 10 hormonal peptides. Classification in four groups correlated with long follow-up and outcome of these cases. Histological examination showed 30 group I, four group II, 41 group III and seven group IV tumours. Twenty-one (70%) of group I tumours were insulinomas, whereas 25% of group III tumours were glucagonomas and 25% were unclassified. Most group IV tumours were unclassified, showing no immunohistochemical staining with any of the 10 hormonal peptides tested. Outcome was clearly correlated with tumour group. Among the 14 patients who died of the disease, four had group IV and 10 group III tumours. Thus, unclassified asymptomatic tumours without immunohistochemical staining had a poorer prognosis than asymptomatic tumours with staining., Conclusion: This study validates the Capella classification as easy to apply and useful in predicting clinical outcome.

Purpose: To assess the value of MR cholangiopancreatography (MRCP) in the diagnosis and preoperative evaluation of choledochal cysts., Material and Methods: Five patients (aged between 6 days and 28 years) were investigated by MRCP, referred for ultrasonographic detection of a bile duct dilatation or a cystic structure, of antenatal diagnosis (1 case), for jaundice or abdominal pain (3 cases) or in late follow-up of a choledochal cyst surgery. Two endoscopic-ultrasonographic studies were performed. The five patients underwent surgery without preoperative biliary cholangiography. MRCP was performed using a HASTE sequence in frontal, oblique, axial planes (1,5 Tesla MR unit)., Results: MRCP allowed to confirm choledochal cyst, helps to specify the anatomical type (2 type I, 3 type II), detects choledocholithiasis (3 cases). Anatomic correlation was perfect. MRCP allowed to exclude gastrointestinal duplication. Anomalous junction of the pancreaticobiliary duct was found in one case., Conclusion: MRCP diagnoses choledochal cysts, specifies type, helps surgery and can avoid endoscopic retrograde cholangiography or endoscopic sonographic examinations especially for children. It may find an anomalous junction of the pancreaticobiliary duct.

The aim of this retrospective study on 52 operated medullary thyroid carcinoma (MTC) was to assess clinical and biochemical factors influencing survival without clinical recidive. There were 52% of familial cases. Mean age was 44 years (3 to 78 years) with 58% of women. The diagnostic was made prostoperatively in 38% of case (nodular specimen), when it was strongly suspected for 50% of patients before intervention (familial context, and/or preoperative Calcitonin (CT) levels, and/or mutation). The medial survival rate was 54 month (3 to 360 month). The absence of postoperative negativation of the CT (between 1 to 3 month) was meeting in 43% of case. Twenty one patients (42%) had presented one or several clinical relapse. At the end of the study, five patients were died in a postoperative time-limit of 22 to 110 month. The different parameters studed were: the sex, the age, the tumoral stage, the familial cases, the tum-oral size, the calcitonin levels normalisation in the three month postoperatively, and the local nodes extent. The 5-year survival rate was 90%, and the 10-year survival was 80%. The familial cases had a better pronostic than the sporadic (no death in the familial group versus 80% of 5-year survival rate in the sporadic cases). In univariate analysis, the good survival-factors without clinical recidive were: the stage I or II (p < 0,0001), the female sex (p = 0,02), the tumoral size under 10 mm (p < 0,02), the postoperative negativation of CT levels (p < 0, 0002), and the absence of cervical node extent (p < 0,0005). In multivariate analysis, only the postoperative negativation of CT-levels was a good survival-factor without clinical relapse (p < 0, 001).

Background: Interleukin (IL) 1beta converting enzyme (now known as caspase 1) is able to process pro-IL-1beta into its active form and is involved in proapoptotic signalling., Aims: To characterise IL-1 and caspase 1 expression in human colonic epithelial cells., Methods: Intracellular IL-1 content (IL-1alpha and IL-1beta) was measured by ELISA in freshly isolated human normal colonocytes. Caspase 1 expression was determined both at the mRNA level using in situ hybridisation and reverse transcription polymerase chain reaction, and at the protein level by immunoblotting experiments using antibodies specific for the proform of caspase 1 and for its cleavage forms., Results: Low amounts of IL-1beta were found in nearly all preparations (92%), and IL-1alpha was detected in only 45% of human colonocyte preparations. The normal colonic epithelium strongly expressed caspase 1, both at the mRNA level and at the protein level in its latent form. In contrast, caspase 1 was not expressed in colon cancer (primary colonic adenocarcinomas and cancer cell lines)., Conclusions: The demonstration that the human colonic epithelial barrier is able to express caspase 1 and its substrate IL-1beta reinforces the concept that, under certain conditions, the epithelium could trigger an inflammatory reaction. In addition, the finding that caspase 1 was downregulated in colonic adenocarcinomas supports the concept that disrupted apoptosis pathways may be involved in tumour formation and/or may confer resistance to treatment.

Objective: To better characterize the presentation of gangrenous and non-gangrenous ischemic colitis in subjects older than 60 years, and to identify risk factors of gangrenous outcome., Methods: Retrospective analysis of 80 cases of ischemic colitis (22 male, 58 female; mean age 76.9 +/- 8.7 years) with 64 and 16 non gangrenous and gangrenous forms, respectively., Results: Hematochezia and diarrhea were significantly less prevalent in gangrenous colitis compared to the non-gangrenous group (31.2% vs 81.2%, P < 0.0001 and 6.2% vs 53.1%, P < 0.0001, respectively), whereas nausea and vomiting, and hyperleukcocytosis were significantly more frequent in the former group (50.0% vs 18.7%, P < 0.01 and 93.7% vs 62.5%, P < 0.02 respectively). Hypertension (P < 0.03), angina (P < 0.05), history of cancer (P < 0.03) and age older than 90 (P < 0.002) were risk factors for gangrenous outcome. After multivariate analysis, only two independent factors were identified, i.e.: hypertension and history of cancer. These factors predicted gangrenous course in 85% of cases., Conclusion: Patients older than 60 years suffering from ischemic colitis are at high risk of gangrenous course if they have hypertension or history of cancer.

The Multiple Endocrine Neoplasia (MEN I) or Wermer's syndrome is an uncommon disease which is most often inherited and affects mainly parathyroid glands, pancreatic islets and pituitary gland. The aim of this study concerning 61 pancreatic tumors in 16 patients suffering from MEN I was to define the macroscopic, histological and immunohistochemical characteristics of these tumors. The pancreatic endocrine tumors as part of the MEN I syndrome concern multiple tumors of small size, localized most often to the pancreas's tail. In 79% of cases, these tumors have a different predominating peptidic hormonal secretion in a same patient though most of them have plurihormonal secretions. The pancreatic polyendocrinopathy detection imposes a family investigation to look for a type I polyendocrinopathy.

Appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. The latter occurs rarely after open appendectomy (0.133%), but accounts for 10% of the morbidity rate. The authors reviewed 22 cases of these fistulas, treated during a 24-year period (January 1970 to December 1993). The aim of these retrospective study was to precise their clinical features, to evaluate paraclinical examinations in diagnosing these complications and to give guidelines for their treatment. Fistulas occurred at day 14 in the postoperative course. In 21 case, appendicitis was severe (suppurative, gangrenous or perforated) or appendectomy quoted as technically difficult. Location of the appendix was atypical in 7 cases. Drainage of the site was performed in 17 cases at the time of appendectomy. Diagnosis was made on the aspect of the drainage fluid in 14 cases. Diagnosis workup of the fistula associated plain abdominal radiograph and abdominal ultrasonography (n = 22). Fistulography (n = 6) confirmed the clinical diagnosis of fistula, showing the leaking in all cases. Medical treatment was attempted first in 14 cases and was successful in 11 cases with a healing time from 13 to 72 days. Surgical treatment (open drainage of the site) was attempted first in 11 cases, and was mandatory in 3 other cases because of medical treatment failure: one patient died and 5 patients underwent re-operation (right colectomy in 3 cases, bypass in 1 case and re-drainage in 1 case). Fistulography in our experience, is highly reliable and is considered to be a great assistance in management of these fistulas. Medical treatment remains the best initial treatment modality. Surgery must be contemplated in case of established external fistulas, and of purulent or faecal fistulas. Nevertheless, prognosis remains poor (50% re-operation rate).

Operative survival is impaired by anastomotic fistula after esophageal resection and reconstruction. Hypovascularisation of esophageal substitute is essential. Stomach is a useful esophageal substitute however proximal resection of lesser curvature compromises vascularisation of the highest point of fundus which is usually sutured to esophagus. To improve this a new S shape esophagoplasty with isoperistaltique stomach was achieved. Fifteen cadaveric stomachs were assigned to three equal groups prepared as follow: narrow J shape stomachs, large J shape stomachs, large S shape stomachs. The arterial tree was studied following injection of contrast media barium from the right gastroepiploic artery. Proximal arteries of the S shape stomachs were well filled comparing to the others. This was allowed by keeping intact the tronc of the left gastric artery branches, severing the left gastroepiploic artery close to the spleen, and dividing the proximal fundal region as a curve.

The treatment of perforation of duodenopyloric ulcers varies according to the risks of immediate mortality and long-term recurrence. The authors carried out a retrospective study on 140 duodenopyloric ulcers which had been treated over a 13 year period. The study high identified 3 factors of immediate mortality. Age over 70 years, admission delayed by more than 24 h and preoperative hemodynamic shock. Global mortality in this series is 8.6% and varied between 2.3% and 66.7% according to the absence or presence of these 3 risk factors, respectively. The authors recommend a simple operative protocol guided exclusively by the risk factors for mortality. The presence of a single factor requires simple suture of the perforation. Suture of the perforation and vagotomy should be performed in the absence of risk factors.

Lumbar hernias are rare (2% of abdominal wall hernias). Symptomatology consists frequently only of an arch formation seen best with the patient sitting and when coughing. In adults it is twice as frequent in women and on the left side. Acute events, dominated by incarceration of a digestive segment, particularly colic, often suggest the diagnosis (10% of cases). Diagnosis is simple when confronted with a large hernia, but difficulties arise with those less than 5 cm in diameter, often diagnosed as a lipoma or parietal tumor. Conventional radiographs and ultrasound images are usually sufficient to establish the correct diagnosis and to determine the content of the hernial sac, but computed tomography scans can provide data on the exact limits of the defect and allow evaluation of possible problems during surgical repair. Rarely congenital (10%), these hernias occur either secondary to a violent lumbo-abdomino-pelvic injury (25%) or following surgical intervention to the lumbar region (50% of cases). Small hernias can be repaired using the direct approach but larger deficits require the insertion of a reinforcing non absorbable prosthesis. Long term results, both for the 4 cases reported and those published in the literature, were assessed as satisfactory.

A special emergency ward for paediatric patients was established at the University Hospital in Nantes on November 7, 1990. Both medical and surgical patients less than 15 years, 3 months of age are admitted. The initial organization of the ward (facilities personnel, on call duty) are described for the emergency paediatric surgery unit. The activity of the unit over a 4 month period (from June to September 1992) was retrospectively examined. During this period, 4,438 children were referred to the emergency ward and 2,905 (64.8%) involved a surgical pathology. The epidemiological characteristics of the patients (age, geographic origin, day and hour of admission), the causal pathology, the examinations and procedures performed, and outcome (length of stay in the ward long-term outcome) were studied. Based on these results, the authors analyzed the factors leading to dysfunction and proposed improvements in the organization of this emergency ward.

Over a period of 7 years, 100 patients (70 males and 30 females; mean age 66 years) were operated for digestive tract haemorrhage originating in an ulcer. There was a past history of ulcer in 21% and 29% had been taking drugs known to have a toxic effect on the stomach. Patent bleeding was observed by endoscopy in 32% with clear arterial flow, or a visible vessel in 10. In 20 patients a fresh clot was observed. Surgery had been indicated for massive haemorrhage in 25 cases, for persistent bleeding in 27, for recurrent bleeding in 37 and due to a visible vessel in 11. Conservative treatment was possible in three-fourths of the cases. Gastrectomy was performed in 26. Follow-up was uneventful in 55. There were 18 cases with complications and 27 deaths factors leading to fatal outcome and the data reported in the literature were analyzed.

Between January 1982 and 1987, 772 consecutive endoscopic retrograde cholangiopancreatographic examinations (ERCP) were performed in 673 consecutive patients suspected of having biliary tract lithiasis (mean age: 62.1 +/- 18.2 years). Two hundred and thirty-two were emergency procedures (30%). Endoscopic sphincterotomy was performed for common bile duct stones (CBDS) in 257 cases (38.0%), of whom 143 (55.6%) had undergone previous cholecystectomy. In 17.2% of cases, ERCP was either a complete (7.8%) or partial (9.4%) failure. In 124 patients for whom microlithiasis was not identified by sonography and who underwent operation, sensitivity and specificity of ERCP was 70% and 87%, respectively. Of 266 patients in whom ES was attempted, 96.6% were achieved and the common bile duct was cleared of stones in 72% of cases. Nineteen percent of patients required two or more attempts at extraction. After ERCP without ES, mortality and morbidity rates were 0.96 and 3.6% respectively. After ES, complications followed in 12.1% of patients and 3.9% died. Mortality and morbidity directly related to ES were 3.1% and 11.3% respectively. The most common complications after ERCP were acute cholangitis and pancreatitis, whereas after ES, acute cholangitis was the most common complication, followed by hemorrhage and duodenocholechocal perforations. These complications occurred independently of age and previous cholecystectomy but was closely related to stone clearance (P < 0.05). Seventy-one patients (10.5%) required operation. Twenty-nine patients underwent emergency surgery for complications with a mortality rate of 17%. Forty-two patients underwent elective surgery for retained CBDS after ES without any mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of abdominal wounds is presently the subject of discussion between the partisans of routine laparotomy and those preferring "armed" surveillance. Results of study of a series of 176 abdominal wounds subjected to surgical dogma showed: that the diagnosis of non penetrating wounds (17.6%) was not always evident, due either to their anatomical localization (frontier region wounds) or to insufficient local exploration in urgent cases (6.6% of false-negatives), that the existence of serious clinical signs (50 cases) was always associated with one or more visceral lesions, requiring urgent laparotomy with a morbidity of 20% and a mortality of 8% (4 cases), that in the case of asymptomatic penetrating wounds (96 cases), routine laparotomy did nevertheless allow the diagnosis of visceral lesions in 50 cases (including 23 major lesions) but was of no utility in 46 cases (31.5% of blind laparotomies for the total series). The elevated proportion of useless laparotomies (30% in the literature), the result of a dogmatic attitude, or the risk of a delayed intervention (5 to 8%) in the series practising the selective method, led to a modification in the authors' attitude. The existence of serious signs should obviously result in a laparotomy. In their absence, and when confronted with a penetrating or doubtful (frontier region) wound, an exploratory celioscopy is proposed to ensure complete abdominal exploration, to confirm the presence or absence of penetration, to treat minimal lesions and to perform a classical laparotomy in case of evident necessity.

Collection of 10 or more stones in the extrahepatic common bile duct causes lithiasic obstruction of the CBD, a fairly rare entity observed in less than 10% of cases of bile duct lithiasis. This study is based on 35 cases recorded over 10 years, including 60% in patients aged more than 75 years. Endoscopic treatment was attempted in 28% of patients and was totally successful in one case our of four only because of insufficient removal of obstruction after sphincterotomy. Surgery, either necessary (8 cases) or systematic (25 cases) combines cholecystectomy, choledocotomy and biliary fiberendoscopy for a complete treatment minimizing the risks of residual lithiasis. While biliodigestive anastomoses prevailed (58%) during the first years of this study, external biliary drainage was most often chosen during the last 5 years. This surgery in aged patients still entails high morbidity (25%) and considerable mortality (9%). Better efficacy may be provided in the future by the combination of fiberendoscopic means and of lithotrity for aged subjects at high surgical risks.

Nissen's fundal plication is acknowledged as the most effective procedure to suppress gastroesophageal reflux. It entails some morbidity (dysphagia, gas bloat syndrome), in which obstruction is the least frequently evoked but most severe risk. We report about 6 cases (4 children and 2 adults). The 4 children had been operated 3 times during the first few months of life, and their reflux was secondary to the cure of atresia of the esophagus in 2 cases, and caused severe apneas in 1 case, a former premature infant. In three cases, the obstruction was complicated within a few hours by intestinal ischemia causing death. In one case, the emergent insertion of a gastric tube allowed the decompression of the digestive tract and second surgery; the obstruction recurred 2 months later, with no postoperative complications. Two adults (aged 64 and 66) presented with gastric perforation 7 days and 9 months after fundal pliction; one of them died. These cases show how serious these obstructions are (4 deaths/6 cases). The emergent measure in such cases consists of inserting a gastric tube, although which may be impossible (1 case). The patients and their parents must be informed of this risk of complication and of its expressions. Prevention is based on a strictly submesocolic surgical approach, without any exposure of the small bowel.

From 1985 to 1990, we treated 155 patients presenting with a hemoperitoneum secondary to a splenic or hepatic injury (diagnosis established by sonography, puncture and washout and/or laparotomy). These were 39 children and 116 young adults (average age 33 years). Fifty-eight of them (37%) suffered from multiple injuries (11 children, 47 adults). Splenic lesions were observed in 110 cases and hepatic lesions in 45. Ninety-one patients were operated, 55 in emergency and 36 later, while a watch-and-wait policy was applied to 64 (42%), with repeated clinical and complementary (ultrasound and/or CT) examinations. The indication for surgery was based on the clinical findings and the necessity of blood transfusion (more than 40 ml/kg/24 h in children, more than 2 to 5 U/24 h in adults, according to the context). This attitude allowed us to avoid operating two-thirds of the children and one third of the adults. We assess the limitations of this method.

Eleven cases of rupture of bladder were observed within 7 years. Four of them were due to a direct trauma on a full bladder (group I), the other seven occurred during a complex trauma, constantly with a fracture of the pelvis (group II). In group I, the rupture was situated on the apex of the bladder. The symptoms were a suprapubic pain in four patients, a hematuria in two, and an anuria in one. In the four patients, intraperitoneal fluid was clinically evident, and confirmed ultrasonographically. An urography was performed in two patients and showed an intraperitoneal leak in our patient, and intravesical clots in the other one. The four patients were operated on within 48 hours, and were successfully treated by suture and vesical catheter. In group II, the vesical injury was revealed by hematuria (2 patients) hemorragic shock (2 patients) or both (2 patients). In the last patient, an abdominal pain after 10 days was the only symptom. Clinical signs of hemoperitoneum were present in only four patients and were confirmed ultrasonographically in two out of five patients. The urogram was normal in two of four patients. In one patient it showed a small bladder, and in another one a vesical leak. Five patients were operated on among where three in emergency and two after 9 and 10 days. Four patients with intraperitoneal rupture were successfully tread by suture of the bladder. Among three patients with extraperitoneal rupture, one had an additional tear of the mesentery and died from intravascular coagulation, the second was successfully treated by a suture, and the last one by a vesical catheter only.(ABSTRACT TRUNCATED AT 250 WORDS)

Three cases of diffuse esophageal leiomyomatosis are discussed. Two of these are familial one, the mother being affected. These familial cases can occur in association with Alport's syndrome. The occurrence of a case of esophageal leiomyomatosis imply a familial survey and the search of a renal or ocular disease. The surgical treatment of this affection in sub total oesophagectomy with esophageal substitution (with the colon especially). The long term prognosis is unknown, with the risk of renal failure if Alport's syndrome is associated or of other leiomyomatous localisation.

Seven cases of torsion of normal uterine adnexa are reported in children aged 4 to 15 years. In one case diagnosis was made by ultrasonography, allowing conservative treatment under coelioscopy. In the 6 other cases the necrosis of the ovary required its excision. The torsion concerned the ovary and uterine tube in 6 cases and the uterine tube alone in one. In 2 cases, the apparently healthy contralateral ovary was enlarged. From this series, the authors review the clinical and ultrasonographic features of the torsion of normal uterine adnexa. Ultrasonography should be performed in emergency as the conservation of the ovary depends on the precocity of diagnosis and treatment.

The authors report 4 new cases of stenosis of the small intestine of endometrial origin. They emphasize the rareness of these stenosing forms which in most recent series intervened in 1 case of endometriosis out of 1,000 (Martinbeau). They consider the various clinical presentations encountered, asymptomatic forms discovered by chance, forms associated with suggestive gynecological disorders, chronic stenosis of the small intestine or presentation with intestinal obstruction. They consider the diagnostic difficulty in the isolated forms (2 cases) in the absence of pelvi-genital lesions. Among the positive factors, they consider the recrudescence during theperiods of the digestive signs, the macroscopic appearance of the lesions and, above all, the mucosal integrity noted on opening the specimen after intestinal resection. Finally, they consider certain special problems, that of bi-polar intestinal involvement with double localisation, involving the ileum and the recto-sigmoid areas.

Urgent surgical operation to treat massive hemmorrhage of colorectal origin was necessary in 12 patients: --colon diverticulosis: 7 cases, --cecal angiodysplasia: 1 case, --pancreatocolic fistula: 1 case, --ischemic colitis: 2 cases, --post-radiation therapy rectitis: 1 case. Lesions exclused from discussion in this report and provoking hemorrhage were colorectal tumors, chronic inflammatsry colitis, rectosigmoid angiomatosis, and post-traumatic or iatrogenic lesions. After a definition of massive hemmorrhage based on pre-operative transfusional requirements, the exploratory procedures necessary for localization of the site of the hemorrhage or for detecting a right colon angiodysplasia are discussed. Bimesenteric arteriography represents the exploration of choice, but its usefulness is limited in patients with several risk factors and an average age of 70 years. The respective values of a barium enema and peroperative endoscopy in this particular context are also discussed. Elective surgery should be performed only when the exact site of bleeding has been determined or when an angiodysplasia is present. Particular problems arise when treating diffuse colon diverticulosis hemorrhage, and that provoked by the association of an angiodysplasia and a diverticulosis, as well as hemorrhagic lesions that may require emergency therapy in much rarer affections: ischemic colitis, pancreatocolic fistula, iliosigmoidal fistula, colorectal varices, colon and rectal ulcers, and colorectal radiolesions.

Between 1970 and 1983, 30 children have been treated for a liver trauma. 16 were from 5 to 10 years old. 6 had solitary hepatic lesions and 24 had visceral or polytraumatic associated lesions. All but one were operated and 27 underwent an emergency laparotomy. Superficial tears and subcapsular hematoma were found in 11 cases while penetrating wounds (14), vascular injuries (3) and ruptures (2) represent 2/3 of the whole lesions. In five cases, hepatectomy was necessary. Half of the 6 deaths result of a vascular injury, the others of the associated lesions. We have a resolutely surgical behavior when collapse or polyvisceral lesions are patent, while in isolated blunt injury a single clinical and echographic follow up is justified. A CT scan is necessary when a penetrating wound is suspected completed with an angiography.

As a result of improvements in accident prevention, traumatic rupture of the diaphragm is less commonly observed. Young adults are anatomically more exposed to the injury. Beside the classical factors, falls from great heights and direct traumas must be borne in mind as possible causes. Tears in the diaphragm are only dangerous when accompanied by visceral lesions involving the oesophagus, the large vessels, the heart, etc. Only respiratory symptoms are suggestive of a notoriously difficult diagnosis. Ultrasonography appears to be of value. The prognosis depends on associated lesions, which are frequent. The surgical treatment is usually simple, the only problem being the approach. If no complication occurs, sequelae are minimal.

Of 116 Meckel's diverticula operated upon over a period of 13 years, 35 had provoked severe disorders and 80 p. cent of the cases concerned patients under 30 years of age. Occlusions represented half of the lesions involved, perforations, hemorrhages, and diverticulitis being less frequently involved. Mucosal heterotopia was a relatively frequent finding: 13 p. cent of cases, and was often the origin of hemorrhagic accidents. Asymptomatic diverticula can be potentially pathologic, as 2 carcinoid tumors and 2 cases of gastric heterotopia were discovered during routine examinations, suggesting that prophylactic excision of apparently healthy diverticula should be performed in young subjects.

The authors report of 34 cases of sigmoid colon volvulus occurring in young subjects (15%) and in elderly subjects (60% over the age of 75 years). The diagnosis is frequently suggested by the clinical features and the history (30% of patients have a history of a previous identical episode) and is confirmed by a plain abdominal x-ray and/or an opaque enema. Endoscopy is performed in every case, except in the presence of peritoneal signs, in an attempt to perform detorsion and colonic intubation under direct vision in order to avoid emergency surgery; this procedure is effective in 87% of cases. Emergency surgery has a high mortality rate (43.5%). Elective or deferred emergency surgery after preparation is much safer (6.6% mortality). In patients with multiple diseases, non-surgical conservative management after detorsion too frequently results in repeated complications, leading to decompensation of the concurrent illnesses and a mortality rate of 34%. Endoscopic detorsion followed by surgical resection after a short 3 to 4 day preparation seems to be the best guarantee of therapeutic success.

Intraoperative autotransfusion was used in 15 patients undergoing peripheral vascular, porta-caval and liver surgery. This technique is blood saving in these indications. The most important physiopathological consequence is disseminated intravascular coagulation, whatever anticoagulation protocol is used. Low-dose heparin continuously administered is considered.